Her nails clicking on the kitchen floor as she danced about, Lisa looked more like an exuberant puppy than the highly trained service animal that helps Clark-Gutierrez manage the symptoms of post-traumatic stress disorder.

“Having her now, it’s like I can go anywhere,” Clark-Gutierrez said. “And, yes, if somebody did come at me, I’d have warning — I could run.”

A growing body of research into PTSD and service animals paved the way for President Joe Biden to sign into law the Puppies Assisting Wounded Servicemembers for Veterans Therapy Act. The legislation, enacted in August, requires the Department of Veterans Affairs to open its service dog referral program to veterans with PTSD and to launch a five-year pilot program in which veterans with PTSD train service dogs for other veterans.

Clark-Gutierrez, 33, is among the 25 percent of female veterans who have reported experiencing while serving in the U.S. armed services.

Military sexual trauma, combat violence and brain injuries are some of the experiences that increase the risk that service members will develop . Symptoms include flashbacks to the traumatic event, severe anxiety, nightmares and hypervigilance — all normal reactions to experiencing or witnessing violence, according to psychologists. Someone receives a PTSD diagnosis when symptoms worsen or remain for months or years.

That’s what Clark-Gutierrez said happened to her after ongoing sexual harassment by a fellow airman escalated to a physical attack about a decade ago. A lawyer with three children, she said that to feel safe leaving her home she needed her husband by her side. After diagnosing Clark-Gutierrez with PTSD, doctors at VA hospitals prescribed a cascade of medications for her. At one point, Clark-Gutierrez said, her prescriptions added up to more than a dozen pills a day.

“I had medication, and then I had medication for the two or three side effects for each medication,” she said. “And every time they gave me a new med, they had to give me three more. I just couldn’t do it anymore. I was just getting so tired. So we started looking at other therapies.”

And that’s how she got her service dog, Lisa. Clark-Gutierrez’s husband, also an Air Force veteran, discovered the nonprofit group , which rescues dogs — many from kill shelters — and trains them to be service animals for veterans with PTSD. Lisa is one of about 700 dogs the group has paired with veterans dealing with symptoms caused by traumatic experiences.

“Now with Lisa we take bike rides, we go down to the park, we go to Home Depot,” said Clark-Gutierrez. “I go grocery shopping — normal-people things that I get to do that I didn’t get to do before Lisa.”

That comes as no surprise to Maggie O’Haire, an associate professor of human-animal interaction at Purdue University. Her research suggests that while service dogs aren’t necessarily a cure for PTSD, they do ease its symptoms. Among her is that veterans partnered with these dogs experience less anger and anxiety and get better sleep than those without a service dog. Another of her studies that service dogs lower cortisol levels in veterans who have been traumatized.

“We actually saw patterns of that stress hormone that were more similar to healthy adults who don’t have post-traumatic stress disorder,” O’Haire said.

A congressionally mandated VA study that focuses on service dogs’ impact on veterans with PTSD and was published this year suggests that those partnered with the animals experience less suicidal ideation and more improvement to their symptoms than those without them.

Until now, the federal dog referral program — which relies on nonprofit service dog organizations to pay for the dogs and to provide them to veterans for free — required that participating veterans have a physical mobility issue, such as a lost limb, paralysis or blindness. Veterans like Clark-Gutierrez who have PTSD but no physical disability were on their own in arranging for a service dog.

The pilot program created by the new federal law will give veterans with PTSD the chance to train mental health service dogs for other veterans. It’s modeled on a program at the VA hospital in Palo Alto, California, and will be offered at five VA medical centers nationwide in partnership with accredited service dog training organizations.

“This bill is really about therapeutic, on-the-job training, or ‘training the trainer,’” said Adam Webb, a spokesperson for Sen. Thom Tillis (R-N.C.), who introduced the legislation in the Senate. “We don’t anticipate VA will start prescribing PTSD service dogs, but the data we generate from this pilot program will likely be useful in making that case in the future.”

The Congressional Budget Office estimates the pilot program will cost the VA about $19 million. The law stops short of requiring the VA to pay for the dogs. Instead, the agency will partner with accredited service dog organizations that use private money to cover the cost of adopting, training and pairing the dogs with veterans.

Still, the law represents a welcome about-face in VA policy, said Rory Diamond, CEO of K9s for Warriors.

“For the last 10 years, the VA has essentially told us that they don’t recognize service dogs as helping a veteran with post-traumatic stress,” Diamond said.

PTSD service dogs are often confused with emotional support dogs, Diamond said. The latter provide companionship and are not trained to support someone with a disability. PTSD service dogs cost about $25,000 to adopt and train, he said.

Diamond explained that the command “cover” means “the dog will sit next to the warrior, look behind them and alert them if someone comes up from behind.” The command “block” means the dog will “stand perpendicular and give them some space from whatever’s in front of them.”

Retired Army Master Sgt. David Crenshaw of Kearny, New Jersey, said his service dog, Doc, has changed his life.

“We teach in the military to have a battle buddy,” Crenshaw said. “And these service animals act as a battle buddy.”

A few months ago, Crenshaw experienced this firsthand. He had generally avoided large gatherings because persistent hypervigilance is one symptom of his combat-caused PTSD. But this summer, Doc, a pointer and Labrador mix, helped Crenshaw navigate the crowds at Disney World — a significant first for Crenshaw and his family of five.

“I was not agitated. I was not anxious. I was not upset,” said Crenshaw, 39. “It was truly, truly amazing and so much so that I didn’t even have to even stop to think about it in the moment. It just happened naturally.”

Thanks to Doc, Crenshaw said, he no longer takes PTSD drugs or self-medicates with alcohol. Clark-Gutierrez said Lisa, too, has helped her quit using alcohol and stop taking VA-prescribed medications for panic attacks, nightmares and periods of disassociation.

The dogs actually save the VA money over time, Diamond said. “Our warriors are far less likely to be on expensive prescription drugs, are far less likely to use other VA services and far more likely to go to school or go to work. So it’s a win-win-win across the board.”

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“It was even better than the hospital,” Yetenekian said, laughing. “They were constantly reaching out — it’s time for you to do your vitals, or it’s time for you to take your medications.”

Yetenekian contracted the virus that causes covid in December, after friends invited her family to an afternoon barbecue. It seemed like a safe antidote to the isolation caused by the pandemic. But the day after the gathering, the host came down with a fever. A test confirmed it was covid. Within two weeks, Yetenekian’s husband and two teenage children developed mild symptoms. She came down with a more serious case, however, and her blood oxygen plummeted to dangerously low levels.

She went to the hospital at Adventist Health in Glendale, where doctors told her she would need an intravenous infusion of the antiviral drug remdesivir and constant monitoring. And it surprised Yetenekian when her doctor offered to move all her care home to be monitored virtually.

Doctors and nurses at a command center nearly 200 miles away in the San Joaquin Valley town of Hanford, California, managed Yetenekian’s care as part of a new federal effort aimed at freeing up hospital beds during public health emergencies. Under the model, about 60 illnesses — including covid — qualify for home treatment.

“Heart failure, pneumonia, skin infections — those are all patient populations we can safely care for in the home,” said , who leads the Mayo Clinic’s new home-based care program in rural Wisconsin.

Hospital care at home is nothing new for patients with low-level health needs. But since the pandemic began, a growing number of health systems, including Adventist Health, the Mayo Clinic and Kaiser Permanente (which is not affiliated with KHN) are offering people with more serious health conditions hospital-level treatment in the comfort of their homes.

Paulson said that, once her patients understand home care does not mean less care, they eagerly embrace it.

“Especially for patients who have been in the hospital a lot, to know that they can actually go home and sleep in their own bed and be with their family and have their pets by their side, it’s just really reassuring,” Paulson said.

And studies suggest at-home care provides to provide than traditional inpatient care.

“This is actually a higher level of touch from physicians and advanced practitioners,” said , a physician and health policy fellow at the Brookings Institution.

Regular video conferencing and 24/7 monitoring is augmented by twice-daily, in-person visits by nurses and other health workers who provide basic care — such as antibiotics — that can’t be given virtually.

“This isn’t just sending Mom or Dad to the bedroom,” Patel said.

The technology infrastructure is key, Patel said, for patients and doctors. It includes Wi-Fi phones that ring directly into a hospital’s command center, iPads that allow videoconferencing with health professionals and wearable devices with emergency call buttons.

is co-founder of Medically Home, a Boston-based technology company that supports at-home programs for Adventist Health. Mayo Clinic and Kaiser Permanente announced on May 13 a combined $100 million investment in Medically Home to help expand the service to other health systems. Rakowski said another selling point of the at-home care model is that there are no facility transfers as patients heal.

“We stay with the patient until they’re fully recovered, and that averages anywhere from 20 to 30 days, sometimes longer,” he said. “So, we substitute not just for the hospital, but for all the care that follows.”

Still, the program is not a good fit for every patient. To be eligible for care at home, patients must live within 30 minutes of emergency care; they also need high-speed internet and, said Patel, they can’t be too sick.

“This can’t be something where it’s so complicated that you are monitoring a patient, worried that they could crash and need to be in the ICU within minutes,” she said.

But for moderate covid and dozens of other conditions, acute hospital care at home is likely to become a more common option as more health systems adopt the program and even more diseases are included. It is offered now in 30 states.

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He did not.

What he got instead from those town halls last month was encouragement to return to class at the institution affectionately known as Mizzou. The university, in Columbia, would be testing only people with symptoms, and at that point, the university said people who test positive off campus to inform the school.

“It feels like the university doesn’t really care whether we get sick or not,” said El-Jayyousi, who is scheduled for two in-person classes, and lives at home with his parents and 90-year-old grandmother.

He’s seen the studies from researchers at Yale and Harvard that suggest testing needs to be much more widespread. He asked his instructors if he could join lectures remotely once classes begin Monday. One was considering it; the other rejected it.

“It was kind of very dismissive, like ‘so what?’” El-Jayyousi said.

But it’s an enormous “so what?” packed with fear and unknowns for Jayyousi and some 20 million other students enrolled in some level of postsecondary education in America, if they are not already online only.

As with the uncoordinated and chaotic national response to the COVID-19 pandemic, higher education has no clear guidance or set of standards to adhere to from the federal government or anywhere else. Policies for reentry onto campuses that were abruptly shut in March are all over the map.

Hundreds Undecided

According to the , or C2i, a project of Davidson College that monitors how higher ed is responding to the pandemic, there is nothing resembling a common approach. Of 2,958 institutions it follows, 151 were planning to open fully online, 729 were mostly online and 433 were taking a hybrid approach. Just 75 schools were insisting on students attending fully in person, and 614 were aiming to be primarily in-person. Some 800 others were still deciding, just weeks before instruction was to start.

The decisions often have little correlation with the public health advisories in the region. Mizzou, which is in an area with recent COVID spikes, is holding some in-person instruction and has nearly 7,000 students signed up to live in dorms and other university-owned housing. Harvard, in a region with extremely low rates of viral spread, has opted to go all online and allowed students to defer a year.

The specific circumstances colleges and universities face are as much determined by local fiscal and political dictates as by medicine and epidemiology. It is often unclear who is making the call. So it’s every-student-for-herself to chart these unknown waters, even as students (or their families) have written tuition checks for tens of thousands of dollars and signed leases for campus and off-campus housing.

And the risks — health, educational and financial — boomerang back on individual students: Two weeks after University of North Carolina students, as instructed, returned to the flagship campus in Chapel Hill with the promise of at least some in-person learning, all classes went online. Early outbreaks surged from a few students to more than 130 in a matter of days. Most undergrads have about a week to clear out of their dorms.

“It’s really tough,” said neuroscience major Luke Lawless, 20. “Chapel Hill is an amazing place, and as a senior it’s tough to know that my time’s running out — and the virus only adds to that.”

Location, Location, Location

C2i’s creator, Davidson education Assistant Professor , said the extreme diversity of approaches comes from the sheer diversity of schools, the penchant of many to follow the leads of more prestigious peers, and local politics.

“Some states have very strong and stringent mask requirements. Some have stronger stay-at-home orders. Others are sort of leaving it up to localities. So the confluence of politics, institutional isomorphism — that imitation — and different needs that the institutions have are driving the differences,” Marsicano said.

Location matters a lot, too, Marsicano said, pointing to schools like George Washington University and Boston University in urban settings where the environment is beyond the control of the school, versus a place like the University of the South in remote, rural Sewanee, Tennessee, where 90% of students will return to campus.

“It’s a lot easier to control an outbreak if you are a fairly isolated college campus than if you are in the middle of a city,” Marsicano said.

Student behavior is another wild card, Marsicano said, since even the best plans will fail if college kids “do something stupid, like have a massive frat party without masks.”

“You’ve got student affairs professionals across the country who are screaming at the top of their lungs, ‘We can’t control student behavior when they go off campus’” Marsicano said.

Another factor is a vacuum at the federal level. Although the Department of Education says Secretary Betsy DeVos has held dozens of calls with governors and state education superintendents, there’s no sign of an attempt to offer unified guidance to colleges beyond that links to relaxed regulatory requirements and anodyne fact sheets from the Centers for Disease Control and Prevention on preventing viral spread.

Even the money that the department notes it has dispensed — $30 billion from Congress’ CARES Act — is weighted toward K-12 schools, with about $13 billion for higher education, including student aid.

The U.S. Senate adjourned last week until Sept. 8, having never taken up a House-passed relief package that included some $30 billion for higher education. A trio of Democratic senators, including Sen. Elizabeth Warren, standards on college campuses.

No Benchmarks

Campus communities with very different levels of contagion are making opposite calls about in-person learning. Mizzou’s Boone County has seen more than 1,400 confirmed COVID cases after a spike in mid-July. According to the Harvard Global Health Institute’s COVID risk map, Boone has accelerated spread, with 14 infections per day per 100,000 people. The institute advises stay-at-home orders or rigorous testing and tracing at such rates of infection. Two neighboring counties were in the red zone recently, with more than 25 cases per day per 100,000 people. Mizzou has left it up to deans whether classes will meet in person, making a strong argument for face-to-face instruction.

Meanwhile, Columbia University in New York City opted for all online instruction, even though the rate of infection there is a comparatively low 3.8 cases per day per 100,000 people.

Administrators at Mizzou considered and rejected mandatory testing. “All that does is provide one a snapshot of the situation,” University of Missouri system President Mun Choi said in one of the town halls.

Mizzou has an in-house team that will carry out case investigation and contact tracing with the local health department. This week, following questions from the press and pressure from the public, the university announced any positive COVID test to the school.

Who Do You Test? When?

CDC guidance for higher education suggests there’s not enough data to know whether testing everyone is effective, but some influential researchers, such as those at Harvard and Yale, disagree.

“This virus is subject to silent spreading and asymptomatic spreading, and it’s very hard to play catch-up,” said Yale professor , who studies public health policy. “And so thinking that you can keep your campus safe by simply waiting until students develop symptoms before acting, I think, is a very dangerous game.”

conducted by Paltiel and his colleagues show that, of all the factors university administrators can control — including the sensitivity and specificity of COVID-19 tests — the frequency of testing is most important.

He’s “painfully aware” that testing everyone on campus every few days sets a very high bar — logistically, financially, behaviorally — that may be beyond what most schools can reach. But he says the consequences of reopening campuses without those measures are severe, not just for students, but for vulnerable populations among school workers and in the surrounding community.

“You really have to ask yourself whether you have any business reopening if you’re not going to commit to an aggressive program of high-frequency testing,” he said.

The Fighting — And Testing — Illini

Some institutions that desperately want students to return to campus are backing the goal with a maximal approach to safety and testing.

About a four-hour drive east along the interstates from Mizzou is the University of Illinois at Urbana-Champaign, whose sports teams are known as the Fighting Illini.

Weeks ago, large white tents with signs reading “Walk-Up COVID-19 Testing” have popped up across campus; there students take a simple saliva test.

“This seems to be a lot easier than sticking a cotton swab up your nose,” graduate student Kristen Muñoz said after collecting a bit of her saliva in a plastic tube and sealing it in a bag labeled “Biohazard.”

In just a few hours, she got back her result: negative.

The school plans to offer free tests to the 50,000 students expected to return this month, as well as some 11,000 faculty and staff members.

“The exciting thing is, because we can test up to 10,000 per day, it allows the scientist to do what’s really the best for trying to protect the community as opposed to having to cut corners, because of the limitations of the testing,” said University of Illinois chemist , who helped develop the , which received emergency use authorization from the federal Food and Drug Administration this week.

The test is similar to one designed by Yale and funded by the NBA that cleared the FDA hurdle just before the Illinois test. Both Yale and Illinois hope aggressive testing will allow most undergraduate students to live on campus, even though most classes will be online.

University of Illinois epidemiologist said they are following data that suggest campuses need to test everyone every few days because the virus is not detectable in infected people for three or four days.

“But about two days after that, your infectiousness peaks,” she said. “So, we have a very small window of time in which to catch people before they have done most of the infection that they’re going to be doing.”

Campus officials accepted Smith’s recommendation that all faculty, staffers and students participating in any on-campus activities be required to get tested twice a week.

Illinois can do that because its test is convenient and not invasive, which spares the campus from using as much personal protective equipment as the more invasive tests require, Burke said. And on-site analysis avoids backlogs at public health and commercial labs.

Muddled in the Middle

Most other colleges fall somewhere between the approaches of Mizzou and the University of Illinois, and many of their students still are uncertain how their fall semester will go.

At the University of Southern California, a private campus of about 48,500 students in Los Angeles, officials had hoped to have about 20% of classes in person — but the county government , insisting on for reopening than the statewide standards.

If students eventually are allowed back, they will have to show a recent coronavirus test result that they obtained on their own, said Dr. Sarah Van Orman, chief health officer of USC Student Health.

They will be asked to do daily health assessments, such as fever checks, and those who have been exposed to the virus or show symptoms will receive a rapid test, with about a 24-hour turnaround through the university medical center’s lab. “We believe it is really important to have very rapid access to those results,” Van Orman said.

At California State University — the nation’s largest four-year system, with 23 campuses and nearly a half-million students — officials decided to move nearly all its fall courses online.

“The first priority was really the health and safety of all of the campus community,” said Mike Uhlenkamp, spokesperson for the CSU Chancellor’s Office. About 10% of CSU students are expected to attend some in-person classes, such as nursing lab courses, fine art and dance classes, and some graduate classes.

Uhlenkamp said testing protocols are being left up to each campus, though all are required to follow local safety guidelines. And without a medical campus in the system, CSU campuses do not have the same capacity to take charge of their own testing, as the University of Illinois is doing.

For students who know they won’t be on campus this fall, there is regret at lost social experiences, networking and hands-on learning so important to college.

But the certainty also brings relief.

“I don’t think I would want to be indoors with a group of, you know, even just a handful of people, even if we have masks on,” said Haley Gray, a 28-year-old graduate student at the University of California-Berkeley starting the second year of her journalism program.

She knows she won’t have access to Berkeley’s advanced media labs or the collaborative sessions students experience there. And she said she realized the other day she probably won’t just sit around the student lounge and strike up unexpected friendships.

“That’s a pretty big bummer but, you know, I think overall we’re all just doing our best, and given the circumstances, I feel pretty OK about it,” she said.

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We laughed and had fun during our half-hour FaceTime meetup. But unlike our pre-pandemic visits, we now worried out loud about a lot of things — like our millennial-aged kids: their health and jobs. And what about the fragile elders, the economy? Will life ever return to ‘normal’?

“It feels like a free fall,” said , a Santa Rosa, California, psychotherapist. “What we once held as solid is no longer something we can rely upon.”

The coronavirus pandemic sweeping the globe has not only left many anxious about life-and-death issues, but it also has left people struggling with a host of less obvious, existential losses as they heed stay-home warnings and wonder how bad all this will get.

To weather these uncertain times, it’s important to acknowledge and grieve lost routines, social connections, family structures and our sense of security — and then create new ways to move forward — said interfaith chaplain and trauma counselor .

“We need to recognize that mixed in with all the feelings we’re having of anger, disappointment, perhaps rage, blame and powerlessness is grief,” said Daniel, who works with the dying and bereaved.

Left unrecognized and unattended, grief can negatively affect “every aspect of our being — physically, cognitively, emotionally, spiritually,” said , a Philadelphia psychologist specializing in grief counseling.

Yet with our national focus on the daily turn of events as the new coronavirus spreads and with the chaos it has brought, these underlying or secondary losses may escape us. People who are physically well may not feel entitled to their emotional upset over the disruption of normal life. Yet, Lott argued, it’s important to honor our own losses even if those losses seem small compared with others.

“We can’t heal what we don’t have an awareness of,” said Lott.

Recognize Our Losses

Whether we’ve named them or not, these are some of the communitywide losses many of us are grieving. Consider how you feel when you think of these.

Social connections. Perhaps the most impactful of the immediate losses as we hunker down at home is the separation from close friends and family. “Children aren’t able to play together. There’s no in-person social engagement, no hugging, no touching — which is disruptive to our emotional well-being,” said Daniel.

Separation from our colleagues and office mates also creates a significant loss. Said Lott: “Our work environment is like a second family. Even if we don’t love all the people we work with, we still depend on each other.”

Habits and habitat. With the world outside our homes no longer safe to inhabit the way we once did, Daniel said, we’ve lost our “habits and habitats.” We can no longer engage in our usual routines and rituals. And no matter how mundane they may have seemed — whether grabbing a morning coffee at the local cafe, driving to work or picking up the kids from school — routines help define your sense of self in the world. Losing them, Daniel said, “shocks your system.”

Assumptions and security. We go to sleep assuming that we’ll wake up the next morning, “that the sun will be there and your friends will all be alive and you’ll be healthy,” Weller said. But the spread of the coronavirus has shaken nearly every assumption we once counted on. “And so we’re losing our sense of safety in the world and our assumptions about ourselves,” he said.

Trust in our systems. When government leaders, government agencies, medical systems, religious bodies, the stock market and corporations fail to meet public expectations, citizens can feel betrayed and emotionally unmoored. “We are all grieving this loss,” Daniel said.

Sympathy for others’ losses. Even if you’re not directly affected by a particular loss, you may feel the grief of others, including that of displaced workers, of health care workers on the front lines, of people barred from visiting older relatives in nursing homes, of those who have already lost friends and family to the virus, and of those who will.

4 Ways To Honor Your Grief

Once you identify the losses you’re feeling, look for ways to honor the grief surrounding you, grief experts urge.

Bear witness and communicate. Sharing our stories is an essential step, Daniel said. “If you can’t talk about what’s happened to you and you can’t share it, you can’t really start working on it,” Daniel said. “So communicate with your friends and family about your experience.”

It can be as simple as picking up the phone and calling a friend or family member, said Weller. He suggests simply asking for and offering a space in which to share your feelings without either of you offering advice or trying to fix anything for the other.

“Grief is not a problem to be solved,” he said. “It’s a presence in the psyche awaiting, witnessing.”

For those with robust social networks, Daniel suggests gathering a group of friends virtually to share these losses together. Using apps like Zoom, Skype, FaceTime or Facebook Live, virtual meetups are easy to set up daily or weekly.

Write, create, express. Whether you’re an extrovert or introvert, keeping a written or recorded journal of these days offers another way to express, to identify and to acknowledge loss and grief.

And then there’s art therapy, which can be especially helpful for children unable to express themselves well with words, and also for teens and even many adults. “Make a sculpture, draw a picture or create a ceremonial object,” said Daniel, who often incorporates shamanic ceremonies into grief workshops she conducts.

Another exercise she often uses in grief workshops is a simple one in which participants use their breath to blow their sadness, fear and anger into a rock they then throw away.

“What this does is takes all that intense, painful energy out of your body and into an inanimate object that they symbolically throw far away from themselves,” Daniel said.

Meditate. Regular meditation or just taking time to slow down and take several deep, calming breaths throughout the day also works to lower stress — and is available to everyone, Lott said. For beginners who want guidance, she suggests downloading a meditation app onto your smartphone or computer.

Be open to joy. And finally, Lott urges, make sure to let joy and gratitude into your life during these challenging times. Whether it’s a virtual happy hour, teatime or dance party, reach out to others, she said.

“If we can find gratitude in the creative ways that we connect with each other and help somebody,” she said, “then we can hold our grief better and move through it with less difficulty and more grace.”

This story was produced in partnership with NPR and Kaiser Health News.

Stephanie O’Neill is the recipient of a journalism fellowship at the Natural Hazards Center at the University of Colorado-Boulder, supported by .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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So she was surprised to hear what sounded like raindrops tapping her roof a short time later. Holcomb, 56, stepped outside to investigate and saw a chunk of pine bark floating down from the sky.

“It was about 3 inches by 2 inches,” she said. “And it was smoking.”

It was her first glimpse of the approaching wildfire that would become the deadliest and most destructive in California history — one she continues to relive in debilitating nightmares and flashbacks.

The Camp Fire virtually incinerated Paradise, a town of 27,000. It killed 85 people in the region — many of them elderly. Most died in their homes — others while fleeing in their cars or trying to flee on foot.

For thousands of residents, the terror of sitting in traffic jams as the wildfire bore down left emotional scars. “Everyone who experienced this went through trauma,” said Linnea Duncan, a licensed clinical social worker who fled the fast-moving firestorm from her home in Magalia, a community just north of Paradise.

Dr. Sandro Galea, dean of Boston University’s School of Public Health, said: “We would expect to find a high burden of post-traumatic stress disorder and depression.”

Galea, a leading researcher in the field of mass trauma and disaster, said the consequences for individuals can vary depending on factors such as the intensity of their experience, the type of support available to them after the disaster and whether the community comes together in the recovery and rebuilding process.

For Holcomb, it took nearly three hours to escape Paradise as smoke from burning houses, cars and brush turned day to night and cut visibility to mere feet. Barely able to see the road, she got behind a large truck — its tail lights her guide. As she watched the flames devour nearly everything around her, she could hear residential propane tanks exploding like steel-encased kernels of popcorn.

“You could hear ‘Boom, boom, boom,’” she said.

Just as she got out of the flames, her truck caught fire. Holcomb pulled onto the median of the highway and jumped out in time to save herself and her cat. A man she didn’t know told her to get into his truck, and together they made it to safety. In the commotion, she left a backpack next to her burning truck. It contained treasures: her mother’s Bible, her grandfather’s Purple Heart medal from World War I and photographs of both of them.

Diagnosis: PTSD

Nightmares and flashbacks in the immediate aftermath of a disaster are normal, said Barbara Rothbaum, director of a trauma and anxiety recovery program at Emory University School of Medicine. So too are irritability, anger, hyper-vigilance and problems with sleep and concentration. But when these symptoms persist for at least a month, the diagnosis can be post-traumatic stress disorder, or PTSD. First acknowledged by America’s mental health community in 1980, it’s the one mental health disorder predicated on exposure to traumatic events.

For most people, Rothbaum said, the psychological distress will fade. But for others, especially those who avoid thinking, speaking or writing about the event, symptoms may stick around for years, affecting their relationships, their work and their ability to heal.

“It’s very similar to the grief process,” Rothbaum said. “We don’t think there’s any way to the other side of the pain except through it.”

In the general population, Galea said, about 10% of those with direct exposure to a disaster will experience PTSD. But among children, women and those with prior mental illness, susceptibility to disaster-induced PTSD is significantly higher,

“It’s the magnitude of a disaster that oftentimes can help us to predict how severe the mental health distress is going to be among affected populations,” said sociology professor Lori Peek, director of the Natural Hazards Center at the University of Colorado at Boulder.

And in Paradise, the “magnitude of the disaster” was staggering.

Paradise officials report that 9 in 10 homes burned down in this middle- to low-income town popular with retirees.

“It’s been pretty traumatic,” said Elissa Crane, who lost the low-income rental she shared in Paradise with her husband and her disabled adult son. The family has been staying in an insurance-paid hotel since November as they search for an affordable apartment for themselves and their two cats. And now, with temporary housing insurance about to run out, they’re considering a permanent move to Idaho.

“We are animals and our nests are very important to us,” Rothbaum said. “One of the most stressful things you can do to an animal is mess up its nest.”

Martha Bryant’s house was one of three remaining in a ravaged neighborhood. On her first visit back, she said, she failed to recognize her own house.

She continues to have nightmares; traffic jams trigger panic attacks.

“What I remember the most is just the sheer fear and panic and my heart pounding,” said Bryant, 60, a third-generation resident of Paradise. “Nobody was moving. And I was just screaming, ‘Move! Move! Get going! Move!’”

She said she knows she needs counseling, but life’s been too full of other decisions to seek it out.

In a 2017 study published in JAMA Psychiatry, Galea and colleagues found that one way to address the psychological consequences of disaster is through “stepped care,” which screens survivors as they move through the recovery process, “so that you can direct them to the care they need, when they have that need,” said Galea.

Providing regular mental health treatment — including practical approaches like cognitive behavior therapy — is one of two key steps to recovery. The other, Galea said, is through restoring a community’s social and economic functioning.

Sociologist Peek, who studied PTSD after Hurricane Katrina, said for those who want to return to Paradise, participation in community-wide conversations is essential.

Virtual town halls helped people displaced by the 2005 hurricane participate in the recovery, Peek said. “It was those moments of connection and the sense of cultural familiarity that sometimes made a big difference in terms of the emotional healing process,” she said.

The seems to be filling that role. In addition to providing notices about building regulations, safety issues and where to get free drinking water, it’s acting as a public forum where people can participate in live planning meetings and discussions about the town’s future. Social worker Linnea Duncan is part of aÌýÌýoffering free treatment for Paradise residents.

For Carol Holcomb, though, there will be no going home to Paradise. She is healing — getting treatment for PTSD symptoms and, thanks to a thoughtful person who put the backpack she’d left on the median back in her burned-out truck, she recovered some of her family’s treasures.

But Holcomb won’t rebuild, she said. She is instead looking for a home in a farming community with trees in orchards, which can resist a wildfire. “I can’t live in the forest again,” said Holcomb. “I just can’t.”

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“It’s very painful, sometimes I can’t even open my hand,” Avedon said.

So for the second time in two months, she’s climbed on board a bus that provides seniors at the Laguna Woods Village retirement community in Orange County, Calif., with a free shuttle to a nearby marijuana dispensary.

The retired manager of an oncology office says she’s seeking the same relief she saw cancer patients get from smoking marijuana 25 years ago.

“At that time [marijuana] wasn’t legal, so they used to get it off their children,” she said with a laugh. “It was fantastic what it did for them.”

Avedon, who doesn’t want to get high from anything she uses, picked up a topical cream on her first trip that was sold as a pain reliever. It contained cannabidiol, or CBD, but was formulated without THC, or tetrahydrocannabinol, marijuana’s psychoactive ingredient.

“It helped a little,” she said. “Now I’m going back for the second time hoping they have something better.”

As more states legalize marijuana for medical or recreational use — 30 states plus the District of Columbia to date — the cannabis industry is booming. AmongÌýÌýof users: people over 50, with especially steep increases among those 65 and older. And some dispensaries are tailoring their pitches to seniors like Avedon who are seeking alternative treatments for their aches, pains and other medical conditions.

On this particular morning, about 35 seniors climb on board the free shuttle — paid for by Bud and Bloom, a licensed cannabis dispensary in Santa Ana. After about a half-hour drive, the large white bus pulls up to the parking lot of the dispensary.

About half of the seniors on board today are repeat customers; the other half are cannabis newbies who’ve never tried it before, said Kandice Hawes, director of community outreach for Bud and Bloom.

“Not everybody is coming to be a customer,” Hawes said. “A lot are just coming to be educated.”

Among them, Layla Sabet, 72, a first-timer seeking relief from back pain that keeps her awake at night, she said.

“I’m taking so much medication to sleep and still I can’t sleep,” she said. “So I’m trying it for the back pain and the sleep.”

Hawes invited the seniors into a large room with chairs and a table set up with free sandwiches and drinks. As they ate, she gave a presentation focused on the potential benefits of cannabis as a reliever of anxiety, insomnia and chronic pain and the various ways people can consume it.

Several vendors on site took turns speaking to the group about the goods they sell. Then, the seniors entered the dispensary for the chance to buy everything from old-school rolled joints and high-tech vaporizer pens to liquid sublingual tinctures, topical creams and an assortment of sweet, cannabis-infused edibles.

Jim Lebowitz, 75, is a return customer who suffers pain from back surgery two years ago.

He prefers to eat his cannabis, he said.

“I got chocolate and I got gummies,” he told a visitor. “Never had the chocolate before, but I’ve had the gummies and they worked pretty good.”

“Gummies” are cannabis-infused chewy candies. His contain both the CBD and THC, two active ingredients in marijuana.

Derek Tauchman rings up sales at one of several Bud and Bloom registers in the dispensary. Fear of getting high is the biggest concern expressed by senior consumers, who make up the bulk of the dispensary’s new business, he said.

“What they don’t realize is there’s so many different ways to medicate now that you don’t have to actually get high to relieve all your aches and pains,” he said.

But despite such enthusiasm, marijuana isn’t well researched, said Dr. David Reuben, the Archstone Foundation professor of medicine and geriatrics at UCLA’s David Geffen School of Medicine.

While cannabis is legal both medically and recreationally in California, it remains a Schedule 1 substance — meaning it’s illegal under federal law. And that makes it harder to study.

The limited research that exists suggests that marijuana may be helpful in treating pain and nausea, according to aÌýÌýpublished last year by the National Academies of Sciences, Engineering and Medicine. Less conclusive research points to it helping with sleep problems and anxiety.

Reuben said he sees a growing number of patients interested in using it for things like anxiety, chronic pain and depression.

“I am, in general, fairly supportive of this because these are conditions [for which] there aren’t good alternatives,” he said.

But Reuben cautions his patients that products bought at marijuana dispensaries aren’t FDA-regulated, as are prescription drugs. That means dose and consistency can vary.

“There’s still so much left to learn about how to package, how to ensure quality and standards,” he said. “So the question is how to make sure the people are getting high-quality product and then testing its effectiveness.”

And there are risks associated with cannabis use too, saidwho directs the Substance Abuse and Mental Health Services Administration.

“When you have an industry that does nothing but blanket our society with messages about the medicinal value of marijuana, people get the idea this is a safe substance to use. And that’s not true,” she said.

Side effects can include increased heart rate, nausea and vomiting, and with long-term use, there’s a potential for addiction, some studies say.ÌýÌýthat between 9 and 30 percent of those who use marijuana may develop some degree of marijuana use disorder.

Still, Reuben said, if it gets patients off more addictive and potentially dangerous prescription drugs — like opioids — all the better.

Jim Levy, 71, suffers a pinched nerve that shoots pain down both his legs. He uses a topical cream and ingests cannabis gelatin capsules and lozenges.

“I have no way to measure, but I’d say it gets rid of 90 percent of the pain,” said Levy, who — like other seniors here — pays for these products out-of-pocket, as Medicare doesn’t cover cannabis.

“I got something they say is wonderful and I hope it works,” said Shirley Avedon. “It’s a cream.”

The price tag: $90. Avedon said if it helps ease the carpal tunnel pain she suffers, it’ll be worth it.

“It’s better than having surgery,” she said.

Precautions To Keep In Mind

Though marijuana use remains illegal under federal law, it’s legal in some form in 30 states and the District of Columbia. And a growing number of Americans are considering trying it for health reasons. For people who are, doctors advise the following cautions.

Talk to your doctor.ÌýTell your doctor you’re thinking about trying medical marijuana. Although he or she may have some concerns, most doctors won’t judge you for seeking out alternative treatments.

Make sure your prescriber is aware of all the medications you take. Marijuana might have dangerous interactions with prescription medications, particularly medicines that can be sedating, said Dr. Benjamin Han, a geriatrician at New York University School of Medicine who studies marijuana use in the elderly.

Watch out for dosing.ÌýOlder adults metabolize drugs differently than young people. If your doctor gives you the go-ahead, try the lowest possible dose first to avoid feeling intoxicated. And be especially careful with edibles. They can have very concentrated doses that don’t take effect right away.

Elderly people are also more sensitive to side effects. If you start to feel unwell, talk to your doctor right away. “When you’re older, you’re more vulnerable to the side effects of everything,” Han said. “I’m cautious about everything.”

Look for licensed providers.ÌýIn some states like California, licensed dispensaries must test for contaminants. Be especially careful with marijuana bought illegally. “If you’re just buying marijuana down the street … you don’t really know what’s in that,” said Dr. Joshua Briscoe, a palliative care doctor at Duke University School of Medicine who has studied the use of marijuana for pain and nausea in older patients. “Buyer, beware.”

Bottom line: The research on medical marijuana is limited. There’s even less we know about marijuana use in older people. Proceed with caution.

Jenny Gold and Mara Gordon contributed to this report.

This story is part of a partnership that includes and Kaiser Health News.

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“So you have to take your block of wood, shape it, sand it, paint it, use your imagination,” Lopez said, pointing to some favorites from derbies past that sit on a shelf in his home office — cars in the shape of an ice cream cone, a penguin and an Altoids peppermint box.

But one derby project lives in infamy: an S. Pellegrino bottle on wheels. It was the brainchild of his son Theo, then 9, in the fall of 2016, a time when Lopez recalls he was frantically busy at work.

“I was in a hurry and I did a horrible thing,” he said, recalling how his hand slipped as he was using a handheld power tool called a router with a fast-spinning, blade that shaves and shapes wood. He had flipped the machine over to try to save time. Improvising was a bad idea.

After surgery and a two-day hospital stay, Lopez returned home with his pinkie finger sewn together at an odd angle and his right hand immobilized in a cast.

Then, about a week later, it was déjà vu — Theo seriously injured his hand carving a Halloween pumpkin.

“My knife got stuck and my fingers slipped down the blade,” Theo recalled. He cut down to the tendon of his pinkie finger and required a complex surgical repair. Surprisingly, he said it didn’t hurt.

Following their surgeries, doctors ordered father and son to undertake numerous rounds of occupational therapy to help them regain full use of their hands.

For Theo, therapy lasted about a year. For Lopez, it was several months and then repeated after follow-up surgery. The healing went well for both, and Lopez was pleased. Lopez has insurance through the Writers Guild of America, and has always been happy with its low premiums and deductibles. He wasn’t worried about coverage for this specialized occupational therapy that both father and son clearly needed.

And then the bills came.

Patients: Angel Dean Lopez, a television writer, Los Angeles. Theo Lopez, 11, student, Los Angeles.

Total bill: $10,190 for occupational therapy for two patients, father and son. Of that total, the Lopez family paid $8,561 — $4,836 for son Theo and $3,725 for dad Angel.

Service providers: Children’s Hospital Los Angeles for Theo Lopez; Cedars-Sinai Medical Center Hand Therapy Clinic for Angel Dean Lopez.

Medical procedures: Angel had reconstructive plastic surgery on three fingers as well as a second surgery to remove a pin stabilizing his fourth finger; he was in a cast for two months. Theo also had reconstructive plastic surgery to repair his tendon.

After such injuries, patients typically need sessions of occupational therapy where specialists use techniques such as massage, strengthening and stretching exercises to regain normal function and movement. Both father and son needed custom splints made and tweaked by the therapists throughout the healing.

Lopez said if it weren’t for the odd coincidence of two family members requiring the same medical care at the same time, he may have let all this slide. But the financial double whammy has left him facing thousands in out-of-pocket costs that he wasn’t expecting.

What Gives: Lopez’s Writers Guild of America insurance covers and paid $60 for each occupational therapy visit. The providers charge a list price of over $500 per session, an amount that was reduced to about $325 when billed to the insurer because of its negotiated discounts.

The proper rate for occupational (and physical) therapy is a bone of contention between insurers and therapists. And the Lopez family is caught in the middle, in need of treatments to regain full use of their hands so Angel can again type his television scripts and Theo can again play bluegrass music on his fiddle.

The union’s payment of a flat fee of $60 “is lower than any private insurer we’ve seen,” said Randall Steward, vice president of enterprise contracting and payor relations at Children’s Hospital Los Angeles. But rates insurers pay for occupational or physical therapy are highly variable.

Medicare would pay $124 per 45-minute session for occupational therapy — more than double what Lopez’s insurer paid. Healthcare Bluebook, a company that analyzes claims data for consumers and hospitals, pegs the fair range in Los Angeles .

The Writers Guild declined to comment for this article, but one reason its rate is so low is that it classifies occupational and physical therapy not as ancillary medical services but as alternative treatment, on par with acupuncture and chiropractic care, according to insurance policy documents provided by Lopez.

“This is not typical. I’ve worked for payors and hospitals now for close to 25 years,” Steward said. “I’ve never seen an insurance plan categorize occupational and physical therapy, as this plan does, as an alternative treatment.”

Also, because of that categorization in Lopez’s plan, the amount not covered by insurance that Lopez has to pay out-of-pocket does not even count toward the family’s “out-of-pocket maximum” — that’s when the sum of deductibles, premiums and other charges reaches a threshold that triggers the insurer to pick up the remainder of the tab.

Sharmila Sandhu, who is counsel and director of regulatory affairs for the American Occupational Therapy Association, said that insurers are using various techniques to limit payouts, leaving patients on the hook for bigger bills. “We are finding that insurance companies are increasing the copayment amounts for occupational therapy services or identifying other ways to limit the frequency or duration of visits a client can access,” Sandhu said.

The Resolution: Lopez appealed the decision in a four-page letter to the Writers Guild of America claims department. The Writers Guild health policy denied the appeal. Lopez said a representative for the union told him it would be reviewing its reimbursement policy for occupational therapy.

The Takeaway: Remember that occupational and physical therapy rates vary considerably and health insurers vary greatly in their coverage. Out-of-pocket payments can really add up since almost all patients need a number of sessions.

Ask questions about how your insurance will cover those services as they are prescribed by your doctor. If you feel it is inadequate, negotiate with both the insurer and the provider. If the costs are unaffordable, ask your prescribing doctor if a more limited course of therapy would do the trick.

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“Our goal is to get that vaccine in as many arms as possible for that first dose,” said Dr. Wilma Wooten,Ìýwho is leading the fight against an epidemic that has ravaged unsanitary homeless encampments in San Diego County for the , sickening 544 people and killing 20 of them as of Nov. 6.

Nurses and other county medical workers are fanning out across the most at-risk areas to offer onsite inoculations, and if they run into people who are due for the second shot, they will still give it to them,Ìýsaid Wooten,ÌýPublic HealthÌýDirectorÌýatÌýthe county’s Health and Human Services Agency.

The two hepatitis A vaccinations, considered the to control the spread of the virus, should be administered six months apart. The first shot is the most important, Wooten said, because it protects people 90 to 95 percent of the time against the virus that causes the disease. The second shot raises the protection level to “close to 100 percent,” she said.

So far, 90,735 people have received vaccinations in San Diego County — most of them the first of the two-shot series, according to the county’s health agency.

The San Diego outbreak, and a number of others in California and across the United States, have generated a for hepatitis A vaccine and put a squeeze on supplies, according to the federal Centers for Disease Control and Prevention. Unexpectedly high demand worldwide has constrained availability outside the U.S. as well, the agency said.

Merck & Co. and GlaxoSmithKline, the two companies with to sell the vaccine in the United States, said they have been hard-pressed to keep up with the demand and are working to boost their production.

The effects of hepatitis A can range from mild to fatal. In addition to the deaths in San Diego, an has sickened 486 people and killed 19, as of last Friday, according to the Michigan Department of Health & Human Services.

counties are also fighting the illness, and infections linked to California’s outbreaks are spreading to homeless people in Utah and Arizona, and to men engaging in gay sex in Colorado, the CDC said. In New York City, health officials are confronting a smaller outbreak, mostly among gay or bisexual men.

The deadly nature of the epidemics in San Diego and Michigan worries public health officials the most, said Dr. Noele Nelson, a CDC specialist in hepatitis vaccine research and policy. “The number of deaths in the Michigan and San Diego outbreaks are quite high from what we’ve seen in the past,” she told members of the CDC’s Advisory Committee on Immunization Practices at a in Atlanta.

Hepatitis A is through the ingestion of fecal matter from an infected person — even in microscopic amounts. That can happen when people carrying the virus fail to wash their hands after defecatingÌýand then contaminate objects, food or water used by others. It can also spread through sexual contact.

On Oct. 13, California Gov. Jerry Brown in an effort to increase the state’s supply of adult hepatitis A vaccine. The declaration allowed the state “to immediately purchase additional vaccines directly from manufacturers and coordinate distribution to people at greatest risk in affected areas,” the California Department of Public Health said.

Before Brown’s emergency declaration, the department had distributed nearly 80,000 doses of the vaccine obtained through a federal vaccine program, but those supplies were insufficient, it said.

Merck and GlaxoSmithKline sell the hepatitis A vaccine in pre-filled syringes and less costly single-dose vials.

Pamela Eisele, a Merck spokeswoman, said the unexpectedly sharp rise in demand for the vaccine has limited availability of the company’s vaccine this year.

Single-dose vials of the company’s VAQTA brand vaccine have been on backorder since May and weren’t available until last week, Eisele said. The company expects prefilled syringes to be unavailable until the first quarter of next year, she added.

Likewise, GlaxoSmithKline has been struggling to fill orders for its Havrix brand of the vaccine.

“It’s unprecedented, and it’s very large what’s happening,” said Robin Gaitens, a spokeswoman for the company. GlaxoSmithKline only recently received a shipment of prefilled syringes and has a “limited supply of vials in stock,” she said.

“We will continue to work with CDC, the California Department of Public Health, which is coordinating vaccine orders and distribution on behalf of the counties, and our private customers in California to help address the needs in the state,” Gaitens added.

San Diego County’s Wooten said that despite the supply constraints nationwide, the county now has enough vaccine on hand to give the first injection, but not the second, to those most at risk of contracting the virus — namely, the county’s homeless people, illicit drug users and the professionals who provide care to them.

The biggest challenge posed by the San Diego outbreak is getting the vaccines to people in the transient homeless population, Wooten said. To help address that, the county has hired about 100 temporary nurses to supplement the public health nursing staff, nurse volunteers from local hospitals, paramedics and homeless outreach workers who are on the front lines of the vaccination effort.

The city of San Diego has also been taking actions to curb the spread of the infection. In addition to spraying the streets in infected areas with a bleach solution, it has so far installed 78 hand-washing stations and 16 portable toilets for the homeless.

The city has also opened a public campsite with tents, sinks and restrooms for up to 200 people in a municipal operations yard downtown, said Katie Keach, spokeswoman for the city.

Amy Gonyeau, chief operating officer of the Alpha Project, a homeless outreach organization that is operating the campsite for the city, said 181 people, including 40 children, are living there so far.

Whether those efforts are making a dent in the spread of the hepatitis A infection isn’t yet known.

“San Diego has reported fewer cases per week over the past two weeks than it reported previously,” the CDC’s Nelson said at last month’s advisory committee meeting in Atlanta. “But it’s too early to say this indicates a downward trend in the overall outbreak.”

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The U.S. postal worker and Little League coach was “very environmentally friendly,” said Teri McCall, his wife of 41 years. He avoided chemicals, using only his tractor-mower to root out the thistle and other weeds that continually sprouted on the flat areas of the ranch.

But he did make one exception to that rule — a fateful one, his wife now believes. For more than three decades, on the hilly parts of the ranch where he grew the avocados, and around newly planted fruit trees, Jack donned a backpack sprayer and doused weeds with the widely sold herbicide Roundup.

“He believed Roundup was safe,” Teri McCall said, noting that St. Louis-based Monsanto Co. has regularly touted its flagship product as .

In 2012, the McCalls’ 6-year-old dog, Duke, who regularly accompanied Jack around the farm, fell ill with swollen lymph nodes in his neck and died shortly afterward of lymphoma — a type of blood cancer. Three years later, Jack discovered swollen lymph nodes in his own neck, Teri said. The diagnosis: a rare form of non-Hodgkin lymphoma, which killed him on Dec. 26, 2015.

“I thought, ‘That’s kind of a coincidence that they both got lumps in their neck,’” Teri recalled. “Then I thought about all the time Duke spent sticking his nose in grass that had been sprayed with Roundup.”

In March 2016, McCall filed a against Monsanto, alleging that the company concealed the cancer risk posed by a chemical called “glyphosate,” the active ingredient in Roundup, which she now blames for the deaths of her husband and their dog.

Hundreds of similar lawsuits are pending in federal and state courthouses around the United States.

Monsanto vigorously contests them.

“To be clear: The underlying science behind glyphosate is not at question,” said Scott Partridge, the company’s vice president of global strategy. “Monsanto’s glyphosate-based herbicides have a long history of safe use and have been studied in real-world application, including the largest study ever of the actual use of pesticides by farmers.”

Monsanto’s Partridge contended that “cherry-picking isolated documents out of context is an attempt by the plaintiffs’ attorneys in pending litigation to distract from the science, which is not on their side.”

The use of glyphosate has grown exponentially in the past two decades. The chemical has found its way into the food chain — and into people’s bodies. A published this week in the medical journal JAMA showed that the number of Southern California adults who tested positive for glyphosate in their urine rose dramatically from 1993 to 2016, as did the amount of the chemical in those who excreted it.

In July, California added glyphosate to its list of cancer-causing chemicals under the The act, also known as Proposition 65, requires businesses to warn consumers if their products or facilities contain potentially unsafe amounts of any toxic substances known to cause cancer, birth defects or other reproductive harm.

California is the first state in the U.S. to “take regulatory action to protect our residents from this chemical,” said Olga Naidenko, senior science adviser for the Environmental Working Group, a nonprofit research and advocacy organization. The move is “a huge step and has global implications.”

The state’s Office of Environmental Health Hazard Assessment, which is responsible for listing chemicals under Proposition 65, has proposed a of 1.1 milligrams of glyphosate a day for an adult weighing 70 kilograms, or 154 pounds. That’s about 122 times more stringent than the federal Environmental Protection Agency’s safety guideline.

The state agency is studying more than 1,300 written public comments, along with oral testimony from a , to decide whether it should implement or revise its proposed limit.

The Prop. 65 listing requires warning labels beginning next July.

Other companies, including Dow AgroSciences and DuPont, also sell products containing glyphosate, since Monsanto’s patent expired in 2000.

California’s decision to list the chemical was triggered by a 2015 from the World Health Organization that described the chemical as “probably carcinogenic to humans” and cited “convincing evidence that glyphosate also can cause cancer in laboratory animals.”

The organization’s International Agency for Research on Cancer found a “positive association” between exposure to glyphosate and malignancy in humans, though it added that other explanations could not be excluded. In particular, the international agency found a possible link to non-Hodgkin lymphoma, the type of cancer that killed Jack McCall.

Monsanto sued in state Superior Court to overrule the California listing but , and it has appealed that decision. Its bid to temporarily halt the cancer listing pending trial was rejected by a state appellate court and the California Supreme Court. The company says that labeling glyphosate a cancer risk is unjustified.

It argues thatÌýthe International Agency for Research on Cancer erred by neglecting to consider dataÌýsuggesting no link between glyphosate and non-Hodgkin lymphoma. That research was in an unpublished part of the multiyear and multifaceted , which assesses the effects of pesticide exposure on farmers. The international cancer agency, an independent panel of scientists, said it weighs only published, peer-reviewed studies.

Other studies also have failed to establish a convincing link between glyphosate and cancer. Earlier this year, the European Union’s chemical safety regulator determined there was to classify glyphosate as a carcinogen, though it did say the compound could cause eye damage and long-term harm to aquatic life.

But the international cancer agency, which said it examined about 1,000 studies, determined there was enough information to support its finding of a link between glyphosate and cancer.

Advocates for farmers say California’s plan to require warning labels for glyphosate-based products is wrong-headed. At a June hearing, Cynthia Cory, environmental affairs director for the nonprofit California Farm Bureau Federation, told the board of the health hazard assessment agency that the herbicide is an important tool for farmers. It ultimately benefits the environment, she said, because “it allows us to reduce our tractor passes, which means you have cleaner air.”

Dr. Michelle Perro, a pediatrician who treats children for glyphosate exposure, offered the board a different viewpoint. “What I am seeing is sicker kids,” she said.

Research suggests that Roundup and other glyphosate-based herbicides may be linked not only to cancer but to a variety of . Recent studies link the compound to DNA and chromosomal damage in human cells, kidney failure, chronic kidney disease, intestinal disorders, and autism.

About 250 million pounds of glyphosate were sprayed on U.S. crops in 2014, a ninefold increase in just under two decades, according to in the journal Environmental Sciences Europe. Two-thirds of all the glyphosate used in the U.S. during the 40 years from 1974 to 2014 was sprayed in the last decade.

And you don’t need to live next to farm fields to be exposed to it, said Dr. Paul Winchester, a clinical professor of neonatology at Indiana University School of Medicine and medical director of the neonatal unit atÌýFranciscan St. Francis Health in Indianapolis. “It turns out it’s in almost every [non-organic] food.”

That concerns him in light of a that suggests chromosomal damage caused by pesticides has the potential to embed in DNA and get passed down to future generations.

Teri McCall said she applauds California’s decision to list glyphosate as a carcinogen and hopesÌýit will help protect others from the kind of loss she’s suffered.

Since her husband’s death, “it’s kind of like my life of living color has gone to black-and-white,” she said. “My life with Jack was just so full of joy and laughter and fun, and this has just left a huge void. … Every day is just a series of efforts to escape the loss and there’s just no escaping it.”

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Hundreds more have become ill and been hospitalized, mostly in the San Diego area, often not far from tourist destinations. The diseaseÌýalso has cropped up farther north in Los Angeles and Santa Cruz counties. Poor access to restrooms and sinks in homeless encampments is largely to blame.

Public health officials say the crisis has caught them off guard because it’s rare for the disease to spread so rampantly when it isn’t tied to a common source, such as a tainted food product. Meanwhile, as cases mount with no end in sight, critics fault authorities’ response as lethargic.

The California Department of Public Health says San Diego County’s is “the largest outbreak in the U.S. that is not related to a contaminated food product” since the U.S. first introduced a vaccine for hepatitis A in 1995.

“This is an unprecedented outbreak,” said Dr. Wilma Wooten, the county’s public health officer and director of Public Health Services for theÌý San Diego County Health & Human Services Agency. “This is new territory.”

Wooten, who earlier this month declared a public health emergency, said about 65 percent of the 461 people known to have contracted the liver-attacking virus in San Diego County since last November through Tuesday are homeless and/or illicit drug users.

Under the direction of the county health department, the city is now power-washing heavily soiled sections of downtown sidewalks and streets with a bleach solution.

Earlier this month, the county installed about 40 portable hand-washing stations throughout the downtown areas hardest hit by the virus. Also this month, city officials announced plans to add restrooms to downtown areas.

And Los Angeles County announced that 10 cases had been identified among homeless people either on the streets or in shelters. Half of those patients had been to the San Diego or Santa Cruz areas, but at least two cases were locally acquired. In Santa Cruz County on the Northern California coast, about 70 people, mostly homeless or drug users, have been diagnosed since last April.

is a highly contagious but typically mild illness and often does not require treatment. It does not cause chronic liver disease, as do hepatitis B and C, and is rarely fatal. But among those with existing liver disease and other illnesses common among the homeless, it can cause an acute liver infection and death. The best way to prevent hepatitis A is to get vaccinated, according to the federal Centers for Disease Control and Prevention.Ìý

Hepatitis A is usually spread when a person ingests fecal matter from an infected person — even in microscopic amounts, according to the CDC. That can happen when an infected person doesn’t wash his or her hands after defecatingÌýand then contaminates objects, food or water with which another person comes into contact.

Once the virus gains a foothold in a crowded homeless community lacking enough restrooms and sinks, it can spread easily. It can also spread through sexual contact, according to the CDC.

Leslie, 42, who asked that her last name not be used to protect her privacy, said she’s been camping out on San Diego’s streets for five years. She became ill with the virus last spring and was hospitalized.

“It was awful,” she said. “My skin was yellow, my pee — my urine — it looked like chocolate milk. And everything just hurt. I was achy all the time and tired. I couldn’t sleep enough.”

It took Leslie more than two months to fully recover but, she says, she’s grateful to have survived.

The California Department of Public Health said it has no protocol on how best to deal with large outbreaks of this kind. However, state officialsÌý say they are consulting with the CDC and other states and working with county health authorities “to identify strategies that may be effective.”

In 2014, there were an estimated 2,500 cases of acute hepatitis A infections nationwide, according to the CDC.

Michigan is currently experiencing , as well, apparently spread in part through intravenous drug use and sexual contact. At least 14 people have died. Also escalating this year are hepatitis A infections among men who have sex with men in Colorado and New York City, and other cities worldwide, according to California health officials.

Slowing the spread among homeless people isn’t easy. Hepatitis A has a long incubation period before a person shows symptoms — between 15 to 50 days, in which a person can be infectious but not know it. What’s more, not everyone who becomes infected shows symptoms, such as fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, jaundice and joint pain.

The transience of the homeless population makes it challenging to educate and vaccinate people once an outbreak happens.

“This outbreak has really resulted in us needing to be creative and utilize strategies different from what we’ve utilized in the past,” said Wooten of San Diego County.

But critics say health officials have been too slow to act, especially to install toilets and sinks.

“This whole crisis is man-made,” Michael McConnell, a La Jolla, Calif., coin dealer and advocate for homeless residents, told the San Diego Union Tribune . “The response is certainly much too late, based on when they knew they had a serious problem. Even today, all they’ve done is the most easy stuff. They have taken zero bold action.”

Some told the newspaper that the reaction is symptomatic of a lackluster response to the problems of Ìýpoor and homeless people in their midst.

The city and county of San Diego deny any unnecessary delays in handling the outbreak. Countywide, nearly 23,000 people have received vaccinations against the virus.

“We’ll continue to do whatever it takes to address this,” said San Diego spokeswoman Katie Keach.

Public health workers now are working with homeless outreach teams who have long-established ties to those living on the streets or in the wildlands of San Diego County.

“We go into the canyons, we go everywhere,” said Amy Gonyeau, chief operating officer for the Alpha Project, a nonprofit that provides homeless services. “We go out every day. We have our own vehicles and vans … we educate people on what’s going on.”

On a recent morning, an Alpha Project team delivered hygiene kits — soap, hand sanitizer and other toiletries packaged in clear plastic bags — to a crowded encampment in downtown San Diego’s East Village neighborhood. Tents and shopping carts line the sidewalks in this section of downtown that’s largely hidden from the city’s tourists.

“It looks like a war zone,” said Larissa Wimberly, an outreach supervisor for Alpha Project. “There’s people out here with HIV, people out here with cancer, there’s people out here with heart issues. There are people who are just old and feeble and they’re not eating right. It’s really sad.”

As Wimberly rides shotgun in a large, white Alpha Project van driven by her colleague Cain Mariscal, she points to the myriad tents and shopping carts. Behind and between them, she says, many residents relieve themselves.

“It’s everywhere,” she says of excrement. “It’s just really bad right now.”

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