CAIRO, Ga. — Zita Magloire carefully adjusted a soft measuring tape across Kenadie Evans’ pregnant belly.

Determining a baby’s size during a 28-week obstetrical visit is routine. But Magloire, a family physician trained in obstetrics, knows that finding the mother’s uterus and, thus, checking the baby, can be tricky for inexperienced doctors.

“Sometimes it’s, like, off to the side,” Magloire said, showing a visiting medical student how to press down firmly and complete the hands-on exam. She moved her finger slightly to calculate the fetus’s height: “There she is, right here.”

Evans smiled and later said Magloire made her “comfortable.”

The 21-year-old had recently relocated from Louisiana to southeastern Georgia, two states where both maternal and infant mortality are persistently high. She moved in with her mother and grandfather near Cairo, an agricultural community where the hospital has a busy labor and delivery unit. Magloire and other doctors at the local clinic where she works deliver hundreds of babies there each year.

Scenes like the one between Evans and Magloire regularly play out in this rural corner of Georgia despite grim realities mothers and babies face nationwide. Maternal deaths keep rising, with Black and Indigenous mothers most at risk; the number of babies who died before their 1st birthday climbed last year; and more than half of all rural counties in the United States have no hospital services for delivering babies, increasing travel time for parents-to-be and causing declines in prenatal care.

There are many reasons labor and delivery units close, including high operating costs, declining populations, low Medicaid reimbursement rates, and staffing shortages. Family medicine physicians still provide the majority of labor and delivery care in rural America, but few new doctors recruited to less populated areas offer obstetrics care, partly because they don’t want to be on call 24/7. Now, with rural America hemorrhaging health care providers, the federal government is investing dollars and attention to increase the ranks.

“Obviously the crisis is here,” said Hana Hinkle, executive director of the Rural Training Track Collaborative, which works with more than 70 rural residency training programs. Federal grants have boosted training programs in recent years, Hinkle said.

In July, the Department of Health and Human Services announced a nearly $11 million investment in new rural programs, including family medicine residencies that focus on obstetrical training.

Nationwide, a declining number of primary care doctors — internal and family medicine — has made it difficult for patients to book appointments and, in some cases, find a doctor at all. In rural America, training family medicine doctors in obstetrics can be more daunting because of low government reimbursement and increasing medical liability costs, said Hinkle, who is also assistant dean of Rural Health Professions at the University of Illinois College of Medicine in Rockford.

In the 1980s, about 43% of general family physicians who completed their residencies were trained in obstetrics. In 2021, the American Academy of Family Physicians’ annual practice profile survey found that 15% of respondents had practiced obstetrics.

Yet family doctors, who also provide the full spectrum of primary care services, are “the backbone of rural deliveries,” said Julie Wood, a doctor and senior vice president of research, science, and health of the public at the AAFP.

In a survey of 216 rural hospitals in 10 states, family practice doctors delivered babies in 67% of the hospitals, and at 27% of the hospitals they were the only ones who delivered babies. The data counted babies delivered from 2013 to 2017. And, the authors found, if those family physicians hadn’t been there, many patients would have driven an average of 86 miles round-trip for care.

Mark Deutchman, the report’s lead author, said he was “on call for 12 years” when he worked in a town of 2,000 residents in rural Washington. Clarifying that he was exaggerating, Deutchman explained that he was one of just two local doctors who performed cesarean sections. He said the best way to ensure family physicians can bolster obstetric units is to make sure they work as part of a team to prevent burnout, rather than as solo do-it-all doctors of old.

There needs to be a core group of physicians, nurses, and a supportive hospital administration to share the workload “so that somebody isn’t on call 365 days a year,” said Deutchman, who is also associate dean for rural health at the University of Colorado Anschutz Medical Campus School of Medicine. The school’s College of Nursing received a $2 million federal grant this fall to train midwives to work in rural areas of Colorado.

Nationwide, teams of providers are ensuring rural obstetric units stay busy. In Lakin, Kansas, Drew Miller works with five other family physicians and a physician assistant who has done an obstetrical fellowship. Together, they deliver about 340 babies a year, up from just over 100 annually when Miller first moved there in 2010. Word-of-mouth and two nearby obstetric unit closures have increased their deliveries. Miller said he has seen friends and partners “from surrounding communities stop delivering just from sheer burnout.”

In Galesburg, Illinois, Annevay Conlee has watched four nearby obstetric units close since 2012, forcing some pregnant people to drive up to an hour and a half for care. Conlee is a practicing family medicine doctor and medical director overseeing four rural areas with a team of OB-GYNs, family physicians, and a nurse-midwife. “There’s no longer the ability to be on 24/7 call for your women to deliver,” Conlee said. “There needs to be a little more harmony when recruiting in to really support a team of physicians and midwives.”

In Cairo, Magloire said practicing obstetrics is “just essential care.” In fact, pregnancy care represents just a slice of her patient visits in this Georgia town of about 10,000 people. On a recent morning, Magloire’s patients included two pregnant people as well as a teen concerned about hip pain and an ecstatic 47-year-old who celebrated losing weight.

Cairo Medical Care, an independent clinic situated across the street from the 60-bed Archbold Grady hospital, is in a community best known for its peanut crops and as the birthplace of baseball legend Jackie Robinson. The historical downtown has brick-accented streets and the oldest movie theater in Georgia, and a corner of the library is dedicated to local history.

The clinic’s six doctors, who are a mix of family medicine practitioners, like Magloire, and obstetrician-gynecologists, pull in patients from the surrounding counties and together deliver nearly 300 babies at the hospital each year.

Deanna Buckins, a 36-year-old mother of four boys, said she was relieved when she found “Dr. Z” because she “completely changed our lives.”

“She actually listens to me and accepts my decisions instead of pushing things upon me,” said Buckins, as she held her 3-week-old son, whom Magloire had delivered. Years earlier, Magloire helped diagnose one of Buckins’ older children with autism and built trust with the family.

“Say I go in with one kid; before we leave, we’ve talked about every single kid on how they’re doing and, you know, getting caught up with life,” Buckins said.

Magloire grew up in Tallahassee, Florida, and did her residency in rural Kansas. The smallness of Cairo, she said, allows her to see patients as they grow — chatting up the kids when the mothers or siblings come for appointments.

“She’s very friendly,” Evans said of Magloire. Evans, whose first child was delivered by an OB-GYN, said she was nervous about finding the right doctor. The kind of specialist her doctor was didn’t matter as much as being with “someone who cares,” she said.

As a primary care doctor, Magloire can care for Evans and her children for years to come.

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The FDA conducted an investigation into morel mushrooms after the severe illness outbreak linked to Dave’s Sushi in Bozeman in late March and April. The investigation found that undercooked or raw morels were the likely culprit, and it led the agency to issue its first guidelines on preparing morels.

“The toxins in morel mushrooms that may cause illness are not fully understood; however, using proper preparation procedures, such as cooking, can help to reduce toxin levels,” according to the FDA guidance.

Even then, a risk remains, according to the FDA: “Properly preparing and cooking morel mushrooms can reduce risk of illness, however there is no guarantee of safety even if cooking steps are taken prior to consumption.”

Jon Ebelt, spokesperson for Montana’s health department, said there is limited public health information or medical literature on morels. And samples of the morels taken from Dave’s Sushi detected no specific toxin, pathogen, pesticide, or volatile or nonvolatile organic compound in the mushrooms.

Aaron Parker, the owner of Dave’s Sushi, said morels are a “boutique item.” In season, generally during the spring and fall, morels can cost him $40 per pound, while morels purchased out of season are close to $80 per pound, he said.

Many highly regarded recipe books describe sauteing morels to preserve the sought-after, earthy flavor. At Dave’s, a marinade, sometimes boiling, was poured over the raw mushrooms before they were served, Parker said. After his own investigation, Parker said he found boiling them between 10 and 30 minutes is the safest way to prepare morel mushrooms.

Parker said he reached out to chefs across the country and found that many, like him, were surprised to learn about the toxicity of morels.

“They had no idea that morel mushrooms had this sort of inherent risk factor regardless of preparation,” Parker said.

According to the FDA’s Food Code, the vast majority of the more than 5,000 fleshy mushroom species that grow naturally in North America have not been tested for toxicity. Of those that have, 15 species are deadly, 60 are toxic whether raw or cooked — including “false” morels, which look like spongy edible morels — and at least 40 are poisonous if eaten raw, but safer when cooked.

The North American Mycological Association, a national nonprofit whose members are mushroom experts, recorded 1,641 cases of mushroom poisonings and 17 deaths from 1985 to 2006. One hundred and twenty-nine of those poisonings were attributed to morels, but no deaths were reported.

Marian Maxwell, the outreach chairperson for the Puget Sound Mycological Society, based in Seattle, said cooking breaks down the chitin in mushrooms, the same compound found in the exoskeletons of shellfish, and helps destroy toxins. Maxwell said morels may naturally contain a type of hydrazine — a chemical often used in pesticides or rocket fuel that can cause cancer — which can affect people differently. Cooking does boil off the hydrazine, she said, “but some people still have reactions even though it’s cooked and most of that hydrazine is gone.”

Heather Hallen-Adams, chair of the toxicology committee of the North American Mycological Association, said hydrazine has been shown to exist in false morels, but it’s not as “clear-cut” in true morels, which were the mushrooms used at Dave’s Sushi.

Mushroom-caused food poisonings in restaurant settings are rare — the Montana outbreak is believed to be one of the first in the U.S. related to morels — but they have happened infrequently abroad. In 2019, a morel food poisoning outbreak at a Michelin-star-rated restaurant in Spain sickened about 30 customers. One woman who ate the morels died, but her death was determined to be from natural causes. Raw morels were served on a pasta salad in Vancouver, British Columbia, in 2019 and poisoned 77 consumers, though none died.

Before the new guidelines were issued, the FDA’s Food Code guidance to states was only that serving wild mushrooms must be approved by a “regulatory authority.”

The FDA’s Food Code bans the sale of wild-picked mushrooms in a restaurant or other food establishment unless it’s been approved to do so, though cultivated wild mushrooms can be sold if the cultivation operations are overseen by a regulatory agency, as was the case with the morels at Dave’s Sushi. States’ regulations vary, according to a 2021 study by the Georgia Department of Public Health and included in the Association of Food and Drug Officials’ regulatory guidelines. For example, Montana and a half-dozen other states allow restaurants to sell wild mushrooms if they come from a licensed seller, according to the study. Seventeen other states allow the sale of wild mushrooms that have been identified by a state-credentialed expert.

The study found that the varied resources states use to identify safe wild mushrooms — including mycological associations, academics, and the food service industry — may suggest a need for better communication.

The study recognized a “guidance document” as the “single most important step forward” given the variety in regulations and the demand for wild mushrooms.

Hallen-Adams said raw morels are known to be poisonous by “mushroom people,” but that’s not common knowledge among chefs.

In the Dave’s Sushi case, Hallen-Adams said, it was obvious that safety information didn’t get to the people who needed it. “And this could be something that could be addressed by labeling,” she said.

There hasn’t been much emphasis placed on making sure consumers know how to properly prepare the mushrooms, Hallen-Adams said, “and that’s something we need to start doing.”

Hallen-Adams, who trains people in Nebraska on mushroom identification, said the North American Mycological Association planned to update its website and include more prominent information about the need to cook mushrooms, with a specific mention of morels.

Montana’s health department intends to publish guidelines on morel safety in the spring, when morel season is approaching.

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Assisted living centers have become an appealing retirement option for hundreds of thousands of boomers who can no longer live independently, promising a cheerful alternative to the institutional feel of a nursing home.

But their cost is so crushingly high that most Americans can’t afford them.

What to Know About Assisted Living

The facilities can look like luxury apartments or modest group homes and can vary in pricing structures. Here’s a guide.

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These highly profitable facilities often charge $5,000 a month or more and then layer on fees at every step. Residents’ bills and price lists from a dozen facilities offer a glimpse of the charges: $12 for a blood pressure check; $50 per injection (more for insulin); $93 a month to order medications from a pharmacy not used by the facility; $315 a month for daily help with an inhaler.

The facilities charge extra to help residents get to the shower, bathroom, or dining room; to deliver meals to their rooms; to have staff check-ins for daily “reassurance” or simply to remind residents when it’s time to eat or take their medication. Some even charge for routine billing of a resident’s insurance for care.

“They say, ‘Your mother forgot one time to take her medications, and so now you’ve got to add this on, and we’re billing you for it,’” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit.

About 850,000 older Americans reside in assisted living facilities, which have become one of the most lucrative branches of the long-term care industry that caters to people 65 and older. Investors, regional companies, and international real estate trusts have jumped in: Half of operators in the business of assisted living earn returns of 20% or more than it costs to run the sites, an industry survey shows. That is far higher than the money made in most other health sectors.

Rents are often rivaled or exceeded by charges for services, which are either packaged in a bundle or levied à la carte. Overall prices have been rising faster than inflation, and rent increases since the start of last year have been higher than at any previous time since at least 2007, according to the National Investment Center for Seniors Housing & Care, which provides data and other information to companies.

There are now 31,000 assisted living facilities nationwide — twice the number of skilled nursing homes. Four of every five facilities are run as for-profits. Members of racial or ethnic minority groups account for only a tenth of residents, even though they make up a quarter of the population of people 65 or older in the United States.

A public opinion survey conducted by KFF found that 83% of adults said it would be impossible or very difficult to pay $60,000 a year for an assisted living facility. Almost half of those surveyed who either lived in a long-term care residence or had a loved one who did encountered unexpected add-on fees for things they assumed were included in the price.

Assisted living is part of a broader affordability crisis in long-term care for the swelling population of older Americans. Over the past decade, the market for long-term care insurance has virtually collapsed, covering just a tiny portion of older people. Home health workers who can help people stay safely in their homes are generally poorly paid and hard to find.

And even older people who can afford an assisted living facility often find their life savings rapidly drained.

Unlike most residents of nursing homes, where care is generally paid for by Medicaid, the federal-state program for the poor and disabled, assisted living residents or their families usually must shoulder the full costs. Most centers require those who can no longer pay to move out.

The industry says its pricing structures pay for increased staffing that helps the more infirm residents and avoids saddling others with costs of services they don’t need.

Prices escalate greatly when a resident develops dementia or other serious illnesses. At one facility in California, the monthly cost of care packages for people with dementia or other cognitive issues increased from $1,325 for those needing the least amount of help to $4,625 as residents’ needs grew.

“It’s profiteering at its worst,” said Mark Bonitz, who explored multiple places in Minnesota for his mother, Elizabeth. “They have a fixed amount of rooms,” he said. “The way you make the most money is you get so many add-ons.” Last year, he moved his mother to a nonprofit center, where she lived until her death in July at age 96.

LaShuan Bethea, executive director of the National Center for Assisted Living, a trade association of owners and operators, said the industry would require financial support from the government and private lenders to bring prices down.

“Assisted living providers are ready and willing to provide more affordable options, especially for a growing elderly population,” Bethea said. “But we need the support of policymakers and other industries.” She said offering affordable assisted living “requires an entirely different business model.”

Others defend the extras as a way to appeal to the waves of boomers who are retiring. “People want choice,” said Beth Burnham Mace, a special adviser for the National Investment Center for Seniors Housing & Care. “If you price it more à la carte, you’re paying for what you actually desire and need.”

Yet residents don’t always get the heightened attention they paid for. Class-action lawsuits have accused several assisted living chains of failing to raise staffing levels to accommodate residents’ needs or of failing to fulfill billed services.

“We still receive many complaints about staffing shortages and services not being provided as promised,” said Aisha Elmquist, until recently the deputy ombudsman for long-term care in Minnesota, a state-funded advocate. “Some residents have reported to us they called 911 for things like getting in and out of bed.”

‘Can You Find Me a Money Tree?’

Florence Reiners, 94, adores living at the Waters of Excelsior, an upscale assisted living facility in the Minneapolis suburb of Excelsior. The 115-unit building has a theater, a library, a hair salon, and a spacious dining room.

“The windows, the brightness, and the people overall are very cheerful and very friendly,” Reiners, a retired nursing assistant, said. Most important, she was just a floor away from her husband, Donald, 95, a retired water department worker who served in the military after World War II and has severe dementia.

She resisted her children’s pleas to move him to a less expensive facility available to veterans.

Reiners is healthy enough to be on a floor for people who can live independently, so her rent is $3,330 plus $275 for a pendant alarm. When she needs help, she’s billed an exact amount, like a $26.67 charge for the 31 minutes an aide spent helping her to the bathroom one night.

Her husband’s specialty care at the facility cost much more: $6,150 a month on top of $3,825 in rent.

Month by month, their savings, mainly from the sale of their home, and monthly retirement income of $6,600 from Social Security and his municipal pension, dwindled. In three years, their assets and savings dropped to about $300,000 from around $550,000.

Her children warned her that she would run out of money if her health worsened. “She about cried because she doesn’t want to leave her community,” Anne Palm, one of her daughters, said.

In June, they moved Donald Reiners to the VA home across the city. His care there costs $3,900 a month, 60% less than at the Waters. But his wife is not allowed to live at the veterans’ facility.

After nearly 60 years together, she was devastated. When an admissions worker asked her if she had any questions, she answered, “Can you find me a money tree so I don’t have to move him?”

Heidi Elliott, vice president for operations at the Waters, said employees carefully review potential residents’ financial assets with them, and explain how costs can increase over time.

“Oftentimes, our senior living consultants will ask, ‘After you’ve reviewed this, Mr. Smith, how many years do you think Mom is going to be able to, to afford this?’” she said. “And sometimes we lose prospects because they’ve realized, ‘You know what? Nope, we don’t have it.’”

Potential Buyers From the Bahamas

For residents, the median annual price of assisted living has increased 31% faster than inflation, nearly doubling from 2004 to 2021, to $54,000, according to surveys by the insurance firm Genworth. Monthly fees at memory care centers, which specialize in people with dementia and other cognitive issues, can exceed $10,000 in areas where real estate is expensive or the residents’ needs are high.

Diane Lepsig, president of CarePatrol of Bellevue-Eastside, in the Seattle suburbs, which helps place people, said that she has warned those seeking advice that they should expect to pay at least $7,000 a month. “A million dollars in assets really doesn’t last that long,” she said.

Prices rose even faster during the pandemic as wages and supply costs grew. Brookdale Senior Living, one of the nation’s largest assisted living owners and operators, reported to stockholders rate increases that were higher than usual for this year. In its assisted living and memory care division, Brookdale’s revenue per occupied unit rose 9.4% in 2023 from 2022, primarily because of rent increases, financial disclosures show.

In a statement, Brookdale said it worked with prospective residents and their families to explain the pricing and care options available: “These discussions begin in the initial stages of moving in but also continue throughout the span that one lives at a community, especially as their needs change.”

Many assisted living facilities are owned by real estate investment trusts. Their shareholders expect the high returns that are typically gained from housing investments rather than the more marginal profits of the heavily regulated health care sector. Even during the pandemic, earnings remained robust, financial filings show.

Ventas, a publicly traded real estate investment trust, reported earning revenues in the third quarter of this year that were 24% above operating costs from its investments in 576 senior housing properties, which include those run by Atria Senior Living and Sunrise Senior Living.

Ventas said the prices for its services were affordable. “In markets where we operate, on average it costs residents a comparable amount to live in our communities as it does to stay in their own homes and replicate services,” said Molly McEvily, a spokesperson.

In the same period, Welltower, another large real estate investment trust, reported a 24% operating margin from its 883 senior housing properties, which include ones operated by Sunrise‌, Atria, Oakmont Management Group, and Belmont Village.‌ Welltower did not respond‌‌ to requests for comment.

The median operating margin for assisted living facilities in 2021 was 23% if they offered memory care and 20% if they didn’t, according to David Schless, chief executive of the American Seniors Housing Association, a trade group that surveys the industry each year.

Bethea said those returns could be invested back into facilities’ services, technology, and building updates. “This is partly why assisted living also enjoys high customer satisfaction rates,” she said.

Brandon Barnes, an administrator at a family business that owns three small residences in Esko, Minnesota, said he and other small operators had been approached by brokers for companies, including one based in the Bahamas. “I don’t even know how you’d run them from that far away,” he said.

Rating the Cost of a Shower, on a Point Scale

To consistently get such impressive returns, some assisted living facilities have devised sophisticated pricing methods. Each service is assigned points based on an estimate of how much it costs in extra labor, to the minute. When residents arrive, they are evaluated to see what services they need, and the facility adds up the points. The number of points determines which tier of services you require; facilities often have four or five levels of care, each with its own price.

Charles Barker, an 81-year-old retired psychiatrist with Alzheimer’s, moved into Oakmont of Pacific Beach, a memory care facility in San Diego, in November 2020. In the initial estimate, he was assigned 135 points: 5 for mealtime reminders; 12 for shaving and grooming reminders; 18 for help with clothes selection twice a day; 36 to manage medications; and 30 for the attention, prompting, and redirection he would need because of his dementia, according to a copy of his assessment provided by his daughter, Celenie Singley.

Barker’s points fell into the second-lowest of five service levels, with a charge of $2,340 on top of his $7,895 monthly rent.

Singley became distraught over safety issues that she said did not seem as important to Oakmont as its point system. She complained in a May 2021 letter to Courtney Siegel, the company’s chief executive, that she repeatedly found the doors to the facility, located on a busy street, unlocked — a lapse at memory care centers, where secured exits keep people with dementia from wandering away. “Even when it’s expensive, you really don’t know what you’re getting,” she said in an interview.

Singley, 50, moved her father to another memory care unit. Oakmont did not respond to requests for comment.

Other residents and their families brought a class-action lawsuit against Oakmont in 2017 that said the company, an assisted living and memory care provider based in Irvine, California, had not provided enough staffing to meet the needs of residents it identified through its own assessments.

Jane Burton-Whitaker, a plaintiff who moved into Oakmont of Mariner Point in Alameda, California, in 2016, paid $5,795 monthly rent and $270 a month for assistance with her urinary catheter, but sometimes the staff would empty the bag just once a day when it required multiple changes, the lawsuit said.

She paid an additional $153 a month for checks of her “fragile” skin “up to three times a day, but most days staff did not provide any skin checks,” according to the lawsuit. (Skin breakdown is a hazard for older people that can lead to bedsores and infections.) Sometimes it took the staff 45 minutes to respond to her call button, so she left the facility in 2017 out of concern she would not get attention should she have a medical emergency, the lawsuit said.

Oakmont paid $9 million in 2020 to settle the class-action suit and agreed to provide enough staffing, without admitting fault.

Similar cases have been brought against other assisted living companies. In 2021, Aegis Living, a company based in Bellevue, Washington, agreed to a $16 million settlement in a case claiming that its point system — which charged 64 cents per point per day — was “based solely on budget considerations and desired profit margins.” Aegis did not admit fault in the settlement or respond to requests for comment.

When the Money Is Gone

Jon Guckenberg’s rent for a single room in an assisted living cottage in rural Minnesota was $4,140 a month before adding in a raft of other charges.

The facility, New Perspective Cloquet, charged him $500 to reserve a spot and a $2,000 “entrance fee” before he set foot inside two years ago. Each month, he also paid $1,080 for a care plan that helped him cope with bipolar disorder and kidney problems, $750 for meals, and another $750 to make sure he took his daily medications. Cable service in his room was an extra $50 a month.

A year after moving in, Guckenberg, 83, a retired pizza parlor owner, had run through his life’s savings and was put on a state health plan for the poor.

Doug Anderson, a senior vice president at New Perspective, said in a statement that “the cost and complexity of providing care and housing to seniors has increased exponentially due to the pandemic and record-high inflation.”

In one way, Guckenberg has been luckier than most people who run out of money to pay for their care. His residential center accepts Medicaid to cover the health services he receives.

Most states have similar programs, though a resident must be frail enough to qualify for a nursing home before Medicaid will cover the health care costs in an assisted living facility. But enrollment is restricted. In 37 states, people are on waiting lists for months or years.

“We recognize the current system of having residents spend down their assets and then qualify for Medicaid in order to stay in their assisted living home is broken,” said Bethea, with the trade association. “Residents shouldn’t have to impoverish themselves in order to continue receiving assisted living care.”

Only 18% of residential care facilities agree to take Medicaid payments, which tend to be lower than what they charge self-paying clients, according to a federal survey of facilities. And even places that accept Medicaid often limit coverage to a minority of their beds.

For those with some retirement income, Medicaid isn’t free. Nancy Pilger, Guckenberg’s guardian, said that he was able to keep only about $200 of his $2,831 monthly retirement income, with the rest going to paying rent and a portion of his costs covered by the government.

In September, Guckenberg moved to a nearby assisted living building run by a nonprofit. Pilger said the price was the same. But for other residents who have not yet exhausted their assets, Guckenberg’s new home charges $12 a tray for meal delivery to the room; $50 a month to bill a person’s long-term care insurance plan; and $55 for a set of bed rails.

Even after Guckenberg had left New Perspective, however, the company had one more charge for him: a $200 late payment fee for money it said he still owed.

KFF Health 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 KFF.

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She recalled vividly one baby who stayed in the NICU for 90 days with neonatal abstinence syndrome, a form of withdrawal, because his mother had used substances while pregnant.

The mother came in every day, Peterson said. She took three buses to get to the hospital to see her baby. Peterson watched her sing to him some days and read to him on others.

“I saw in the NICU the love that she had for that baby,” Peterson said. “When it came down to it, she lost custody.”

At the time, Peterson said, she felt more could be done to help people like that mother. That’s why, in 2018, she founded Empowered, a program that provides services for pregnant and postpartum women who have a history of opioid or stimulant use or are currently using drugs.

The program helps about 100 women at any given time, Peterson said. Pregnancy often motivates people to seek treatment for substance use, she said. Yet significant barriers stand in the way of those who want care, even as national rates of fatal drug overdoses during and shortly after pregnancy continue to rise. In addition to the risk of overdose, substance use during pregnancy can result in premature birth, low birth weight, and sudden infant death syndrome.

A federal initiative seeking to combat those overdoses is distributing millions of dollars to states to help fund and expand programs like Empowered. Six states will receive grant funding from the Substance Abuse and Mental Health Services Administration to increase access to treatment during and after pregnancy. The Nevada Health and Human Services Department is distributing the state’s portion of that funding, about $900,000 annually for up to three years, to help the Empowered program expand into northern Nevada, including by establishing an office in Reno and sending mobile staff into nearby rural communities.

Other states are trying to spread the federal funds to maximize reach. State officials in Montana have awarded their state’s latest $900,000 grant to a handful of organizations since first receiving a pool of funding in 2020. Connecticut, Iowa, Maryland, and South Carolina will also receive $900,000 each.

Officials hope the financial boosts will help tamp down the rise in overdoses.

Deaths from drug overdoses hit record highs in 2021, according to the Centers for Disease Control and Prevention. More recent preliminary data shows that the rates of fatal drug overdoses have continued to rise since.

Deaths in pregnant and postpartum people have also increased. Homicides, suicides, and drug overdoses are the leading causes of pregnancy-related death.

Fatal overdoses among pregnant and postpartum people increased by approximately 81% from 2017 to 2020, according to a 2022 study. Of 7,642 reported deaths related to pregnancy during those years, 1,249 were overdoses. Rates of pregnancy-related opioid overdose deaths had already more than doubled from 2007 to 2016.

Meanwhile, mothers and mothers-to-be in rural parts of the country, some of the hardest hit by the opioid crisis, face greater barriers to care because of fewer treatment facilities specializing in pregnant and postpartum people in their communities and fewer providers who can prescribe buprenorphine, a medication used to treat opioid addiction.

Data distinguishing the rates of overdose mortality among pregnant and postpartum people in urban and rural areas is hard to come by, but studies have found higher rates of neonatal opioid withdrawal syndrome in rural parts of the country. Women in rural areas also died at higher rates from drug overdoses in 2020 compared with women in urban areas, while the overall rate and the rate among men were greater in urban areas.

In Nevada, a 2022 maternal mortality and severe maternal morbidity report found that most of the state’s pregnancy-related deaths, 78%, happened in Clark County, home to Las Vegas and two-thirds of the state’s population. However, the state’s rural counties had the highest pregnancy-related death rate — 179.5 per 100,000 live births — while Clark County’s was 123 per 100,000 live births.

During a recent event hosted by Empowered, four mothers recounted their struggles with addiction while pregnant. “It was never my intention to actually have a drug addiction,” said a mother named Amani. “I’ve always wanted to get out of the cycle of relapsing and drug usage.”

Amani, who asked to be identified only by her first name for fear of stigma associated with using drugs while pregnant or after giving birth, said she found the support she needed to treat her addiction in 2021. That’s when she began seeking help at Empowered.

Substance use while pregnant or postpartum is “incredibly stigmatizing,” said Emilie Bruzelius, a postdoctoral fellow in the Department of Epidemiology at Columbia University’s Mailman School of Public Health and author of a study of trends in drug overdose mortality during and after pregnancy. The stigma and fear of interacting with child welfare or law enforcement agencies prevents people from seeking help, she said.

A Rand Corp. study found that states with punitive policies toward mothers with substance use disorders have more cases of neonatal abstinence syndrome. Nevada was among them.

Researchers have found that, in addition to facing fear of punishment, many women don’t have access to treatment during and after pregnancy because few outpatient centers specialize in treating mothers.

Both Nevada and Montana had fewer than one treatment facility with specialized programs for pregnant and postpartum women per 1,000 reproductive-age women with substance use disorders, with Montana ranking in the lowest quintile.

One Health, a community health center covering Montana’s sprawling southeastern plains, is using the newly awarded federal money to train peer support specialists as doulas, professionals specialized in childbirth who can provide support throughout pregnancy and after.

Megkian Doyle, who directs the center’s community-based work, said in one case a survivor of sex trafficking who was drugged by her abusers worked with a recovery doula to prepare for the potential triggers of being exposed to medical workers or needing an IV. In another, a mom in stable recovery from addiction was able to keep her baby when hospital staffers called child protective services because she already had a safety plan with her doula and the agency.

After birth, recovery doulas visit families daily for two weeks, “the window when overdose, relapse, and suicide is happening,” Doyle said. The workers, in their peer support role, can continue helping clients for years.

While doula care, rarely covered by insurance, is unaffordable for many, Medicaid typically covers peer support care. As of late September, 37 states and Washington, D.C., had extended Medicaid benefits to cover care for 12 months postpartum. Montana and Nevada have approved plans to do so. Health centers in similarly rural states have taken note. The program’s latest cohort of recovery doulas includes five peer support specialists from Utah.

With its trauma-informed approach, the Nevada-based Empowered program takes a different tack.

The program focuses on meeting its participants’ most pressing need, which varies depending on the person. Some people need help getting government-issued identification so they can access other social services, including aid from food pantries, said Peterson, the founder and executive director. Others may need safe housing above all.

Empowered is not abstinence-based, meaning its participants do not lose access to services if they relapse or use substances while seeking help. Because some participants may be actively using drugs, the Empowered office is also a distribution site for the overdose reversal medication naloxone and test strips that detect fentanyl, a powerful synthetic opioid that has contributed to jumps in fatal overdose rates in recent years. The program’s staff also provide education about the effects drugs have on an unborn baby during pregnancy.

Being able to be honest with Empowered staff made a difference for Amani.

“I can’t tell you how many times I’ve tripped and fallen but tried to get back up and fallen again,” she said.

The goal is not only to stabilize participants’ lives but to make them resilient — whatever that may look like for each individual. For many, that includes having stable housing, food security, job security, and custody of their children.

To her, Amani said, the Empowered program means love, support, and not being alone.

“I wouldn’t be here, literally, without them,” she said.

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El cansancio y las náuseas de su marido fueron tan intensas que no fue a trabajar por tres días. Pero bebió agua con lima en lugar de ir al médico porque no tienen seguro médico. “A mucha gente le pasa esto”, agregó.

No existen normas federales para proteger a los trabajadores como los García cuando los días son excesivamente calurosos. Y sin el apoyo bipartidista del Congreso, incluso con la atención urgente de la administración Biden, es posible que el alivio no llegue en años.

El presidente Joe Biden encargó en 2021 a la Administración de Seguridad y Salud Ocupacional (OSHA) la elaboración de normas para prevenir los accidentes y las enfermedades causados por el calor.

Pero ese proceso de 46 pasos puede llevar más de una década y podría estancarse si un republicano es elegido presidente en 2024, porque el Partido Republicano se ha opuesto generalmente a las regulaciones de salud laboral en los últimos 20 años.

Estas normas podrían obligar a los empleadores a proporcionar abundante agua potable, descansos y un espacio para refrescarse a la sombra o con aire acondicionado cuando las temperaturas superen un determinado umbral.

El 7 de septiembre, OSHA comenzó reuniones con propietarios de pequeñas empresas para discutir sus propuestas, incluidas las medidas que deberían adoptar las empresas cuando las temperaturas llegan a los 90 grados.

Como este verano se han batido récords de calor, la congresista Judy Chu (demócrata de California) y otros miembros del Congreso han impulsado una legislación que aceleraría el proceso de elaboración de normas de OSHA.

El proyecto de ley lleva el nombre de Asunción Valdivia, una trabajadora agrícola que se desmayó mientras recogía uvas en California en un día de 105 grados en 2004. Su hijo la recogió del campo y Valdivia murió de un golpe de calor en el trayecto a su casa.

“Ya sea en una granja, conduciendo un camión o trabajando en un almacén, los trabajadores como Asunción mantienen nuestro país en funcionamiento mientras soportan algunas de las condiciones más difíciles”, dijo Chu en declaraciones en julio en la que instaba al Congreso a aprobar el proyecto de ley.

Las organizaciones profesionales que representan a los empresarios se han opuesto a las normas, calificándolas de “exageradas”. También afirman que faltan datos que justifiquen regulaciones generales, dada la diversidad de trabajadores y lugares de trabajo, desde restaurantes de comida rápida hasta granjas.

La Cámara de Comercio de Estados Unidos, uno de los grupos de presión más poderosos de Washington, argumentó que tales medidas carecen de sentido “porque cada empleado experimenta el calor de forma diferente”. Además, según la Cámara, normas como los ciclos de trabajo-descanso “amenazan con perjudicar directa y sustancialmente… la productividad de los empleados y, por lo tanto, la viabilidad económica de su empleador”.

“Muchos de los problemas relacionados con el calor no son consecuencia del trabajo agrícola ni de la mala gestión del empresario, sino del moderno estilo de vida de los empleados”, escribió el Consejo Nacional del Algodón en su respuesta a la legislación propuesta.

Por ejemplo, el aire acondicionado hace más difícil que las personas se adapten a un ambiente caluroso después de haber estado en una vivienda o un vehículo fríos, y señaló que “los trabajadores más jóvenes, más acostumbrados a un estilo de vida más sedentario, no pueden aguantar un día trabajando al aire libre”.

La Asociación de Recursos Forestales, que representa a los propietarios de terrenos forestales, la industria maderera y los aserraderos, agregó que “las enfermedades y muertes relacionadas con el calor no figuran entre los riesgos laborales más graves a los que se enfrentan los trabajadores”. Citaron cifras de OSHA: la agencia documentó 789 hospitalizaciones y 54 muertes relacionadas con el calor a través de investigaciones e infracciones de 2018 a 2021.

OSHA admite que sus datos son cuestionables. Ha dicho que sus cifras “sobre enfermedades, accidentes y muertes relacionadas con el calor en el trabajo son probablemente grandes subestimaciones”.

Los accidentes y enfermedades no siempre se registran, las muertes provocadas por las altas temperaturas no siempre se atribuyen al calor, y los daños relacionados con el calor pueden ser acumulativos, provocando infartos, insuficiencia renal y otras dolencias después de que la persona haya abandonado su lugar de trabajo.

El efecto de la temperatura

Para establecer normas, OSHA debe conocer los efectos del calor en los que trabajan en interiores y al aire libre. La justificación es una parte necesaria del proceso, porque las normativas aumentarán los costos para los empresarios que necesiten instalar sistemas de aire acondicionado y ventilación en el interior, y para aquellos cuya productividad pueda bajar si se permite a los que trabajan a la intemperie tomar descansos o reducir las jornadas cuando suban las temperaturas.

Lo ideal sería que los empresarios tomaran medidas para proteger a los trabajadores del calor independientemente de las normas, afirmó Georges Benjamin, director ejecutivo de la Asociación Americana de Salud Pública. “Tenemos que hacer un mejor trabajo para convencer a los empresarios de que hay una compensación entre la eficiencia y los trabajadores enfermos”, dijo.

García y su marido sufrieron los síntomas del golpe de calor: vómitos, náuseas y fatiga. Pero sus casos forman parte de los miles que no se contabilizan cuando la gente no va al hospital ni presenta denuncias por miedo a perder su empleo o estatus migratorio.

Los trabajadores agrícolas están notoriamente subrepresentados en las estadísticas oficiales sobre accidentes y enfermedades laborales, según David Michaels, epidemiólogo de la Universidad George Washington y ex administrador de OSHA.

Investigadores que encuestaron a trabajadores agrícolas de Carolina del Norte y Georgia encontraron que más de un tercio presentaba síntomas de enfermedad por calor durante los veranos analizados, una cifra muy superior a la registrada por OSHA. En particular, el estudio de Georgia reveló que el 34% de los trabajadores agrícolas no tenía descansos regulares, y una cuarta parte no tenía acceso a espacios con sombra.

Incluso los casos en los que los trabajadores son hospitalizados pueden no atribuirse al calor si los médicos no documentan la conexión. Muchos estudios relacionan los accidentes laborales con el estrés térmico, que puede causar fatiga, deshidratación y vértigo.

En un estudio realizado en el estado de Washington, se observó que los trabajadores agrícolas se caían de las escaleras con más frecuencia en junio y julio, unos de los meses más calurosos y húmedos. Y en un informe de 2021, investigadores calcularon que las temperaturas más cálidas causaron aproximadamente 20,000 accidentes laborales al año en California entre 2001 y 2018, según los reclamos de compensación de los trabajadores.

Las lesiones renales por calor también aparecen en la base de datos de OSHA de trabajadores lesionados gravemente en el trabajo, como el caso de un empleado de una planta de procesamiento de carne hospitalizado por deshidratación y lesión renal aguda en un caluroso día de junio en Arkansas.

Sin embargo, la investigación revela que el daño renal provocado por el calor también puede ser gradual. Un estudio de trabajadores de la construcción que estuvieron durante un verano en Arabia Saudita reveló que el 18% presentaba signos de lesión renal, lo que los ponía en riesgo de insuficiencia renal futura.

Además de cuantificar las lesiones y muertes causadas por el calor, OSHA trata de atribuirles un costo para poder calcular el ahorro potencial derivado de la prevención. “Hay que medir las cosas, como ¿cuánto vale una vida?”, afirmó Michaels.

Para los trabajadores y sus familias, el sufrimiento tiene consecuencias de largo alcance que son difíciles de enumerar. Los gastos médicos son más obvios. Por ejemplo, OSHA calcula que el costo directo de la postración por calor (sobrecalentamiento debido a insolación o hipertermia), es de casi $80,000 en costos directos e indirectos por caso.

Si esto parece elevado, hay que pensar en un trabajador de la construcción de Nueva York que perdió el conocimiento en un día caluroso y se cayó de una plataforma, y sufrió una laceración renal, fracturas faciales y varias costillas rotas.

El precio de los golpes de calor

Investigadores también han intentado determinar el costo que supone para los empresarios la pérdida de productividad. El trabajo es menos eficiente cuando suben las temperaturas, y si los trabajadores se ausentan por enfermedad y tienen que ser reemplazados, la producción disminuye mientras se entrena a nuevos trabajadores.

Cullen Page, cocinero de Austin, Texas, y miembro del sindicato Restaurant Workers United, trabaja durante horas frente a un horno de pizza, donde, según dijo, las temperaturas oscilaron entre los 90 y los 100 grados cuando las olas de calor golpeaban la ciudad en agosto.

“Es brutal. Afecta tu forma de pensar. Estás confundido”, dijo. “Me dio un sarpullido por calor que no se me quitaba”. Como hace tanto calor, agregó, el restaurante tiene un alto índice de rotación de empleados. Una campana extractora adecuada sobre los hornos y un mejor aire acondicionado ayudarían, pero los propietarios aún no han hecho las mejoras, dijo.

Via 313, la cadena de pizzerías en la que trabaja Page, no respondió al pedido de comentario.

Page no es el único. Una organización que representa a los empleados de restaurantes, Restaurant Opportunities Centers United, encuestó a miles de trabajadores, muchos de los cuales informaron de condiciones inseguras por el calor: el 24% de los trabajadores de Houston, por ejemplo, y el 37% de los de Philadelphia.

“Los trabajadores estuvieron expuestos a temperaturas de hasta 100 grados después de que se rompieron los aparatos de aire acondicionado y los ventiladores de las cocinas, lo que les dificultaba respirar”, escribió el Sindicato Internacional de Empleados de Servicios, que incluye a trabajadores del sector de comida rápida, en una nota a OSHA. “No hay razón para retrasar más la creación de una norma cuando conocemos la magnitud del problema y sabemos cómo proteger a los trabajadores”, dijeron.

Investigadores del Atlantic Council calculan que Estados Unidos perderá una media de $100,000 millones anuales por la baja de la productividad laboral inducida por el calor a medida que el clima se vuelve más cálido. “A los empresarios les cuesta mucho dinero no proteger a sus trabajadores”, afirmó Juley Fulcher, defensora de salud y  seguridad de los trabajadores de Public Citizen, organización de Washington D.C. que aboga por que el proyecto de ley Asunción Valdivia permita a OSHA promulgar normas el año que viene.

Como modelo, Fulcher sugirió fijarse en California, Maryland, Nevada, Oregon y Washington, los únicos estados con normas que obligan a que todos los trabajadores al aire libre tengan acceso a agua, descanso y sombra.

Aunque las normas no siempre se hacen cumplir, parece que surten efecto. Después de que California instaurara la suya en 2005, se registraron menos accidentes en los reclamos de indemnización de los trabajadores cuando las temperaturas superaban los 85 grados.

Michaels afirmó que OSHA ha demostrado que puede actuar con más rapidez de lo habitual cuando el Congreso se lo permite.

En los primeros días de la epidemia de VIH/SIDA, la agencia aprobó rápidamente normas para evitar que médicos, enfermeras y dentistas se infectaran accidentalmente con agujas. Ahora existe una urgencia similar, dijo. “Dada la crisis climática y la prolongación de los períodos de calor extremo”, señaló, “es imperativo que el Congreso apruebe una legislación que permita a OSHA promulgar rápidamente una norma que salve vidas”.

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Shementé Jones knew something wasn’t right. Her back hurt. She felt pain during sex.

She said she kept telling her doctor something was wrong.

Her doctor told her, “Just wash your underwear in Dreft,” Jones said, referring to a brand of detergent.

Within months of that 2016 appointment, Jones, who lives in a suburb of Jackson, Mississippi, was diagnosed with stage 3 cervical cancer. She underwent a hysterectomy then weeks of radiation therapy.

“I ended up fine,” said Jones, now 43. “But what about all the other women?”

The question is especially pertinent in Jones’ home state, which had the nation’s second-highest age-adjusted cervical cancer mortality rate, 3.4 deaths per 100,000 women and girls annually from 2016 through 2020, behind only Oklahoma, according to National Cancer Institute data. And, for non-Hispanic Black women such as Jones, the rates in the state are even higher — 3.7 deaths per 100,000 people. This all translates to about 50 avoidable deaths of Mississippi women from cervical cancer each year in this largely rural state.

Health care experts said such a high death rate from a cancer that is preventable, detectable, and successfully treatable when found early is a warning sign about the general state of health care in Mississippi.

“They desperately need help there,” said Otis Brawley, a professor of oncology at Johns Hopkins School of Medicine and an expert on health disparities. “Political leadership is incredibly important in turning this around, and in Mississippi, the political leadership don’t give a damn.”

Despite the beauty of Mississippi, from the rolling hills of the Natchez Trace to white-sand beaches on the Gulf of Mexico, and the cultural renown of its famous musicians and storytellers, the state’s reputation is marred by its high rates of poverty. People who live there are accustomed to being the butt of jokes, but it hurts.

“Often Mississippi gets represented poorly,” said Mildred Ridgway, an OB-GYN at the University of Mississippi Medical Center in Jackson.

Recently the state has reeled from crisis after crisis. As recently as March, tornadoes and other severe weather killed more than two dozen people and caused extensive damage. Last year, the water in Jackson, the state capital, was undrinkable for months because of treatment plant failures.

On just about any measure of health, Mississippi ranks near or at the bottom. Nationally, an estimated 10% of people under 65 lack health insurance, but in Mississippi it is about 14%. Deaths from cardiovascular disease, diabetes, cancer, and many other illnesses are among the highest per capita in the country.

The high rates of poverty contribute to the high cervical cancer mortality, health experts said. About 19% of Mississippians — nearly 1 in 5 — live in poverty, while nationally it is about 13%.

“If I had to pinpoint what that’s from, it’s from lack of education,” said Ridgway, referring to a lack of knowledge about regular cervical cancer screening, which the U.S. Preventive Services Task Force recommends every three years for women 21 to 65.

But it likely goes far beyond that, many health experts said. Doctors may be less likely to stress preventive care to less educated women and women of color, studies suggest.

“There’s a big difference in the quality of care,” said Rajesh Balkrishnan, a professor of public health at the University of Virginia who has extensively studied oncology care in Appalachia and other underserved areas.

In her case, Jones said, she could not get her doctor’s office to return her calls in a timely manner. She was concerned about her symptoms.

“I felt I wasn’t listened to. I called her more than she called me,” Jones said of her doctor. “I was going to my appointments, and I was ignored.”

And getting access to any care — let alone quality, culturally competent care from providers who acknowledge a patient’s heritage, beliefs, and values during treatment — may be difficult.

Most of the state’s 82 counties are rural. The average travel distance to a grocery store is 30 miles, and half the population lives in a county that is considered medically underserved, said Letitia Thompson, a vice president in Mississippi for the American Cancer Society.

Low-income rural residents often lack reliable transportation, she said, and even if they own a vehicle, they lack gas money. They often can’t find — or pay for — someone to take care of their children so they can go to the doctor. Women with low-paying jobs often lack the time to drive to a clinic in a distant town, or the ability to take off from work without losing pay.

“Women who work and take care of children often have a huge burden of responsibility,” Ridgway said. “They don’t have time or the money.”

Many also don’t have insurance. While the Affordable Care Act has lowered the uninsured rate in Mississippi, an estimated additional 88,000 Mississippians could have coverage through Medicaid if the state expanded eligibility for the federal-state insurance program for low-income Americans. But the state is one of 10 that have not agreed to expand coverage to more adults.

Mississippi Gov. Tate Reeves, a Republican up for reelection this year, is opposed to expansion. His Democratic challenger, Brandon Presley, a second cousin of the music legend Elvis, favors it. Polls show Presley lagging Reeves.

Without expansion of Medicaid, people who have low incomes are often left to decide between forgoing insurance and purchasing a policy through the Affordable Care Act marketplace if they cannot get insurance through employment. Even if they qualify for subsidized marketplace plans, they may face high deductibles or copayments for visits, health experts said. That often means going to the doctor only when sick. Preventive care becomes a luxury.

“You save your health care dollars for when you are sick or your kids are sick,” said Thompson, of the American Cancer Society.

But regular medical care can make all the difference with cervical cancer. Pap tests have long helped detect abnormal cervical cells that could turn malignant. Brawley said the test is “one of the best” cancer screening tests because of its accuracy.

In 2006, vaccines to prevent cervical cancer were first approved by the FDA. The vaccines guard against the common sexually transmitted infection called the human papillomavirus, which causes nearly all cervical cancers. The HPV vaccine is most effective when administered before a person has become sexually active; the federal recommendation is to get the shots by age 12.

Only a handful of places in the U.S. — including Hawaii, Rhode Island, Virginia, Puerto Rico, and the District of Columbia — require the vaccines to attend school. California has pending legislation that initially would have required that middle schoolers get the shots, but the bill has since been watered down to recommend them instead.

Mississippi does not require the vaccine, and the state has had the lowest share of fully vaccinated teens by a large margin for years. Fewer than 39% of teens there were up to date on HPV vaccination as of 2022, according to the CDC, compared with an estimated 63% nationally.

Thompson said she thinks many parents are hesitant to have their children vaccinated because they believe it would encourage sexual activity.

“This is an anti-cancer vaccine,” Thompson said.

Krista Guynes, director of the women’s health program at the Mississippi State Department of Health, said the state has several efforts underway to better inform women about the need for screening. It also has clinics for uninsured women. In partnership with the National Cancer Institute and University of Mississippi Medical Center, she said, the health department is conducting a study to evaluate risk and look for new biomarkers in women undergoing screening for cervical cancer.

As for Jones, she considers herself lucky to have survived stage 3 cancer.

“I would just like to say to every woman, ‘Get the vaccine.’ The vaccine will make the difference, so they won’t have to be told, ‘I’m sorry, you have cancer.’”

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On July 1, Idaho became the only state without a legal requirement or specialized committee to review maternal deaths related to pregnancy.

The change comes after state lawmakers, in the midst of a national upsurge in maternal deaths, decided not to extend a sunset date for the panel set in 2019, when they established the state’s Maternal Mortality Review Committee, or MMRC.

The committee was composed of a family medicine physician, an OB-GYN, a midwife, a coroner, and a social worker, in addition to others who track deaths in Idaho that occur from pregnancy-related complications. Wyoming studies its maternal deaths through a shared committee with Utah. All other states, as well as Washington, D.C., New York City, Philadelphia, and Puerto Rico, have an MMRC, according to the Guttmacher Institute, a reproductive rights research group.

A majority of the state committees were established within the past decade as federal officials scrambled to understand state and local data to address gaps in maternal care. The committees review deaths that occur within a year of pregnancy and identify trends, share findings, and suggest policy changes.

Liz Woodruff, executive director of the Idaho Academy of Family Physicians, said she was “incredibly disappointed” by the legislature’s decision to scuttle the committee. “It seems relevant that the state of Idaho supports a committee that works toward preventing the deaths of pregnant women,” she said. “This should be easy.”

The committee disbanded despite a high rate of maternal mortality in the United States that exceeds those of other high-income countries. The U.S. recorded 23.8 maternal deaths per 100,000 live births in 2020, compared with 8.4 in Canada and 3.6 in Germany, according to the Organization for Economic Cooperation and Development and the Centers for Disease Control and Prevention.

And the U.S. rate is sharply rising. In March, a few weeks before Idaho lawmakers adjourned their 2023 session, the CDC released data that showed the maternal mortality rate in the U.S. climbed in 2021 to 32.9 deaths per 100,000 live births.

Idaho has a particularly acute problem. Its pregnancy-related mortality ratio was 41.8 pregnancy-related deaths per 100,000 live births in 2020, according to the Maternal Mortality Review Committee report from that year.

Hillarie Hagen of Idaho Voices for Children, a nonprofit focused on low- and moderate-income families, said that the committee used the Idaho-specific data to do deep-dive analyses and that an information void would be left by shuttering the board.

“How do we make decisions and policy decisions to improve the health of mothers and their babies if we’re not tracking the data?” she asked. “From our perspective, having consistent data and trends shown over time helps make more sound policy decisions.”

The decision to disband the board came as two hospitals that serve rural areas announced they would stop providing services for expectant mothers. One of the hospitals cited trouble recruiting and retaining OB-GYNs after the state last summer enacted one of the strictest abortion bans in the country.

The committee, tasked with investigating deaths both individually and collectively, found that almost half of the maternal deaths in Idaho in 2020 occurred after delivery.

Amelia Huntsberger, an OB-GYN and a member of the committee, noted also that patients covered by Medicaid during pregnancy are overrepresented in maternal death rates, which led the panel to recommend expansion of postpartum Medicaid coverage to 12 months rather than the current 60 days.

Huntsberger made national headlines this year when she announced plans to leave both her job and the state, citing the state’s abortion ban and the move to dissolve the MMRC.

But in their legislative session, Idaho lawmakers decided not to advance a bill that would have embraced the committee’s recommendation to expand postpartum Medicaid coverage.

The legislation creating the review committee included a “sunset clause” to dissolve the committee on July 1, 2023. Following a contentious session of the Health and Welfare Committee of the Idaho House of Representatives in February, House Bill 81, which would have renewed the committee, failed to advance.

Republican state Rep. Dori Healey said she sponsored the bill because of her work as an advanced practice registered nurse when the legislature is out of session. “For me, being in the health care field, I think it’s always important to understand the why behind anything. Why is this happening? What can we do better?” Healey said. “I feel like in health care we can only improve with knowledge.”

Healey said she hadn’t anticipated the strong opposition to the bill. In declining to advance it, lawmakers cited costs of running the panel, although some, like Huntsberger, say its operation was covered by a federal grant.

The MMRC was funded by the federal Title V Maternal and Child Health Block Grant program, aimed at improving the health of mothers, infants, and children. Idaho has received more than $3 million annually in Title V funds in recent years, according to statistics cited by Huntsberger.

The MMRC, whose members say annual operation costs stand at about $15,000, was deemed budget-neutral, running at no cost to the state.

In an interview with KFF Health News, Marco Erickson, vice chair of the Health and Welfare Committee, said Idaho’s Republican Party has been focused on reducing government spending. He said the same maternal data could be adequately culled through epidemiology reports already published by the Department of Health and Welfare.

“Anytime that there is a death of a mother and child, there is value in evaluating why it occurred,” Erickson said. “The whole committee saw the importance but saw there was another way to do it. It wasn’t that they didn’t think it was valuable.”

Erickson, who previously oversaw elements of maternal and child health in his role as a health program manager for Nevada’s Division of Public and Behavioral Health, said that information could become siloed in government, but it was worthwhile to improve existing bodies, rather than creating a committee anew.

“I think it could be covered elsewhere, and if it’s not being done, they need to make a loud voice to cover it in the existing programs,” he said. “We’re happy to sit down together to find a solution that works.”

The lobbying group Idaho Freedom Foundation celebrated the end of the committee, contending it was a “vehicle to promote more government intervention in health care,” and citing the group’s recommendation to extend Medicaid coverage to mothers for 12 months postpartum.

Elke Shaw-Tulloch, public health administrator at the Department of Health and Welfare, said the department would “continue to collect raw data on maternal deaths and gather as much data as possible through limited, existing sources.” But, she said, it will not have the ability to compel reporting on cases or convene committee members to investigate deaths.

“We are currently assessing what actions we can take and working with stakeholders to address solutions moving forward,” she said.

A group to do so has not yet convened since the legislative session ended in April, although stakeholders say they will focus on bringing another bill before the Idaho Legislature to reinstitute the committee in the 2024 session.

Stacy Seyb, a maternal-fetal specialist who grew up in rural western Kansas and chaired the committee until its dissolution, said that supporting medical providers in more rural areas was part of his lifelong mission and that the work won’t necessarily stop.

“We knew once it didn’t get out of committee that ‘Oh, well, we’re sunk,’” Seyb said. “I know one thing we want to do is collect as much information as we can over the year. Whether it will get reviewed or not, I don’t know.”

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Son parte de una nueva migración de estadounidenses que se están desarraigando debido a una oleada de leyes que restringen la prestación de servicios de salud para personas transgénero.

Missouri, Florida y Texas se encuentran entre al menos 20 estados que han limitado la atención de afirmación de género para jóvenes trans. Los tres estados también están entre aquellos que impiden que Medicaid, el seguro de salud público para personas de bajos ingresos, cubra aspectos clave de estos servicios para pacientes de todas las edades.

Más de una cuarta parte de los adultos trans encuestados por KFF y The Washington Post a fines del año pasado dijeron que se mudaron a otro vecindario, ciudad o estado en busca de un ambiente más tolerante. Ahora se sienten impulsados por las nuevas restricciones en la atención de la salud y la posibilidad de que estas se sigan multiplicando.

Muchos de ellos optan por estados que están aprobando leyes para proteger y apoyar estos servicios, lugares que se han convertido en santuarios. En California, por ejemplo, se aprobó una ley el otoño pasado que protege de demandas a las personas que reciben o brindan servicios de afirmación de género. Y ahora, los proveedores en California están recibiendo cada vez más llamadas de personas que quieren mudarse al estado para evitar interrupciones en sus servicios, dijo Scott Nass, médico local de familia y experto en atención de personas transgénero.

Pero esta afluencia de pacientes presenta un desafío, dijo Nass, “ya que el sistema actual no puede recibir a todos los refugiados que pudiera haber”.

En Florida, la persecución legislativa de las personas trans y su atención médica convenció a Arlo Dennis, de 35 años, de que es hora de irse. Hace más de una década que vive con los cinco miembros de su familia en Orlando. Ahora, tienen planes de mudarse a Maryland.

Dennis ya no tiene acceso a su terapia de reemplazo hormonal. Esto se debe a que desde fines de agosto, el seguro de Medicaid de Florida ya no cubre la atención médica relacionada con la transición. El estado considera que estos tratamientos son experimentales y que su eficacia no está suficientemente probada. Dennis dijo que su medicación se acabó en enero.

“Sin duda esto me ha causado problemas de salud mental y física”, explicó Dennis.

Agregó que mudarse a Maryland requiere recursos que su familia no tiene. Lanzaron una campaña de GoFundMe en abril y ya recaudaron más de $5,600, la mayoría donada por desconocidos, contó Dennis. Ahora la familia de tres adultos y dos niños piensa irse de Florida en julio. La decisión no fue fácil, pero sintieron que no había otra opción.

“No me importa si a mi vecino no le gusta mi forma de vivir”, dijo Dennis. “Pero esto era una prohibición literal de mi ser y me impedía el acceso a la atención médica”.

Mitch y Tiffany Tillison decidieron irse de Texas después de que los republicanos del estado enfocaron su agenda legislativa en las políticas anti-trans para los jóvenes. Su hija de 12 años se declaró trans hace unos dos años. Los padres pidieron que se publicara solo su segundo nombre, Rebecca: temen por su seguridad debido a las amenazas de violencia contra las personas trans.

Este año, la Legislatura de Texas aprobó una ley que limita la atención médica de afirmación de género para jóvenes menores de 18 años. La ley prohíbe específicamento aquellos servicios de salud física. Sin embargo, defensores de los derechos LGBTQ+ en el estado dicen que las medidas recientes también han tenido un escalofriante efecto sobre la prestación de servicios de salud mental para personas trans.

Los Tillison se negaron a precisar si su hija está recibiendo tratamiento y cuál. Pero afirmaron que reservan el derecho, como padres, de poder brindarle a su hija la atención que necesita, y que el estado de Texas les ha quitado ese derecho.

A esto se suman las amenazas cada vez más serias de violencia en su comunidad, sobre todo después del tiroteo masivo del 6 de mayo por parte de un supuesto neonazi. La masacre, que ocurrió en el centro comercial Allen Premium Outlets, en los suburbios de Dallas, a 20 millas de su casa, hizo que la familia decidiera mudarse al estado de Washington. 

“La he mantenido a salvo”, dijo Tiffany Tillison, agregando que suele recordar el momento en que su hija le dijo que era trans durante un largo viaje a casa después de un torneo de fútbol. “Es mi responsabilidad seguir protegiéndola. Mi amor es interminable, incondicional”.

Por su parte, Rebecca tiene una actitud pragmática sobre la mudanza, que está planeada para julio. “Es triste pero tenemos que hacerlo”, dijo.

En Missouri, donde casi se aprueba una medida que limitaba la atención de la salud trans, algunas personas empezaron a repensar si deberían vivir ahí.

En abril, el fiscal general de Missouri, Andrew Bailey, presentó una norma de emergencia para limitar el acceso a la cirugía relacionada con la transición y el tratamiento hormonal cruzado para personas de todas las edades, además de restringir los bloqueadores de la pubertad, medicamentos que detienen la pubertad pero no alteran las características de género.

Al día siguiente, Dempsey, de 24 años, lanzó una campaña de GoFundMe para recaudar fondos para irse con sus parejas de Springfield, Missouri.

“Somos tres personas trans que dependen de la terapia de reemplazo hormonal y de la atención de afirmación de género que pronto será casi prohibida”, escribió Dempsey en su campaña de GoFundMe, agregando que querían “escapar de Missouri cuando se termine nuestro contrato de alquiler a fines de mayo.”

Dempsey dijo que su médico en Springfield les recetó un suministro de tres meses de terapia hormonal para cubrirlos hasta la mudanza.

Bailey retiró la norma en mayo, cuando la legislatura estatal restringió el acceso a estos tratamientos para menores pero no para adultos como Dempsey y sus parejas. Aún así, Dempsey dijo que no tenía muchas esperanzas para su futuro en Missouri.

El estado vecino de Illinois era una opción obvia para mudarse; la legislatura allí aprobó una ley en enero que exige que los seguros médicos regulados por el estado cubran la atención médica de afirmación de género sin ningún costo adicional. Dónde en Illinois exactamente era una pregunta más importante. Chicago y sus suburbios parecían demasiado caros. Sus parejas querían una comunidad progresista similar en tamaño y costo de vida a la ciudad que estaban dejando. Buscaban “un Springfield”, en Illinois.

“Pero no Springfield, Illinois”, bromeó Dempsey.

Gwendolyn Schwarz, de 23 años, también esperaba quedarse en Springfield, Missouri, su ciudad natal, donde recientemente se graduó de Missouri State University con un título en estudios de cine y medios de comunicación. Pensaba seguir su carrera académica en un programa de posgrado de la universidad y, en el siguiente año, someterse a una cirugía de transición, que puede requerir varios meses de recuperación.Pero sus planes cambiaron cuando la norma propuesta por Bailey generó miedo y confusión.“No quiero quedarme atrapada y temporalmente discapacitada en un estado que no reconoce mi humanidad”, dijo Schwarz.

Ella y un grupo de amigos tienen planeado mudarse al oeste, al estado de Nevada, cuyos legisladores aprobaron una medida que requiere que Medicaid cubra el tratamiento de afirmación de género para pacientes trans.

Schwarz espera que mudarse de Missouri a Carson City, la capital de Nevada, le permita seguir viviendo su vida sin miedo y eventualmente someterse a la cirugía que desea.

Dempsey y sus parejas finalmente decidieron mudarse a Moline, Illinois. Los tres tuvieron que renunciar a sus trabajos, pero han recaudado $3,000 en GoFundMe, más que suficiente para cubrir el depósito de un nuevo departamento.

El 31 de mayo, empacaron las pertenencias que no habían vendido e hicieron el viaje de 400 millas hasta su nuevo hogar.

Dempsey ya tuvo una cita con un proveedor médico en una clínica en Moline que atiende a la comunidad LGBTQ+, y consiguió que le recetaran los medicamentos que necesita para su terapia hormonal.

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Hal Dempsey wanted to “escape Missouri.” Arlo Dennis is “fleeing Florida.” The Tillison family “can’t stay in Texas.”

They are part of a new migration of Americans who are uprooting their lives in response to a raft of legislation across the country restricting health care for transgender people.

Missouri, Florida, and Texas are among at least 20 states that have limited components of gender-affirming health care for trans youth. Those three states are also among the states that prevent Medicaid — the public health insurance for people with low incomes — from paying for key aspects of such care for patients of all ages.

More than a quarter of trans adults surveyed by KFF and The Washington Post late last year said they had moved to a different neighborhood, city, or state to find more acceptance. Now, new restrictions on health care and the possibility of more in the future provide additional motivation.

Many are heading to places that are passing laws to support care for trans people, making those states appealing sanctuaries. California, for example, passed a law last fall to protect those receiving or providing gender-affirming care from prosecution. And now, California providers are getting more calls from people seeking to relocate there to prevent disruptions to their care, said Scott Nass, a family physician and expert on transgender care based in the state.

But the influx of patients presents a challenge, Nass said, “because the system that exists, it can’t handle all the refugees that potentially are out there.”

In Florida, the legislative targeting of trans people and their health care has persuaded Arlo Dennis, 35, that it is time to uproot their family of five from the Orlando area, where they’ve lived for more than a decade. They plan to move to Maryland.

Dennis, who uses they/them pronouns, no longer has access to hormone replacement therapy after Florida’s Medicaid program stopped covering transition-related care in late August under the claim that the treatments are experimental and lack evidence of being effective. Dennis said they ran out of their medication in January.

“It’s definitely led to my mental health having struggles and my physical health having struggles,” Dennis said.

Moving to Maryland will take resources Dennis said their family does not have. They launched a GoFundMe campaign in April and have raised more than $5,600, most of it from strangers, Dennis said. Now the family, which includes three adults and two children, plans to leave Florida in July. The decision wasn’t easy, Dennis said, but they felt like they had no choice.

“I’m OK if my neighbor doesn’t agree with how I’m living my life,” Dennis said. “But this was literally outlawing my existence and making my access to health care impossible.”

Mitch and Tiffany Tillison decided they needed to leave Texas after the state’s Republicans made anti-trans policies for youth central to their legislative agenda. Their 12-year-old came out as trans about two years ago. They asked for only her middle name, Rebecca, to be published because they fear for her safety due to threats of violence against trans people.

This year, the Texas Legislature passed a law limiting gender-affirming health care for youth under 18. It specifically bans physical care, but local LGBTQ+ advocates say recent crackdowns also have had a chilling effect on the availability of mental health therapy for trans people.

While the Tillisons declined to specify what treatment, if any, their daughter is getting, they said they reserve the right, as her parents, to provide the care their daughter needs — and that Texas has taken away that right. That, plus increasing threats of violence in their community, particularly in the wake of the May 6 mass shooting by a professed neo-Nazi at Allen Premium Outlets, about 20 miles from their home in the Dallas suburbs, caused the family to decide to move to Washington state.

“I’ve kept her safe,” said Tiffany Tillison, adding that she often thinks back to the moment her daughter came out to her during a long, late drive home from a daylong soccer tournament. “It’s my job to continue to keep her safe. My love is unending, unconditional.”

For her part, Rebecca is pragmatic about the move planned for July: “It’s sad, but it is what we have to do,” she said.

A close call on losing key medical care in Missouri also pushed some trans people to rethink living there. In April, Missouri Attorney General Andrew Bailey issued an emergency rule seeking to limit access to transition-related surgery and cross-sex hormones for all ages, and restrict puberty-blocking drugs, which pause puberty but don’t alter gender characteristics. The next day, Dempsey, 24, who uses they/them pronouns, launched a GoFundMe fundraiser for themself and their two partners to leave Springfield, Missouri.

“We are three trans individuals who all depend on the Hormone Replacement Therapy and gender affirming care that is soon to be prohibitively limited,” Dempsey wrote in the fundraising appeal, adding they wanted to “escape Missouri when our lease is up at the end of May.”

Dempsey said they also got a prescription for a three-month supply of hormone therapy from their doctor in Springfield to tide them over until the move.

Bailey withdrew his rule after the state legislature in May restricted new access to such treatments for minors, but not adults like Dempsey and their partners. Still, Dempsey said their futures in Missouri didn’t look promising.

Neighboring Illinois was an obvious place to move; the legislature there passed a law in January that requires state-regulated insurance plans to cover gender-affirming health care at no extra cost. Where exactly was a bigger question. Chicago and its suburbs seemed too expensive. The partners wanted a progressive community similar in size and cost of living to the city they were leaving. They were looking for a Springfield in Illinois.

“But not Springfield, Illinois,” Dempsey quipped.

Gwendolyn Schwarz, 23, had also hoped to stay in Springfield, Missouri, her hometown, where she had recently graduated from Missouri State University with a degree in film and media studies. She had planned to continue her education in a graduate program at the university and, within the next year, get transition-related surgery, which can take a few months of recovery.

But her plans changed as Bailey’s rule stirred fear and confusion.

“I don’t want to be stuck and temporarily disabled in a state that doesn’t see my humanity,” Schwarz said.

She and a group of friends are planning to move west to Nevada, where state lawmakers have approved a measure that requires Medicaid to cover gender-affirming treatment for trans patients.

Schwarz said she hopes moving from Missouri to Nevada’s capital, Carson City, will allow her to continue living her life without fear and eventually get the surgery she wants.

Dempsey and their partners settled on Moline, Illinois, as the place to move. All three had to quit their jobs to relocate, but they have raised $3,000 on GoFundMe, more than enough to put a deposit down on an apartment.

On May 31, the partners packed the belongings they hadn’t sold and made the 400-mile drive to their new home.

Since then, Dempsey has already been able to see a medical provider at a clinic in Moline that caters to the LGBTQ+ community — and has gotten a new prescription for hormone therapy.

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Cuando los antepasados de John Mestas se mudaron a Colorado hace más de 100 años para criar ovejas en el Valle de San Luis, “llegaron al paraíso”, contó.

“Había tanta agua que pensaron que nunca se acabaría”, dijo Mestas refiriéndose a la región agrícola en la cabecera del río Grande.

Ahora, décadas de sequía impulsada por el cambio climático, combinada con la sobre explotación de los acuíferos, están dejando al valle desesperadamente seco, y parece estar intensificando los niveles de metales pesados en el agua potable.

Al igual que un tercio de las personas que viven en este desierto alpino de gran altitud, Mestas depende de un pozo privado que extrae agua de un acuífero para beber. Y, al igual que muchos agricultores de la zona, usa la misma fuente para regar la alfalfa que alimenta a sus 550 vacas.

“Aquí, el agua lo es todo”, dijo.

Mestas, de 71 años, ahora es uno de los cientos de propietarios de pozos que participan en un estudio que aborda la pregunta: ¿Cómo afecta la sequía no solo a la cantidad, sino también a la calidad del agua?

El estudio, dirigido por Kathy James, profesora asociada en la Escuela de Salud Pública de Colorado, se centra en el arsénico en los pozos privados de agua potable. El arsénico, un carcinógeno que se encuentra naturalmente en el suelo, ha estado apareciendo en niveles crecientes en el agua potable del valle, según James.

En California, México y Vietnam, las investigaciones han relacionado el aumento de los niveles de arsénico en el agua subterránea con la sequía y la sobre explotación de los acuíferos.

A medida que el oeste lucha contra una mega sequía que ha durado más de dos décadas y los estados corren el riesgo de recortes en el agua del menguante río Colorado, el Valle de San Luis ofrece pistas sobre lo que el futuro puede deparar.

A nivel nacional, alrededor de 40 millones de personas dependen de pozos domésticos, estimó Melissa Lombard, investigadora en hidráulica del U.S. Geological Survey. Nevada, Arizona y Maine tienen el mayor porcentaje de usuarios de pozos domésticos —que oscilan entre aproximadamente un cuarto y una quinta parte de estos usuarios—, que utilizan agua con niveles elevados de arsénico, según encontró en un otro estudio.

Durante la sequía, el número de personas en los Estados Unidos continental expuestas a niveles elevados de arsénico en pozos domésticos podría aumentar de aproximadamente 2,7 millones a 4,1 millones, estimó Lombard utilizando modelos estadísticos.

Se ha comprobado que el arsénico afecta la salud a lo largo de la vida, comenzando con los espermatozoides y los óvulos, explicó James. Incluso una pequeña exposición, acumulada a lo largo de la vida de una persona, es suficiente para causar problemas de salud, agregó.

En un estudio anterior en el valle, James encontró que la exposición de por vida a niveles bajos de arsénico inorgánico en el agua potable, entre 10 y 100 microgramos por litro (µg/L), estuvo relacionada con un mayor riesgo de enfermedad coronaria. Otras investigaciones han vinculado la exposición crónica a niveles bajos de arsénico con hipertensión, diabetes y cáncer.

Las mujeres embarazadas y los niños corren un mayor riesgo de sufrir daños.

La Organización Mundial de la Salud establece el límite recomendado de arsénico en el agua potable en 10 µg/L, que también es el estándar de los Estados Unidos para los suministros públicos de agua. Pero las investigaciones han demostrado que, incluso a 5 µg/L, el arsénico está relacionado con tasas más altas de lesiones en la piel.

“Creo que es un problema del que mucha gente no está consciente”, dijo Lombard. “El cambio climático probablemente afectará la calidad del agua”, dijo, pero se necesita más investigación para comprender cómo y por qué.

Un foco de esperanza

El Valle de San Luis, que ha sido sede de una gran cantidad de investigación e innovación, es el lugar ideal para explorar esas preguntas, y posibles soluciones.

Conocido por sus impresionantes vistas montañosas y la cercanía al Parque y Reserva Nacional Great Sand Dunes, el valle abarca una región aproximadamente del tamaño de Massachusetts, convirtiéndolo en el valle alpino más grande de América del Norte.

Rico en herencia indígena, mexicana y española, contiene 500,000 acres de tierra de riego que producen papas, alfalfa para forraje y cebada para la cerveza de Coors. Es hogar de casi 50,000 personas, muchas de ellas trabajadores agrícolas y aproximadamente la mitad de ellas hispanas.

También es un lugar desafiante para vivir: los condados aquí se encuentran entre los más pobres del estado, y las tasas de diabetes, enfermedad renal y depresión son altas.

Dado que llueve muy poco, aproximadamente 7 pulgadas al año en promedio, los agricultores dependen de dos grandes acuíferos y de las cabeceras del río Grande, que continúa hacia México. El deshielo de las imponentes cordilleras de Sangre de Cristo y San Juan recarga el suministro cada primavera.

Sin embargo, a medida que el clima se calienta, hay menos nieve y el agua se evapora más rápidamente de lo normal tanto del suelo como de los cultivos. “Esta comunidad entera, esta cultura, se construyó en torno a la agricultura de riego”, dijo Cleave Simpson, senador estatal de Alamosa, republicano y agricultor de cuarta generación.

Pero desde 2002, el acuífero no confinado del valle ha perdido 1 millón de acres-pie de agua, o suficiente para cubrir 1 millón de acres de tierra con un pie de agua de profundidad, debido a la sequía persistente y el uso excesivo. Ahora las comunidades del valle enfrentan una fecha límite para reponer el acuífero, o enfrentar el cierre estatal de cientos de pozos de riego.

“Estamos una década adelante de lo que está sucediendo en el resto de Colorado” debido a la intensidad de la escasez de agua, dijo Simpson, quien administra el Río Grande Water Conservation District.

“Esto ya no es una sequía, esto es realmente la desertificación del Oeste“, dijo Simpson. Así es como los científicos describen una tendencia a largo plazo hacia la sequedad y aridez persistentes que solo puede detenerse abordando el cambio climático causado por los humanos.

James, quien es epidemióloga e ingeniera, ha estado estudiando las conexiones entre el clima y la salud en el valle durante los últimos 15 años. Descubrió que durante las tormentas de polvo en el Valle de San Luis, que se han vuelto más frecuentes, más personas llegan al hospital por ataques de asma. Y ha encuestado a los trabajadores agrícolas sobre cómo la sequía está afectando su salud mental.

En el estudio de los pozos domésticos, James se está centrando en el arsénico, que según dijo ha ido aumentando gradualmente en los pozos de agua potable del valle en los últimos 50 años. Los niveles de arsénico en el agua subterránea del Valle de San Luis son “considerablemente más altos que en muchas otras áreas de los Estados Unidos”, según James. También está investigando las disparidades étnicas, ya que un estudio mostró que los adultos hispanos tenían niveles más altos de arsénico en su orina que los adultos blancos no hispanos. (Las personas hispanas pueden ser de cualquier raza o combinación de razas).

Ahora, James tiene como objetivo analizar 1,000 pozos privados en el valle para explorar las conexiones entre la sequía, la calidad del agua y la salud. Hasta ahora, dijo que una pequeña proporción de los pozos muestra niveles elevados de metales pesados, incluyendo arsénico, uranio, tungsteno y manganeso, que se encuentran naturalmente en el suelo.

A diferencia de los suministros públicos de agua, los pozos domésticos privados no están regulados y pueden pasar años sin ser analizados. James ofrece pruebas de agua gratuitas y consultas sobre los resultados a los participantes. En el condado de Conejos, la hija de John Mestas, Angie Mestas, aprovechó la oportunidad de hacer una prueba gratuita, que costaría $195 en un laboratorio local.

Angie, maestra de 35 años, dijo que utilizó los ahorros de toda una vida para perforar un pozo de agua potable en su terreno, un campo abierto de hierba chamisa con vistas panorámicas a las Colinas de San Luis. Pero no beberá de este pozo hasta que se realicen pruebas de arsénico y E. coli, que son comunes en la zona.

Mientras espera los resultados de las pruebas, ha estado llevando barriles de agua de 5 galones desde la casa de su padre cada vez que pasa el fin de semana en su nueva carpa.

Amenaza sin olor ni color

Mientras tanto, Julie Zahringer, cuya familia se estableció en el valle desde España hace casi 400 años, ha estado observando las tendencias de calidad del agua de primera mano.

Zahringer, de 47 años, creció conduciendo un tractor en el rancho de su abuelo cerca de San Luis, la ciudad más antigua de Colorado, y pasó tiempo en el laboratorio con su madre, que es científica.

Como química y directora de laboratorio de SDC Laboratory en Alamosa, Zahringer analiza el agua potable privada y pública en el valle. Estimó que el 25% de los pozos privados analizados por su laboratorio muestran niveles elevados de arsénico. “Es incoloro, es inodoro”, dijo Zahringer. “La mayoría de las familias no saben si están bebiendo arsénico”.

Para ella, el vínculo con el clima parece claro: durante los períodos de sequía, un pozo que normalmente tiene alrededor de 10 µg/L de arsénico puede fácilmente duplicar o triplicar su concentración, dijo. Una posible razón es que hay menos agua para diluir los contaminantes naturales del suelo, aunque también intervienen otros factores.

Dijo que los niveles de arsénico solían ser bastante estables, pero después de 20 años de sequía, fluctúan de manera descontrolada.

“Ahora, cada vez más rápido, veo el mismo pozo que analicé hace tres años, y ni siquiera parece el mismo” porque los niveles de contaminantes han aumentado tanto, dijo Zahringer, quien también es miembro de la Comisión de Control de Calidad del Agua de Colorado.

En su propio pozo de agua potable, el nivel de arsénico aumentó de 13 a 20 µg/L este año, dijo.

Las observaciones de Zahringer son importantes historias de primera mano. James tiene como objetivo explorar, en un estudio científico riguroso con una muestra representativa de pozos y datos geoquímicos extensos, la prevalencia del arsénico y su conexión con la sequía.

La investigación todavía se encuentra en etapas iniciales, pero los científicos tienen varias hipótesis sobre cómo la sequía podría afectar el arsénico en el agua potable. En el Valle de San Joaquín, un importante centro agrícola en California, la investigación liderada por el experto en hidráulica Ryan Smith relacionó el aumento de arsénico en las aguas subterráneas con el “hundimiento del terreno”, un fenómeno documentado por primera vez en Vietnam.

El hundimiento del terreno, cuando el suelo se hunde debido a la sobreexplotación de los acuíferos, parece liberar arsénico de la arcilla hacia el agua, dijo Smith, profesor asistente de la Universidad Estatal de Colorado. En California, la sobreexplotación estaba fuertemente correlacionada con la sequía, agregó.

Sin embargo, otros factores, como la profundidad de un pozo, también juegan un papel: otro estudio del mismo sistema de acuíferos en California encontró que mientras el arsénico aumentaba en las aguas subterráneas más profundas, disminuía en las aguas más superficiales debido, en parte, a la oxidación.

Smith está trabajando ahora con James en el estudio del Valle de San Luis, donde espera que una gran cantidad de datos geoquímicos brinden más respuestas. Mientras tanto, los líderes comunitarios en el valle se están adaptando de formas impresionantes e innovadoras, dijo James.

Zahringer dijo que si el arsénico aparece en un pozo privado, anima a los clientes a instalar un sistema de filtración de agua por ósmosis inversa en el fregadero de la cocina. El equipo cuesta alrededor de $300 con un proveedor externo, aunque los filtros que cuestan menos de $50 pueden necesitar cambiarse cada seis a 18 meses, dijo.

Aquellas personas que tratan su agua para eliminar el arsénico deben seguir realizando pruebas cada seis meses para asegurarse de que los filtros sean efectivos, agregó Zahringer. SDC Laboratory ofrece una prueba de arsénico por $25.

“A las personas no les gusta analizar el agua porque sabe bien y sus abuelos la bebían”, dijo. Pero “la solución es tan fácil”.

Una campaña de calidad del agua en 2009, liderada por el Consejo del Ecosistema del Valle de San Luis, también encontró niveles elevados de arsénico en los pozos a lo largo del valle. Como parte de sus actividades, la organización sin fines de lucro trabajó con agentes inmobiliarios para asegurarse de que los pozos domésticos sean analizados antes de que alguien compra una casa.

Eso es lo que hizo Sally Wier cuando compró una casa hace cinco años en una parcela de 8 acres en el condado de Rio Grande, rodeada de campos de cebada y alfalfa. La primera vez que probó su pozo, el nivel de arsénico era de 47 µg/L, casi cinco veces más del límite establecido por la Agencia de Protección Ambiental (EPA). Wier instaló un sistema de filtración de agua por ósmosis inversa, pero dijo que el nivel de arsénico aumenta antes de que cambie los filtros cada pocos meses.

“Me pone muy ansiosa”, dijo Wier, de 38 años. “Probablemente estoy ingiriendo arsénico. Eso no es bueno para la salud a largo plazo”.

Wier es una de muchas personas que trabajan en soluciones innovadoras para la escasez de agua. Como gerente de proyectos de conservación en Colorado Open Lands, trabajó en un acuerdo mediante el cual se le pagó a un agricultor local, Ron Bowman, para que dejara de regar su granja de 1,800 acres. Según Wier, este acuerdo marca la primera vez en el país que se utiliza un acuerdo de uso de conservación para salvar agua subterránea y reponer acuíferos.

Canalizando dinero hacia una solución

En el condado de Costilla, el Move Mountains Youth Project ha estado pagando a agricultores locales, a través de una subvención gubernamental, para que conviertan una parte de sus tierras en cultivos de vegetales en lugar de cultivos de alfalfa que requieren mucha agua.

Los agricultores luego entrenan a los jóvenes para cultivar brócoli, espinaca y frijoles bolita, que se venden en una tienda de comestibles local. El proyecto tiene como objetivo fomentar la próxima generación de agricultores y “combatir la diabetes” al proporcionar alimentos cultivados localmente, dijo la directora ejecutiva Shirley Romero Otero.

Su grupo trabajó con tres agricultores el verano pasado y planea hacerlo con siete esta temporada, si hay suficiente agua disponible, contó.

En otro esfuerzo, agricultores como los Mestas se están gravando a sí mismos para extraer agua de sus propios pozos de riego. Y Simpson, del Distrito de Conservación del Agua del Río Grande, recientemente aseguró $30 millones en fondos federales para apoyar la conservación del agua. El plan incluye pagar a los agricultores $3,000 por acre-pie de agua para retirar permanentemente sus pozos de riego.

Dado que el arsénico no se limita a los pozos privados, también han respondido las agencias públicas: la ciudad de Alamosa construyó una nueva planta de tratamiento de agua en 2008 para cumplir con los estándares federales de arsénico.

En 2020, el estado de Colorado demandó a una granja de hongos en Alamosa por exponer a sus trabajadores al arsénico presente en el agua de grifo.

En la comunidad de casas móviles High Valley Park en el condado de Alamosa, un pozo que abastece a 85 personas ha excedido los niveles legales de arsénico desde 2006, cuando EPA endureció su estándar de 50 a 10 µg/L. En la prueba más reciente en febrero, la concentración fue de 19 µg/L.

En una tarde de abril, cuatro niños saltaban en un trampolín y se perseguían unos a otros alrededor de un árbol. “Tío, tengo sed y no quedan botellas de agua”, dijo uno de los niños, sin aliento.

El pozo abastece a 28 hogares. Sin embargo, los inquilinos de cinco viviendas han afirmado que no han estado bebiendo el agua durante años, no por el arsénico, del cual algunos no estaban conscientes, sino porque el agua a menudo sale de color marrón.

Eduardo Rodríguez, de 29 años, quien trabaja en excavación, dijo que compra dos cajas de botellas de agua cada semana para su esposa y sus cinco hijos.

“Esto debe arreglarse”, afirmó.

“El agua es terrible”, coincidió Craig Nelson, de 51 años, quien ha vivido en el parque de casas móviles durante dos años. “No se puede tomar”. Debido a que el pozo abastece al menos a 25 personas, está regulado por el estado.

El propietario del terreno, Rob Treat, de Salida, compró la propiedad en febrero de 2022 por casi medio millón de dólares. Cumplir con los estándares federales en cuanto al contenido de arsénico ha sido difícil, afirmó, porque sus niveles fluctúan cuando los agricultores cercanos extraen agua del acuífero para regar sus cultivos.

Treat estaba utilizando cloro para convertir un tipo de arsénico en una forma más tratable. Sin embargo, si agregaba demasiado cloro, esto creaba subproductos tóxicos, lo cual también llamó la atención de los reguladores. Bajo presión del estado, comenzó a mejorar el sistema de tratamiento de agua en mayo, con un costo de $150,000. Para cubrir los gastos, planea aumentar el alquiler mensual de $250 a $300 por lote.

“Si el estado se mantuviera al margen”, se quejó, “podríamos proporcionar viviendas asequibles”.

Mientras tanto, John Mestas aún está esperando los resultados de su pozo de agua potable.

Cuando regresa de viajar para administrar su rebaño de ganado, “lo primero que hago cuando entro a la casa es beber dos vasos de agua”, dijo. “Eso es lo que extraño, mi agua y mis perros. Saltan sobre mí mientras tomo mi agua. No sé quién está más feliz, si yo bebiendo el agua o ellos saltando”.

Este artículo fue apoyado por The Water Desk, una iniciativa de periodismo independiente con sede en el Center for Environmental Journalism de la Universidad de Colorado-Boulder.

KFF Health 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 KFF.

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