The 38-year-old medical journal editor of Menifee in Riverside County, California, hadn’t been immunized as a teenager because there wasn’t yet a vaccine for HPV, which causes nearly all cervical cancers and a handful of other potentially lethal forms of the disease in men and women. Now, her 10-year-old daughter, Samantha, is scheduled to get her first shot this month.

“This is the only vaccine that prevents cancer,” Chaiprasert-Paguio said.

A in the California legislature would require schools to notify parents that their kids are expected to be vaccinated for HPV before entering eighth grade, as part of a push to get more children inoculated against the cancer-causing strains of the virus, theoretically before they become sexually active. AB 659 stops short of mandating the vaccine for middle schoolers, as the bill originally proposed. Lawmakers stripped out that provision without any debate, reflecting the contentious nature of school vaccine mandates even in a state with some of the nation’s strictest immunization laws.

“Now is a tough time to be taking up that fight,” said Michelle Mello, a professor of law and health policy at Stanford University, noting that anti-vaccine sentiment has drawn more attention since the beginning of the covid-19 pandemic.

The proposed legislation by Assembly member Cecilia Aguiar-Curry would instead require public college students under 26 to provide proof of immunization against the virus, a more palatable idea for parents uncomfortable with a vaccine that links teens to sex.

Anti-vaccine activists pounced on the bill, denouncing it as an egregious example of government overreach. A group called the Freedom Angels claimed credit for pressuring lawmakers into dropping the vaccine mandate for young teens, calling it “a huge victory.”

Since its debut in 2006, the HPV vaccine has elicited that the shots or make teens sterile. Fewer than 55% of kids in the U.S. ages 13-15 were in 2020, far lower than those for other routine childhood shots. By comparison, more than 90% of adolescents are , which protects against tetanus, diphtheria, and pertussis. A single dose of the HPV vaccine , according to drug manufacturer Merck.

Most states do not require HPV immunizations for school as for , which can spread easily in classrooms through the air or touch. Just three states, Rhode Island, Virginia, and Hawaii, as well as Washington, D.C., currently require student vaccination against HPV for .

Mostly Republican pushback against covid vaccine mandates has spawned a spate of proposed legislation in , such as and , which weaken or roll back government and private-sector requirements. In Iowa, which has the nation’s second-highest cancer rate, lawmakers are considering a bill that would strike a requirement that schools inform students about the HPV vaccine.

Even before covid, a rising wave of parents who refused to vaccinate their kids allowed diseases that had been all but eliminated decades ago — like and , or whooping cough — to return.

In this reality, passing good public health policy means long-term strategizing, said Crystal Strait, who leads the pro-vaccination group ProtectUS. That’s how she sees Aguiar-Curry’s amended HPV vaccination bill.

“It’s a step,” she said. “We have to do something. Too many people are being harmed by preventable cancer.”

Nearly everyone at some point, though usually without symptoms. But a handful of strains of the virus can and develop into cancer of the cervix, vagina, vulva, penis, anus, or throat. Studies have confirmed that the HPV vaccine reduced the risk of getting cancer by nearly 90% when given to girls and boys in their early teens, likely before they’re exposed to dangerous strains of the virus.

Academic research shows that teens in states with HPV vaccine mandates have been much .

“We’ve had this war against cancer for decades, and now we have a cancer vaccine and people are debating whether we should work to assure that everyone gets it,” said Dr. Jeffrey Klausner, a public health professor at the University of Southern California who previously served as San Francisco’s director of STD Prevention and Control Services. “It’s hard to wrap your mind around.”

Rates of cervical cancer, once a leading cause of cancer deaths for American women, with the vaccine and stepped-up Pap smears. Still, more than 37,000 cancers caused by HPV are diagnosed annually, and cervical cancer alone still killed more than last year.

By contrast, Australia is on track to become the first country to within the next two decades after launching a national school-based program in which school nurses administer HPV shots to 12- and 13-year-olds willing to get the vaccine.

Public health mandates work best when they require things that have already reached a certain level of social acceptance, like wearing a seat belt or not smoking indoors, said Saad Omer, who heads the Yale Institute for Global Health and has studied vaccine skepticism.

“Mandates are strong medicine, but like every strong medicine, they come with side effects,” said Omer.

Santa Clara graphic designer Gilma Pereda, who was always a little skeptical of vaccines, admits to not being crazy about mandates. On the other hand, since she was diagnosed with cervical cancer in 2016, she’s undergone numerous surgeries and repeated rounds of chemotherapy. She has lost her uterus, her eyelashes, and her waist-length brown hair. She reached a low point in 2021 upon learning the cancer had spread to her bones.

In deciding whether to vaccinate her daughter for HPV, the choice was clear. “I did not want my child to go through this,” she said.

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She received a surprise bill for $650, launching her into a maze of claim forms and hours on the phone being routed from one office to the next to dispute the charges — insurance red tape that so many Americans have encountered. A decade later, Founds captured her experience in a graphic novel, “Bipolar Bear and the Terrible, Horrible, No Good, Very Bad Health Insurance,” a richly illustrated, darkly funny fable for adults about the country’s dysfunctional health system.

The book, published in November, follows Theodore, an intelligent but angst-ridden bear, on his quest for treatment for his own manic-depressive illness. But first he must navigate the demands of the WeCare company, a shady outfit run by cigar-smoking felines who profit unfairly from a lopsided economy and a corrupt justice system, among other things. His fellow outcasts include such characters as an overeducated owl drowning in student debt and a bomb-sniffing puppy suffering from PTSD.

America is internationally known for high-quality care, for those who can afford it. A new shows that a record-high proportion of Americans — 38% — postponed medical care because of high costs in 2022. and of the past few years seek to protect consumers from unexpected medical bills. But they don’t prevent hidden in the fine print of their insurance policies.

“Bipolar Bear” joins other recent works to shine a light on health inequities — part of the emerging genre of . It includes seminal such as by Brian Fies and nurse MK Czerwiek’s ” as well as Rachel Lindsay’s memoirs about taking a job at a pharmaceutical company to secure insurance to cover treatment for bipolar disorder.

Descended from the underground comics of the 1960s, graphic medicine has grown into a new on the medium’s role in the study and delivery of health care, said Ian Williams, the Welsh physician who back in 2007. “It’s ideal for exploring subjects having to do with one’s life and well-being in an ironic and funny way,” he said.

As Founds puts it, humor is a powerful weapon against despair.

The 40-year-old mother of two teaches English at a community college in Santa Cruz County on California’s central coast. She has never taken an art class and didn’t set out to write a graphic novel. The book began as a doodle in the margins of her notebook while studying for a master’s degree in fiction writing at Syracuse University in New York. Her 2014 novel in short stories, is about a teacher who suffers a nervous breakdown and communicates with her students from a psychiatric hospital.

KHN contributing reporter Rachel Scheier spoke to Founds about bringing Theodore to life. The interview has been edited for length and clarity.

Q: How did you come to write a book about a bear with bipolar disorder?

I’d been making children’s books for my little brother. They were all about angst-ridden animals: a lonely giant squid, a possum with social anxiety disorder who falls asleep whenever he’s in an awkward situation, a burro who wants to be a unicorn. My goal was to write a novel. But whenever I was too depressed to string a sentence together, I’d draw bears. Then I realized that anyone dealing with a mental health issue in this country is going to have to deal with the labyrinth of health insurance. And I thought it would be fun to depict it as an actual labyrinth with trapdoors and man-eating flowers. Once I went in that direction, it was no longer a children’s book.

Q: Was the book based on your own experience with mental illness?

Yes. I had my first major depressive episode at the end of high school, but I didn’t seek out professional help. I just sort of muddled through it. Then, when I was a sophomore at Stanford, I had my first manic episode. I had a series of realizations about the nature of the universe, and I didn’t sleep or eat very much. Then, in graduate school, I went to a clinic because I was going through a depression, and the psychiatrist asked me questions like “Was there ever a time when you had a lot of energy and didn’t feel a need to sleep?” And I said, “Oh, sure, but that was a spiritual awakening.” So, I had to reframe my life story a bit after that.

Q: But religion still has a role in your life?

I’m a Quaker. It’s something I came to through my interest in nonviolent social change. When I am severely depressed, I feel like life has no purpose. So, following a code that says life does have meaning, that we are all connected by a force of love that undergirds the universe, is something that has helped me a lot.

Q: Why animals?

People are hard to draw! Cartoon animals are a lot easier. I wasn’t interested in art in school — actually, when I started drawing was during that first manic episode. I do not recommend writing a 200-page graphic novel with no artistic training. I mean, it took 13 years, but I did finish it.

Q: Why did it take so long?

I worked on it off and on while I was writing essays and working on the beginnings of several other novels. When I finally finished it, I was so excited. I was ready to see it on bookshelves within a year. I sent it to my agent, and she wrote me a very nice email which said, “I love this. It’s very creative. But there’s no way I can sell it.” Most graphic novels for grownups are memoir — there wasn’t a clear genre. Then another agent I reached out to said, “I can’t take this on, but you should try Graphic Mundi, which had published several novels in the field of graphic medicine.”

Q: What made you want to write about health insurance?

Our system is actually killing people. We have a in this country, and people are not able to access mental health care. And then, when they do get help, it’s not necessarily the psychiatrist who determines the course of care; it’s the insurance company. If you go into a room of 10 Americans, five can tell you a health insurance nightmare story.

But I also wanted to explore what it means to develop a healthy lifestyle and grow a strong community and go through all this growth and healing that Bipolar Bear goes through in the story, only to have the depression come back again. What is the meaning of my journey if I find myself right back where I was before? Ultimately, there’s no answer to that question, but there is a right thing to do, which is to ask for help. We’re all saved by each other.

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From the heavily Armenian neighborhood of Tujunga in the foothills of the San Gabriel Mountains, Abramyan and other hookah shop and cafe owners began spreading the word that the ban, prompted by a burgeoning among teens, could put them out of business and extinguish a beloved social ritual that many feel is part of their heritage.

“We were going to be collateral damage,” said Abramyan, now president of the .

As their movement grew, the business owners hired a lobbyist and traveled to Sacramento to meet with lawmakers. They posted YouTube videos on “the history and centuries-old tradition” of smoking the popular in the Middle East. Their work paid off: State lawmakers passed the ban in August 2020, which outlawed the sale of flavored tobacco, including menthol cigarettes — but exempted premium cigars, loose pipe tobacco, and the “” used in hookah pipes.

It never went into effect. Big Tobacco quickly launched a referendum drive and gathered enough signatures to bring the issue to voters. This month, Californians will decide — — whether to uphold or block the law, which would make it illegal for brick-and-mortar retailers to sell flavored cigarettes, e-cigarettes, and other flavored tobacco products. Sales of gums or gummies that contain nicotine and are not approved by the FDA would also be prohibited.

If the law is upheld — indicates that a majority of likely voters support it — California would become the second state to rid stores of both flavored vapes and menthol cigarettes, which have and Latino smokers since tobacco companies began marketing them in inner-city neighborhoods half a century ago.

The question of why California has granted hookah smokers an exception while banning menthol cigarettes, the choice of smokers, has sparked a debate about which tobacco products — if any — merit protection. Until recently, menthols had failed in the face of aggressive tactics by tobacco companies, which have staved off billions in losses by and .

Anti-tobacco groups warn that this strategy has become a model for fending off government interference. They decry the hookah exemption as the latest example of business successfully using identity politics to keep profiting from a deadly product.

“Hookah has been given a pass for no scientific reason,” said Carol McGruder, co-founder of the . McGruder, who has spent years waging war against tobacco companies for their “predatory targeting” of Black communities with menthol cigarettes, said hookah smoking has become increasingly trendy among Black youths.

Many young people mistakenly believe that than other forms of smoking, but experts say tobacco smoked through water pipes is just as addictive as cigarette tobacco and tar, nicotine, and heavy metals.

“They bring out a beautiful antique hookah pipe and they say that hookah is all about family and community,” McGruder said. “But it’s all about money.”

Big Tobacco itself is assailing the hookah exemption, saying it proves that the law discriminates against Black and Latino smokers by banning menthol flavors, while giving “special treatment to the rich,” as an paid for by the industry argues.

“Prop. 31 will increase crime and expand illegal markets, cut revenue for critical services and could backfire on the very communities its proponents say they want to help,” said Beth Miller, a spokesperson for the “No on Prop 31” campaign.

, clustered primarily in California and Massachusetts, have restricted the sale of flavored tobacco products, including e-cigarette pods in — strawberry, chocolate milk, and pink punch — which health officials say have provided a gateway to teenage smoking. Roughly half of the ordinances restrict menthol, while fewer than 20 — nearly all of them in California — exempt hookah tobacco and/or hookah bars.

In 2021, and nearly 75% of middle school students who had used a tobacco product in the previous 30 days reported using flavored tobacco, the Centers for Disease Control and Prevention reported. In 2019 and 2020, an lung disease, known as EVALI, killed 68 people.

The vaping epidemic has given anti-smoking activists an opening to lobby against menthol cigarettes. Invented in the 1920s, their cool, minty flavor helped new smokers adjust to them more easily than non-flavored cigarettes, and the industry marketed them as a healthier option. In the 1960s, tobacco companies turned to the Black community, to hip, young “communicators” in barbershops and bars. Menthol cigarettes account for more than a third of the $80 billion U.S. cigarette market.

Reynolds American, the country’s largest maker of menthol cigarettes, including Newport, has battled menthol bans by ’s National Action Network and other civil rights groups. When the a menthol cigarette ban in 2019, Sharpton cited the case of , a Black man who died in police custody in 2014 after he was stopped for allegedly selling single, untaxed cigarettes on the street.

But the success of these efforts came at a devastating price, public health experts say. African American men have the in America, according to the CDC.

Earlier this year, the FDA to ban sales of menthol-flavored cigarettes, a long-awaited move hailed by health officials and some Black leaders, even as they braced themselves for a protracted legal battle with the tobacco industry that .

For years, anti-smoking activists have been focused on menthol, said Valerie Yerger, an associate professor of health policy at the University of California-San Francisco. “Nobody was focused on hookah,” she said.

But water-pipe use among young people has been in recent decades.

At across the United States and Europe, contestants compete to build the most elaborate water pipe, often to a hip-hop soundtrack. Elaborate water pipes, with their billowing puffs of smoke, are often in rap videos.

“It’s just another way the industry has found to keep our young people addicted to these products,” Yerger said.

Hookah purveyors argue that blanket prohibitions endanger small-business owners, many of them immigrants, and threaten to erase a “” by effectively outlawing hookah pipes, which are often part of gatherings and celebrations for Arabs, Armenians, Persians, and others hailing from the Middle East. They reject the claim that their fight is only about money.

“Hookah lounges are a hallmark of community,” said Rima Khoury, general counsel for .

For Abramyan, smoking a hookah was an after-dinner, adult ritual his Iranian-born parents brought with them when they immigrated to America in the 1980s. The ornate water pipes are often several feet tall and take at least 20 minutes to set up.

“This is not something kids are smoking in the bathrooms at school,” he said. “We don’t want our kids to smoke, but why shouldn’t my grandpa be able to smoke his hookah in his backyard?”

Bible study groups and the local Rotary Club chapter regularly meet at his Tujunga hookah lounge, Garden on Foothill, which features outdoor gazebos for families and groups. “For Muslims who don’t drink alcohol, or people who don’t like to go to strip clubs, this is a safe space,” he said.

The shop he runs a few blocks away, Munchies Mart, sells handmade hookah pipes and tobacco in flavors such as Strawberry Lemonade, Orange Pop, and Agua Fresca, a far cry from the apple-soaked tobacco he remembers his Persian grandmother mixing in her kitchen.

Using cultural practices to argue for public policy exemptions is nothing new, said Arnab Mukherjea, an associate professor of public health at California State University-East Bay.

But he said that communities often suffer when corporate interests “use cultural identity to market a product for mass consumption.”

“You go to any college town,” he said, “and the hookah bars are filled not with practicing Muslims, but with college-age kids who are going there to socialize, consuming flavors in bubble gum and cotton candy.”

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But like many librarians, she saw plenty of chaos. Patrons racked by untreated mental illness or high on drugs sometimes spit on library staffers or overdosed in the bathrooms. She remembers a co-worker being punched in the face on his way back from a lunch break. One afternoon in 2017, a man jumped to his death from the library’s fifth-floor balcony.

Dunseth retired the following year at age 61, making an early exit from a nearly 40-year career.

“The public library should be a sanctuary for everyone,” she said. The problem was she and many of her colleagues no longer felt safe doing their jobs.

Libraries have long been one of society’s great equalizers, offering knowledge to anyone who craves it. As public buildings, often with long hours, they also have become orderly havens for people with nowhere else to go. In recent years, amid unrelenting demand for safety-net services, libraries have been asked by community leaders to formalize that role, expanding beyond books and computers to providing on-site outreach and support for people living on the streets. In big cities and small towns, many now offer help accessing housing, food stamps, medical care, and sometimes even showers or haircuts. Librarians, in turn, have been called on to play the role of welfare workers, first responders, therapists, and security guards.

Librarians are divided about those evolving duties. Although many embrace the new role — some voluntarily carry the opioid overdose reversal drug naloxone — others feel overwhelmed and unprepared for regular run-ins with aggressive or unstable patrons.

“Some of my co-workers are very engaged with helping people, and they’re able to do the work,” said Elissa Hardy, a trained social worker who until recently supervised a small team of caseworkers providing services in the Denver Public Library system. The city boasts that some 50 lives have been saved since library staffers five years ago began volunteering for training to respond to drug overdoses. Others, Hardy said, simply aren’t informed about the realities of the job. They enter the profession envisioning the cozy, hushed neighborhood libraries of their youth.

“And that’s what they think they’re walking into,” she said.

Across the U.S., more than are employed in public libraries and schools, universities, museums, government archives, and the private sector, charged with managing inventory, helping visitors track down resources, and creating educational programs. Often, the post requires they hold a master’s degree or teaching credential.

But many were ill prepared for the transformation in clientele as drug addiction, untreated psychosis, and a lack of affordable housing have swelled homeless populations in a broad array of U.S. cities and suburbs, particularly on the West Coast.

Amanda Oliver, author of “Overdue: Reckoning With the Public Library,” which recounted nine months she worked at a Washington, D.C., branch, said that while an employee of the library, she was legally forbidden to talk publicly about frequent incidents such as patrons passing out drunk, screaming at invisible adversaries, and carrying bed bug-infested luggage into the library. This widespread “denial of how things are” among library managers was a complaint Oliver said she heard echoed by many staffers.

The , spearheaded by a group of New York City-based librarians, surveyed urban library workers and found nearly 70% said they had dealt with patrons whose behavior was violent or aggressive, from intimidating rants and sexual harassment to people pulling guns and knives or hurling staplers at them. Few of the workers felt supported by their bosses.

“As the social safety net has been dismantled and underfunded, libraries have been left to pick up the slack,” wrote the authors, adding that most institutions lack practical guidelines for treating traumatic incidents that over time can lead to “compassion fatigue.”

Library administrators have begun to acknowledge the problem by providing training and hiring staff members experienced in social services. Ensuring library staffers did not feel traumatized was a large part of her focus during her years with the Denver libraries, said Hardy. She and other library social workers in cities such as San Francisco and Washington have worked in recent years to organize training programs for librarians on topics from self-care to strategies for defusing conflict.

About are women, and the library workforce skews older, with nearly a third of staff members over 55. As in many professions, salaries have failed to keep pace with rising costs. According to the American Library Association-Allied Professional Association, the average salary for a public librarian in the U.S. was , the most recent year for which data is available.

Studies confirm that many librarians .

In Los Angeles County, with more than 60,000 people who are homeless, the past few years have tested the limits of a public library system with more than 80 sites.

“The challenge is that the level of need is off the charts,” said L.A. city librarian John Szabo. “Unfortunately, we are not fully and effectively trained to deal with these issues.”

Libraries began their transition more than a decade ago in response to the number of patrons seeking bathrooms and temporary respite from life on the streets. In 2009, San Francisco decided to formally address the situation by hiring a full-time .

Leah Esguerra leads a team of formerly homeless “health and safety associates” who patrol San Francisco’s 28 library sites looking to connect sick or needy patrons with services big and small, from shelter beds and substance use treatment to public showers, a model that has been copied in cities around the world.

“The library is a safe place, even for those who no longer trust the system,” said Esguerra, who worked at a community mental health clinic before becoming the “library lady,” as she’s sometimes called on the streets.

But hiring a lead social worker hasn’t erased the many challenges San Francisco’s librarians face. So the city has become more aggressive in setting standards of behavior for patrons.

In 2014, then-Mayor Ed Lee called for library officials to impose in response to rampant complaints about inappropriate conduct, including indecent exposure and urinating in the stacks. Soon after, officials released an amended that explicitly spelled out the penalties for violations such as sleeping, fighting, and “depositing bodily fluids on SFPL property.”

The city has installed extra security and taken other steps, like lowering bathroom stall doors to discourage drug use and sex and installing disposal boxes for used needles, although people still complain about conditions at the main library.

Some rural libraries have sought to make social services more accessible, as well. In Butte County, along the western slope of the Sierra Nevada in Northern California, library workers used a $25,000 state grant to host informational sessions on mental health issues such as depression, anxiety, and schizophrenia, as well as how to help people access treatment. Books on these topics were marked with green tags to make them easier to find, said librarian Sarah Vantrease, who helped build the program. She now works as a library administrator in Sonoma County.

“The library,” said Vantrease, “shouldn’t just be for people who are really good at reading.”

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In late May, Ho, 32, flew to Cambridge, Massachusetts, to collect her Ph.D. in public policy from Harvard University. A few days after returning home to the Bay Area, she tested positive for covid-19. At first, the Ivy League-educated researcher found herself at a loss for what to do.

“The protocols on how to respond after you test positive are extremely confusing,” Ho said.

But a few days later, after talking to an advice nurse, she found herself in the scrubby courtyard of a defunct senior center in West Berkeley that had been transformed into one of the state’s new “test-to-treat” sites.

The senior center is one of 138 free covid testing locations California has expanded into one-stop treatment sites to improve the accessibility of antiviral medication. The state’s initiative is modeled after the Biden administration’s program, announced in March, which aims to provide high-risk patients who test positive with instant access to antiviral medications. To do so, California is contracting with OptumServe, a Minnesota-based managed-care company, to spend $18.2 million a year on the effort.

One month into the initiative at sites , state health workers are slow to get Pfizer’s Paxlovid and Merck’s molnupiravir into the hands of patients, who must take them in the first few days of symptoms to avoid serious illness. Officials say fewer than 800 people statewide have received prescriptions at OptumServe sites despite new covid infections reaching an average of nearly 14,000 a day in early June in California.

And though the initiative aims to serve the uninsured, about two-thirds of those undergoing screenings already have insurance. For those with health coverage, OptumServe bills the insurer and then reimburses the state.

Dr. Tomás Aragón, the state public health officer, said the goal of the test-to-treat campaign is to “ensure high-risk patients have access to treatments that can keep them out of the hospital.”

The state says its priority is to make the pills accessible to millions of older, chronically ill, and disabled Americans, especially the poor and uninsured — even if few people have heard about the drugs.

Liliya Sekreta, head nurse at the West Berkeley OptumServe site, has seen demand for testing and treatment ebb and flow. During the winter’s covid surges linked to the omicron and delta variants, the line for tests extended around the corner of the senior center.

“We had the National Guard here and extra staff on duty to make sure people didn’t get angry or antsy,” Sekreta recalled. At the time, rapid tests were not widely available.

These days, the site is run by a skeleton staff of two young nurses, a couple of medical assistants, and a burly Spanish-language translator. Located a few blocks from University Avenue, Berkeley’s main drag, it’s in a formerly working-class neighborhood of stucco bungalows.

On a foggy morning in early June, medical assistants stayed glued to their phones between patients, who trickled in for covid tests at a rate of one every five minutes.

Ho was one of them. She is among millions of Californians at risk of getting seriously ill from the virus — in her case, because she takes immunosuppressive drugs for chronic arthritis. Ho has health insurance, but a nurse who answered the advice number at the bottom of the text message notifying her of a positive covid test result suggested it might be easier to return to the OptumServe site in West Berkeley where she’d gotten her test to find out whether she was eligible for antivirals.

Though she felt fine, Ho knew it was important to get treatment early. The Centers for Disease Control and Prevention says Paxlovid and molnupiravir are nearly 90% effective at reducing hospitalizations and deaths from covid if taken during the first five days of symptoms.

The FDA authorized the pills in December for emergency use, but supplies were initially scarce. By April, production had increased but, by that time, few physicians seemed to be prescribing the medicine, with pharmacists nationwide on their shelves.

“I had read the reports about people who should be taking these meds,” Ho said. “But they just didn’t know about them.”

She also worried about infecting her elderly mother, whom she lives with along with her husband and 14-month-old son in the city of Albany.

Ho sat at a folding table across from a nurse draped in yellow plastic and answered questions to determine her eligibility for the pills. Afterward, Ho talked via iPad with a doctor who concluded Ho would be eligible for a prescription if she showed symptoms. Those who qualify can go home with the medicines without having to make a trip to the pharmacy.

“I was glad to have somewhere to go that was accessible,” said Ho. “But honestly, it wasn’t very well advertised. Not everyone has the time to call around like I did and ask, ‘What should I do next?’”

Screenings for treatment can take up to an hour and a half. Workers must make sure the patient isn’t taking a drug that can interact with the antivirals, including cholesterol-lowering medications and some birth control pills. Sekreta, the head nurse, said patients who may qualify include those 65 and older, people with chronic diseases, and those who are obese or unvaccinated. People shouldn’t take the pills if they are too sick, or if they’re not sick at all.

Such in-person screenings have made the test-to-treat model confusing and inefficient, said Dr. Kirsten Bibbins-Domingo, an epidemiologist at the University of California-San Francisco.

“It should be easy — if the doctor says yes — to get these pills by telehealth,” she said.

So far, staffers say, demand for medicine has been low enough that no one in need has had to wait long. Officials said 1,219 people statewide had been screened for the drugs at OptumServe sites as of mid-June, and 768 of them walked away with Paxlovid pills.

“I think it’s a new concept that people are still getting used to,” said Katharine Sullivan, a Berkeley city employee overseeing the West Berkeley site, which has served as a community testing site since early in the pandemic.

Some residents prefer the peace of mind of speaking to a nurse or doctor over taking a test at home.

When Mary White, an art teacher and Berkeley resident of 53 years, came down with cold symptoms in late May, she got on her collapsible bike and rode to the West Berkeley center for a PCR test, where she’s gone for tests since the first months of the shutdown. White has health insurance but said she finds this more convenient than the hassle of trying to schedule an appointment that might be days away at a Kaiser Permanente facility in neighboring Oakland.

For the first time, her test came back positive.

“I was just like, ‘Oh no! What can I do? I’ve got to do something!’” said White, 74.

She returned to the center and underwent antiviral screening. After meeting remotely with a doctor in Chicago, she left with a full five-day course of Paxlovid, which she took for just two days before stopping because the drugs made her feel nauseated.

Back for a follow-up test a few days later, White reported feeling much better following the age-old remedy of rest and fluids. She added that with no end to the pandemic in sight she was grateful for a community facility where locals could simply walk in and talk to a health worker.

“For people like me,” she said, “that’s very comforting.”

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The college sophomore, home for the holidays, had taken half a pill she bought from a dealer on Snapchat. It turned out to be fentanyl, the powerful synthetic opioid that helped drive in the U.S. to more than 100,000 last year. “She was poisoned, and nothing was going to happen to the person who did it,” he said. “I couldn’t stand for that.”

The self-described political moderate said the experience made him cynical about California’s reluctance to impose harsh sentences for drug offenses.

So Capelouto, the suburban dad who once devoted all his time to running his print shop and raising his four daughters, launched a group called and traveled from his home to Sacramento in April to lobby for legislation known as “.” The bill would have made it easier for California prosecutors to convict the sellers of lethal drugs on homicide charges.

Capelouto’s organization is part of a nationwide movement of parents-turned-activists fighting the increasingly deadly drug crisis — and they are challenging California’s doctrine that drugs should be treated as a health problem rather than prosecuted by the criminal justice system. Modeled after Mothers Against Drunk Driving, which sparked a movement in the 1980s, organizations such as and the seek to raise public awareness and influence drug policy. One group, , pays homage to MADD by borrowing its acronym.

The groups press state lawmakers for stricter penalties for dealers and lobby technology companies to allow parents to monitor their kids’ communications on social media. They erect billboards blaming politicians for the drug crisis and stage protests against open-air drug markets in Los Angeles’ and San Francisco’s Tenderloin neighborhood.

“This problem is going to be solved by the grassroots efforts of affected families,” said Ed Ternan, who runs the Pasadena-based group , which focuses on educating youths about the dangers of counterfeit pills.

Many parents mobilized after a wave of deaths that began in 2019. Often, they involved high school or college students who thought they were taking OxyContin or Xanax purchased on social media but were actually ingesting pills containing fentanyl. The drug first hit the East Coast nearly a decade ago, largely through the heroin supply, but Mexican drug cartels have since introduced counterfeit pharmaceuticals laced with the highly addictive powder into California and Arizona to hook new customers.

In many cases, the overdose victims are straight-A students or star athletes from the suburbs, giving rise to an army of educated, engaged parents who are challenging the silence and stigma surrounding drug deaths.

Ternan knew almost nothing about fentanyl when his 22-year-old son, Charlie, died in his fraternity house bedroom at Santa Clara University a few weeks before he was scheduled to graduate in spring 2020. Relatives determined from messages on Charlie’s phone that he had intended to buy Percocet, a prescription painkiller he had taken after back surgery two years earlier. First responders said the strapping 6-foot-2-inch, 235-pound college senior died within a half-hour of swallowing the counterfeit pill.

Ternan discovered a string of similar deaths in other Silicon Valley communities. In 2021, 106 people died from fentanyl overdoses in Santa Clara County — up from 11 in 2018. The deaths have included a sophomore and a .

With the help of two executives at Google who to pills laced with fentanyl, Ternan persuaded Facebook, Instagram, TikTok, YouTube, and other social media platforms to donate ad space to warnings about counterfeit drugs. Pressure from parent groups has also spurred Santa Monica-based Snapchat to to detect drug sales and restrictions designed to make it harder for dealers to target minors.

Since the earliest days of the opioid epidemic, the families of people dealing with addiction and of those who have died from overdoses have supported one another in and on online platforms from to . Now, the family-run organizations that have sprung from California’s fentanyl crisis have begun cooperating with one another.

A network of parent groups and other activists that calls itself the was formed recently by Michael Shellenberger, a Berkeley author and activist .

One critic of California’s progressive policies is Jacqui Berlinn, a legal processing clerk in the East Bay who started — a name she chose as an homage to the achievements of Mothers Against Drunk Driving founder Candace Lightner, a Fair Oaks housewife whose 13-year-old daughter was killed in 1980 by a driver under the influence.

Berlinn’s son, Corey, 30, has used heroin and fentanyl for seven years on the streets of San Francisco. “My son isn’t trash,” Berlinn said. “He deserves to get his life back.”

She believes the city’s decision not to charge dealers has allowed open-air narcotics markets to flourish in certain neighborhoods and have enabled drug use, rather than encouraged people dealing with addiction to get help.

In April, Berlinn’s group spent $25,000 to erect a billboard in the upscale retail district of Union Square. Over a glowing night shot of the Golden Gate Bridge, the sign says: “Famous the world over for our brains, beauty and, now, dirt-cheap fentanyl.”

This month, the group installed a sign along Interstate 80 heading into Sacramento that targets Democratic Gov. Gavin Newsom. Playing off signage used at parks, the billboard features a “Welcome to Camp Fentanyl” greeting against a shot of a homeless encampment. The group said a will also circle the state Capitol for an undisclosed period.

New Billboards from Mothers Against Drug Deaths on I-80 in Sacramento.

— MADAAD-Mothers Against Drug Addiction and Deaths (@JacquiBerlinn)

Mothers Against Drug Deaths is calling for more options and funding for drug treatment and more arrests of dealers. The latter would mark a sharp turn from the gospel of “harm reduction,” a public health approach embraced by state and local officials that holds abstention as unrealistic. Instead, this strategy calls for helping people dealing with addiction stay safe through things like needle exchanges and naloxone, an overdose reversal drug that has saved thousands of lives.

The parent movement echoes recall efforts happening in two major cities. Progressive prosecutors Chesa Boudin in San Francisco and George Gascón in Los Angeles have , which they call a pointless game of whack-a-mole that punishes poor minorities.

California lawmakers are wary of repeating the mistakes of the war-on-drugs era and have blocked a series of bills that would stiffen penalties for fentanyl sales. They say the legislation would accomplish little apart from packing the state’s jails and prisons.

“We can throw people in jail for a thousand years, and it won’t keep people from doing drugs, and it won’t keep them from dying,” said state Sen. Scott Wiener (D-San Francisco). “We know that from experience.”

Some parents agree. After watching her son cycle in and out of the criminal justice system on minor drug charges in the 1990s, Gretchen Burns Bergman became convinced that charging people with minor drug offenses, such as possession, is counterproductive.

In 1999, the San Diego fashion show producer started , which has advocated for marijuana legalization and an end to California’s “” law. A decade later, she formed , a nationwide coalition. Today, both her sons have recovered from heroin addiction with the help of “compassionate support” and work as drug counselors, she said.

“I’ve been at this long enough to see the pendulum swing,” Burns Bergman said of the public’s shifting views on law enforcement.

In December, Brandon McDowell, 22, of Riverside, was arrested and the tablet that killed Matt Capelouto’s daughter. McDowell was charged with distributing fentanyl resulting in death, which carries a mandatory minimum sentence of 20 years in federal prison.

Although Alexandra’s Law failed to make it out of committee, Capelouto pointed out that years of lobbying went into the passage of stricter drunken driving laws. He vowed not to give up on the bill named for his daughter, who wrote poetry and loved David Bowie.

“I’m going to be back in front of them,” he said, “every year.”

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“These are people who were unwell to begin with,” said Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention.

Walensky’s remarks infuriated Americans with disabilities, who say the pandemic how the medical establishment — and society at large — treats their lives as expendable. Among those leading the protest was San Franciscan Alice Wong, an activist who took to Twitter to denounce Walensky’s comments as “ableism.” .

A few more thoughts:

The release of the recent unedited remarks by Dr. Walensky does not minimize the harm and mistrust created by the Administration. They have to work to gain back the trust of many communities.

— Alice Wong 王美華 (@SFdirewolf)

Wong, 47, moves and breathes with the aid of a power wheelchair and a ventilator because of a genetic neuromuscular condition. Unable to walk from around age 7, she took refuge in science fiction and its stories of mutants and misunderstood minorities.

Her awakening as an activist happened in 1993, when she was in college in Indiana, where she grew up. Indiana’s Medicaid program had paid for attendants who enabled Wong to live independently for the first time, but state cuts forced her to switch schools and move back in with her parents. Wong relocated to the Bay Area for graduate school, choosing a state that would help her cover the cost of hiring personal care attendants. She has since for people who are poor, sick, or older or have disabilities.

The founder of the , which collects oral histories of Americans with disabilities in conjunction with , Wong has about how covid and its unparalleled disruption of lives and institutions have underscored challenges that disabled people have always had to live with. She has exhorted others with disabilities to dive into the political fray, rallying them through her , with tens of thousands of followers, and a nonpartisan online movement called .

Wong is nocturnal — she typically starts working at her computer around 9 p.m. On a recent evening, she spoke with KHN via Zoom from her condo in the city’s Mission District, where she lives with her parents, immigrants from Hong Kong, and her pet snail, Augustus. The interview has been edited for length and clarity.

Q: Why do you often refer to people with disabilities as oracles?

Disabled people have always lived on the margins. And people on the margins really notice what’s going on, having to navigate through systems and institutions, not being understood. When the pandemic first hit, the public was up in arms about adjusting to life at home — the isolation, the lack of access. These are things that many disabled and chronically ill people had experienced. Disabled people had been trying forever to advocate for online learning, for accommodations in the workplace. The response was: “Oh, we don’t have the resources,” “It’s just not possible.” But with the majority inconvenienced, it happened. Suddenly people actually had to think about access, flexibility. That is ableism, where you don’t think disabled people exist, you don’t think sick people exist.

Q: Have you noticed that kind of thinking more since the pandemic began?

Well, yes, in the way our leaders talk about the risks, the mortality, about people with severe illnesses, as if they’re a write-off. I am so tired of having to assert myself. What kind of world is this where we have to defend our humanity? What is valued in our society? Clearly, someone who can walk and talk and has zero comorbidities. It is an ideology, just like white supremacy. All our systems are centered around it. And so many people are discovering that they’re not believed by their doctors, and this is something that a lot of disabled and sick people have long experienced. We want to believe in this mythology that everybody’s equal. My critique is not a personal attack against Dr. Walensky; it’s about these institutions that historically devalued and excluded people. We’re just trying to say, “Your messaging is incredibly harmful; your decisions are incredibly harmful.”

Q: Which decisions?

The overemphasis on vaccinations versus other mitigation methods. That is very harmful because people still don’t realize, yeah, there are people with chronic illnesses who are immunocompromised and have other chronic conditions who cannot get vaccinated. And this back and forth, it’s not strong or consistent about mask mandates. With omicron, there is this huge pressure to reopen schools, to reopen businesses. Why don’t we have free tests and free masks? You’re not reaching the poorest and the most vulnerable who need these things and can’t afford them.

Q: How has your life changed during the pandemic?

For the last two years, I have not been outside except to get my vaccinations.

Q: Because you’re so high-risk?

Yeah. I have delayed so many things for my own health. For example, physiotherapy. I don’t get lab tests. I’ve not been weighed in over two years, which is a big deal for me because I should be monitoring my weight. These are things I’ve put on hold. I don’t see myself going in to see my doctor any time this year. Everything’s been online — it’s in a holding pattern. How long can I take this? I really don’t know. Things might get better, or they might get worse. So many things disabled people have been saying have been dismissed, and that’s been very disheartening.

Q: What kinds of things?

For example, in California, it was almost this time last year when they for covid vaccine priority. I was really looking forward to getting vaccinated. I was thinking for sure that I was part of a high-risk group, that I’d be prioritized. And then the governor announced that he was eliminating the third tier that I was a part of in favor of an age-based system. For young people who are high-risk, they’re screwed. It just made me so angry. These kinds of decisions and values and messages are saying that certain people are disposable. They’re saying I’m disposable. No matter what I produce, what value I bring, it doesn’t matter, because on paper I have all these comorbidities and I take up resources. This is wrong, it’s not equity, and it’s not justice. It took a huge last year to get the state to backtrack. We’re saying, “Hey we’re here, we exist, we matter just as much as anyone else.”

Q: Do you think there’s any way this pandemic has been positive for disabled people?

I hope so. There’s been a lot of mutual aid efforts, you know, people helping each other. People sharing information. People organizing online. Because we can’t wait for the state. These are our lives on the line. Things were a little more accessible in the last two years, and I say a little because a lot of universities and workplaces are going backward now. They’re doing away with a lot of the hybrid methods that really gave disabled people a chance to flourish.

Q: You mean they’re undoing things that helped level the playing field?

Exactly. People who are high-risk have to make very difficult choices now. That’s really unfortunate. I mean, what is the point of this if not to learn, to evolve? To create a new normal. I can’t really see that yet. But I still have some hope.

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Garcia’s regular OB/GYN — like most medical offices at the time — was closed, and she was terrified by the prospect of spending hours waiting in an emergency room shoulder to shoulder with people who might have covid.

By the time she stumbled into the newly opened at the Santa Clara Valley Medical Center, clutching a pillow to her belly, Garcia was pale and dehydrated from blood loss and certain she was dying.

“If I didn’t get to the clinic when I did, I think, things could have ended up very different,” said Garcia, 34, who underwent an emergency hysterectomy for uterine fibroids.

Her story illustrates a long-standing gap in women’s health care. For years, many women with common but urgent conditions like painful urinary tract infections or excessive bleeding in the aftermath of a miscarriage have faced a grim choice between waiting weeks for an appointment with their regular OB-GYN or braving hours in an ER waiting room.

Urgent care OB-GYN clinics have begun popping up around the country in recent years, and the covid pandemic has increased demand. While no data is available on the number of urgent care clinics for women, they are part of a in general and other alternative models like retail clinics and so-called digital-first health care startups. One of these, the New York-based women’s health startup Tia (“aunt” in Spanish), won $24 million in venture capital funding last spring and is opening physical clinics nationwide.

“It’s clear that access and convenience are increasingly more important to consumers than seeing a specific provider,” said Rob Rohatsch, chief medical officer at Solv, an app that books urgent care appointments.

The Urgent Care Association has steadily who use its members’ walk-in clinics as an alternative to hospital emergency departments. Traffic to these clinics has surged during the past year, according to Solv.

The Bascom clinic had been a nearly decadelong dream of Drs. and , two obstetrician-gynecologists at the Santa Clara Valley Medical Center, a sprawling public hospital that serves as the regional trauma center, treating critical cases like car accident and gunshot victims and relegating people suffering less life-threatening problems to long waits.

“Women — perhaps pregnant or bleeding — could be sitting there 12 to 14 hours, depending on the time of day,” Pan said.

After the onset of the pandemic, doctors worried that women with serious or even deadly issues like Garcia’s might avoid seeking treatment for fear of contracting covid. ER visits in the early months of the pandemic, according to the Centers for Disease Control and Prevention. noted that, while the number of ER visits for heart attacks had increased, visits for nonspecific chest pain had decreased, suggesting that people might be risking their lives by avoiding the ER.

“You can imagine that a woman with three kids at home might be even more scared,” Sit said. “We just couldn’t keep sending women having miscarriages to wait hours in the covid tent.”

Instead, women can now be triaged over the phone and seen within a day or two at the Bascom OB-GYN urgent care clinic — much the way they would at their local Planned Parenthood branch for contraceptives or a sexually transmitted disease screening. Bascom is equipped to treat conditions from severe morning sickness to ectopic pregnancies that require emergency surgery. In its first year, the clinic has treated some 1,300 women and served as a backup to local clinics that provide basic reproductive health services in counties hundreds of miles away.

It’s still in its pilot phase, however, operating weekdays from 8:30 a.m. to 5 p.m., which “leaves a big chunk of off-hours that we cannot serve women,” Sit acknowledges.

A handful of other clinics have taken the concept of urgent care for women a step further. Dr. Miriam Mackovic runs , a chain of four clinics in the Los Angeles area that also has an emergency care center in Long Beach, which is staffed 24/7 with a nurse practitioner and equipped with a lab and a pharmacy. Women who walk in are typically seen within 30 minutes, according to Mackovic, and every patient receives a follow-up call the next day.

One woman who turned up at a Complete Women Care clinic said that, after desperately seeking treatment at an ER one Saturday night for a nasty yeast infection, she got a bill in the mail for $1,500.

“In the middle of the night, urgent care centers are closed. OB-GYN offices are definitely closed. So, what is her option except the ER?” asked Mackovic, an obstetrician-gynecologist who also has an MBA.

Mackovic ticked off cautionary tales of patients who’ve arrived at her clinics from as far away as Arizona and Nevada after suffering for weeks while trying to schedule routine operations for uterine cysts or twisted ovaries.

“The medical advances are here. Most emergencies can be resolved on an outpatient basis — a woman can have a hysterectomy with just a fine incision and be home the same day,” Mackovic said. “But a woman who has a miscarriage calls her OB, who says there’s no openings for weeks, so she goes to the ER, and the physician says: Are you dying? No? Then follow up with your OB-GYN.”

Fees for the uninsured — around 20% of Mackovic’s clientele — run from $100 to around $600, she said.

Women in the United States have for years those in other rich countries in both their access to health care and their health status. America has the highest among developed nations.

Some women see a doctor only in an emergency.

“We have diagnosed so many cancers in the last few years because women walked in for another reason,” said Dr. Adeeti Gupta, founder and CEO of a chain of open-daily clinics in New York City called that provides comprehensive care without appointments.

Gupta’s three clinics have grown steadily since she opened them seven years ago, largely out of frustration with the months-long wait for an appointment at her own Queens OB-GYN practice. But after the coronavirus hit the city hard, she has seen an uptick in patients — 40% in one location.

The country needs more accessible, comprehensive women’s health care to treat everything from the menstrual pains of adolescents to the hot flashes of postmenopausal grannies, Gupta said.

“The thing about women,” she said, “is their problems never stop.”

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“You saved my life,” wrote Wolf, who had finally gotten clean after that bust and 90 days in jail, ending six months of sleeping on scraps of cardboard on the sidewalk.

Today, he joins a growing chorus of people, including the mayor, calling for the city to crack down on an increasingly deadly drug trade. But there is little agreement on how that should be done. Those who demand more arrests and stiffer penalties for dealers face powerful opposition in a city with little appetite for locking people up for drugs, especially as the Black Lives Matter and Defund the Police movements push to drastically limit the power of law enforcement to deal with social problems.

Drug overdoses killed 621 people in the of 2020, up from 441 in all of 2019 and 259 in 2018. San Francisco is on track to lose an average of nearly two people a day to drugs in 2020, compared with the who had died by Dec. 20 of the coronavirus.

As in other parts of the country, most of the overdoses have been linked to fentanyl, the powerful synthetic opioid that laid waste to the eastern United States starting in 2013 but didn’t arrive in the Bay Area until about five years later. Just as the city’s drug scene was awash with the lethal new product — which is 50 times stronger than heroin and sells on the street for around $20 for a baggie weighing less than half a gram — the coronavirus pandemic hit, absorbing the attention and resources of health officials and isolating drug users, making them more likely to overdose.

The pandemic is contributing to rising , according to the Centers for Disease Control and Prevention, which reported last month that a record 81,000 Americans died of an overdose in the 12 months ending in May.

“This is moving very quickly in a horrific direction, and the solutions aren’t matching it,” said Supervisor Matt Haney, who represents the Tenderloin and South of Market neighborhoods, where nearly 40% of the deaths have occurred. Haney, who has hammered City Hall for what he sees as its indifference to a life-or-death crisis, is calling for a more coordinated response.

“It should be a harm reduction response, it should be a treatment response — and yes, there needs to be a law enforcement aspect of it too,” he said.

Tensions within the city’s leadership came to a head in September, when Mayor London Breed supported an effort by City Attorney Dennis Herrera to clean up the Tenderloin by legally blocking 28 known drug dealers from entering the neighborhood.

But District Attorney Chesa Boudin, a progressive elected in 2019 on a platform of police accountability and racial justice, the move. He called it a “recycled, punishment-focused” approach that would accomplish nothing.

People have died on the Tenderloin’s needle-strewn sidewalks and alone in hotel rooms where they were housed by the city to protect them from covid-19. Older Black men living alone in residential hotels are dying at particularly high rates; Blacks make up around 5% of the city’s population but account for a quarter of the 2020 overdoses. Last February, a man was , ice-cold, in the front pew at St. Boniface Roman Catholic Church.

The only reason drug deaths aren’t in the thousands, say health officials, is the outreach that has become the mainstay of the city’s drug policy. From January to October, 2,975 deaths were prevented by naloxone, an overdose reversal drug that’s usually sprayed up the nose, according to the , a city-funded program that trains outreach workers, drug users, the users’ family members and others.

“If we didn’t have Narcan,” said program manager Kristen Marshall, referring to the common naloxone brand name, “there would be no room at our morgue.”

The city is also hoping that this year state lawmakers will approve safe consumption sites, where people can do drugs in a supervised setting. Other initiatives, like a 24-hour meth sobering center and an overhaul of the city’s behavioral health system, have been put on hold because of pandemic-strained resources.

Efforts like the DOPE Project, the country’s largest distributor of naloxone, reflect a seismic shift over the past few years in the way cities confront drug abuse. As more people have come to see addiction as a disease rather than a crime, there is little appetite for locking up low-level dealers, let alone drug users — policies left over from the “war on drugs” that began in 1971 under President Richard Nixon and disproportionately punished Black Americans.

In practice, San Francisco police don’t arrest people for taking drugs, certainly not in the Tenderloin. On a sunny afternoon in early December, a red-haired young woman in a beret crouched on a Hyde Street sidewalk with her eyes closed, clutching a piece of foil and a straw. A few blocks away, a man sat on the curb injecting a needle into a thigh covered with scabs and scars, while two uniformed police officers sat in a squad car across the street.

Last spring, after the pandemic prompted a citywide shutdown, police stopped arresting dealers to avoid contacts that might spread the coronavirus. Within weeks, the sidewalks of the Tenderloin were lined with transients in tents. The streets became such a narcotics free-for-all that many of the working-class and immigrant families living there felt afraid to leave their homes, according to a federal lawsuit filed by business owners and residents. It accuses City Hall of treating less wealthy ZIP codes as “containment zones” for the city’s ills.

The suit was settled a few weeks later after officials moved most of the tents to designated “safe sleeping sites.” But for many, the deterioration of the Tenderloin, juxtaposed with the gleaming headquarters of companies like Twitter and Uber just blocks away, symbolizes San Francisco’s starkest contradictions.

Mayor Breed, who to a drug overdose in 2006, has called for a on drug dealing.

The Federal Initiative for the Tenderloin was one such effort, announced in 2019. It aims to “reclaim a neighborhood that is being smothered by lawlessness,” U.S. Attorney David Anderson said at a recent virtual news conference held to announce in which the feds arrested seven people and seized 10 pounds of fentanyl.

Law enforcement agencies have blamed the continued availability of cheap, potent drugs on lax prosecutions. Boudin, however, said his office files charges in 80% of felony drug cases, but most involve low-level dealers whom cartels can easily replace in a matter of hours.

He pointed to a 2019 federal sting that culminated in the arrest of 32 dealers — mostly Hondurans who were later deported — after a two-year undercover operation involving 15 agencies.

“You go walk through the Tenderloin today and tell me if it made a difference,” said Boudin.

His position reflects a growing that questions whether decades-old policies that focus on putting people behind bars are effective or just. In May, the killing of George Floyd by the Minneapolis police energized a nationwide police reform campaign. Cities around the country, , have promised to of dollars from law enforcement to social programs.

“If our city leadership says in one breath that they want to defund the police and are for racial and economic justice and in the next talk about arresting drug dealers, they’re hypocrites and they’re wrong,” said Marshall, the leader of the DOPE Project.

But Wolf, 50, believes a concerted crackdown on dealers would send a message to the drug networks that San Francisco is no longer an open-air illegal drug market.

Like hundreds of thousands of other Americans who’ve succumbed to opiate misuse, he began with a prescription for the painkiller oxycodone, in his case following foot surgery in 2015. When the pills ran out, he made his way from his tidy home in Daly City, just south of San Francisco, to the Tenderloin, where dealers in hoodies and backpacks loiter three or four deep on some blocks.

When he could no longer afford pills, Wolf switched to heroin, which he learned how to inject on YouTube. He soon lost his job as a caseworker for the city and his wife threw him out, so he became homeless, holding large quantities of drugs for Central American dealers, who sometimes showed him photos of the lavish houses they were having built for their families back home.

Looking back, he wishes it hadn’t taken six arrests and three months behind bars before someone finally pushed him toward treatment.

“In San Francisco, it seems like we’ve moved away from trying to urge people into treatment and instead are just trying to keep people alive,” he said. “And that’s not really working out that great.”

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With her cat, Bodhi, in his carrier in the back seat, 80-year-old Diana Dimas, who doesn’t see well at night, kept her eyes glued to the rear lights of her neighbor’s Toyota. She and Magdalena Mulay had met a few years before at a bingo night in their sprawling retirement community on the outskirts of Santa Rosa. Both Libras, each with two marriages behind her, the two women soon became the sort of friends who finish each other’s sentences.

Now, for the second time in three years, they heard the alarms and fled together as fire consumed the golden hills of Northern California’s wine country.

“I thought, where on earth are we going to go?” recalled Dimas. She remembered that when the catastrophic Tubbs Fire hit back in 2017, people had sought refuge outside well-lit supermarkets, which had water and bathrooms. Which is how Dimas and Mulay and dozens of other seniors ended up spending the night of the most recent evacuation in the parking lot of the Sonoma Safeway.

At midnight, Mulay was trying to get comfortable enough to catch a few winks in her driver’s seat when her phone began to chirp. A friend was calling to wish her a happy 74th birthday.

The stories of that Sunday night — as a 20-acre fire started that morning merged with two other fires to become an 11,000-acre conflagration forcing tens of thousands from their homes in two counties — spotlight the challenges of evacuating elderly and infirm residents from the deadly wildfires that have become an annual occurrence in California. This year, the coronavirus, which is especially dangerous to the elderly, has further complicated the problem.

While the 2020 fire season will go down as the state’s biggest on record, rescuers have so far managed to avoid horrors on the scale of three years ago, when the firestorm that raced through California’s wine country killed 45 people. Almost all were over 65 — found in wheelchairs, trapped in their garages, isolated and hard of hearing, or simply too stubborn to leave. The same grim pattern emerged from the Camp Fire, which leveled the Northern California town of Paradise in 2018.

Assisted care homes in particular came under scrutiny after the 2017 fire, when ill-equipped and untrained workers at two Santa Rosa facilities abandoned two dozen frail, elderly residents as the flames closed in, according to state investigators. They concluded the seniors would have died in the flames had emergency workers and relatives not arrived at the last minute to rescue them.

“The problem is we don’t value elders as a society,” said Debbie Toth, CEO of Choice in Aging, an advocacy group. “If children needed to be evacuated, we’d have a freaking Romper Room stood up overnight to entertain them so they wouldn’t be damaged by the experience.”

The destructive effects of climate change in California have dovetailed with a rapidly graying population — which in a decade is projected to include 8.6 million senior citizens. That has fueled a growing demand for senior housing, from assisted care homes to swanky “active adult” facilities complete with golf courses and pools.

Proximity to nature is a major selling point of Oakmont Village, Dimas and Mulay’s upscale community of nearly 5,000 over-55s, which has everything from bridge games to cannabis clubs. But the woodlands and vineyards surrounding this suburban sprawl have put thousands of elderly citizens in hazardous wildfire zones.

“With seniors, there’s mobility issues, hearing issues — even the sense of smell is often gone in the later years,” said Marrianne McBride, who heads Sonoma County’s Council on Aging. Getting out fast in an emergency is especially challenging for those who no longer drive. In Sunday’s evacuation, some residents who followed official advice to call ride services had to wait hours, until 3 or 4 a.m., for the overtaxed vans.

Dimas and Mulay managed to scramble into their cars and get on the road shortly after 10 p.m., when a mandatory evacuation order went out for the thousands of seniors in Oakmont Village. But it was after midnight when residents of two Santa Rosa assisted care homes in the evacuation zone were shuffled onto city buses in their bathrobes, some with the aid of walkers. Off-duty drivers braved thick smoke and falling embers to ferry some of them to safety, only to spend hours being sent from one shelter to another as evacuation sites filled up fast because of social distancing rules designed to prevent the spread of COVID-19.

Other precautions, including masks and temperature checks, were followed. But health officials nonetheless voiced concerns that vulnerable people in their 80s and 90s — especially residents of skilled nursing homes, the source of most of Sonoma County’s coronavirus deaths so far — had been moved among multiple locations, upping their chance for exposure.

In the following days, shelters were fielding frantic calls from out-of-town relatives searching for their loved ones. “We were getting phone calls from Michigan, other places across the country, saying, ‘I’m trying to find my mother!’” said Allison Keaney, CEO of the Sonoma-Marin Fairgrounds, which sheltered several hundred horses, chickens, goats and llamas as well as displaced people.

By Wednesday afternoon, a few dozen evacuees remained at the shelters, mostly seniors without relatives or friends nearby to take them in, like Dimas and Mulay. The two women had left the Safeway lot and were sleeping on folding cots in a gym at the Veterans Memorial Building in Petaluma, an old poultry industry town dotted with upscale subdivisions.

This was their first time out and around other people since March, when the two friends had been planning a big night out to see Il Volo, an Italian pop group. Seven months later, the new outfits they bought for the concert still hang unworn in their closets.

“All we do since the shutdown is stay home and talk on the phone,” said Mulay, who spoke to a reporter while sitting next to her friend on a folding chair outside the shelter. “Now, with all these crowds — it’s terrifying.”

Dimas likened the pandemic followed by the fires to “a ball rolling downhill, getting bigger and bigger. And then there we were, with the flashing lights all around us and the cops shouting, ‘Go this way!’ ‘Keep moving!’”

Listos California — an outreach program, for seniors and other vulnerable people, run out of the Governor’s Office of Emergency Services — allotted $50 million to engage dozens of nonprofits and community groups around the state to help warn and locate people during disasters. (Listos means “Ready” in Spanish.)

In Sonoma and Napa counties, where the Glass Fire had destroyed at least 630 structures by late last week, the bolstered threat of wildfires in recent years has promoted new alert systems — including a weather radio that has strobe lights for the deaf or can shake the bed to awaken you.

But while counties are legally responsible for alerting people and providing shelter for them once they’re out, no public agency is responsible for overseeing the evacuation. Practices differ widely from county to county, said Listos co-director Karen Baker.

If Sonoma County has learned anything from the disasters of the past few years, it’s not to depend too much on any system in an emergency. “You’ve got to have a neighborhood network,” McBride said. “As community members, we have to rely on each other when these things happen.”

Early last week, word filtered through the shelters that the fire had consumed a triplex and two single-family homes in the Oakmont neighborhood, but firefighters had battled the blaze through the night with hoses, shovels and chainsaws and miraculously managed to save the rest of the community.

A week later, to their relief, Oakmont’s senior residents were allowed to return home. By then, Mulay had developed severe back pain. Dimas missed her TV.

Back in her apartment with Bodhi, Dimas noted with horror that the blaze had come close enough to her building to incinerate several juniper bushes and scorch a redwood just 2 feet away.

“The whole thing feels surreal, like ‘Oh, my God, did that really happen, or did I dream it?’” she said.

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The 38-year-old medical journal editor of Menifee in Riverside County, California, hadn’t been immunized as a teenager because there wasn’t yet a vaccine for HPV, which causes nearly all cervical cancers and a handful of other potentially lethal forms of the disease in men and women. Now, her 10-year-old daughter, Samantha, is scheduled to get her first shot this month.

“This is the only vaccine that prevents cancer,” Chaiprasert-Paguio said.

A in the California legislature would require schools to notify parents that their kids are expected to be vaccinated for HPV before entering eighth grade, as part of a push to get more children inoculated against the cancer-causing strains of the virus, theoretically before they become sexually active. AB 659 stops short of mandating the vaccine for middle schoolers, as the bill originally proposed. Lawmakers stripped out that provision without any debate, reflecting the contentious nature of school vaccine mandates even in a state with some of the nation’s strictest immunization laws.

“Now is a tough time to be taking up that fight,” said Michelle Mello, a professor of law and health policy at Stanford University, noting that anti-vaccine sentiment has drawn more attention since the beginning of the covid-19 pandemic.

The proposed legislation by Assembly member Cecilia Aguiar-Curry would instead require public college students under 26 to provide proof of immunization against the virus, a more palatable idea for parents uncomfortable with a vaccine that links teens to sex.

Anti-vaccine activists pounced on the bill, denouncing it as an egregious example of government overreach. A group called the Freedom Angels claimed credit for pressuring lawmakers into dropping the vaccine mandate for young teens, calling it “a huge victory.”

Since its debut in 2006, the HPV vaccine has elicited that the shots or make teens sterile. Fewer than 55% of kids in the U.S. ages 13-15 were in 2020, far lower than those for other routine childhood shots. By comparison, more than 90% of adolescents are , which protects against tetanus, diphtheria, and pertussis. A single dose of the HPV vaccine , according to drug manufacturer Merck.

Most states do not require HPV immunizations for school as for , which can spread easily in classrooms through the air or touch. Just three states, Rhode Island, Virginia, and Hawaii, as well as Washington, D.C., currently require student vaccination against HPV for .

Mostly Republican pushback against covid vaccine mandates has spawned a spate of proposed legislation in , such as and , which weaken or roll back government and private-sector requirements. In Iowa, which has the nation’s second-highest cancer rate, lawmakers are considering a bill that would strike a requirement that schools inform students about the HPV vaccine.

Even before covid, a rising wave of parents who refused to vaccinate their kids allowed diseases that had been all but eliminated decades ago — like and , or whooping cough — to return.

In this reality, passing good public health policy means long-term strategizing, said Crystal Strait, who leads the pro-vaccination group ProtectUS. That’s how she sees Aguiar-Curry’s amended HPV vaccination bill.

“It’s a step,” she said. “We have to do something. Too many people are being harmed by preventable cancer.”

Nearly everyone at some point, though usually without symptoms. But a handful of strains of the virus can and develop into cancer of the cervix, vagina, vulva, penis, anus, or throat. Studies have confirmed that the HPV vaccine reduced the risk of getting cancer by nearly 90% when given to girls and boys in their early teens, likely before they’re exposed to dangerous strains of the virus.

Academic research shows that teens in states with HPV vaccine mandates have been much .

“We’ve had this war against cancer for decades, and now we have a cancer vaccine and people are debating whether we should work to assure that everyone gets it,” said Dr. Jeffrey Klausner, a public health professor at the University of Southern California who previously served as San Francisco’s director of STD Prevention and Control Services. “It’s hard to wrap your mind around.”

Rates of cervical cancer, once a leading cause of cancer deaths for American women, with the vaccine and stepped-up Pap smears. Still, more than 37,000 cancers caused by HPV are diagnosed annually, and cervical cancer alone still killed more than last year.

By contrast, Australia is on track to become the first country to within the next two decades after launching a national school-based program in which school nurses administer HPV shots to 12- and 13-year-olds willing to get the vaccine.

Public health mandates work best when they require things that have already reached a certain level of social acceptance, like wearing a seat belt or not smoking indoors, said Saad Omer, who heads the Yale Institute for Global Health and has studied vaccine skepticism.

“Mandates are strong medicine, but like every strong medicine, they come with side effects,” said Omer.

Santa Clara graphic designer Gilma Pereda, who was always a little skeptical of vaccines, admits to not being crazy about mandates. On the other hand, since she was diagnosed with cervical cancer in 2016, she’s undergone numerous surgeries and repeated rounds of chemotherapy. She has lost her uterus, her eyelashes, and her waist-length brown hair. She reached a low point in 2021 upon learning the cancer had spread to her bones.

In deciding whether to vaccinate her daughter for HPV, the choice was clear. “I did not want my child to go through this,” she said.

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She received a surprise bill for $650, launching her into a maze of claim forms and hours on the phone being routed from one office to the next to dispute the charges — insurance red tape that so many Americans have encountered. A decade later, Founds captured her experience in a graphic novel, “Bipolar Bear and the Terrible, Horrible, No Good, Very Bad Health Insurance,” a richly illustrated, darkly funny fable for adults about the country’s dysfunctional health system.

The book, published in November, follows Theodore, an intelligent but angst-ridden bear, on his quest for treatment for his own manic-depressive illness. But first he must navigate the demands of the WeCare company, a shady outfit run by cigar-smoking felines who profit unfairly from a lopsided economy and a corrupt justice system, among other things. His fellow outcasts include such characters as an overeducated owl drowning in student debt and a bomb-sniffing puppy suffering from PTSD.

America is internationally known for high-quality care, for those who can afford it. A new shows that a record-high proportion of Americans — 38% — postponed medical care because of high costs in 2022. and of the past few years seek to protect consumers from unexpected medical bills. But they don’t prevent hidden in the fine print of their insurance policies.

“Bipolar Bear” joins other recent works to shine a light on health inequities — part of the emerging genre of . It includes seminal such as by Brian Fies and nurse MK Czerwiek’s ” as well as Rachel Lindsay’s memoirs about taking a job at a pharmaceutical company to secure insurance to cover treatment for bipolar disorder.

Descended from the underground comics of the 1960s, graphic medicine has grown into a new on the medium’s role in the study and delivery of health care, said Ian Williams, the Welsh physician who back in 2007. “It’s ideal for exploring subjects having to do with one’s life and well-being in an ironic and funny way,” he said.

As Founds puts it, humor is a powerful weapon against despair.

The 40-year-old mother of two teaches English at a community college in Santa Cruz County on California’s central coast. She has never taken an art class and didn’t set out to write a graphic novel. The book began as a doodle in the margins of her notebook while studying for a master’s degree in fiction writing at Syracuse University in New York. Her 2014 novel in short stories, is about a teacher who suffers a nervous breakdown and communicates with her students from a psychiatric hospital.

KHN contributing reporter Rachel Scheier spoke to Founds about bringing Theodore to life. The interview has been edited for length and clarity.

Q: How did you come to write a book about a bear with bipolar disorder?

I’d been making children’s books for my little brother. They were all about angst-ridden animals: a lonely giant squid, a possum with social anxiety disorder who falls asleep whenever he’s in an awkward situation, a burro who wants to be a unicorn. My goal was to write a novel. But whenever I was too depressed to string a sentence together, I’d draw bears. Then I realized that anyone dealing with a mental health issue in this country is going to have to deal with the labyrinth of health insurance. And I thought it would be fun to depict it as an actual labyrinth with trapdoors and man-eating flowers. Once I went in that direction, it was no longer a children’s book.

Q: Was the book based on your own experience with mental illness?

Yes. I had my first major depressive episode at the end of high school, but I didn’t seek out professional help. I just sort of muddled through it. Then, when I was a sophomore at Stanford, I had my first manic episode. I had a series of realizations about the nature of the universe, and I didn’t sleep or eat very much. Then, in graduate school, I went to a clinic because I was going through a depression, and the psychiatrist asked me questions like “Was there ever a time when you had a lot of energy and didn’t feel a need to sleep?” And I said, “Oh, sure, but that was a spiritual awakening.” So, I had to reframe my life story a bit after that.

Q: But religion still has a role in your life?

I’m a Quaker. It’s something I came to through my interest in nonviolent social change. When I am severely depressed, I feel like life has no purpose. So, following a code that says life does have meaning, that we are all connected by a force of love that undergirds the universe, is something that has helped me a lot.

Q: Why animals?

People are hard to draw! Cartoon animals are a lot easier. I wasn’t interested in art in school — actually, when I started drawing was during that first manic episode. I do not recommend writing a 200-page graphic novel with no artistic training. I mean, it took 13 years, but I did finish it.

Q: Why did it take so long?

I worked on it off and on while I was writing essays and working on the beginnings of several other novels. When I finally finished it, I was so excited. I was ready to see it on bookshelves within a year. I sent it to my agent, and she wrote me a very nice email which said, “I love this. It’s very creative. But there’s no way I can sell it.” Most graphic novels for grownups are memoir — there wasn’t a clear genre. Then another agent I reached out to said, “I can’t take this on, but you should try Graphic Mundi, which had published several novels in the field of graphic medicine.”

Q: What made you want to write about health insurance?

Our system is actually killing people. We have a in this country, and people are not able to access mental health care. And then, when they do get help, it’s not necessarily the psychiatrist who determines the course of care; it’s the insurance company. If you go into a room of 10 Americans, five can tell you a health insurance nightmare story.

But I also wanted to explore what it means to develop a healthy lifestyle and grow a strong community and go through all this growth and healing that Bipolar Bear goes through in the story, only to have the depression come back again. What is the meaning of my journey if I find myself right back where I was before? Ultimately, there’s no answer to that question, but there is a right thing to do, which is to ask for help. We’re all saved by each other.

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From the heavily Armenian neighborhood of Tujunga in the foothills of the San Gabriel Mountains, Abramyan and other hookah shop and cafe owners began spreading the word that the ban, prompted by a burgeoning among teens, could put them out of business and extinguish a beloved social ritual that many feel is part of their heritage.

“We were going to be collateral damage,” said Abramyan, now president of the .

As their movement grew, the business owners hired a lobbyist and traveled to Sacramento to meet with lawmakers. They posted YouTube videos on “the history and centuries-old tradition” of smoking the popular in the Middle East. Their work paid off: State lawmakers passed the ban in August 2020, which outlawed the sale of flavored tobacco, including menthol cigarettes — but exempted premium cigars, loose pipe tobacco, and the “” used in hookah pipes.

It never went into effect. Big Tobacco quickly launched a referendum drive and gathered enough signatures to bring the issue to voters. This month, Californians will decide — — whether to uphold or block the law, which would make it illegal for brick-and-mortar retailers to sell flavored cigarettes, e-cigarettes, and other flavored tobacco products. Sales of gums or gummies that contain nicotine and are not approved by the FDA would also be prohibited.

If the law is upheld — indicates that a majority of likely voters support it — California would become the second state to rid stores of both flavored vapes and menthol cigarettes, which have and Latino smokers since tobacco companies began marketing them in inner-city neighborhoods half a century ago.

The question of why California has granted hookah smokers an exception while banning menthol cigarettes, the choice of smokers, has sparked a debate about which tobacco products — if any — merit protection. Until recently, menthols had failed in the face of aggressive tactics by tobacco companies, which have staved off billions in losses by and .

Anti-tobacco groups warn that this strategy has become a model for fending off government interference. They decry the hookah exemption as the latest example of business successfully using identity politics to keep profiting from a deadly product.

“Hookah has been given a pass for no scientific reason,” said Carol McGruder, co-founder of the . McGruder, who has spent years waging war against tobacco companies for their “predatory targeting” of Black communities with menthol cigarettes, said hookah smoking has become increasingly trendy among Black youths.

Many young people mistakenly believe that than other forms of smoking, but experts say tobacco smoked through water pipes is just as addictive as cigarette tobacco and tar, nicotine, and heavy metals.

“They bring out a beautiful antique hookah pipe and they say that hookah is all about family and community,” McGruder said. “But it’s all about money.”

Big Tobacco itself is assailing the hookah exemption, saying it proves that the law discriminates against Black and Latino smokers by banning menthol flavors, while giving “special treatment to the rich,” as an paid for by the industry argues.

“Prop. 31 will increase crime and expand illegal markets, cut revenue for critical services and could backfire on the very communities its proponents say they want to help,” said Beth Miller, a spokesperson for the “No on Prop 31” campaign.

, clustered primarily in California and Massachusetts, have restricted the sale of flavored tobacco products, including e-cigarette pods in — strawberry, chocolate milk, and pink punch — which health officials say have provided a gateway to teenage smoking. Roughly half of the ordinances restrict menthol, while fewer than 20 — nearly all of them in California — exempt hookah tobacco and/or hookah bars.

In 2021, and nearly 75% of middle school students who had used a tobacco product in the previous 30 days reported using flavored tobacco, the Centers for Disease Control and Prevention reported. In 2019 and 2020, an lung disease, known as EVALI, killed 68 people.

The vaping epidemic has given anti-smoking activists an opening to lobby against menthol cigarettes. Invented in the 1920s, their cool, minty flavor helped new smokers adjust to them more easily than non-flavored cigarettes, and the industry marketed them as a healthier option. In the 1960s, tobacco companies turned to the Black community, to hip, young “communicators” in barbershops and bars. Menthol cigarettes account for more than a third of the $80 billion U.S. cigarette market.

Reynolds American, the country’s largest maker of menthol cigarettes, including Newport, has battled menthol bans by ’s National Action Network and other civil rights groups. When the a menthol cigarette ban in 2019, Sharpton cited the case of , a Black man who died in police custody in 2014 after he was stopped for allegedly selling single, untaxed cigarettes on the street.

But the success of these efforts came at a devastating price, public health experts say. African American men have the in America, according to the CDC.

Earlier this year, the FDA to ban sales of menthol-flavored cigarettes, a long-awaited move hailed by health officials and some Black leaders, even as they braced themselves for a protracted legal battle with the tobacco industry that .

For years, anti-smoking activists have been focused on menthol, said Valerie Yerger, an associate professor of health policy at the University of California-San Francisco. “Nobody was focused on hookah,” she said.

But water-pipe use among young people has been in recent decades.

At across the United States and Europe, contestants compete to build the most elaborate water pipe, often to a hip-hop soundtrack. Elaborate water pipes, with their billowing puffs of smoke, are often in rap videos.

“It’s just another way the industry has found to keep our young people addicted to these products,” Yerger said.

Hookah purveyors argue that blanket prohibitions endanger small-business owners, many of them immigrants, and threaten to erase a “” by effectively outlawing hookah pipes, which are often part of gatherings and celebrations for Arabs, Armenians, Persians, and others hailing from the Middle East. They reject the claim that their fight is only about money.

“Hookah lounges are a hallmark of community,” said Rima Khoury, general counsel for .

For Abramyan, smoking a hookah was an after-dinner, adult ritual his Iranian-born parents brought with them when they immigrated to America in the 1980s. The ornate water pipes are often several feet tall and take at least 20 minutes to set up.

“This is not something kids are smoking in the bathrooms at school,” he said. “We don’t want our kids to smoke, but why shouldn’t my grandpa be able to smoke his hookah in his backyard?”

Bible study groups and the local Rotary Club chapter regularly meet at his Tujunga hookah lounge, Garden on Foothill, which features outdoor gazebos for families and groups. “For Muslims who don’t drink alcohol, or people who don’t like to go to strip clubs, this is a safe space,” he said.

The shop he runs a few blocks away, Munchies Mart, sells handmade hookah pipes and tobacco in flavors such as Strawberry Lemonade, Orange Pop, and Agua Fresca, a far cry from the apple-soaked tobacco he remembers his Persian grandmother mixing in her kitchen.

Using cultural practices to argue for public policy exemptions is nothing new, said Arnab Mukherjea, an associate professor of public health at California State University-East Bay.

But he said that communities often suffer when corporate interests “use cultural identity to market a product for mass consumption.”

“You go to any college town,” he said, “and the hookah bars are filled not with practicing Muslims, but with college-age kids who are going there to socialize, consuming flavors in bubble gum and cotton candy.”

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But like many librarians, she saw plenty of chaos. Patrons racked by untreated mental illness or high on drugs sometimes spit on library staffers or overdosed in the bathrooms. She remembers a co-worker being punched in the face on his way back from a lunch break. One afternoon in 2017, a man jumped to his death from the library’s fifth-floor balcony.

Dunseth retired the following year at age 61, making an early exit from a nearly 40-year career.

“The public library should be a sanctuary for everyone,” she said. The problem was she and many of her colleagues no longer felt safe doing their jobs.

Libraries have long been one of society’s great equalizers, offering knowledge to anyone who craves it. As public buildings, often with long hours, they also have become orderly havens for people with nowhere else to go. In recent years, amid unrelenting demand for safety-net services, libraries have been asked by community leaders to formalize that role, expanding beyond books and computers to providing on-site outreach and support for people living on the streets. In big cities and small towns, many now offer help accessing housing, food stamps, medical care, and sometimes even showers or haircuts. Librarians, in turn, have been called on to play the role of welfare workers, first responders, therapists, and security guards.

Librarians are divided about those evolving duties. Although many embrace the new role — some voluntarily carry the opioid overdose reversal drug naloxone — others feel overwhelmed and unprepared for regular run-ins with aggressive or unstable patrons.

“Some of my co-workers are very engaged with helping people, and they’re able to do the work,” said Elissa Hardy, a trained social worker who until recently supervised a small team of caseworkers providing services in the Denver Public Library system. The city boasts that some 50 lives have been saved since library staffers five years ago began volunteering for training to respond to drug overdoses. Others, Hardy said, simply aren’t informed about the realities of the job. They enter the profession envisioning the cozy, hushed neighborhood libraries of their youth.

“And that’s what they think they’re walking into,” she said.

Across the U.S., more than are employed in public libraries and schools, universities, museums, government archives, and the private sector, charged with managing inventory, helping visitors track down resources, and creating educational programs. Often, the post requires they hold a master’s degree or teaching credential.

But many were ill prepared for the transformation in clientele as drug addiction, untreated psychosis, and a lack of affordable housing have swelled homeless populations in a broad array of U.S. cities and suburbs, particularly on the West Coast.

Amanda Oliver, author of “Overdue: Reckoning With the Public Library,” which recounted nine months she worked at a Washington, D.C., branch, said that while an employee of the library, she was legally forbidden to talk publicly about frequent incidents such as patrons passing out drunk, screaming at invisible adversaries, and carrying bed bug-infested luggage into the library. This widespread “denial of how things are” among library managers was a complaint Oliver said she heard echoed by many staffers.

The , spearheaded by a group of New York City-based librarians, surveyed urban library workers and found nearly 70% said they had dealt with patrons whose behavior was violent or aggressive, from intimidating rants and sexual harassment to people pulling guns and knives or hurling staplers at them. Few of the workers felt supported by their bosses.

“As the social safety net has been dismantled and underfunded, libraries have been left to pick up the slack,” wrote the authors, adding that most institutions lack practical guidelines for treating traumatic incidents that over time can lead to “compassion fatigue.”

Library administrators have begun to acknowledge the problem by providing training and hiring staff members experienced in social services. Ensuring library staffers did not feel traumatized was a large part of her focus during her years with the Denver libraries, said Hardy. She and other library social workers in cities such as San Francisco and Washington have worked in recent years to organize training programs for librarians on topics from self-care to strategies for defusing conflict.

About are women, and the library workforce skews older, with nearly a third of staff members over 55. As in many professions, salaries have failed to keep pace with rising costs. According to the American Library Association-Allied Professional Association, the average salary for a public librarian in the U.S. was , the most recent year for which data is available.

Studies confirm that many librarians .

In Los Angeles County, with more than 60,000 people who are homeless, the past few years have tested the limits of a public library system with more than 80 sites.

“The challenge is that the level of need is off the charts,” said L.A. city librarian John Szabo. “Unfortunately, we are not fully and effectively trained to deal with these issues.”

Libraries began their transition more than a decade ago in response to the number of patrons seeking bathrooms and temporary respite from life on the streets. In 2009, San Francisco decided to formally address the situation by hiring a full-time .

Leah Esguerra leads a team of formerly homeless “health and safety associates” who patrol San Francisco’s 28 library sites looking to connect sick or needy patrons with services big and small, from shelter beds and substance use treatment to public showers, a model that has been copied in cities around the world.

“The library is a safe place, even for those who no longer trust the system,” said Esguerra, who worked at a community mental health clinic before becoming the “library lady,” as she’s sometimes called on the streets.

But hiring a lead social worker hasn’t erased the many challenges San Francisco’s librarians face. So the city has become more aggressive in setting standards of behavior for patrons.

In 2014, then-Mayor Ed Lee called for library officials to impose in response to rampant complaints about inappropriate conduct, including indecent exposure and urinating in the stacks. Soon after, officials released an amended that explicitly spelled out the penalties for violations such as sleeping, fighting, and “depositing bodily fluids on SFPL property.”

The city has installed extra security and taken other steps, like lowering bathroom stall doors to discourage drug use and sex and installing disposal boxes for used needles, although people still complain about conditions at the main library.

Some rural libraries have sought to make social services more accessible, as well. In Butte County, along the western slope of the Sierra Nevada in Northern California, library workers used a $25,000 state grant to host informational sessions on mental health issues such as depression, anxiety, and schizophrenia, as well as how to help people access treatment. Books on these topics were marked with green tags to make them easier to find, said librarian Sarah Vantrease, who helped build the program. She now works as a library administrator in Sonoma County.

“The library,” said Vantrease, “shouldn’t just be for people who are really good at reading.”

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In late May, Ho, 32, flew to Cambridge, Massachusetts, to collect her Ph.D. in public policy from Harvard University. A few days after returning home to the Bay Area, she tested positive for covid-19. At first, the Ivy League-educated researcher found herself at a loss for what to do.

“The protocols on how to respond after you test positive are extremely confusing,” Ho said.

But a few days later, after talking to an advice nurse, she found herself in the scrubby courtyard of a defunct senior center in West Berkeley that had been transformed into one of the state’s new “test-to-treat” sites.

The senior center is one of 138 free covid testing locations California has expanded into one-stop treatment sites to improve the accessibility of antiviral medication. The state’s initiative is modeled after the Biden administration’s program, announced in March, which aims to provide high-risk patients who test positive with instant access to antiviral medications. To do so, California is contracting with OptumServe, a Minnesota-based managed-care company, to spend $18.2 million a year on the effort.

One month into the initiative at sites , state health workers are slow to get Pfizer’s Paxlovid and Merck’s molnupiravir into the hands of patients, who must take them in the first few days of symptoms to avoid serious illness. Officials say fewer than 800 people statewide have received prescriptions at OptumServe sites despite new covid infections reaching an average of nearly 14,000 a day in early June in California.

And though the initiative aims to serve the uninsured, about two-thirds of those undergoing screenings already have insurance. For those with health coverage, OptumServe bills the insurer and then reimburses the state.

Dr. Tomás Aragón, the state public health officer, said the goal of the test-to-treat campaign is to “ensure high-risk patients have access to treatments that can keep them out of the hospital.”

The state says its priority is to make the pills accessible to millions of older, chronically ill, and disabled Americans, especially the poor and uninsured — even if few people have heard about the drugs.

Liliya Sekreta, head nurse at the West Berkeley OptumServe site, has seen demand for testing and treatment ebb and flow. During the winter’s covid surges linked to the omicron and delta variants, the line for tests extended around the corner of the senior center.

“We had the National Guard here and extra staff on duty to make sure people didn’t get angry or antsy,” Sekreta recalled. At the time, rapid tests were not widely available.

These days, the site is run by a skeleton staff of two young nurses, a couple of medical assistants, and a burly Spanish-language translator. Located a few blocks from University Avenue, Berkeley’s main drag, it’s in a formerly working-class neighborhood of stucco bungalows.

On a foggy morning in early June, medical assistants stayed glued to their phones between patients, who trickled in for covid tests at a rate of one every five minutes.

Ho was one of them. She is among millions of Californians at risk of getting seriously ill from the virus — in her case, because she takes immunosuppressive drugs for chronic arthritis. Ho has health insurance, but a nurse who answered the advice number at the bottom of the text message notifying her of a positive covid test result suggested it might be easier to return to the OptumServe site in West Berkeley where she’d gotten her test to find out whether she was eligible for antivirals.

Though she felt fine, Ho knew it was important to get treatment early. The Centers for Disease Control and Prevention says Paxlovid and molnupiravir are nearly 90% effective at reducing hospitalizations and deaths from covid if taken during the first five days of symptoms.

The FDA authorized the pills in December for emergency use, but supplies were initially scarce. By April, production had increased but, by that time, few physicians seemed to be prescribing the medicine, with pharmacists nationwide on their shelves.

“I had read the reports about people who should be taking these meds,” Ho said. “But they just didn’t know about them.”

She also worried about infecting her elderly mother, whom she lives with along with her husband and 14-month-old son in the city of Albany.

Ho sat at a folding table across from a nurse draped in yellow plastic and answered questions to determine her eligibility for the pills. Afterward, Ho talked via iPad with a doctor who concluded Ho would be eligible for a prescription if she showed symptoms. Those who qualify can go home with the medicines without having to make a trip to the pharmacy.

“I was glad to have somewhere to go that was accessible,” said Ho. “But honestly, it wasn’t very well advertised. Not everyone has the time to call around like I did and ask, ‘What should I do next?’”

Screenings for treatment can take up to an hour and a half. Workers must make sure the patient isn’t taking a drug that can interact with the antivirals, including cholesterol-lowering medications and some birth control pills. Sekreta, the head nurse, said patients who may qualify include those 65 and older, people with chronic diseases, and those who are obese or unvaccinated. People shouldn’t take the pills if they are too sick, or if they’re not sick at all.

Such in-person screenings have made the test-to-treat model confusing and inefficient, said Dr. Kirsten Bibbins-Domingo, an epidemiologist at the University of California-San Francisco.

“It should be easy — if the doctor says yes — to get these pills by telehealth,” she said.

So far, staffers say, demand for medicine has been low enough that no one in need has had to wait long. Officials said 1,219 people statewide had been screened for the drugs at OptumServe sites as of mid-June, and 768 of them walked away with Paxlovid pills.

“I think it’s a new concept that people are still getting used to,” said Katharine Sullivan, a Berkeley city employee overseeing the West Berkeley site, which has served as a community testing site since early in the pandemic.

Some residents prefer the peace of mind of speaking to a nurse or doctor over taking a test at home.

When Mary White, an art teacher and Berkeley resident of 53 years, came down with cold symptoms in late May, she got on her collapsible bike and rode to the West Berkeley center for a PCR test, where she’s gone for tests since the first months of the shutdown. White has health insurance but said she finds this more convenient than the hassle of trying to schedule an appointment that might be days away at a Kaiser Permanente facility in neighboring Oakland.

For the first time, her test came back positive.

“I was just like, ‘Oh no! What can I do? I’ve got to do something!’” said White, 74.

She returned to the center and underwent antiviral screening. After meeting remotely with a doctor in Chicago, she left with a full five-day course of Paxlovid, which she took for just two days before stopping because the drugs made her feel nauseated.

Back for a follow-up test a few days later, White reported feeling much better following the age-old remedy of rest and fluids. She added that with no end to the pandemic in sight she was grateful for a community facility where locals could simply walk in and talk to a health worker.

“For people like me,” she said, “that’s very comforting.”

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The college sophomore, home for the holidays, had taken half a pill she bought from a dealer on Snapchat. It turned out to be fentanyl, the powerful synthetic opioid that helped drive in the U.S. to more than 100,000 last year. “She was poisoned, and nothing was going to happen to the person who did it,” he said. “I couldn’t stand for that.”

The self-described political moderate said the experience made him cynical about California’s reluctance to impose harsh sentences for drug offenses.

So Capelouto, the suburban dad who once devoted all his time to running his print shop and raising his four daughters, launched a group called and traveled from his home to Sacramento in April to lobby for legislation known as “.” The bill would have made it easier for California prosecutors to convict the sellers of lethal drugs on homicide charges.

Capelouto’s organization is part of a nationwide movement of parents-turned-activists fighting the increasingly deadly drug crisis — and they are challenging California’s doctrine that drugs should be treated as a health problem rather than prosecuted by the criminal justice system. Modeled after Mothers Against Drunk Driving, which sparked a movement in the 1980s, organizations such as and the seek to raise public awareness and influence drug policy. One group, , pays homage to MADD by borrowing its acronym.

The groups press state lawmakers for stricter penalties for dealers and lobby technology companies to allow parents to monitor their kids’ communications on social media. They erect billboards blaming politicians for the drug crisis and stage protests against open-air drug markets in Los Angeles’ and San Francisco’s Tenderloin neighborhood.

“This problem is going to be solved by the grassroots efforts of affected families,” said Ed Ternan, who runs the Pasadena-based group , which focuses on educating youths about the dangers of counterfeit pills.

Many parents mobilized after a wave of deaths that began in 2019. Often, they involved high school or college students who thought they were taking OxyContin or Xanax purchased on social media but were actually ingesting pills containing fentanyl. The drug first hit the East Coast nearly a decade ago, largely through the heroin supply, but Mexican drug cartels have since introduced counterfeit pharmaceuticals laced with the highly addictive powder into California and Arizona to hook new customers.

In many cases, the overdose victims are straight-A students or star athletes from the suburbs, giving rise to an army of educated, engaged parents who are challenging the silence and stigma surrounding drug deaths.

Ternan knew almost nothing about fentanyl when his 22-year-old son, Charlie, died in his fraternity house bedroom at Santa Clara University a few weeks before he was scheduled to graduate in spring 2020. Relatives determined from messages on Charlie’s phone that he had intended to buy Percocet, a prescription painkiller he had taken after back surgery two years earlier. First responders said the strapping 6-foot-2-inch, 235-pound college senior died within a half-hour of swallowing the counterfeit pill.

Ternan discovered a string of similar deaths in other Silicon Valley communities. In 2021, 106 people died from fentanyl overdoses in Santa Clara County — up from 11 in 2018. The deaths have included a sophomore and a .

With the help of two executives at Google who to pills laced with fentanyl, Ternan persuaded Facebook, Instagram, TikTok, YouTube, and other social media platforms to donate ad space to warnings about counterfeit drugs. Pressure from parent groups has also spurred Santa Monica-based Snapchat to to detect drug sales and restrictions designed to make it harder for dealers to target minors.

Since the earliest days of the opioid epidemic, the families of people dealing with addiction and of those who have died from overdoses have supported one another in and on online platforms from to . Now, the family-run organizations that have sprung from California’s fentanyl crisis have begun cooperating with one another.

A network of parent groups and other activists that calls itself the was formed recently by Michael Shellenberger, a Berkeley author and activist .

One critic of California’s progressive policies is Jacqui Berlinn, a legal processing clerk in the East Bay who started — a name she chose as an homage to the achievements of Mothers Against Drunk Driving founder Candace Lightner, a Fair Oaks housewife whose 13-year-old daughter was killed in 1980 by a driver under the influence.

Berlinn’s son, Corey, 30, has used heroin and fentanyl for seven years on the streets of San Francisco. “My son isn’t trash,” Berlinn said. “He deserves to get his life back.”

She believes the city’s decision not to charge dealers has allowed open-air narcotics markets to flourish in certain neighborhoods and have enabled drug use, rather than encouraged people dealing with addiction to get help.

In April, Berlinn’s group spent $25,000 to erect a billboard in the upscale retail district of Union Square. Over a glowing night shot of the Golden Gate Bridge, the sign says: “Famous the world over for our brains, beauty and, now, dirt-cheap fentanyl.”

This month, the group installed a sign along Interstate 80 heading into Sacramento that targets Democratic Gov. Gavin Newsom. Playing off signage used at parks, the billboard features a “Welcome to Camp Fentanyl” greeting against a shot of a homeless encampment. The group said a will also circle the state Capitol for an undisclosed period.

New Billboards from Mothers Against Drug Deaths on I-80 in Sacramento.

— MADAAD-Mothers Against Drug Addiction and Deaths (@JacquiBerlinn)

Mothers Against Drug Deaths is calling for more options and funding for drug treatment and more arrests of dealers. The latter would mark a sharp turn from the gospel of “harm reduction,” a public health approach embraced by state and local officials that holds abstention as unrealistic. Instead, this strategy calls for helping people dealing with addiction stay safe through things like needle exchanges and naloxone, an overdose reversal drug that has saved thousands of lives.

The parent movement echoes recall efforts happening in two major cities. Progressive prosecutors Chesa Boudin in San Francisco and George Gascón in Los Angeles have , which they call a pointless game of whack-a-mole that punishes poor minorities.

California lawmakers are wary of repeating the mistakes of the war-on-drugs era and have blocked a series of bills that would stiffen penalties for fentanyl sales. They say the legislation would accomplish little apart from packing the state’s jails and prisons.

“We can throw people in jail for a thousand years, and it won’t keep people from doing drugs, and it won’t keep them from dying,” said state Sen. Scott Wiener (D-San Francisco). “We know that from experience.”

Some parents agree. After watching her son cycle in and out of the criminal justice system on minor drug charges in the 1990s, Gretchen Burns Bergman became convinced that charging people with minor drug offenses, such as possession, is counterproductive.

In 1999, the San Diego fashion show producer started , which has advocated for marijuana legalization and an end to California’s “” law. A decade later, she formed , a nationwide coalition. Today, both her sons have recovered from heroin addiction with the help of “compassionate support” and work as drug counselors, she said.

“I’ve been at this long enough to see the pendulum swing,” Burns Bergman said of the public’s shifting views on law enforcement.

In December, Brandon McDowell, 22, of Riverside, was arrested and the tablet that killed Matt Capelouto’s daughter. McDowell was charged with distributing fentanyl resulting in death, which carries a mandatory minimum sentence of 20 years in federal prison.

Although Alexandra’s Law failed to make it out of committee, Capelouto pointed out that years of lobbying went into the passage of stricter drunken driving laws. He vowed not to give up on the bill named for his daughter, who wrote poetry and loved David Bowie.

“I’m going to be back in front of them,” he said, “every year.”

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“These are people who were unwell to begin with,” said Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention.

Walensky’s remarks infuriated Americans with disabilities, who say the pandemic how the medical establishment — and society at large — treats their lives as expendable. Among those leading the protest was San Franciscan Alice Wong, an activist who took to Twitter to denounce Walensky’s comments as “ableism.” .

A few more thoughts:

The release of the recent unedited remarks by Dr. Walensky does not minimize the harm and mistrust created by the Administration. They have to work to gain back the trust of many communities.

— Alice Wong 王美華 (@SFdirewolf)

Wong, 47, moves and breathes with the aid of a power wheelchair and a ventilator because of a genetic neuromuscular condition. Unable to walk from around age 7, she took refuge in science fiction and its stories of mutants and misunderstood minorities.

Her awakening as an activist happened in 1993, when she was in college in Indiana, where she grew up. Indiana’s Medicaid program had paid for attendants who enabled Wong to live independently for the first time, but state cuts forced her to switch schools and move back in with her parents. Wong relocated to the Bay Area for graduate school, choosing a state that would help her cover the cost of hiring personal care attendants. She has since for people who are poor, sick, or older or have disabilities.

The founder of the , which collects oral histories of Americans with disabilities in conjunction with , Wong has about how covid and its unparalleled disruption of lives and institutions have underscored challenges that disabled people have always had to live with. She has exhorted others with disabilities to dive into the political fray, rallying them through her , with tens of thousands of followers, and a nonpartisan online movement called .

Wong is nocturnal — she typically starts working at her computer around 9 p.m. On a recent evening, she spoke with KHN via Zoom from her condo in the city’s Mission District, where she lives with her parents, immigrants from Hong Kong, and her pet snail, Augustus. The interview has been edited for length and clarity.

Q: Why do you often refer to people with disabilities as oracles?

Disabled people have always lived on the margins. And people on the margins really notice what’s going on, having to navigate through systems and institutions, not being understood. When the pandemic first hit, the public was up in arms about adjusting to life at home — the isolation, the lack of access. These are things that many disabled and chronically ill people had experienced. Disabled people had been trying forever to advocate for online learning, for accommodations in the workplace. The response was: “Oh, we don’t have the resources,” “It’s just not possible.” But with the majority inconvenienced, it happened. Suddenly people actually had to think about access, flexibility. That is ableism, where you don’t think disabled people exist, you don’t think sick people exist.

Q: Have you noticed that kind of thinking more since the pandemic began?

Well, yes, in the way our leaders talk about the risks, the mortality, about people with severe illnesses, as if they’re a write-off. I am so tired of having to assert myself. What kind of world is this where we have to defend our humanity? What is valued in our society? Clearly, someone who can walk and talk and has zero comorbidities. It is an ideology, just like white supremacy. All our systems are centered around it. And so many people are discovering that they’re not believed by their doctors, and this is something that a lot of disabled and sick people have long experienced. We want to believe in this mythology that everybody’s equal. My critique is not a personal attack against Dr. Walensky; it’s about these institutions that historically devalued and excluded people. We’re just trying to say, “Your messaging is incredibly harmful; your decisions are incredibly harmful.”

Q: Which decisions?

The overemphasis on vaccinations versus other mitigation methods. That is very harmful because people still don’t realize, yeah, there are people with chronic illnesses who are immunocompromised and have other chronic conditions who cannot get vaccinated. And this back and forth, it’s not strong or consistent about mask mandates. With omicron, there is this huge pressure to reopen schools, to reopen businesses. Why don’t we have free tests and free masks? You’re not reaching the poorest and the most vulnerable who need these things and can’t afford them.

Q: How has your life changed during the pandemic?

For the last two years, I have not been outside except to get my vaccinations.

Q: Because you’re so high-risk?

Yeah. I have delayed so many things for my own health. For example, physiotherapy. I don’t get lab tests. I’ve not been weighed in over two years, which is a big deal for me because I should be monitoring my weight. These are things I’ve put on hold. I don’t see myself going in to see my doctor any time this year. Everything’s been online — it’s in a holding pattern. How long can I take this? I really don’t know. Things might get better, or they might get worse. So many things disabled people have been saying have been dismissed, and that’s been very disheartening.

Q: What kinds of things?

For example, in California, it was almost this time last year when they for covid vaccine priority. I was really looking forward to getting vaccinated. I was thinking for sure that I was part of a high-risk group, that I’d be prioritized. And then the governor announced that he was eliminating the third tier that I was a part of in favor of an age-based system. For young people who are high-risk, they’re screwed. It just made me so angry. These kinds of decisions and values and messages are saying that certain people are disposable. They’re saying I’m disposable. No matter what I produce, what value I bring, it doesn’t matter, because on paper I have all these comorbidities and I take up resources. This is wrong, it’s not equity, and it’s not justice. It took a huge last year to get the state to backtrack. We’re saying, “Hey we’re here, we exist, we matter just as much as anyone else.”

Q: Do you think there’s any way this pandemic has been positive for disabled people?

I hope so. There’s been a lot of mutual aid efforts, you know, people helping each other. People sharing information. People organizing online. Because we can’t wait for the state. These are our lives on the line. Things were a little more accessible in the last two years, and I say a little because a lot of universities and workplaces are going backward now. They’re doing away with a lot of the hybrid methods that really gave disabled people a chance to flourish.

Q: You mean they’re undoing things that helped level the playing field?

Exactly. People who are high-risk have to make very difficult choices now. That’s really unfortunate. I mean, what is the point of this if not to learn, to evolve? To create a new normal. I can’t really see that yet. But I still have some hope.

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Garcia’s regular OB/GYN — like most medical offices at the time — was closed, and she was terrified by the prospect of spending hours waiting in an emergency room shoulder to shoulder with people who might have covid.

By the time she stumbled into the newly opened at the Santa Clara Valley Medical Center, clutching a pillow to her belly, Garcia was pale and dehydrated from blood loss and certain she was dying.

“If I didn’t get to the clinic when I did, I think, things could have ended up very different,” said Garcia, 34, who underwent an emergency hysterectomy for uterine fibroids.

Her story illustrates a long-standing gap in women’s health care. For years, many women with common but urgent conditions like painful urinary tract infections or excessive bleeding in the aftermath of a miscarriage have faced a grim choice between waiting weeks for an appointment with their regular OB-GYN or braving hours in an ER waiting room.

Urgent care OB-GYN clinics have begun popping up around the country in recent years, and the covid pandemic has increased demand. While no data is available on the number of urgent care clinics for women, they are part of a in general and other alternative models like retail clinics and so-called digital-first health care startups. One of these, the New York-based women’s health startup Tia (“aunt” in Spanish), won $24 million in venture capital funding last spring and is opening physical clinics nationwide.

“It’s clear that access and convenience are increasingly more important to consumers than seeing a specific provider,” said Rob Rohatsch, chief medical officer at Solv, an app that books urgent care appointments.

The Urgent Care Association has steadily who use its members’ walk-in clinics as an alternative to hospital emergency departments. Traffic to these clinics has surged during the past year, according to Solv.

The Bascom clinic had been a nearly decadelong dream of Drs. and , two obstetrician-gynecologists at the Santa Clara Valley Medical Center, a sprawling public hospital that serves as the regional trauma center, treating critical cases like car accident and gunshot victims and relegating people suffering less life-threatening problems to long waits.

“Women — perhaps pregnant or bleeding — could be sitting there 12 to 14 hours, depending on the time of day,” Pan said.

After the onset of the pandemic, doctors worried that women with serious or even deadly issues like Garcia’s might avoid seeking treatment for fear of contracting covid. ER visits in the early months of the pandemic, according to the Centers for Disease Control and Prevention. noted that, while the number of ER visits for heart attacks had increased, visits for nonspecific chest pain had decreased, suggesting that people might be risking their lives by avoiding the ER.

“You can imagine that a woman with three kids at home might be even more scared,” Sit said. “We just couldn’t keep sending women having miscarriages to wait hours in the covid tent.”

Instead, women can now be triaged over the phone and seen within a day or two at the Bascom OB-GYN urgent care clinic — much the way they would at their local Planned Parenthood branch for contraceptives or a sexually transmitted disease screening. Bascom is equipped to treat conditions from severe morning sickness to ectopic pregnancies that require emergency surgery. In its first year, the clinic has treated some 1,300 women and served as a backup to local clinics that provide basic reproductive health services in counties hundreds of miles away.

It’s still in its pilot phase, however, operating weekdays from 8:30 a.m. to 5 p.m., which “leaves a big chunk of off-hours that we cannot serve women,” Sit acknowledges.

A handful of other clinics have taken the concept of urgent care for women a step further. Dr. Miriam Mackovic runs , a chain of four clinics in the Los Angeles area that also has an emergency care center in Long Beach, which is staffed 24/7 with a nurse practitioner and equipped with a lab and a pharmacy. Women who walk in are typically seen within 30 minutes, according to Mackovic, and every patient receives a follow-up call the next day.

One woman who turned up at a Complete Women Care clinic said that, after desperately seeking treatment at an ER one Saturday night for a nasty yeast infection, she got a bill in the mail for $1,500.

“In the middle of the night, urgent care centers are closed. OB-GYN offices are definitely closed. So, what is her option except the ER?” asked Mackovic, an obstetrician-gynecologist who also has an MBA.

Mackovic ticked off cautionary tales of patients who’ve arrived at her clinics from as far away as Arizona and Nevada after suffering for weeks while trying to schedule routine operations for uterine cysts or twisted ovaries.

“The medical advances are here. Most emergencies can be resolved on an outpatient basis — a woman can have a hysterectomy with just a fine incision and be home the same day,” Mackovic said. “But a woman who has a miscarriage calls her OB, who says there’s no openings for weeks, so she goes to the ER, and the physician says: Are you dying? No? Then follow up with your OB-GYN.”

Fees for the uninsured — around 20% of Mackovic’s clientele — run from $100 to around $600, she said.

Women in the United States have for years those in other rich countries in both their access to health care and their health status. America has the highest among developed nations.

Some women see a doctor only in an emergency.

“We have diagnosed so many cancers in the last few years because women walked in for another reason,” said Dr. Adeeti Gupta, founder and CEO of a chain of open-daily clinics in New York City called that provides comprehensive care without appointments.

Gupta’s three clinics have grown steadily since she opened them seven years ago, largely out of frustration with the months-long wait for an appointment at her own Queens OB-GYN practice. But after the coronavirus hit the city hard, she has seen an uptick in patients — 40% in one location.

The country needs more accessible, comprehensive women’s health care to treat everything from the menstrual pains of adolescents to the hot flashes of postmenopausal grannies, Gupta said.

“The thing about women,” she said, “is their problems never stop.”

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“You saved my life,” wrote Wolf, who had finally gotten clean after that bust and 90 days in jail, ending six months of sleeping on scraps of cardboard on the sidewalk.

Today, he joins a growing chorus of people, including the mayor, calling for the city to crack down on an increasingly deadly drug trade. But there is little agreement on how that should be done. Those who demand more arrests and stiffer penalties for dealers face powerful opposition in a city with little appetite for locking people up for drugs, especially as the Black Lives Matter and Defund the Police movements push to drastically limit the power of law enforcement to deal with social problems.

Drug overdoses killed 621 people in the of 2020, up from 441 in all of 2019 and 259 in 2018. San Francisco is on track to lose an average of nearly two people a day to drugs in 2020, compared with the who had died by Dec. 20 of the coronavirus.

As in other parts of the country, most of the overdoses have been linked to fentanyl, the powerful synthetic opioid that laid waste to the eastern United States starting in 2013 but didn’t arrive in the Bay Area until about five years later. Just as the city’s drug scene was awash with the lethal new product — which is 50 times stronger than heroin and sells on the street for around $20 for a baggie weighing less than half a gram — the coronavirus pandemic hit, absorbing the attention and resources of health officials and isolating drug users, making them more likely to overdose.

The pandemic is contributing to rising , according to the Centers for Disease Control and Prevention, which reported last month that a record 81,000 Americans died of an overdose in the 12 months ending in May.

“This is moving very quickly in a horrific direction, and the solutions aren’t matching it,” said Supervisor Matt Haney, who represents the Tenderloin and South of Market neighborhoods, where nearly 40% of the deaths have occurred. Haney, who has hammered City Hall for what he sees as its indifference to a life-or-death crisis, is calling for a more coordinated response.

“It should be a harm reduction response, it should be a treatment response — and yes, there needs to be a law enforcement aspect of it too,” he said.

Tensions within the city’s leadership came to a head in September, when Mayor London Breed supported an effort by City Attorney Dennis Herrera to clean up the Tenderloin by legally blocking 28 known drug dealers from entering the neighborhood.

But District Attorney Chesa Boudin, a progressive elected in 2019 on a platform of police accountability and racial justice, the move. He called it a “recycled, punishment-focused” approach that would accomplish nothing.

People have died on the Tenderloin’s needle-strewn sidewalks and alone in hotel rooms where they were housed by the city to protect them from covid-19. Older Black men living alone in residential hotels are dying at particularly high rates; Blacks make up around 5% of the city’s population but account for a quarter of the 2020 overdoses. Last February, a man was , ice-cold, in the front pew at St. Boniface Roman Catholic Church.

The only reason drug deaths aren’t in the thousands, say health officials, is the outreach that has become the mainstay of the city’s drug policy. From January to October, 2,975 deaths were prevented by naloxone, an overdose reversal drug that’s usually sprayed up the nose, according to the , a city-funded program that trains outreach workers, drug users, the users’ family members and others.

“If we didn’t have Narcan,” said program manager Kristen Marshall, referring to the common naloxone brand name, “there would be no room at our morgue.”

The city is also hoping that this year state lawmakers will approve safe consumption sites, where people can do drugs in a supervised setting. Other initiatives, like a 24-hour meth sobering center and an overhaul of the city’s behavioral health system, have been put on hold because of pandemic-strained resources.

Efforts like the DOPE Project, the country’s largest distributor of naloxone, reflect a seismic shift over the past few years in the way cities confront drug abuse. As more people have come to see addiction as a disease rather than a crime, there is little appetite for locking up low-level dealers, let alone drug users — policies left over from the “war on drugs” that began in 1971 under President Richard Nixon and disproportionately punished Black Americans.

In practice, San Francisco police don’t arrest people for taking drugs, certainly not in the Tenderloin. On a sunny afternoon in early December, a red-haired young woman in a beret crouched on a Hyde Street sidewalk with her eyes closed, clutching a piece of foil and a straw. A few blocks away, a man sat on the curb injecting a needle into a thigh covered with scabs and scars, while two uniformed police officers sat in a squad car across the street.

Last spring, after the pandemic prompted a citywide shutdown, police stopped arresting dealers to avoid contacts that might spread the coronavirus. Within weeks, the sidewalks of the Tenderloin were lined with transients in tents. The streets became such a narcotics free-for-all that many of the working-class and immigrant families living there felt afraid to leave their homes, according to a federal lawsuit filed by business owners and residents. It accuses City Hall of treating less wealthy ZIP codes as “containment zones” for the city’s ills.

The suit was settled a few weeks later after officials moved most of the tents to designated “safe sleeping sites.” But for many, the deterioration of the Tenderloin, juxtaposed with the gleaming headquarters of companies like Twitter and Uber just blocks away, symbolizes San Francisco’s starkest contradictions.

Mayor Breed, who to a drug overdose in 2006, has called for a on drug dealing.

The Federal Initiative for the Tenderloin was one such effort, announced in 2019. It aims to “reclaim a neighborhood that is being smothered by lawlessness,” U.S. Attorney David Anderson said at a recent virtual news conference held to announce in which the feds arrested seven people and seized 10 pounds of fentanyl.

Law enforcement agencies have blamed the continued availability of cheap, potent drugs on lax prosecutions. Boudin, however, said his office files charges in 80% of felony drug cases, but most involve low-level dealers whom cartels can easily replace in a matter of hours.

He pointed to a 2019 federal sting that culminated in the arrest of 32 dealers — mostly Hondurans who were later deported — after a two-year undercover operation involving 15 agencies.

“You go walk through the Tenderloin today and tell me if it made a difference,” said Boudin.

His position reflects a growing that questions whether decades-old policies that focus on putting people behind bars are effective or just. In May, the killing of George Floyd by the Minneapolis police energized a nationwide police reform campaign. Cities around the country, , have promised to of dollars from law enforcement to social programs.

“If our city leadership says in one breath that they want to defund the police and are for racial and economic justice and in the next talk about arresting drug dealers, they’re hypocrites and they’re wrong,” said Marshall, the leader of the DOPE Project.

But Wolf, 50, believes a concerted crackdown on dealers would send a message to the drug networks that San Francisco is no longer an open-air illegal drug market.

Like hundreds of thousands of other Americans who’ve succumbed to opiate misuse, he began with a prescription for the painkiller oxycodone, in his case following foot surgery in 2015. When the pills ran out, he made his way from his tidy home in Daly City, just south of San Francisco, to the Tenderloin, where dealers in hoodies and backpacks loiter three or four deep on some blocks.

When he could no longer afford pills, Wolf switched to heroin, which he learned how to inject on YouTube. He soon lost his job as a caseworker for the city and his wife threw him out, so he became homeless, holding large quantities of drugs for Central American dealers, who sometimes showed him photos of the lavish houses they were having built for their families back home.

Looking back, he wishes it hadn’t taken six arrests and three months behind bars before someone finally pushed him toward treatment.

“In San Francisco, it seems like we’ve moved away from trying to urge people into treatment and instead are just trying to keep people alive,” he said. “And that’s not really working out that great.”

This story was produced by , which publishes , an editorially independent service of the .

This <a target="_blank" href="/public-health/san-francisco-wrestles-with-drug-approach-as-death-and-chaos-engulf-tenderloin/">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;">

With her cat, Bodhi, in his carrier in the back seat, 80-year-old Diana Dimas, who doesn’t see well at night, kept her eyes glued to the rear lights of her neighbor’s Toyota. She and Magdalena Mulay had met a few years before at a bingo night in their sprawling retirement community on the outskirts of Santa Rosa. Both Libras, each with two marriages behind her, the two women soon became the sort of friends who finish each other’s sentences.

Now, for the second time in three years, they heard the alarms and fled together as fire consumed the golden hills of Northern California’s wine country.

“I thought, where on earth are we going to go?” recalled Dimas. She remembered that when the catastrophic Tubbs Fire hit back in 2017, people had sought refuge outside well-lit supermarkets, which had water and bathrooms. Which is how Dimas and Mulay and dozens of other seniors ended up spending the night of the most recent evacuation in the parking lot of the Sonoma Safeway.

At midnight, Mulay was trying to get comfortable enough to catch a few winks in her driver’s seat when her phone began to chirp. A friend was calling to wish her a happy 74th birthday.

The stories of that Sunday night — as a 20-acre fire started that morning merged with two other fires to become an 11,000-acre conflagration forcing tens of thousands from their homes in two counties — spotlight the challenges of evacuating elderly and infirm residents from the deadly wildfires that have become an annual occurrence in California. This year, the coronavirus, which is especially dangerous to the elderly, has further complicated the problem.

While the 2020 fire season will go down as the state’s biggest on record, rescuers have so far managed to avoid horrors on the scale of three years ago, when the firestorm that raced through California’s wine country killed 45 people. Almost all were over 65 — found in wheelchairs, trapped in their garages, isolated and hard of hearing, or simply too stubborn to leave. The same grim pattern emerged from the Camp Fire, which leveled the Northern California town of Paradise in 2018.

Assisted care homes in particular came under scrutiny after the 2017 fire, when ill-equipped and untrained workers at two Santa Rosa facilities abandoned two dozen frail, elderly residents as the flames closed in, according to state investigators. They concluded the seniors would have died in the flames had emergency workers and relatives not arrived at the last minute to rescue them.

“The problem is we don’t value elders as a society,” said Debbie Toth, CEO of Choice in Aging, an advocacy group. “If children needed to be evacuated, we’d have a freaking Romper Room stood up overnight to entertain them so they wouldn’t be damaged by the experience.”

The destructive effects of climate change in California have dovetailed with a rapidly graying population — which in a decade is projected to include 8.6 million senior citizens. That has fueled a growing demand for senior housing, from assisted care homes to swanky “active adult” facilities complete with golf courses and pools.

Proximity to nature is a major selling point of Oakmont Village, Dimas and Mulay’s upscale community of nearly 5,000 over-55s, which has everything from bridge games to cannabis clubs. But the woodlands and vineyards surrounding this suburban sprawl have put thousands of elderly citizens in hazardous wildfire zones.

“With seniors, there’s mobility issues, hearing issues — even the sense of smell is often gone in the later years,” said Marrianne McBride, who heads Sonoma County’s Council on Aging. Getting out fast in an emergency is especially challenging for those who no longer drive. In Sunday’s evacuation, some residents who followed official advice to call ride services had to wait hours, until 3 or 4 a.m., for the overtaxed vans.

Dimas and Mulay managed to scramble into their cars and get on the road shortly after 10 p.m., when a mandatory evacuation order went out for the thousands of seniors in Oakmont Village. But it was after midnight when residents of two Santa Rosa assisted care homes in the evacuation zone were shuffled onto city buses in their bathrobes, some with the aid of walkers. Off-duty drivers braved thick smoke and falling embers to ferry some of them to safety, only to spend hours being sent from one shelter to another as evacuation sites filled up fast because of social distancing rules designed to prevent the spread of COVID-19.

Other precautions, including masks and temperature checks, were followed. But health officials nonetheless voiced concerns that vulnerable people in their 80s and 90s — especially residents of skilled nursing homes, the source of most of Sonoma County’s coronavirus deaths so far — had been moved among multiple locations, upping their chance for exposure.

In the following days, shelters were fielding frantic calls from out-of-town relatives searching for their loved ones. “We were getting phone calls from Michigan, other places across the country, saying, ‘I’m trying to find my mother!’” said Allison Keaney, CEO of the Sonoma-Marin Fairgrounds, which sheltered several hundred horses, chickens, goats and llamas as well as displaced people.

By Wednesday afternoon, a few dozen evacuees remained at the shelters, mostly seniors without relatives or friends nearby to take them in, like Dimas and Mulay. The two women had left the Safeway lot and were sleeping on folding cots in a gym at the Veterans Memorial Building in Petaluma, an old poultry industry town dotted with upscale subdivisions.

This was their first time out and around other people since March, when the two friends had been planning a big night out to see Il Volo, an Italian pop group. Seven months later, the new outfits they bought for the concert still hang unworn in their closets.

“All we do since the shutdown is stay home and talk on the phone,” said Mulay, who spoke to a reporter while sitting next to her friend on a folding chair outside the shelter. “Now, with all these crowds — it’s terrifying.”

Dimas likened the pandemic followed by the fires to “a ball rolling downhill, getting bigger and bigger. And then there we were, with the flashing lights all around us and the cops shouting, ‘Go this way!’ ‘Keep moving!’”

Listos California — an outreach program, for seniors and other vulnerable people, run out of the Governor’s Office of Emergency Services — allotted $50 million to engage dozens of nonprofits and community groups around the state to help warn and locate people during disasters. (Listos means “Ready” in Spanish.)

In Sonoma and Napa counties, where the Glass Fire had destroyed at least 630 structures by late last week, the bolstered threat of wildfires in recent years has promoted new alert systems — including a weather radio that has strobe lights for the deaf or can shake the bed to awaken you.

But while counties are legally responsible for alerting people and providing shelter for them once they’re out, no public agency is responsible for overseeing the evacuation. Practices differ widely from county to county, said Listos co-director Karen Baker.

If Sonoma County has learned anything from the disasters of the past few years, it’s not to depend too much on any system in an emergency. “You’ve got to have a neighborhood network,” McBride said. “As community members, we have to rely on each other when these things happen.”

Early last week, word filtered through the shelters that the fire had consumed a triplex and two single-family homes in the Oakmont neighborhood, but firefighters had battled the blaze through the night with hoses, shovels and chainsaws and miraculously managed to save the rest of the community.

A week later, to their relief, Oakmont’s senior residents were allowed to return home. By then, Mulay had developed severe back pain. Dimas missed her TV.

Back in her apartment with Bodhi, Dimas noted with horror that the blaze had come close enough to her building to incinerate several juniper bushes and scorch a redwood just 2 feet away.

“The whole thing feels surreal, like ‘Oh, my God, did that really happen, or did I dream it?’” she said.

This <a target="_blank" href="/aging/california-fires-hotter-faster-older-residents-less-mobile/">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;">