Cuatro años después, pocos días antes de su boda, recibió un diagnóstico de cáncer de cuello uterino que le generó complicaciones cuando quedó embarazada. Se sometió a unaÌýhisterectomía ocho años después, cuando el cáncer reapareció en 2021.

Chaiprasert-Paguio, editora de una revista médica en Menifee, en el condado de Riverside, California, tiene 38 años. No fue inmunizada cuando era adolescente porque aún no había una vacuna contra el VPH, la enfermedad que causa casi todos los casos de cáncer de cuello uterino y otros tipos de cáncer potencialmente mortales en hombres y mujeres.

Su hija de 10 años, Samantha, va a recibir la primera inyección este mes. “Es la única vacuna que previene el cáncer”, dijo Chaiprasert-Paguio.

La legislatura de California está considerando un para requerir que las escuelas notifiquen a los padres que sus hijos deben estar vacunados contra el VPH antes de comenzar octavo grado.

La iniciativa es parte de un esfuerzo para vacunar a más niños contra las cepas del virus que causan cáncer antes de que inicien su vida sexual. La ley propuesta, la AB 659, no exige la vacuna para los estudiantes de escuela media, como se propuso originalmente.

Esa disposición fue eliminada por los legisladores sin ningún debate, lo cual refleja la polémica que causan los mandatos de vacunación en las escuelas, incluso en un estado cuyas leyes de inmunización están entre las más estrictas del país.

“Es un momento difícil para emprender esta lucha”, dijo Michelle Mello, profesora de leyes y políticas de salud en la Universidad de Stanford, y señaló que se le ha prestado más atención a las opiniones antivacunas desde el comienzo de la pandemia de covid-19.

El proyecto de ley de la asambleísta Cecilia Aguiar-Curry también requeriría que los estudiantes de universidades públicas menores de 26 años presenten una prueba de vacunación contra el virus, una propuesta más “tolerable” para aquellos padres a quienes les incomoda la idea de una vacuna que vincula a los adolescentes con el sexo.

Los activistas antivacunas se manifestaron rápidamente en contra del proyecto de ley, que consideran un ejemplo indignante de la extra limitación del gobierno. Un grupo llamado Freedom Angels se jactó de haber presionado a los legisladores para que abandonaran el mandato de vacunación de adolescentes, lo que sus miembros llamaron “una gran victoria”.

Desde 2006, cuando se lanzó la vacuna contra el VPH, han circulado de que causa o hace que los adolescentes se vuelvan infértiles. Menos del 55% de los niños de 13 a 15 años en Estados Unidos en 2020, una tasa mucho más baja que la de otras vacunas infantiles de rutina.

Por ejemplo, más del 90% de los adolescentes están al día con la vacuna Tdap, que protege contra el tétanos, la difteria y la tos ferina.

Una dosis de la vacuna contra el VPH tiene , según Merck, la farmacéutica que la produce.

La mayoría de los estados no requieren la vacunación contra el VPH en las escuelas como lo hacen para , y otras enfermedades que se propagan fácilmente en las aulas por medio del aire o el contacto físico. Solo otros tres estados —Rhode Island, Virginia, y Hawaii— y Washington, DC, requieren que los estudiantes de se vacunen contra el VPH.

La oposición a los mandatos de vacunas contra covid, mayormente de parte de los republicanos, ha generado una serie de proyectos de ley en como y que limitan o ponen fin a los requisitos de inmunización en el sector público y privado.

En Iowa, que tiene la segunda tasa de cáncer más alta del país, los legisladores están considerando un proyecto de ley para que las escuelas no estén obligadas a informar a sus estudiantes sobre la vacuna contra el VPH.Ìý

Incluso antes de covid, un grupo creciente de padres que se resisten a vacunar a sus hijos ha hecho que reaparezcan enfermedades que habían sido eliminadas hace décadas, como el y la .

Frente a esta realidad, es necesario elaborar estrategias de largo plazo para aprobar una buenapolítica de salud pública, dijo Crystal Strait, quien dirige el grupo pro-vacunación ProtectUS. Así es como ve el nuevo proyecto de ley de vacunación contra el VPH de Aguiar-Curry. “Es un paso”, dijo. “Tenemos que hacer algo. Demasiadas personas están sufriendo por cánceres prevenibles”.

Casi todo el mundo en algún momento, aunque normalmente no presenta síntomas. Pero varias cepas del virus pueden y convertirse en cáncer de cuello uterino, vagina, vulva, pene, ano o garganta.

Estudios han confirmado que la vacuna contra el VPH reduce el riesgo de desarrollar cáncer en casi un 90% cuando se administra a niñas y niños en la adolescencia temprana, presumiblemente antes de que estén expuestos a cepas peligrosas del virus.

Estudios académicos demuestran que los adolescentes en estados con mandatos de vacunación contra el VPH tienen .

“Hemos estado luchando contra el cáncer durante décadas, y ahora tenemos una vacuna para el cáncer y la gente está debatiendo si deberíamos o no hacer lo posible para que todos la reciban”, dijo el doctor Jeffrey Klausner, profesor de salud pública en la Universidad de Southern California y ex director de los Servicios de Prevención y Control de Enfermedades de Transmisión Sexual de San Francisco. “Es difícil de entender”.

Las tasas de cáncer de cuello uterino, que una vez fue una de las principales causas de muerte por cáncer entre las mujeres estadounidenses, han con la vacuna y con el aumento en las pruebas de Papanicolaou. Aún así, se diagnostican más de 37,000 casos de cáncer causados por el VPH anualmente, y el año pasado, el cáncer de cuello uterino mató a mujeres.

Australia, por el contrario, está encaminado a convertirse en el primer país en en las próximas dos décadas gracias a un programa escolar nacional en el que enfermeras vacunan contra el VPH a niños de 12 y 13 años que estén dispuestos a recibir la inyección.Ìý

Los mandatos de salud pública son más eficaces cuando exigen cosas que ya han alcanzado cierto nivel de aceptación social, como usar el cinturón de seguridad o no fumar en interiores, dijo Saad Omer, quien dirige el Instituto de Salud Global de Yale y ha estudiado el escepticismo ante las vacunas.

“Los mandatos son un medicamento fuerte, pero como todo medicamento fuerte, vienen con efectos secundarios”, dijo Omer.

Gilma Pereda, diseñadora gráfica que vive en Santa Clara, siempre tuvo sus dudas acerca de las vacunas y confiesa que no le entusiasman los mandatos. Por otro lado, desde que le diagnosticaron cáncer de cuello uterino en 2016, se ha sometido a numerosas cirugías y varias rondas de quimioterapia. Ha perdido el útero, las pestañas y su cabello castaño que le llegaba hasta la cintura. En 2021, descubrió que el cáncer se había propagado a sus huesos.

Al tomar la decisión de vacunar o no a su hija contra el VPH, no lo tuvo que pensar demasiado. “No quiero que mi hija pase por esto”, dijo.

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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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Desde el barrio de Tujunga, con una fuerte presencia de armenios, a los pies de las montañas de San Gabriel, Abramyan y otros propietarios de tiendas y cafés de narguiles comenzaron a correr la voz de que la prohibición, impulsada por una creciente entre los adolescentes, podría dejarlos fuera del negocio y hacer desaparecer un preciado ritual social que muchos sienten como parte de su herencia.

“Íbamos a ser un daño colateral”, dijo Abramyan, ahora presidente de la .

A medida que su movimiento crecía, los propietarios de los negocios contrataron a un cabildero y viajaron a Sacramento para reunirse con legisladores. Publicaron videos en YouTube sobre “la historia y la tradición centenaria” de fumar estas tan populares en Medio Oriente.

Su trabajo dio frutos: en agosto de 2020 los legisladores estatales aprobaron la prohibición de la venta de tabaco aromatizado, incluidos los cigarrillos mentolados, pero eximieron a los puros premium, el tabaco de pipa suelto y el “” utilizado en las pipas de agua.

Nunca entró en vigencia. Las grandes tabacaleras lanzaron rápidamente una campaña de referéndum y reunieron suficientes firmas para llevar el tema a las urnas. Este mes, los californianos decidirán, a través de la , si mantienen o bloquean la ley, que haría ilegal la venta de cigarrillos, cigarrillos electrónicos y otros productos de tabaco aromatizados en comercios. También se prohibiría la venta de chicles o gomas de mascar que contengan nicotina y no estén aprobados por la FDA.

Si la ley se mantiene —los indican que la mayoría de los votantes la apoyan—, California se convertiría en el segundo estado en eliminar de las tiendas los vaporizadores de sabores y los cigarrillos mentolados, que han contribuido a y latinos desde que las compañías tabacaleras empezaron a comercializarlos en los barrios urbanos hace medio siglo.

La cuestión de por qué California ha concedido una excepción a los fumadores de narguiles mientras prohíbe los cigarrillos mentolados, la elección del , ha generado un debate sobre qué productos del tabaco —si es que hay alguno— merecen protección.

Hasta hace poco, los mentolados habían fracasado ante las agresivas tácticas de las tabacaleras, que han evitado pérdidas multimillonarias y .

Los grupos antitabaco advierten que esta estrategia se ha convertido en un modelo para evitar la interferencia del gobierno. Denuncian que la exención del narguile es el último ejemplo de cómo las empresas utilizan con éxito las políticas de identidad para seguir beneficiándose de un producto mortal.

“El narguile ha recibido un pase sin ninguna razón científica”, dijo Carol McGruder, cofundadora del. McGruder, que lleva años librando una guerra contra las empresas tabacaleras por apuntar “de manera depredadora” a las comunidades negras con los cigarrillos mentolados, dijo que fumar narguile se ha puesto cada vez más de moda entre los jóvenes negros.

Muchos jóvenes creen erróneamente que que otras formas de fumar, pero los expertos afirman que el tabaco que se absorve a través de las pipas de agua es tan adictivo como el de los cigarrillos y contiene alquitrán, nicotina y metales pesados.

“Sacan una hermosa pipa de agua antigua y dicen que la pipa de agua tiene que ver con la familia y la comunidad”, dijo McGruder. “Pero todo es cuestión de dinero”.

Las propias grandes tabacaleras están atacando la exención del narguile, al decir que demuestra que la ley discrimina a los fumadores negros y latinos al prohibir los sabores mentolados, mientras que da “un trato especial a los ricos”, como argumenta una por la industria.

“La Propuesta 31 aumentará la delincuencia y ampliará los mercados ilegales, recortará los ingresos para servicios básicos y podría volverse en contra de las mismas comunidades que sus los que la proponen dicen querer ayudar”, dijo Beth Miller, vocera de la campaña “No a la Propuesta 31”.

, agrupados principalmente en California y Massachusetts, han restringido la venta de productos de tabaco aromatizados, incluidas las cápsulas de cigarrillos electrónicos de —fresa, chocolatada y ponche rosa— que, según las autoridades sanitarias, han servido de puerta de entrada al consumo de tabaco entre los adolescentes.

Aproximadamente la mitad de las ordenanzas restringen el mentol, mientras que menos de 20, casi todas ellas en California, exime el tabaco para narguile y los bares de narguiles.

En 2021, y casi el 75% de los estudiantes de secundaria que habían usado un producto de tabaco en los 30 días anteriores informaron que usaban tabaco con sabor, según los Centros para el Control y la Prevención de Enfermedades (CDC). En 2019 y 2020, relacionada con el vaping, conocido como EVALI, mató a 68 personas.

La epidemia de vaping ha dado a los activistas antitabaco una oportunidad para ejercer presión contra los cigarrillos mentolados. Inventados en la década de 1920, su sabor fresco y a menta ayudó a los nuevos fumadores a adoptarlos más fácilmente que los cigarrillos sin sabor, y la industria los comercializó como una opción más saludable.

En los años 60, las tabacaleras apuntaron a la comunidad negra a jóvenes “comunicadores” de moda en barberías y bares. Los cigarrillos mentolados representan más de un tercio de los $80,000 millones del mercado estadounidense de cigarrillos.

Reynolds American, el mayor fabricante de cigarrillos con mentol del país, incluido Newport, batalla contra la prohibición de los mentolados y a otros grupos de derechos civiles.

Cuando el propuso una prohibición de los cigarrillos mentolados en 2019, Sharpton citó el caso de , un hombre negro que murió bajo custodia policial en 2014 después de que lo detuvieran por vender supuestamente cigarrillos sueltos y sin impuestos en la calle.

Pero el éxito de estos esfuerzos ha tenido un precio devastador, dicen expertos en salud pública. Los hombres afroamericanos en Estados Unidos, según los CDC.

A principios de este año, la FDA para prohibir la venta de cigarrillos con sabor a mentol, una medida largamente esperada por las autoridades sanitarias y algunos líderes negros, incluso mientras se preparaban para una prolongada batalla legal con la industria del tabaco que podría .

Los activistas antitabaco se han centrado en el mentol durante años, dijo Valerie Yerger, profesora asociada de política sanitaria en la Universidad de California-San Francisco. “Nadie se centró en el narguile”, agregó.

Pero el uso de la pipa de agua entre los jóvenes en las últimas décadas.

En que se celebran en Estados Unidos y Europa, los concursantes compiten por construir la pipa de agua más elaborada, a menudo con una banda sonora de hip-hop. Las pipas de agua elaboradas, con sus onduladas bocanadas de humo, suelen en los videos de rap.

“Es otra forma que ha encontrado la industria para mantener a nuestros jóvenes adictos a estos productos”, afirma Yerger.

Los proveedores de narguile argumentan que las prohibiciones generales ponen en peligro a los propietarios de pequeños negocios, muchos de ellos inmigrantes, y amenazan con borrar un “” al prohibir de hecho las pipas de narguile, que suelen formar parte de las reuniones y celebraciones de árabes, armenios, persas y otros originarios de Medio Oriente. Rechazan la afirmación de que su lucha es solo por dinero.

“Los salones de narguile son un distintivo de la comunidad”, afirma Rima Khoury, consejera general de.

Para Abramyan, fumar un narguile era un ritual adulto después de la cena que sus padres, de origen iraní, trajeron consigo cuando emigraron a Estados Unidos en la década de 1980. Las ornamentadas pipas de agua suelen tener varios metros de altura y tardan al menos 20 minutos en prepararse.

“Esto no es algo que los niños fumen en los baños de la escuela”, dijo. “No queremos que nuestros hijos fumen, pero ¿por qué no va a poder mi abuelo fumar su narguile en su patio?”.

Los grupos de estudio de la Biblia y la sección local del Rotary Club se reúnen regularmente en su salón de narguile de Tujunga, Garden on Foothill, que cuenta con quioscos al aire libre para familias y grupos. “Para los musulmanes que no beben alcohol o los que no quieren ir a clubes de striptease, este es un espacio seguro”, afirma.

Munchies Mart, la tienda que maneja a pocas cuadras vende pipas de narguile hechas a mano y tabaco de sabores como limonada de fresa, naranja pop y agua fresca, muy lejos del tabaco empapado de manzana que, recuerda, su abuela persa mezclaba en su cocina.

Utilizar las prácticas culturales para argumentar las exenciones de las políticas públicas no es nada nuevo, dijo Arnab Mukherjea, profesor asociado de salud pública en la Universidad Estatal de California-East Bay.

Pero dijo que las comunidades suelen sufrir cuando los intereses corporativos “utilizan la identidad cultural para comercializar un producto de consumo masivo”.

“Vas a cualquier ciudad universitaria”, dijo, “y los bares de narguile están llenos no de musulmanes practicantes, sino de chicos en edad universitaria que van allí a socializar, consumiendo sabores en goma de mascar y algodón de azúcar”.

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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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Pero, al igual que muchos bibliotecarios, vio mucho caos. A veces, los usuarios con enfermedades mentales no tratadas o drogados, escupían a los empleados o sufrían una sobredosis en los baños.

Recuerda que un compañero de trabajo recibió un puñetazo en la cara cuando volvía de su descanso para comer. Una tarde de 2017, un hombre se suicidó lanzándose al vacío desde el balcón del quinto piso de la biblioteca.

Dunseth se jubiló al año siguiente, a los 61 años. Un retiro anticipado después de una carrera de casi 40 años.

“La biblioteca pública debería ser un santuario para todos”, dijo. El problema era que ella y muchos de sus colegas ya no se sentían seguros haciendo su trabajo.

Las bibliotecas han sido durante mucho tiempo uno de los grandes igualadores de la sociedad, ya que ofrecen conocimientos a quien lo desee. Al ser edificios públicos, a menudo abiertos durante muchas horas, también se han convertido en refugio para las personas que no tienen otro lugar donde ir.

En los últimos años, ante la incesante demanda de servicios de protección social, líderes comunitarios han pedido a las bibliotecas que desempeñen ese papel, ampliando su ayuda, más allá de los libros y las computadoras, a las personas que viven en la calle.

En las grandes ciudades y en los pueblos pequeños, muchas ofrecen ahora servicios para acceder a vivienda, a cupones de alimentos, a la atención médica y, a veces, incluso a duchas o cortes de pelo. Los bibliotecarios, a su vez, han sido llamados a desempeñar el papel de trabajadores sociales de primera línea, terapeutas y guardias de seguridad.

Pero no todos los bibliotecarios están de acuerdo con estas obligaciones. Aunque muchos aceptan su nuevo rol —algunos llevan, voluntariamente, naloxona para revertir sobredosis de opioides—, otros se sienten abrumados y no están preparados para enfrentarse a clientes agresivos o inestables.

“Algunos de mis compañeros están muy comprometidos con ayudar a las personas, y son capaces de hacer el trabajo”, comentó Elissa Hardy, trabajadora social que hasta hace poco supervisaba un pequeño equipo que prestaba servicios en el sistema de bibliotecas públicas de Denver. La ciudad estima que se han salvado unas 50 vidas desde que, hace cinco años, el personal de las bibliotecas comenzó a formarse voluntariamente para responder a las sobredosis de drogas. Otros, según Hardy, simplemente no están informados de las realidades del trabajo. Se incorporan a la profesión imaginando las acogedoras y silenciosas bibliotecas de su juventud.

“Ese es el mundo en el que creen que van a vivir”, añadió.

En Estados Unidos, trabajan en bibliotecas públicas y colegios, universidades, museos, archivos gubernamentales y el sector privado, encargados de gestionar el inventario, ayudar a los visitantes a encontrar recursos y crear programas educativos. A menudo, el puesto requiere que tengan un máster o estudios especializados en educación.

Pero muchos no estaban preparados para atender a un nuevo tipo de cliente, ya que la adicción a las drogas, la psicosis no tratada y la falta de viviendas asequibles han hecho crecer la población de personas sin hogar en un amplio abanico de ciudades y suburbios del país, especialmente en la costa oeste.

Amanda Oliver es autora de “Overdue: Reckoning With the Public Library” (“Atrasado: ajuste de cuentas con la biblioteca pública”), donde relata los nueve meses que trabajó en una biblioteca de Washington, DC. Oliver dijo que, en ese tiempo, se le prohibió hablar públicamente de incidentes habituales, como clientes que se desmayaban por estar ebrios, o los que le gritaban a enemigos invisibles, o quienes llegaban a la biblioteca con bolsas infestadas de chinches.

Según Oliver, esta “negación generalizada de cómo son las cosas” para los administradores de la biblioteca fue una queja que escuchó, con frecuencia, entre los empleados.

El de 2022, liderado por un grupo de bibliotecarios de la ciudad de Nueva York, encuestó a los trabajadores de las bibliotecas urbanas y descubrió que casi el 70% había tratado con usuarios cuyo comportamiento era violento o agresivo, desde desplantes intimidatorios y acoso sexual hasta personas que sacaban pistolas y cuchillos o les lanzaban grapadoras. Pocos trabajadores dijeron sentirse apoyados por sus jefes.

“A medida que la red de protección social se ha ido desmantelando y se queda sin fondos, las bibliotecas han tenido que hacerse cargo de la situación”, escribieron los autores del estudio, y agregaron que la mayoría de las instituciones carecen de directrices prácticas para tratar los incidentes traumáticos que, con el tiempo, pueden provocar “fatiga de la compasión”.

Los administradores de las bibliotecas han empezado a reconocer el problema impartiendo formación y contratando a personal con experiencia en el trabajo social. Asegurarse de que el personal de las bibliotecas no se sintiera traumatizado fue una parte importante de su labor durante sus años en las bibliotecas de Denver, señaló Hardy. Ella y otros trabajadores sociales en bibliotecas de ciudades como San Francisco y Washington han organizado, en los últimos años, programas de formación para bibliotecarios sobre temas que van desde el cuidado personal hasta las estrategias para distensión de conflictos.

son mujeres, y el personal de las bibliotecas es mayor, casi un tercio de los empleados tiene más de 55 años. Como en muchas profesiones, los salarios no han podido seguir el ritmo del costo de vida. Según la American Library Association-Allied Professional Association, el salario medio de un bibliotecario público en Estados Unidos fue de , el año más reciente del que se dispone de datos.

Los estudios confirman que muchos bibliotecarios .

En el condado de Los Angeles, con más de 60,000 personas sin hogar, los últimos años han puesto a prueba los límites de un sistema de bibliotecas públicas con más de 80 sedes.

“El reto es que el nivel de necesidad se sale de lo normal”, afirmó John Szabo, bibliotecario de la ciudad de Los Angeles. “Desgraciadamente, no estamos plena y eficazmente capacitados para hacer frente a estos problemas”.

Las bibliotecas comenzaron su transición hace más de una década en respuesta al número de usuarios que buscaban baños y un respiro temporal a la vida en las calles. En 2009, San Francisco decidió abordar formalmente la situación contratando a un a tiempo completo.

Leah Esguerra dirige un equipo de “asociados de salud y seguridad”, que antes eran personas sin hogar, y que patrullan las 28 sedes de las bibliotecas de San Francisco, para poner en contacto a los usuarios, enfermos o necesitados, con servicios grandes y pequeños, desde camas temporales y tratamiento por adicciones hasta duchas públicas, un modelo que se ha copiado en ciudades de todo el mundo.

“La biblioteca es un lugar seguro, incluso para los que ya no confían en el sistema”, señaló Esguerra, que trabajó en una clínica comunitaria de salud mental antes de convertirse en la “señora de la biblioteca”, como la llaman a veces en la calle.

Pero la contratación de una trabajadora social no ha eliminado los numerosos problemas a los que se enfrentan los bibliotecarios de San Francisco. Por ello, la ciudad se ha vuelto más agresiva a la hora de establecer normas de comportamiento para los usuarios.

En 2014, el entonces alcalde Ed Lee pidió a los funcionarios de las bibliotecas que impusieran en respuesta a las contínuas quejas sobre conductas inapropiadas, incluyendo la exposición indecente y el orinar en los estantes. Poco después, los funcionarios publicaron un enmendado que enumeraba las sanciones para infracciones como dormir, pelear y “depositar fluidos corporales en la propiedad de la SFPL”.

La ciudad ha instalado seguridad adicional y ha tomado otras medidas, como bajar las puertas de los baños para prevenir el uso de drogas y el sexo e instalar cajas para desechar las agujas usadas, aunque sigue habiendo quejas sobre las condiciones de la biblioteca principal.

Algunas bibliotecas rurales también han tratado de hacer más accesibles los servicios sociales. En el condado de Butte, en la vertiente occidental de Sierra Nevada, al norte de California, los trabajadores de las bibliotecas utilizaron una subvención estatal de $25,000 para organizar sesiones informativas sobre problemas de salud mental como la depresión, la ansiedad y la esquizofrenia, y cómo ayudar a las personas a acceder al tratamiento.

Los libros sobre estos temas se marcaron con etiquetas verdes para que fueran más fáciles de encontrar, explicó la bibliotecaria Sarah Vantrease, que ayudó a crear el programa. Ahora trabaja como administradora de bibliotecas en el condado de Sonoma.

“La biblioteca”, dijo Vantrease, “no debería ser solo para los que les gusta leer”.

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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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La estudiante de segundo año de la universidad, que estaba pasando las vacaciones en casa, había tomado media pastilla que compró a un dealer a través de Snapchat. Resultó ser fentanilo, el poderoso opioide sintético que ayudó a que las muertes por sobredosis de drogas en los Estados Unidos .

“La envenenaron y a la persona que lo hizo no iba a pasarle nada”, dijo. “No pude soportarlo”.

Capelouto, quien se describe a sí mismo como políticamente moderado, dijo que la experiencia lo volvió cínico sobre la renuencia de California a imponer sentencias severas por delitos de drogas.

Así que el padre suburbano que una vez dedicó todo su tiempo a administrar su imprenta y criar a sus cuatro hijas, lanzó un grupo llamado y viajó a Sacramento en abril para cabildear por una legislación conocida como .

El proyecto de ley habría facilitado que los fiscales de California condenaran a los vendedores de drogas letales por cargos de homicidio.

La organización de Capelouto es parte de un movimiento nacional de padres que se convirtieron en activistas, que luchan contra la cada vez más mortal crisis de las drogas, y están desafiando la doctrina de California de que las drogas deben ser tratadas como un problema de salud en lugar de ser procesadas por el sistema de justicia penal.

Siguiendo el modelo de Mothers Against Drunk Driving, que generó un movimiento en la década de 1980, organizaciones como y buscan aumentar la conciencia pública e influir en las políticas sobre drogas. Un grupo, , rinde homenaje a MADD tomando prestadas sus siglas.

Estos grupos presionan a los legisladores estatales para que impongan sanciones más estrictas a los distribuidores y a las empresas de tecnología de cabildeo para permitir que los padres controlen las comunicaciones de sus hijos en las redes sociales.

Colocan cartels en las calles que culpan a los políticos por la crisis de las drogas y organizan contra los mercados de drogas al aire libre en , en Los Ángeles y el vecindario Tenderloin de San Francisco.

“Este problema se resolverá con los esfuerzos de base de las familias afectadas”, dijo Ed Ternan, quien lidera el grupo , con sede en Pasadena, que se enfoca en educar a los jóvenes sobre los peligros de las píldoras falsificadas.

Muchos padres se movilizaron después de una ola de muertes que comenzó en 2019. A menudo, se trataba de estudiantes de secundaria o universitarios que pensaban que estaban tomando OxyContin o Xanax comprados en las redes sociales, pero en realidad estaban tomando pastillas que contenían fentanilo.

La droga llegó por primera vez a la costa este hace casi una década, en gran parte a través del suministro de heroína, pero desde entonces los cárteles mexicanos han introducido productos farmacéuticos falsificados mezclados con el polvo altamente adictivo en California y Arizona para atraer nuevos clientes.

En muchos casos, las víctimas de sobredosis son estudiantes sobresalientes o atletas estrella de los suburbios, lo que da lugar a un ejército de padres educados y comprometidos que desafían el silencio y el estigma que rodea a las muertes por drogas.

Ternan no sabía casi nada sobre el fentanilo cuando su hijo de 22 años, Charlie, murió en el dormitorio de la casa de su fraternidad en la Universidad de Santa Clara unas semanas antes de que se graduara en la primavera de 2020.

Los familiares determinaron a partir de los mensajes en el teléfono de Charlie que había tenido la intención de comprar Percocet, un analgésico recetado que había tomado después de una cirugía de espalda dos años antes. Los socorristas dijeron que el estudiante universitario de 6 pies y 2 pulgadas, y 235 libras, murió media hora después de tomar una píldora falsificada.

Ternan descubrió una serie de muertes similares en otras comunidades de Silicon Valley. En 2021, 106 personas murieron por sobredosis de fentanilo en el condado de Santa Clara, frente a las 11 de 2018. Las muertes incluían a de la Universidad de Stanford y a en San José.

Con la ayuda de dos ejecutivos de Google que a causa de las píldoras mezcladas con fentanilo, Ternan convenció a Facebook, Instagram, TikTok, YouTube y otras plataformas de redes sociales para que donaran espacios publicitarios para mensajes de advertencia sobre medicamentos falsificados.

La presión de los grupos de padres también ha impulsado a Snapchat, con sede en Santa Mónica, a para detectar la venta de drogas y restricciones diseñadas para dificultar que los traficantes se dirijan a los menores.

Desde los primeros días de la epidemia de opioides, las familias de las personas que se enfrentan a la adicción y de las que han muerto por sobredosis se han apoyado mutuamente en los y en las plataformas en línea desde hasta . Ahora, las organizaciones familiares que surgieron de la crisis del fentanilo en California han comenzado a cooperar entre sí.

Recientemente se formó una red de padres y otros activistas que se hace llamar la liderada por , un autor y activista de Berkeley que se postula para gobernador como independiente.

Una crítica de las políticas progresistas de California es Jacqui Berlinn, una empleada de procesamiento legal en East Bay que inició , un nombre que eligió como homenaje a los logros de la fundadora de Mothers Against Drunk Driving, Candace Lightner, ama de casa de Fair Oaks cuya hija de 13 años fue asesinada en 1980 por un conductor ebrio.

El hijo de Berlinn, Corey, de 30 años, ha consumido heroína y fentanilo durante siete años en las calles de San Francisco. “Mi hijo no es basura”, dijo Berlinn. “Se merece recuperar su vida”.

Berlinn cree que la decisión de la ciudad de no acusar a los traficantes ha permitido que florezcan los mercados de narcóticos al aire libre en ciertos vecindarios y el consumo de drogas, en lugar de alentar a las personas que enfrentan adicciones a buscar ayuda.

En abril, el grupo de Berlinn gastó $25,000 para erigir una valla publicitaria en el exclusivo distrito comercial de Union Square. Sobre una resplandeciente toma nocturna del puente Golden Gate, el letrero dice: “Famosos en todo el mundo por nuestros cerebros, belleza y, ahora, fentanilo sucio muy barato”.

Este mes, el grupo instaló un letrero a lo largo de la Interestatal 80 en dirección a Sacramento que apunta al gobernador demócrata Gavin Newsom.

Reproduciendo la señalización utilizada en los parques nacionales, la cartel presenta un saludo de “Bienvenido al Campamento Fentanyl” contra una toma de un campamento para personas sin hogar. El grupo dijo que también rodeará el Capitolio estatal por un período no revelado.

Mothers Against Drug Deaths está pidiendo más opciones y fondos para el tratamiento de drogas y más arrestos de traficantes. Este último marcaría un giro brusco del evangelio de la “reducción de daños”, un enfoque de salud pública adoptado por funcionarios estatales y locales que considera que la abstención es poco realista.

En cambio, esta estrategia exige ayudar a las personas que enfrentan adicciones a mantenerse seguras a través de intercambios de agujas y naloxona, un fármaco para revertir la sobredosis que ha salvado miles de vidas.

Los fiscales progresistas Chesa Boudin en San Francisco y George Gascón en Los Ángeles han evitado encarcelar a los traficantes callejeros, a lo que llaman un juego sin sentido que castiga a las minorías pobres.

Los legisladores de California temen repetir los errores de la era de la guerra contra las drogas y han bloqueado una serie de proyectos de ley que endurecerían las sanciones por la venta de fentanilo. Dicen que la legislación lograría poco además de llenar las cárceles y prisiones del estado.

“Podemos encarcelar a la gente por mil años, y no evitará que la gente consuma drogas, y no evitará que mueran”, dijo el senador estatal Scott Wiener (demócrata de San Francisco). “Lo sabemos por experiencia”.

Algunos padres están de acuerdo. Después de ver a su hijo entrar y salir del sistema de justicia penal por cargos menores de drogas en la década de 1990, Gretchen Burns Bergman se convenció de que acusar a las personas por delitos menores de drogas, como la posesión, era contraproducente.

En 1999, la productora de desfiles de moda de San Diego inició , que ha abogado por la legalización de la marihuana y el fin de de California. Una década más tarde, formó , una coalición nacional. Hoy, sus dos hijos se han recuperado de la adicción a la heroína con la ayuda de un “apoyo compasivo” y trabajan como consejeros de drogas, dijo.

“He estado en esto el tiempo suficiente para ver el movimiento pendular”, dijo Burns Bergman sobre las opiniones cambiantes del público sobre la aplicación de la ley.

En diciembre, Brandon McDowell, de 22 años, de Riverside, fue arrestado y la tableta que mató a la hija de Matt Capelouto. McDowell fue acusado de distribuir fentanilo con resultado en muerte, lo que conlleva una sentencia mínima obligatoria de 20 años en una prisión federal.

Aunque Alexandra’s Law no logró salir del comité, Capelouto señaló que años se dedicaron años de cabildeo hasta que se aprobaron leyes más estrictas sobre conducir en estado de ebriedad. Prometió no renunciar al proyecto de ley que lleva el nombre de su hija, que escribía poesía y amaba a David Bowie.

“Voy a estar de nuevo frente a ellos”, dijo, “Cada año”.

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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.

— MADAD-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.”

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

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