Los proyectos de ley en consideración abordarían la creciente necesidad de tratar los problemas de salud mental en áreas rurales, que se han visto exacerbados por los impactos de la pandemia y el cambio climático. Esto en un estado que tiene una de las más altas del país.

En las zonas rurales de Colorado hay escasez de profesionales de salud mental, una brecha crítica considerando que las tasas de suicidio han sido en la América rural durante años.

El debate sobre estas dos nuevas medidas está programado para el 7 de febrero. El crearía un enlace de salud mental conductual para la comunidad agrícola y rural que conectaría varias agencias estatales con proveedores de atención mental, organizaciones sin fines de lucro y líderes comunitarios. El fortalecería y publicitaría los recursos de prevención del suicidio para los trabajadores agrícolas.

“Si estás a dos horas de distancia de un profesional de salud, y tal vez en medio de una tormenta de nieve en invierno, serán cuatro o cinco horas de viaje. Simplemente no vas a buscar la ayuda que quieres y necesitas”, dijo el senador estatal Perry Will, republicano que patrocina el proyecto de enlace. “Cualquier cosa que podamos hacer para aumentar el acceso a la atención de salud conductual en las áreas rurales de Colorado y en comunidades rurales es un beneficio”.

Las tensiones de trabajar en el sector agrícola de Colorado se amplifican para los trabajadores migrantes que enfrentan disparadores de estrés adicionales como las barreras del idioma y los estigmas culturales.

El Censo de Agricultura de 2017 (se espera que los datos actualizados de 2022 se publiquen a mediados de febrero) encontró que alrededor del de Colorado emplean a trabajadores hispanos o de habla hispana. Hay más de 19,000 trabajadores agrícolas en todo el estado.

“Cuando hablamos de necesidades emocionales, sienten un vacío. No saben qué hacer debido a este vacío que sienten. Pero sienten que algo está mal”, dijo Ere Juárez, directora regional de , quien trabaja estrechamente con familias migrantes. “La soledad, la tristeza, la culpa, son altas, muy altas”.

Los trabajadores migrantes a menudo están en Colorado durante seis o 10 meses al año para ayudar a sus familias en sus países de origen. Pero las condiciones en las que viven en Estados Unidos son difíciles, dijo Juárez: trabajando turnos de hasta 16 horas al día, viviendo con decenas de personas dentro de apartamentos pequeños y teniendo una comunicación limitada con la familia en casa.

Para algunos trabajadores la barrera del idioma no es solo el inglés sino también el español ya que hablan dialectos regionales y les cuesta aún más comunicarse lo que es muy frustrante, agregó Juárez.

Juárez dijo que esos sentimientos a veces se manifiestan bebiendo demasiado o teniendo pensamientos suicidas. Es necesario fortalecer los recursos de salud mental para ayudar a los trabajadores, enfatizó.

“Todos tenemos comida en nuestras mesas porque ellos trabajan para nosotros”, destacó Juárez. “Están dejando sus cuerpos en nuestros campos para alimentarnos”.

Luego está la baja de los salarios en invierno, cuando tanto los que están empleados todo el año como los estacionales, solo pueden trabajar de 10 a 20 horas por semana, dijo Hunter Knapp, director de desarrollo de Project Protect Food Systems Workers.

“Los trabajadores que se quedan aquí durante todo el año enfrentan muchos desafíos económicos y todos los desafíos de salud mental y conductual asociados con la pérdida de ingresos y trabajo”, explicó.

Iriana Medina, coordinadora de participación comunitaria en , una organización sin fines de lucro, ha identificado problemas similares. Su organización trabaja con comunidades migrantes e inmigrantes en el condado de Mesa, al oeste de Colorado, una región conocida por sus jugosos y dulces duraznos de Palisade y por su vino.

“La diversidad de tener a una persona con un origen cultural y lingüístico diferentes es un puente que debe construirse”, dijo Medina. “Adonde sea que nos lleven estos proyectos de ley será realmente una pieza más del rompecabezas” para beneficiar a la comunidad latina, agregó.

El senador estatal Tom Sullivan, demócrata y defensor de la prevención de la violencia armada, cuyo hijo Alex fue asesinado en la , patrocinó el proyecto de ley para combatir el suicidio. Sullivan dijo que le preocupa que una persona sea en un distrito rural que en un distrito urbano, y citó que revelan que las armas se usan en más del 50% de todos los suicidios.

“Solo estoy tratando de reconocer que hay personas que luchan en estas comunidades y hacerles saber que, cuando llamen, habrá alguien que realmente los escuchará y entenderá sus problemas”, agregó Sullivan.

Paula Andalo, Ethnic Media Editor de ºÚÁϳԹÏÍø News, contribuyó con esta historia.

Si tú mismo o alguien que conoces puede estar experimentando una crisis de salud mental, comunícate con la marcando o enviando un mensaje de texto al “988”. El servicio está disponible en español.

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Colorado lawmakers have proposed a pair of measures they say will improve the availability of mental health resources for the state’s agricultural industry, as stress, anxiety, and depression among ranchers and farmhands have emerged as critical issues that have worsened since the coronavirus pandemic.

The bills under consideration would address a growing need to treat rural mental health issues that have only compounded with the effects of the pandemic and climate change — all in a state that has suicide rates in the nation. Mental health professionals are scarce in rural parts of Colorado, a significant gap considering suicide rates have been than in metropolitan areas for decades.

Legislators were slated to debate the measures on Feb 7. The would create an agricultural and rural community behavioral health liaison position; that person would connect various state agencies with mental health care providers, nonprofits, and community leaders. The is designed shore up and publicize suicide prevention resources for agricultural workers.

“If you’re two hours away from a health professional, and maybe in the winter in a snowstorm it’s a four- or five-hour drive, you’re just not going to seek or get the help that you want and need,” said state Sen. Perry Will, a Republican sponsoring the liaison bill. “Anything we can do to increase access to behavioral health care in rural Colorado and in rural communities is a benefit.”

The stresses of working in Colorado’s agricultural sector are amplified for migrant workers who face language barriers or cultural stigmas. The 2017 Census of Agriculture (updated 2022 data is scheduled to be released in mid-February) of Colorado’s farms employ Hispanic or Spanish-speaking workers. In 2022, there were more than 19,000 farmworkers statewide.

“When we talk about emotional needs, they feel a void. They don’t know what to do because of this void they feel. But they feel that there’s something wrong,” said Ere Juarez, a regional director for the who works closely with migrant families. “The loneliness, the sadness, the guilt, it’s high — super high.”

Migrant workers are routinely in Colorado for six to 10 months of the year to support relatives in their home countries. But they often face difficult conditions while in the U.S., Juarez said: working shifts of up to 16 hours a day, living with dozens of people inside small apartments, and having limited communication with family back home. In addition to the language barrier English presents, some workers don’t even speak Spanish, Juarez added, frustrating those who try to communicate in regional Spanish dialects.

Juarez said those feelings sometimes manifest as alcohol abuse or suicidal thoughts. Behavioral health resources to help workers need to be built up, she said.

“We all have food on our tables because they work for us,” Juarez said. “They are leaving their bodies in our fields in order to feed us.”

Then there is the drop in income when winter and year-round workers might clock in only 10 to 20 hours per week, said Hunter Knapp, development director for Project Protect Food Systems Workers. “Workers who stay here throughout the year face a lot of economic challenges and all the associated mental and behavioral health challenges that come with losing income and work.”

Iriana Medina, community engagement coordinator at the nonprofit , has identified similar issues. Her organization works with migrant and immigrant communities in Mesa County on Colorado’s Western Slope, a region known for its juicy and sweet Palisade peaches and regional wine. “The diversity of having a person that has a different cultural and language background is a bridge that needs to be built,” Medina said. “Whatever these bills will take us to will actually be a piece of the puzzle” toward benefiting the Hispanic community, she added.

State Sen. Tom Sullivan, a Democrat and gun violence prevention advocate whose son, Alex, was murdered in the , sponsored the bill to combat suicide. Sullivan said he is concerned that a person is more likely to take their life in a rural district than in an urban one.

“I’m just trying to acknowledge that there are people struggling in these communities and let them know that there’s somebody out there who will actually listen and understand their problems when they call,” Sullivan said.

ºÚÁϳԹÏÍø News ethnic media editor Paula Andalo contributed to this story.

If you or someone you know may be experiencing a mental health crisis, contact the by dialing or texting “988.” .

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A passenger who was trained as a wilderness first responder, Seth Coley, and found the woman was unresponsive and had a weak pulse. Coley dug through the plane’s medical kit but an oropharyngeal airway, a tool that was supposed to be there and that he needed to help the woman breathe. Instead, he cleared the airway by manipulating her neck.

Afterward, Coley sent a message to Denver-based Frontier Airlines via an online customer service form: “I saved somebody’s life on one of your flights,” he wrote. “I would like to speak about the medical kit you guys have on your flights. You are missing some very valuable and simple things. She almost died.”

Americans are flying at . While covid-19 ushered in new health and cleaning protocols designed to make airplane travel safer, incidents like Coley’s raise questions about airlines’ readiness for medical emergencies because of incomplete or insufficient medical kits and the training of flight crews, who often rely on other passengers in emergencies.

Frontier did not respond to KHN’s requests for comment about that incident or its emergency kits. But Coley’s experience illustrates the risks travelers take every time they board a flight. For every 20,000 passengers who take a flight on a U.S.-based airline, there is one medical event — defined as any health-related incident, not only emergencies — according to estimates from airplane medical services company MedAire.

The Federal Aviation Administration requires commercial aircraft to carry at least one sealed emergency medical kit containing , plus first-aid kits and automated external defibrillators. But the FAA does not track data on the use of those kits during in-flight medical emergencies. Instead, the agency leaves it to the airlines to inspect the kits and replace them if the seals are broken.

“Ensuring complete, sealed emergency medical kits are present is part of the cabin crew’s preflight inspection,” FAA spokesperson Ian Gregor said in a statement.

But, as Coley and other passengers who have responded to an in-flight emergency have found out, an item required in a medical kit can sometimes be missing. Some items the FAA doesn’t require, such as the overdose reversal drug naloxone, are carried voluntarily by some airlines. The agency has issued guidance to the kits, but they are not yet mandated.

Gregor said the FAA investigates all reports of issues with medical kits and ensures any concerns are addressed. He did not respond to a KHN request for details on the number of reports investigated, their outcomes, or whether the emergencies described in this article were among those investigated.

In June, Boston surgeon Dr. Andrea Merrill was aboard a Delta Air Lines flight when she assisted in a medical emergency and found the kit fell short of what she needed.

It needs “a glucometer, epi pen, and automatic blood pressure cuffs — it’s impossible to hear with a disposable stethoscope in the air,” Merrill after the incident. “Please improve this for passenger safety!”

After Merrill’s tweet went viral, Delta , saying it would switch to automatic blood pressure cuffs and “real” stethoscopes, as well as consider glucometers at gates. Merrill declined an interview request.

KHN asked U.S. airlines to detail their medical emergency protocols and the contents of their medical kits. Seven responded with limited information: Alaska, Allegiant, Hawaiian, JetBlue, Southwest, Sun Country, and United. All said that their kits meet or exceed FAA requirements and that they train their staff to respond to medical emergencies. Many airlines also contract with a MedAire that connects flight crews with a medical professional on the ground in an in-flight emergency.

Allegiant officials said passengers with medical conditions should not assume their planes will have everything they need in an emergency. “Although our crews are trained to respond to a wide array of unplanned medical emergencies, we want to remind readers who have anticipated medical needs to bring their own medical supplies in carry-on luggage and not rely on aircraft emergency equipment,” Allegiant spokesperson Andrew Porrello said in a statement.

Delta, along with American, Frontier, and Spirit, did not respond to requests for comment. A said its flight attendants are given training in first aid and CPR. Additionally, Delta wrote that its medical equipment exceeds FAA requirements. The airline mentioned it uses STAT-MD, a service that lets flight crews consult with trained personnel at the University of Pittsburgh Medical Center.

The FAA requires flight attendants to receive , but medical professionals who have intervened as passengers during an in-flight emergency said the crew is not always quick to respond.

“Passengers believe that there are probably more safeguards in place than there actually are,” said Dr. Comilla Sasson, a Denver-area emergency physician and associate clinical professor at the University of Colorado.

Sasson was on a United Airlines flight in 2018 when a passenger passed out. When she volunteered to help, as she mobilized to check the passenger’s vital signs. Sasson questioned the extent to which crew members are trained to help in medical emergencies, saying other health care providers have told her about their own experiences of aiding a passenger in need while the flight personnel stood aside.

“It’s interesting to me that the airlines really kind of depend on the kindness of strangers in a lot of ways, much more so than I would think,” Sasson said.

The goodwill of a fellow passenger is something Bay Area resident Meera Mani is thankful for after a 2011 experience. She was on a United flight from Toronto to San Francisco when her now-deceased father, then in his 80s, began showing concerning symptoms: The right side of his face and arm drooped. Worried her dad was having a stroke, Mani shouted for help but was frustrated by flight attendants’ slow response.

“And then finally, I said: ‘Is there a doctor on the flight?’” Mani recounted.

There was. The doctor used a defibrillator to stabilize her father.

“It was very clear to me that the [flight] staff were completely flummoxed,” Mani said. “They had the equipment, they took it out, they gave it to him, but the doctor took care of it.”

United helped organize an ambulance to meet Mani and her father on the ground at the San Francisco airport and later called to see if her dad was OK. He ended up being diagnosed with a condition that could lead to fainting.

MedAire, which runs the MedLink consulting service, said it covers around 70% of the U.S. market but declined to specify airlines. Dr. Paulo Alves, MedAire’s global medical director of aviation health, said 98% of medical events are managed on board and are non-life-threatening, while 2% are serious cases that might divert a flight.

Alves said his company also provides medical consultations before passengers board a flight.

“An airplane — although I love aviation — is never the best place for you to have a medical event,” Alves said. “The first line of prevention is actually preflight.”

Alves also defended the contents of airlines’ medical kits. The medically trained volunteers who step in to help fellow passengers in an emergency may expect resources available in a hospital, but “the airplane is not a hospital. You cannot carry everything,” he said.

Mani said she would like to see airlines disclose which medical emergencies they’re trained to address — potentially on flight safety cards. Sasson said it would be helpful if airlines clearly shared information about what medical supplies are available on board.

“I think the general public doesn’t realize how much of a crapshoot it is when they’re up in the air that somebody with some sort of medical training will know what to do, if something were to happen,” Sasson said.

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A county in Colorado and a small city in Southern California are splitting from their longtime public health agencies to set up their own local departments. Both Douglas County, Colorado, and West Covina, California, plan to contract some of their health services to private entities.

In Douglas County, Colorado, which is just south of Denver and has one of the nation’s , many residents had opposed mask mandate guidance from the Tri-County Health Department, a partnership among Adams, Arapahoe, and Douglas counties. Tri-County issued a mask order for the counties’ school districts in and, within days, conservative Douglas County announced its commissioners had voted unanimously to form its own health department.

Douglas County, which in 1966 joined what was then called the Tri-County District Health Department, is phasing out of the partnership, with plans to exit entirely by the end of this year. It has already taken over many of its own covid relief efforts from Tri-County.

It is contracting things like covid case investigation, contact tracing, and isolation and quarantine guidance to a private consultant, , founded in early 2021. The contract is worth $1.5 million.

“We believe the greatest challenges are behind us … those associated with being one of three counties with differing and competing public health demands, on a limited budget,” Douglas County spokesperson Wendy Manitta Holmes said in a statement.

Daniel Dietrich, Jogan Health’s president, declined a request for an interview. “All of the data that Jogan Health is collecting is being relayed directly to Douglas County so that public policy aligns with real-time data to keep the residents of Douglas County safe,” Jogan Health spokesperson Sam Shaheen said in a prepared statement.

A similar situation is playing out east of Los Angeles, in West Covina, California. Its City Council has voted to terminate its relationship with the Los Angeles County Department of Public Health over disagreements about covid shutdowns.

West Covina officials have criticized the county health department’s covid restrictions as a one-size-fits-all approach that may work for the second-largest city in the U.S., but not their suburb of about 109,500 people. West Covina plans to join Long Beach, Pasadena, and Berkeley as one of a small number of California cities with its own health agency. A date for the separation has not been set.

As in Douglas County, West Covina plans to contract some services to a private consultant, , that works mainly on city engineering projects and federal contracts, according to its website. Transtech officials did not respond to requests for comment.

West Covina Councilman Tony Wu and area family physician Dr. Basil Vassantachart are leading efforts to form the city’s own department. They hope L.A. County’s oversight of about 10 million people — “bigger than some states,” as Vassantachart noted — can be broken up into regional departments.

, who directs health policy research at the Harvard Kennedy School of Government, said the private sector won’t necessarily have better answers to a public health problem. “It might be the case that they’re good at delivering on some parts of what needs to be done, but other parts still have to be done in-house,” Chandra said.

, a professor of health policy and management at the George Washington University, suggests there are too many local health departments in the U.S. and there should be more regionalization, rather than splitting into smaller departments.

“It’s very hard to effectively spend money and build the foundational capabilities that are associated with a meaningful public health department,” Levi said. “Doing this just because of anger at something like a mask ordinance is really unfortunate.”

Levi noted that public health departments are responsible for everything from restaurant and septic system inspections to administering the Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC, a federal food assistance program. If a department is not adequately resourced or prepared, residents could see lapses in food or water safety efforts in their community, Levi said.

“L.A. County Public Health Department is one of the most sophisticated, and one of the most robust health departments in the country,” Levi said. “You are losing access to just a wide, wide range of both expertise and services that will never be replicable at the local level. Never.”

“The public will be hurt in ways that are not instantly measurable,” he added.

The most recent major private-sector takeover of public health was a flop. A private nonprofit, the Institute for Population Health, took over Detroit’s public health functions in 2012 as the city was approaching bankruptcy.

The experiment failed, leaving a private entity unable to properly oversee public funding and public health concerns placed on the back burner amid the city’s economic woes. Residents also didn’t have a say in where the money went, and the staff on the city’s side was stripped down and couldn’t properly monitor the nonprofit’s use of the funds. By 2015, most services as Detroit emerged from bankruptcy in 2014.

“That private institute thought it was going to issue governmental orders until it was informed it had no power,” said Denise Chrysler, who directs the Network for Public Health Law’s Mid-States Region at the University of Michigan School of Public Health.

In Colorado, Tri-County’s deputy director, Jennifer Ludwig, expressed concerns about Douglas County creating non-covid programs essential to the functioning of a public health department.

“We have programs and services that many single-county health departments are not able to do just because of the resources that we can tap into,” Ludwig said. “Building that from scratch is a huge feat and will take many, many, many years.”

There are also practical benefits. A larger health department, according to Ludwig, is more competitive in securing grant funding, can attract and retain high-quality expertise like a data team, and can buy supplies in bulk.

But West Covina’s Wu accepts that the city will not be able to build its department overnight. “You have to start small,” he said.

Douglas County and West Covina face another key snag: hiring amid a national . Douglas County officials say they are conducting a national search for an executive director who will determine the new health department’s staffing needs.

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KIOWA, Colo. — The yellow-and-green facade of Patty Ann’s Cafe stands out on the main street of this ranching community just 25 miles from the Denver suburbs. Before the pandemic, the cafe was a place for ranchers to gather for meals and to swap stories.

“Some people would call it almost like a conference room,” said Lance Wheeler, a local rancher and regular at the cafe. “There are some guys that, if you drive by Patty Ann’s at a certain time of day, their car or truck will always be there on certain days.”

When covid-19 restrictions closed in-person dining across Colorado last year, Patty Ann’s opened a takeout window. Customers spread their food on the hoods of their trucks and ate there while sharing news and commiserating over the stresses of ranching during the pandemic.

Keeping that community hub operating has been vital for the ranchers around Kiowa as the pandemic takes its toll on mental health in agricultural communities where health providers are scarce and a “pull yourself up by your own bootstraps” mentality is prevalent.

The pandemic over the past year has been a surprising boon for many farms and ranches as higher consumer demand amid food shortages has boosted business.

But coupled with everyday worries about weather and commodity prices, the pandemic also has led to mental health challenges, including serious stress, anxiety and depression among farmers and ranchers, health officials said. The American Farm Bureau Federation that about 3 in 5 rural adults reported that the pandemic has affected mental health in their communities, while two-thirds of farmers and farmworkers said the pandemic has impacted their mental health.

Treatment for mental health problems caused or worsened by the stress and isolation of the pandemic has obstacles particular to ranching and farming country. The stigma of acknowledging the need for mental health care can prevent people from seeking it. For those who overcome that obstacle and look for help, they are likely to find underfunded, understaffed and underequipped health providers who often don’t have the bandwidth or expertise for sufficient mental health support.

“I guess my cows are my therapists,” joked Wheeler. The 54-year-old rancher said he has felt the stress of the added responsibility of providing meat to customers in a time of food shortages, particularly at the beginning of the pandemic. But he feels lucky to have a family that supports him.

Similar to other Rocky Mountain states, Colorado has in the country. The rates are often worse , a factor consistent with rural Americans’ risks nationwide: A Centers for Disease Control and Prevention examining 2001-15 data found the suicide rate in rural counties was more than 17 per 100,000 people, compared with about 15 per 100,000 in small and medium-sized metro counties and about 12 per 100,000 in large metro counties.

Kiowa is in Elbert County, whose 1,850 square miles of mostly dusty, flat plains start where the affluent bedroom communities of Denver end. The county has no urgent care center or hospital like its suburban neighbors, just four clinics to serve a population of 27,000.

Dwayne Smith, Elbert County’s public health director, said that to help solve the problem residents need to talk with their health providers as candidly about their mental health challenges as about skin cancer or heart disease.

“In a more conservative community, where historically mental health issues may not have been talked about as openly and as comfortably as in the [Denver] area, you have to work diligently to increase people’s comfort level,” Smith said. “Even saying the words ‘anxiety,’ ‘depression,’ ‘mental health’ — all those things that in prior generations were very much a taboo subject.”

The public health crisis is just an added burden to the already high stress on people in the agricultural industry. “Farmers and ranchers are absorbing a lot of the shocks to the system for us: hailstorms, pest outbreaks, drought, markets — they’re adjusting for all that to keep food production moving,” said Colorado’s agriculture commissioner, Kate Greenberg.

Unpredictable weather, a volatile commodity market and a 700-acre grass fire cost Laura Negley, a rancher in the southeastern town of Eads, a lot of income around 2012. Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land.

But she was devastated after those losses, followed by her youngest child’s departure for college. “That’s kind of when the wheels fell off for me. And then I kind of spiraled down,” Negley said.

Negley, now 59, said she initially didn’t recognize she needed help even though she was deep into her “dark place” of depression and anxiety, but her brother encouraged her to see a counselor near him in Greeley. So, when the cattle were done grazing for the season, Negley spent six winter weeks getting counseling 200 miles north. Those visits eventually transitioned to phone counseling and an anti-anxiety medication.

“I do think you have to have a support group,” said Negley, who said her faith has helped her, too.

Over the years, slashed budgets to local health departments have cut to the bone. In Elbert County, Smith is one of just three full-time employees in his department. About 15 years ago, it had at least six nurses. It now has none. It is trying to hire one.

“We have a lack of health providers” in rural America, Negley said. “The ones we do have are doing their best — but they’re trying to wear multiple hats.”

Agencies in Colorado recognize the need to improve mental health services offered to rural residents. has a hotline and text-messaging number to refer people to free, confidential support. And the state is working on to help farmers and ranchers understand those numbers are free and confidential to contact. These services can help: According to the CDC, for every adult death by suicide, about 230 people think seriously about suicide.

introduced in Colorado’s legislature would boost funding for rural rehabilitation specialists and help provide vouchers for rural Coloradans to get behavioral health services.

“We have to be flexible: What works in Denver does not work in La Junta” or the rest of rural Colorado, said Robert Werthwein, director of the state’s Office of Behavioral Health.

But in tightknit small towns, ranchers say, even if the resources are there the stigma remains.

“These are normal people with normal problems. We’re just trying to, perhaps first and foremost, destigmatize mental health needs and resources,” Smith said.

Stigmas are something 26-year-old Jacob Walter and his family want to help tackle. As Walter was growing up, a friend’s father and another friend’s mother died by suicide. Before Walter left the family’s ranch in southeastern Colorado to start his sophomore year in college, he lost his own father, Rusty, to suicide in 2016. Walter said there were few local resources at the time to help people like his dad, and the nearest town was 45 minutes away.

Rusty was involved in many community service organizations and gave a lot of his time to others, Walter said, but he suffered from depression.

“The day before he committed suicide, we had been talking at the kitchen table, and he was just talking about [his depression], and he said: ‘You know, you can always get help and stuff.’”

That’s the message agricultural leaders like Ray Atkinson, communications director at the American Farm Bureau Federation, say should be conveyed most: It’s OK to acknowledge when you need help.

“If your tractor needed maintenance … you would stop what you’re doing and you’d get it working right before you go try and go out in the field,” Atkinson said. “You are the most important piece of equipment on your farm.”

[Editor’s note: If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado Crisis Services at 1-844-493-TALK (8255) or text TALK to 38255.]

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The industry, led by Altria Group, one of the world’s largest tobacco companies, has spent exorbitantly in the past to kill similar state ballot initiatives. In 2018, Altria’s lobbying arm more than $17 million to help defeat Montana’s tobacco tax ballot initiative. That same year, it spent around to help defeat South Dakota’s similar measure.

And four years ago, Altria was the leading funder in a successful $16 million campaign to quash Colorado’s previous proposed tobacco tax increase.

In November, by contrast, Altria didn’t spend a penny in opposition and Colorado voters overwhelmingly the tax with two-thirds support. Likewise, in Oregon, Big Tobacco stayed on the sidelines while a tax hike passed there.

The tax measures are major wins for anti-smoking advocates after a string of defeats but, in an example of how politics makes strange bedfellows, Colorado’s tax might not have been possible without Altria’s help. And, advocates said, the way those measures passed could provide a blueprint for states to follow in future elections.

In Colorado, Altria, the parent company of Marlboro cigarette maker Philip Morris, insisted that a minimum price be included in the proposal, , citing emails between political consultants and Gov. Jared Polis’ office. So while supporters see an increased tobacco tax as more revenue for the state, a disincentive for kids to smoke and a win for public health, the measure could also allow America’s premium tobacco companies to gain market share.

The Colorado measure will increase the total state-levied tax from 84 cents to eventually $2.64 per pack by 2027. The tax rate on vaping products, not currently taxed, will be 30% of the manufacturer’s list price in 2021, gradually increasing to 62% by 2027. The proposition also set the minimum price per pack of cigarettes at $7 as of Jan. 1 and that floor rises to $7.50 in 2024. The change could effectively help premium cigarette companies corner the market, since discount cigarettes would rise to at least $7.

Discount cigarette companies Liggett Group, Vector Tobacco and Xcaliber International — which funded opposition to the tax initiative, Proposition EE — tried to sue the state over the minimum tax provision, “Philip Morris will reap huge benefits from the new legislation” and the changes will “destroy their ability to compete in Colorado.” In December, a federal judge rejected the company’s request . A spokesperson for Liggett said the company plans to appeal.

“When it came to entities like Altria and other stakeholders that we engaged in the legislative process, I think that they saw the writing on the wall,” said Jake Williams, executive director of and one of the key organizers behind Proposition EE. “And it helped us get through the legislative process, not just with Democratic votes, but Republican votes to refer the measure to the ballot.”

Altria officials said in a statement that their tobacco companies oppose excise tax increases, but they did not say whether they had worked with Colorado lawmakers.

“Altria did not advocate for or against Proposition EE, and after evaluating the content and intent of this measure, Colorado voters decided to vote in favor of it, some aspects of which were focused on tobacco harm reduction and may help transition adult smokers to a non-combustible future,” the statement said.

Polis’ office did not respond to a request for comment. The Colorado Attorney General’s Office said it would not comment on matters under active litigation. State Democratic Sen. Dominick Moreno and Rep. Julie McCluskie, both state sponsors for the legislation, declined to comment for the same reason. Fellow Democrats Rep. Yadira Caraveo and Sen. Rhonda Fields, also state sponsors for the legislation, did not respond to requests for comment.

Colorado campaign finance records show Altria and Altria’s lobbying arm in 2020 contributed to funds that support both Democratic and Republican candidates in the state — a pattern playing out .

Williams said Altria’s absence of public opposition wasn’t the only factor in the initiative’s success. The tax revenue will initially fund revenue lost during the covid-19 pandemic, then fund tobacco use prevention and preschool education.

The American Lung Association, which supported the Colorado measure, said it believes tobacco taxes are among the most effective ways to reduce tobacco use, especially among youths, who are more sensitive to changes in price. The organization cites studies that every 10% increase in the price of cigarettes reduces consumption by about 4% for adults and 7% for teens.

“Without tobacco industry opposition, it’s very popular among the public,” Thomas Carr, the association’s director of national policy, said of the tax increase. “We’ve long seen it in polling on the subject.”

There was no major industry opposition to the Oregon increase, either. Its tobacco tax increase — — also got a resounding two-thirds of support. But Oregon didn’t negotiate with Altria lobbyists or set a minimum price provision, according to Elisabeth Shepard, campaign manager for Yes for a Healthy Future.

“I don’t know what the [Colorado] deal was,” Shepard said. “All I know is that before it even made it to the ballot, Altria indicated that they were not going to oppose the measure and stuck with their word.”

While Shepard worried until Election Day whether Big Tobacco would swoop in with opposition in Oregon, it didn’t. She believes her campaign worked because the effort had early resources and money, the tax was targeted to fund the Oregon Health Plan (the state’s Medicaid), and her campaign’s coalition had 300 endorsers, including those in health and business communities.

“We had the left, we had the right, we had the far-right, we had the far-left,” Shepard said.

Her campaign paid its advisory committee members, including representatives from affected communities such as Indigenous Oregonian tribes. of American Indian and Alaska Native adults in the state smoke cigarettes. Oregon’s measure tobacco taxes $2 per pack, from $1.33 to $3.33, as well as creates a new tax for e-cigarettes. The revenues will help fund an estimated $300 million for the state’s health plan.

Altria did not respond to a request for comment about Oregon tobacco taxes, but the company has it opposed Oregon’s measure.

Shepard believes her campaign model could work in other states. Other anti-smoking advocates took note of the 2020 election.

“We certainly support establishing minimum prices for all tobacco products in conjunction with tobacco tax increases, as we know increasing the price of tobacco products is one of the most effective ways to reduce tobacco use,” said Cathy Callaway, director of state and local campaigns for the American Cancer Society Cancer Action Network.

It could just come down to a state’s voters and its politics, according to Mark Mickelson, a former Republican in South Dakota’s legislature. Mickelson was behind creating his state’s failed 2018 tobacco tax ballot initiative.

“We just got beat,” Mickelson said. The opposition “got ahead of us on the message. They had a lot more money and had just played on doubts that the [tax revenue] money would go to tech ed.”

The average state cigarette tax is $1.88 per pack, but it across the country — as high as $4.35 in New York but only 44 cents in North Dakota, where a 2016 ballot initiative to increase that to $2.20 was .

Tax increases can translate into hundreds of millions of dollars in new revenue for states, said Richard Auxier, senior policy associate at the nonpartisan Urban-Brookings Tax Policy Center.

“It’s a little easier to pass a tax on someone else, which is often how this is seen — passing this tax on smokers, rather than passing it on all working people, [compared to] if you were to increase income tax or … a sales tax.”

But not all voters get a say.

In Kentucky, which isn’t a referendum state, Republican state Rep. Jerry Miller said there’s not a lot of sympathy for tobacco companies anymore.

“The agriculture community, which used to be on the same page with cigarette companies, are now always in opposition because the cigarette companies are always trying to tweak their formula to use cheaper tobacco,” he said.

Miller’s recent vaping tax failed in the state legislature, but he’s working on .

“We don’t have that tradition or the mechanism that somebody collects 10,000 signatures and they get a referendum on a ballot,” he said. “That’s why things like this have to go through the legislature — and so it really just depends on the state [government].”

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An electrocardiogram revealed that Acharya, a Nepali American from Broomfield, Colorado, had an irregular heartbeat on top of the high blood pressure he already knew about. He had to immediately undergo triple bypass surgery and get seven stents.

Acharya, now 54, thought of his late father and his many uncles who have had heart problems.

“It’s part of my genetics, for sure,” he said.

South Asian Americans — people with roots in Nepal, India, Pakistan, Sri Lanka, Bangladesh, Bhutan and the Maldives — have a disproportionately higher risk of heart disease and other cardiovascular ailments. Worldwide, South Asians account for of all heart disease cases, even though — at 2 billion people — they make up only a quarter of the planet’s population.

In the United States, there’s increasing attention on these risks for Americans of South Asian descent, a growing population of about 5.4 million. Health care professionals attribute the problem to a mix of genetic, cultural and lifestyle influences — but researchers are advocating for more resources to fully understand it.

Rep. (D-Wash.) is sponsoring that would direct $5 million over the next five years toward research into heart disease among South Asian Americans and raising awareness of the issue. The bill passed the U.S. House in September and is up for consideration in the Senate.

The issue could gain more attention after Sen. (D-Calif.) becomes the nation’s first vice president with South Asian lineage. Harris’ mother, Shyamala Gopalan, moved from India to the U.S. in 1958 to attend graduate school. Gopalan, a breast cancer researcher, died in 2009 of colon cancer.

A 2018 for the American Heart Association found South Asian Americans are more likely to die of coronary heart disease than other Asian Americans and non-Hispanic white Americans. The study pointed to their high incidences of diabetes and prediabetes as risk factors, as well as high waist-to-hip ratios. People of South Asian descent have a higher tendency to gain visceral fat in the abdomen, which is associated with insulin resistance. They also were found to be less physically active than other ethnic groups in the U.S.

One of the nation’s largest undertakings to understand these risks is the Mediators of Atherosclerosis in South Asians Living in America study, which began in 2006. The from institutions such as Northwestern University and the University of California-San Francisco, have examined more than 1,100 South Asian American men and women ages 40-79 to better understand the prevalence and outcomes of cardiovascular disease. They stress that high blood pressure and diabetes are common in the community, even for people at normal weights.

That’s why, said Dr. , MASALA’s principal investigator and a professor at UCSF, South Asians cannot rely on traditional body mass index metrics, because BMI numbers considered normal could provide false reassurance to those who might still be at risk.

Kanaya recommends cardiac CT scans, which she said help identify high-risk patients, those who need to make more aggressive lifestyle changes and those who may need preventive medication.

Another risk factor, this one cultural, is diet. Some South Asian Americans are vegetarians, though it’s often a grain-heavy diet reliant on rice and flatbread. The AHA study found risks in such diets, which are high in refined carbohydrates and saturated fat.

“We have to understand the cultural nuances [with] an Indian vegetarian diet,” said Dr. , author of “The South Asian Health Solution” and an internal medicine physician. “That means something totally different than … a Westerner who’s going to be consuming a lot of plant-based protein and tofu, eating lots of salads and things that typical South Asians don’t.”

But getting South Asians to change their eating habits can be challenging, because their culture expresses hospitality and love through food, according to , an associate professor of health sciences at California State University-East Bay. “One of the things South Asians tend to take a lot of pride in is transmitting cultural values and norms knowledge to the next generation,” Mukherjea said.

The intergenerational transmission goes both ways, according to MASALA researchers. Adult, second-generation South Asian Americans might be the key to helping those in the first generation who are resistant to change adopt healthier habits, according to Kanaya.

In the San Francisco Bay Area, El Camino Hospital’s South Asian Heart Center is one of the nation’s leading centers for educating the community. Its three locations are not far from Silicon Valley tech giants, which employ many South Asian Americans.

The center’s medical director, Dr. , said the center treats many relatively young patients of South Asian descent without typical risk factors for cardiovascular disease.

“It was like the typical 44-year-old engineer with a spouse and two kids showing up with a heart attack,” he said.

The South Asian Health Center helps patients make lifestyle changes through meditation, exercise, diet and sleep. The nearby Palo Alto Medical Foundation’s program and the provide medical support for the community. Even patients in the later stages of heart disease can be helped by lifestyle changes, Sinha said.

Dr. , a University of Utah cardiologist who co-authored the AHA study, said people with diabetes, hypertension and obesity are also at higher risk of COVID-19 complications so should now especially work to improve their cardiovascular health and fitness.

In Colorado, Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains.

“Nowadays, I feel very, very good,” he said. “I’m hiking a lot.”

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