Cada semana, docenas de pacientes con diabetes llegan a verlo con heridas profundas, infecciones graves y mala circulación, complicaciones debilitantes de una enfermedad que ya está fuera de control. Armstrong trata de salvar sus extremidades, pero a veces, él y su equipo deben recurrir a la amputación para salvar al paciente, una medida dolorosa y que altera la vida, y que el doctor sabe que casi siempre se puede prevenir.

Hace décadas, la comunidad médica estadounidense ha sabido cómo controlar la diabetes. A pesar que la cantidad de personas que viven con la enfermedad sigue aumentando –se estima que hoy en día hay más de 30 millones en todo el país–�� el pronóstico para las que tienen acceso a una buena atención médica se ha vuelto mucho menos grave. Con medicación, dieta y los cambios de estilo de vida adecuados, los pacientes pueden aprender a controlar su diabetes y tener una buena vida.

Sin embargo, en todo el país, los cirujanos siguen realizando decenas de miles de amputaciones diabéticas cada año. Es un procedimiento drástico, y un ejemplo poderoso de las consecuencias de ser pobre, de no tener seguro y de quedar fuera de un sistema de atención médica consistente y de calidad.

“Las amputaciones son una consecuencia innecesaria de esta enfermedad devastadora”, dijo Armstrong, profesor de cirugía en la Escuela de Medicina Keck de USC. “Es una epidemia dentro de una epidemia. Y es un problema totalmente ignorado”.

En un análisis de Kaiser Health News (KHN) en California, donde los médicos realizaron más de 82,000 amputaciones diabéticas entre 2011 y 2017, las personas de raza negra o latinas (de todas las razas) tuvieron más del doble de probabilidades que los blancos no hispanos de sufrir amputaciones relacionadas con la diabetes.

El patrón no es exclusivo de California. En todo el país, estudios han demostrado que las amputaciones diabéticas varían significativamente no solo por raza y etnia sino también por ingresos y geografía. Según , los pacientes que viven con diabetes en comunidades que se ubican en el nivel más bajo de la nación en base a ingresos tuvieron casi un 39% más de probabilidades de sufrir amputaciones importantes en comparación con los que viven en comunidades de mayores ingresos.

Un por investigadores de la UCLA halló que las personas con diabetes en los barrios más pobres del condado de Los Ángeles tenían el doble de probabilidades de tener una amputación de un pie o una pierna que las de las zonas más ricas. La diferencia fue de más de diez veces en algunas partes del condado.

Las amputaciones se consideran una “mega disparidad” y superan a casi todas las demás disparidades de salud por raza y etnia, dijo el doctor Dean Schillinger, profesor de medicina en la Universidad de California en San Francisco. Para empezar, las personas que son de raza negra o latinas (de todas las razas) corren más riesgo de desarrollar diabetes que otros grupos, una disparidad que a menudo se atribuye a factores socioeconómicos, como tasas más altas de pobreza y niveles más bajos de educación. También pueden vivir en entornos con menos acceso a alimentos saludables o lugares para hacer ejercicio.

Luego, entre las personas con la enfermedad, las de raza negra y las latinas (de todas las razas) a menudo reciben un diagnóstico después que la enfermedad se ha afianzado y tienen más complicaciones, como amputaciones. “Si vas a vecindarios afroamericanos de bajos ingresos, es una zona de guerra”, dijo Schillinger, ex jefe del Programa de Control y Prevención de la Diabetes en el Departamento de Salud Pública de California. “Se ve gente dando vueltas en sillas de ruedas”.

Parte de la indignación de los investigadores es que la ciencia médica ha avanzado mucho en el tratamiento de la diabetes. En todo el país, menos de 5 adultos por cada 1,000 con diabetes sufren amputaciones.

Pero para los que sí las sufren, las consecuencias son profundas. De acuerdo con el análisis de KHN, más de la mitad de las amputaciones en California entre 2011 y 2017 ocurrieron entre personas de 45 a 64 años, lo que significa que muchas quedan discapacitadas y dependen de otras para recibir atención durante sus años de trabajo más productivos.

��De madre a hijo

Jackson Moss se recostó en el sofá y levantó la pierna derecha. Su esposa, Bernadette, roció antiséptico en una herida abierta en la planta del pie antes de frotarla con vaselina y volver a envolverla con una gasa.

Moss, de 47 años, un hombre robusto que solía entregar envíos de aves de corral, contó que tuvo que dejar de trabajar después que le amputaron la pierna izquierda por debajo de la rodilla hace unos 10 años. Más tarde, perdió parte de su pie derecho. Con la ayuda de Bernadette, está tratando de salvar el resto.

“Si no tuviera a mi esposa, no sé dónde estaría”, dijo Moss, quien usa una prótesis en su pierna izquierda y se moviliza en silla de ruedas. “No puedo moverme bien como solía hacerlo”.

Moss, quien vive en Compton, concentra muchas de las características de las personas con mayor probabilidad de sufrir amputaciones diabéticas. Es afroamericano con un ingreso familiar relativamente bajo: aproximadamente $30,000 al año de su cheque de discapacidad del Seguro Social y el trabajo de su esposa en el departamento de salud mental del condado.

Moss no siempre ha recibido atención médica regular. Su madre, quien también sufrió la amputación de una pierna a causa de la diabetes, lo llevaba al médico cuando era niño. Pero de adulto, dejó de ir. No tuvo seguro durante la mayor parte del tiempo entre sus 20 y 40 años. La atención médica no era una prioridad, dijo, hasta que hace unos 25 años, su nivel de azúcar en la sangre se disparó tanto que se desmayó en su casa.

Después que le diagnosticaron diabetes tipo 2, comenzó a ver a un médico con más frecuencia. Intentó evitar el azúcar, como lo recomendó su médico, pero es difícil desterrar los malos hábitos. “Se necesita mucha fuerza de voluntad para comer bien”, dijo, “y cuesta más”.

Un día, hace unos 10 años, se golpeó el pie contra la cama. No le prestó mayor atención hasta que la herida se infectó. Una fiebre lo envió al hospital, donde le amputaron la parte inferior de la pierna. Unos años más tarde, con su diabetes aún mal controlada, perdió los dedos del otro pie.

Moss y su esposa contaron que, en los últimos años, a veces los proveedores de salud han ignorado sus preocupaciones. Recordaron viajes a la sala de emergencias cuando tuvieron que convencer a los médicos que su fiebre provenía de una infección relacionada con la diabetes. “No me creían”, dijo. La pareja no lo vio como discriminación, más bien como desinterés.

Ahora, Moss va a una clínica administrada por el Hospital Comunitario Martin Luther King, Jr., que atiende a una gran población latina (de todas las razas) y de raza negra en el sur de Los Ángeles. En una visita reciente, su médico le preguntó si mantenía inmovilizado su pie herido. “Me levanto cuando tengo que ir al baño y para entrar y salir de la cama”, respondió Moss.

Moss espera que algún día pueda hacer más: volver a llevar a sus nietos a Chuck E. Cheese o jugar dominó con amigos.

“Estoy sentado aquí todo el día”, dijo.

“La métrica más vergonzosa”

Las amputaciones generalmente comienzan con una diabetes mal controlada, una enfermedad que se caracteriza por el exceso de azúcar en sangre. Si no se trata, puede provocar complicaciones graves, como insuficiencia renal y ceguera.

Las personas con diabetes a menudo tienen poca sensibilidad en sus pies, y mala circulación. Hasta un tercio de las personas con la forma más común, la Tipo 2, desarrollan úlceras en los pies o una ruptura en la piel que puede infectarse.

Las amputaciones ocurren después que esas infecciones se vuelven fuera de control y entran al torrente sanguíneo o se filtran más profundamente en el tejido. Las personas con diabetes a menudo tienen una afección que dificulta la circulación de la sangre y la curación de heridas.

Las circunstancias que dan lugar a las amputaciones son complejas y con frecuencia se entrelazan: los pacientes pueden no ir al médico porque sus familiares y amigos no van, o las clínicas están demasiado lejos. Algunos pueden demorar las visitas médicas porque no confían en los médicos o tienen un seguro limitado. Incluso cuando buscan tratamiento, a algunos les resulta difícil tomar los medicamentos según las indicaciones, cumplir con las restricciones dietéticas o inmovilizar el pie infectado.

De acuerdo con un análisis realizado para KHN por el Centro de Investigación de Políticas de Salud de la UCLA, los californianos con diabetes que tienen un lugar regular en donde reciben atención médica que no sea la sala de emergencias tienen menos probabilidades de sufrir amputaciones. Si tienen un plan para controlar su diabetes, también tienen menos posibilidades de amputación.

El análisis muestra que se podrían evitar muchas amputaciones con un mejor acceso a la atención y un mejor manejo de la enfermedad, dijo Ninez Ponce, directora del centro.

“Es la métrica más vergonzosa que tenemos sobre la calidad de atención”, dijo Ponce. “Es un problema de equidad en salud. Somos un estado muy rico. No deberíamos estar viendo estas amputaciones diabéticas”.

Una amputación generalmente genera una cascada de consecuencias: más infecciones, más amputaciones, disminución de la movilidad, aislamiento social. La investigación muestra que hasta tres cuartas partes de las personas con diabetes que han tenido amputaciones de miembros inferiores mueren dentro de los cinco años.

El sistema de salud enfrenta costos sorprendentemente altos para el que sigue siendo un problema relativamente poco frecuente. Una sola amputación de extremidades inferiores puede costar más de $100,000. Por lejos, los programas gubernamentales, Medicaid y Medicare, pagan por la mayoría de las amputaciones.

Los expertos dicen que la mejor opción es intervenir bien antes que sean necesarias. Las personas con diabetes están “muy necesitadas de tratamientos más simples, básicos, costo-eficientes y fáciles de implementar”, dijo el doctor Philip Goodney, director del Centro para la Evaluación de la Atención Quirúrgica en Dartmouth.

Junto con las medidas básicas para controlar la diabetes, los exámenes regulares de los pies son fundamentales. Los Centros para el Control y Prevención de Enfermedades (CDC) estiman que entre el 11% y el 28% de las personas con diabetes reciben la atención podológica recomendada, un examen anual de los pies para verificar la pérdida de sensibilidad y el flujo sanguíneo. Según las normas federales que rigen Medicaid, el programa del gobierno para los estadounidenses de bajos ingresos, esta atención es opcional y no está cubierta por todos los estados.

California la incluye como un beneficio optativo, lo que limita el acceso a esta atención. Un análisis realizado por investigadores de la UCLA estimó que el uso de servicios de podiatría preventivos le ahorró al sistema Medi-Cal, la versión de Medicaid de California, hasta $97 millones en 2014, según los ingresos hospitalarios y las amputaciones que se pudieron prevenir, y que los ahorros podrían ser mucho mayores si más pacientes tuvieran acceso.

Luchando por Jesse

Jesse Guerrero tiene 12 años, pero ya sabe lo que la diabetes, y las amputaciones, pueden hacerle a una familia. Ha visto cómo cambió la vida desde que su madre, Patricia Zamora, tuvo su primera cirugía, lo que la obligó a dejar de trabajar como supervisora. Fueron desalojados y finalmente se mudaron a la casa de su abuela en Pomona.

Ahora, se quedan en casa mucho más que antes. “Quiero que se mejore para que podamos finalmente ir a otros lugares”, dijo Jesse.

Zamora, de 49 años, fue diagnosticada por primera vez con diabetes gestacional y eventualmente se le diagnosticó la Tipo 2. Aunque su madre tiene diabetes, dijo que no entendía los riesgos.

Los problemas graves comenzaron en 2014, cuando se golpeó el dedo gordo del pie y se volvió negro y púrpura. Cuando finalmente fue a la sala de emergencias, los médicos dijeron que tenía que ser amputado. Al año siguiente, después de otro tropiezo y otra infección, los médicos le extirparon los dedos restantes del pie derecho.

Ahora, Zamora está luchando contra una tercera herida y se arriesga a perder la extremidad por debajo de su rodilla. Usa un scooter y una bota para mantener la presión.

Muchos días, quiere darse por vencida.

“Pero no puedo”, dijo ella. “Tengo a Jesse”.

Y la salud de Jesse también es una preocupación. Aunque solo está en la escuela media, tiene sobrepeso, lo que lo pone en mayor riesgo de padecer diabetes tipo 2. La mamá recientemente le quitó su PlayStation y lo inscribió en flag football para que estuviera más activo.

Jesse, también, tiene miedo.

“No quiero cortarme el pie”, dijo. “Prefiero tener una vida plena que una corta”.

El regalo del dolor

A medida que los hospitales ven el impacto y el costo de las amputaciones, algunos han hecho esfuerzos para reducirlas. Algunos, como el Hospital Keck, abrieron centros de preservación de extremidades, que utilizan equipos multidisciplinarios y tecnología para tratar heridas y ayudar a los pacientes a mejorar el manejo de la enfermedad.

Sin embargo, incluso con un equipo de especialistas, salvar una extremidad a menudo depende de que los pacientes lleguen temprano en lugar de esperar hasta que su pie se haya infectado peligrosamente. Pero como no tienen buena sensibilidad, muchas veces no toman conciencia del peligro.

“¿Cómo conseguir que alguien venga si no tiene dolor?”, Dijo Armstrong. “Necesitan el regalo del dolor”.

Uno de los pacientes de Armstrong, Cirilo Delgado, tiene una herida en el talón que podría costarle la parte inferior de la pierna. Ya perdió un dedo del pie.

Delgado, de 41 años, sabía que la diabetes estaba presente en su familia. Su padre, de 68 años, tiene diabetes. Su madre, que tenía diabetes e insuficiencia renal, murió a los 67. Su hermana, que también la padecía, murió a los 35 de un ataque al corazón, una posible complicación de la diabetes.

“Los vi morir jóvenes”, dijo. “No quiero ser el siguiente”.

Al igual que Moss, Delgado no siempre ha tenido seguro. Y no buscó atención para su diabetes hasta que los síntomas se volvieron terribles.

Delgado solía trabajar en una tintorería, pero tuvo que dejar porque no tiene el equilibrio que una vez tuvo. Su presión arterial fluctúa peligrosamente, y necesita diálisis tres veces por semana porque tiene insuficiencia renal. Se mudó con su padre, un conductor de camión que dejó de trabajar para ayudar a cuidarlo.

En noviembre, los médicos usaron un colgajo de piel de su pierna para tratar de curar su última herida. Está rezando para no tener otra.

“Sé que hay una prótesis”, dijo, “pero no es lo mismo que una extremidad”.

Método utilizado

Kaiser Health News analizó los datos de 2011-17 de la Oficina Estatal de Planificación y Desarrollo de la Salud (OSHPD, por sus siglas en inglés) de California en pacientes con diabetes dados de alta después de amputaciones de miembros inferiores. OSPHD agrupó las amputaciones en estas categorías raciales y étnicas: blanca, negra, hispana y otras; y estos grupos de edad: menores de 45, 45-64, 65 y más. Para comparar las tasas de amputación entre grupos, KHN calculó las tasas brutas utilizando los datos de la población de California para cada año de la Oficina del Censo de los EE.UU., y calculó la tasa final ajustada por edad para cada grupo racial/étnico utilizando la distribución de la población de los EE. UU. 2010.

Ngoc Nguyen, editora de medios étnicos de California Healthline y Elizabeth Lucas, editora de datos de Kaiser Health News, colaboraron con este informe.

Esta historia fue producida por , un programa editorialmente independiente de la que no está relacionado con Kaiser Permanente.

�������ýҕ�l 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 .

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Each week, dozens of patients with diabetes come to him with deep wounds, severe infections and poor circulation — debilitating complications of a disease that has spiraled out of control. He works to save their limbs, but sometimes Armstrong and his team must resort to amputation to save the patient, a painful and life-altering measure he knows is nearly always preventable.

For decades now, the American medical establishment has known how to manage diabetes. Even as the number of people living with the illness continues to climb — today, estimated at more than 30 million nationwide — the prognosis for those with access to good health care has become far less dire. With the right medication, diet and lifestyle changes, patients can learn to manage their diabetes and lead robust lives.

Yet across the country, surgeons still perform tens of thousands of diabetic amputations each year. It’s a drastic procedure that stands as a powerful example of the consequences of being poor, uninsured and cut off from a routine system of quality health care.

“Amputations are an unnecessary consequence of this devastating disease,” said Armstrong, professor of surgery at Keck School of Medicine of USC. “It’s an epidemic within an epidemic. And it’s a problem that’s totally ignored.”

In California, where doctors performed more than 82,000 diabetic amputations from 2011 to 2017, people who were black or Latino were more than twice as likely as non-Hispanic whites to undergo amputations related to diabetes, a Kaiser Health News analysis found.

The pattern is not unique to California. Across the country, studies have shown that diabetic amputations vary significantly not just by race and ethnicity but also by income and geography. Diabetic patients living in communities that rank in the nation’s bottom quartile by income were nearly 39% more likely to undergo major amputations compared with people living in the highest-income communities, according to one .

A by UCLA researchers found that people with diabetes in poorer neighborhoods in Los Angeles County were twice as likely to have a foot or leg amputated than those in wealthier areas. The difference was more than tenfold in some parts of the county.

Amputations are considered a “mega-disparity” and dwarf nearly every other health disparity by race and ethnicity, said Dr. Dean Schillinger, a medical professor at the University of California-San Francisco. To begin with, people who are black or Latino are more at risk of diabetes than other groups — a disparity often attributed to socioeconomic factors such as higher rates of poverty and lower levels of education. They also may live in environments with less access to healthy food or places to exercise.

Then, among those with the disease, blacks and Latinos often get diagnosed after the disease has taken hold and have more complications, such as amputations. “If you go into low-income African American neighborhoods, it is a war zone,” said Schillinger, former chief of the Diabetes Prevention and Control Program at the California Department of Public Health. “You see people wheeling themselves around in wheelchairs.”

Part of the outrage for researchers is that medical science has made so much headway in diabetes treatment. Nationwide, fewer than get amputations.

But for those who do, the consequences are profound. More than half of amputations in California from 2011 to 2017 occurred among people ages 45 to 64, according to the KHN analysis, meaning many people are left disabled and dependent on others for care during their prime working years.

From Mother To Son

Jackson Moss leaned back on his couch and raised his right leg. His wife, Bernadette, sprayed antiseptic on a gaping wound on the sole of his foot before dabbing it with Vaseline and rewrapping it with gauze.

A stocky man who used to deliver poultry, Moss, 47, said he had to stop working after his left leg was amputated below the knee about 10 years ago. Later, he lost part of his right foot. With Bernadette’s help, he is trying to save the rest of it.

“If I didn’t have my wife, I don’t know where I’d be,” said Moss, who wears a prosthesis on his left leg and uses a wheelchair. “I can’t get around good like I used to.”

Moss, who lives in Compton, embodies many of the characteristics of people most likely to get diabetic amputations. He is African American with a relatively low family income: about $30,000 a year from his Social Security disability check and his wife’s job with the county mental health department.

Moss has not always received regular medical care. His mother, who also had a leg amputated from diabetes, would take him to the doctor when he was a boy. But he stopped going as an adult. He didn’t have insurance during much of his 20s and 30s. Medical care just wasn’t a priority, he said, until about 25 years ago when his blood sugar shot up so high he passed out at home.

After he was diagnosed with Type 2 diabetes, he started seeing a physician more often. He tried to avoid sugar, as his doctor recommended, but bad habits die hard. “It takes a lot to eat right,” he said, “and it costs more.”

One day, about 10 years ago, he bumped his toe on the bed. He thought little of it until he developed an infected wound. A fever sent him to the hospital, where his lower leg was removed. A few years later, with his diabetes still poorly controlled, he lost the toes on his other foot.

In recent years, Moss and his wife said, health providers have sometimes ignored their concerns. They recalled trips to the emergency room when they had to convince doctors his fever came from a diabetes-related infection. “They wouldn’t take my word,” he said. The couple did not see it as discrimination, more like dismissiveness.

Now, Moss goes to a clinic run by Martin Luther King, Jr. Community Hospital, which serves a large Latino and black population in South Los Angeles. On a recent visit, his doctor asked if he was staying off the foot with the wound. “I just get up when I have to go to the restroom and to get in and out of the bed,” Moss responded.

Moss hopes someday he will be able to do more — get back to taking his grandsons to Chuck E. Cheese or playing dominoes with friends.

“I just sit here all day long,” he said.

‘The Most Shameful Metric’

Amputations typically start with poorly controlled diabetes, a disease characterized by excess sugar in the blood. Untreated, it can lead to serious complications such as kidney failure and blindness.

People with diabetes often have reduced sensation in their feet, as well as poor circulation. of people with the most common form — Type 2 — develop foot ulcers or a break in the skin that can become infected.

Amputations occur after those infections rage out of control and enter the bloodstream or seep deeper into the tissue. People with diabetes often have a condition that makes it harder for blood to circulate and wounds to heal.

The circumstances that give rise to amputations are complex and often intertwined: Patients may avoid doctors because their family and friends do, or clinics are too far away. Some may delay medical visits because they don’t trust doctors or have limited insurance. Even when they seek treatment, some find it difficult to take medication as directed, adhere to dietary restrictions or stay off an infected foot.

Californians with diabetes who have a regular place to go for health care other than the emergency room are less likely to get amputations, according to an analysis conducted for Kaiser Health News by the UCLA Center for Health Policy Research. If they have a plan to control their diabetes, they also have less chance of amputation.

The analysis shows that many amputations could be avoided with better access to care and better disease management, said Ninez Ponce, director of the center.

“It’s the most shameful metric we have on quality of care,” Ponce said. “It is a health equity issue. We are a very rich state. We shouldn’t be seeing these diabetic amputations.”

An amputation often leads to a cascade of setbacks: more infections, more amputations, decreased mobility, social isolation. as many as three-quarters of people with diabetes who have had lower-limb amputations die within five years.

The health system bears surprisingly large costs for what remains a relatively uncommon problem. A single lower-limb amputation can cost more than $100,000. By far, government programs — Medicaid and Medicare — pay for the most amputations.

Experts say the best bet is to intervene well before they become necessary. People with diabetes are “very much in need of the simplest, basic, cost-effective, easy-to-implement treatments,” said Dr. Philip Goodney, director of the Center for the Evaluation of Surgical Care at Dartmouth.

Along with basic measures to control diabetes, regular foot exams are key. The Centers for Disease Control and Prevention estimates somewhere between 11% and 28% of people with diabetes get the recommended podiatric care, a yearly foot exam to check for loss of sensation and blood flow. Under federal rules governing Medicaid, the government program for low-income Americans, such care is optional and not covered by every state.

California includes it as an optional benefit, limiting access to such care. An by UCLA researchers estimated that the use of preventive podiatric services saved the Medi-Cal system — California’s version of Medicaid — up to $97 million in 2014, based on avoided hospital admissions and amputations, and that savings could be much greater if more patients had access.

Fighting For Jesse

Jesse Guerrero is 12, but already knows what diabetes — and amputations — can do to a family. He has seen how life changed since his mom, Patricia Zamora, had her first surgery. She had to stop working as a group home supervisor. They were evicted and eventually moved into his grandmother’s house in Pomona.

Now, they stay home a lot more than they used to. “I want her to get better so we can finally go places,” Jesse said.

First diagnosed with gestational diabetes, Zamora, 49, eventually was diagnosed with conventional Type 2. Though her mother has diabetes, she said, she didn’t understand the risks.

Her serious troubles started in 2014, when she stubbed her big toe and it turned black and purple. When she finally went to an ER, doctors said it had to be amputated. The next year, after another stumble and another infection, doctors removed the remaining toes on her right foot.

Now, she is fighting a third wound and risks losing the limb below her knee. She uses a scooter and wears a boot to keep the pressure off.

Many days, she wants to give up.

“But I can’t,” she said. “I have Jesse.”

His health is also a concern. Though only in middle school, Jesse is overweight, putting him at greater risk for Type 2 diabetes. She recently took away his PlayStation and signed him up for flag football so he would be more active.

Jesse, too, is scared.

“I don’t want to get my foot cut off,” he said. “I’d rather have a full life than a short one.”

The Gift Of Pain

As hospitals have seen the impacts — and cost — of amputations, some have made efforts to reduce them. Some, like Keck Hospital, have started limb preservation centers, which use cross-disciplinary teams and technology to treat wounds and help patients improve disease management.

Even with a team of specialists, however, saving a limb often depends on patients coming in early rather than waiting until their foot has become dangerously infected. But because their sensation is dulled, they often don’t appreciate the danger.

“How do you get someone to come in if they don’t have pain?” Armstrong said. “They need the gift of pain.”

One of Armstrong’s patients, Cirilo Delgado, has a wound on his heel that could cost him his lower leg. He already lost a toe.

Delgado, 41, knew diabetes ran in his family. His father, 68, has diabetes. His mother, who had diabetes and kidney failure, died at 67. His diabetic sister died at 35 of a heart attack, a possible complication of diabetes.

“I saw them die young,” he said. “I don’t want to be the next one.”

Like Moss, Delgado didn’t always have insurance. And he didn’t seek care for his diabetes until the symptoms got dire.

Delgado used to work at a dry cleaning shop but had to stop because he doesn’t have the balance he once did. His blood pressure fluctuates dangerously, and he needs dialysis three times a week for kidney failure. He has moved in with his father, a truck driver who stopped working to help care for him.

In November, doctors used a skin flap from his leg to try to heal his latest wound. He’s praying he doesn’t get another.

“I know there’s a prosthesis,” he said, “but it’s not the same as a limb.”

METHODOLOGY BOX:

Kaiser Health News analyzed 2011-17 data from California’s Office of Statewide Health Planning and Development (OSHPD) on diabetes patients discharged after lower-limb amputations. OSPHD grouped the amputations into these racial and ethnic categories: white, black, Hispanic and other; and these age groups: under 45, 45-64, 65 and over. To compare amputation rates across groups, KHN calculated crude rates using California population data for each year from the U.S. Census Bureau, and calculated the final age-adjusted rate for each racial/ethnic group using U.S. 2010 population distribution as weights.

California Healthline ethnic media editor Ngoc Nguyen and Kaiser Health News data editor Elizabeth Lucas contributed to this report.

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Un análisis de Kaiser Health News (KHN) de datos oficiales muestra que las muertes han aumentado un 76% en los últimos cinco años, superando el crecimiento de la población sin hogar.

Funcionarios

de salud y expertos no identifican una sola causa para explicar este incremento, pero apuntan al aumento de las adicciones como una posible razón. Este aumento también refleja que hay más personas sin hogar de manera crónica y más personas que no usan los refugios, lo que significa que viven más tiempo en las calles con graves problemas de salud física y de comportamiento.

“Son personas que viven durante mucho tiempo en ambientes insalubres y que tienen múltiples problemas de salud”, señaló Michael Cousineau, profesor en la Escuela de Medicina Keck de la Universidad del Sur de California. “Esto crea más complicaciones, y una de ellas es la alta tasa de mortalidad. Es una tragedia”.

Según un realizado el año pasado, había casi 53,000 personas sin hogar en el condado de Los Ángeles, un aumento del 39% desde 2014. La mayoría no vivía en refugios.

La población de personas sin hogar también aumentó en todo el país, pero no hay un cómputo nacional de muertes.

El Departamento del Forense del condado de Los Ángeles considera a alguien sin hogar si esa persona carece de residencia, o si el cuerpo fue encontrado en un campamento, refugio u otro lugar que sugiera que no tiene hogar.

En base a ese criterio, se reportaron 3,612 muertes de personas sin hogar en el condado de Los Ángeles entre 2014 y 2018.

El detalle de las cifras revela un cuadro complejo sobre dónde, y cómo, mueren las personas sin hogar.

Un tercio murió en hospitales y muchos más murieron en lugares como aceras, callejones, estacionamientos, veras de ríos y rampas de autopistas.

Las muertes de hombres superan en número a las de mujeres, pero el porcentaje de mujeres sin hogar que murieron creció más que el de los hombres. Y aunque los afroamericanos son menos de una décima parte de la población del condado, representan casi una cuarta parte de las muertes de personas sin techo.

“Necesitamos tomar medidas ahora”, dijo el reverendo Andy Bales, CEO de Union Rescue Mission, un refugio para personas sin hogar en un barrio marginal de Los Ángeles. “De lo contrario, el año que viene superarán el millar”.

Adicciones

Las drogas y el alcohol causaron al menos una cuarta parte de las muertes de personas sin hogar en los últimos cinco años, según el análisis de los datos del forense. Probablemente contribuyeron a muchas más, como las muertes relacionadas con problemas hepáticos y cardíacos.

La causa de muerte “no cuenta necesariamente toda la historia”, explicó Brian Elias, jefe de investigaciones forenses del condado, quien calificó el aumento de “alarmante”.

Una persona que no tiene hogar puede contraer una infección que se suma a una enfermedad crónica y a una adicción, y las tres juntas generan resultados catastróficos. “Es un castillo de naipes”, dijo el doctor Coley King de la Venice Family Clinic.

Raymond Thill tenía 46 años cuando murió el año pasado de lo que su esposa, Sherry Thill, llamó complicaciones relacionadas con el alcoholismo. La pareja había estado sin hogar durante muchos años cuando se mudaron a un pequeño apartamento en el sur de Los Angeles, poco antes de su muerte.

Thill dijo que su esposo bebía vodka todo el día y que había estado entrando y saliendo del hospital debido al hígado y otros problemas de salud. Intentó con rehabilitación y ella intentó apartarlo del alcohol. Nada funcionó.

“No había nada que hacer”, expresó Thill. “Así que lo cuidé yo”.

Thill contó que, al final, la cirrosis dejó a su esposo sufriendo de ictericia, hinchado e incapaz de alimentarse.

King trató a Raymond Thill y dijo que está convencido de que Thill habría vivido más tiempo si hubiera salido antes de las calles.

“Esto no debería suceder”, sobre todo cuando muchas muertes podrían haberse evitado con un mejor acceso a la salud y la vivienda, señaló David Snow, profesor de sociología de la Universidad de California-Irvine. “Si estás en la calle, no recibes la atención que necesitas”.

“Listos para la mala suerte”

Los residentes sin hogar en Los Ángeles murieron también de las mismas dolencias que la población general: enfermedad cardíaca, cáncer, enfermedad pulmonar, diabetes e infecciones. Pero fue a una edad mucho más temprana, según el doctor Paul Gregerson, director de las clínicas del Instituto JWCH en el área de Los Ángeles.

Un estilo de vida estresante, falta de alimentos saludables y la exposición al clima contribuyen a una muerte prematura, dijo. “Si usted es una persona sin hogar, su cuerpo envejece más rápido por vivir a la intemperie”, explicó Gregerson.

En el condado de Los Ángeles, la edad promedio de muerte de las personas sin hogar fue de 48 años para las mujeres y 51 para los hombres. La de las mujeres en California en 2016 era de 83 años y la de los hombres de 79, una de las mejores estadísticas de longevidad del país.

Durante ese período de cinco años en el condado, también hubo un importante aumento en las muertes de adultos jóvenes sin hogar. Por ejemplo, las muertes de adultos menores de 45 años se duplicaron con creces.

Los datos no incluyen información sobre las enfermedades mentales que, según Elias, de la oficina del forense, podrían ser un factor en algunas de las muertes.

Stephen Rosenstein, de 59 años, caminaba por la calle en Panorama City, un vecindario de Los Ángeles, cuando un auto lo atropelló y lo mató una noche a principios del año pasado, según contó su hermana, Cindy García. Había pasado años entre las calles, los refugios y las casas temporales.

Rosenstein había sido diagnosticado con esquizofrenia y sufría también un trastorno maníaco-depresivo, contó García, y se resistía a recibir ayuda, comportamiento que ella atribuyó a la enfermedad mental.

“La mayoría de la gente quiere vivir bajo techo”, dijo. “Pero él se resistió hasta el final”.

La causa de la muerte de Rosenstein fue por “lesiones traumáticas”. Las muertes por trauma o violencia fueron comunes entre las personas sin hogar en el período analizado. Al menos 800 personas murieron a causa de un traumatismo, y de ellas, unas 200 recibieron un disparo o fueron apuñaladas.

“Están listos para tener mala suerte”, dijo King.

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Deaths have jumped 76% in the past five years, outpacing the growth of the homeless population, according to a KHN analysis of the coroner’s data.

Health officials and experts have not pinpointed a single cause for the sharp increase in deaths, but they say rising substance abuse may be a major reason. The surge also reflects growth in the number of people who are chronically homeless and those who don’t typically use shelters, which means more people are living longer on the streets with serious physical and behavioral health issues, they say.

“It is a combination of people who are living for a long time in unhealthy situations and who have multiple health problems,” said Michael Cousineau, a professor at the Keck School of Medicine of the University of Southern California. “There are more complications, and one of those complications is a high mortality rate. It’s just a tragedy.”

Nearly 53,000 people were homeless in L.A. County last year, according to a of homeless residents, an increase of about 39% since 2014. The majority were not living in shelters.

The homeless population has also grown nationwide, but there is no national count of homeless deaths.

The Los Angeles County Department of Medical Examiner-Coroner considers someone homeless if that person doesn’t have an established residence, or if the body was found in an encampment, shelter or other location that suggests homelessness.

Based on that criteria, the coroner reported 3,612 deaths of homeless people in L.A. County from 2014 to 2018.

A detailed look at the numbers reveals a complex picture of where — and how — homeless people are dying.

One-third died in hospitals and even more died outside, in places such as sidewalks, alleyways, parking lots, riverbeds and on freeway on-ramps.

Male deaths outnumbered female deaths, but the percentage of homeless women who died increased faster than that of men. And although black people make up fewer than one-tenth of the county’s population, they accounted for nearly a quarter of the homeless deaths.

“We need to take action now,” said Rev. Andy Bales, CEO of the Union Rescue Mission, a homeless shelter on L.A.’s skid row. “Otherwise next year it’s going to be more than 1,000.”

Substance Abuse

Drugs and alcohol played a direct role in at least a quarter of the deaths of homeless people over the past five years, according to the analysis of the coroner’s data. It likely contributed to many more, including some whose deaths were related to liver and heart problems.

The coroner’s cause of death determination “doesn’t necessarily tell the whole story,” said Brian Elias, the county’s chief of coroner investigations, who called the increase “alarming.”

A person who is homeless may get an infection on top of a chronic disease on top of a substance abuse disorder — and all of those together lead to bad outcomes. “It’s a house of cards,” said Dr. Coley King, a physician at the Venice Family Clinic.

Raymond Thill was just 46 when he died last year of what his wife, Sherry Thill, called complications related to alcoholism. The couple had been homeless for many years before moving into a small apartment in South Los Angeles shortly before his death.

Thill said her husband often drank vodka throughout the day and had been in and out of the hospital because of liver and other health problems. He tried rehab and she tried taking the alcohol away. Nothing worked, she said.

“His mind was set,” she said. “So I took care of him.”

In the end, Thill said, cirrhosis left her husband jaundiced, swollen and unable to keep food down.

King treated Raymond Thill and said he is convinced that Thill would have lived longer if he’d been off the streets earlier.

“This shouldn’t be happening,” especially when many deaths could have been prevented with better access to health care and housing, said David Snow, a sociology professor at the University of California-Irvine. “If you are on the streets, you are not getting the attention you need.”

‘Ready For Bad Luck To Happen’

Homeless residents in Los Angeles also died from the same ailments as the general population — heart disease, cancer, lung disease, diabetes and infections. But they did so at a much younger age, said Dr. Paul Gregerson, who treats homeless residents as chief medical officer for JWCH Institute clinics in the Los Angeles area.

A stressful lifestyle, lack of healthy food and exposure to the weather contribute to an early death, he said. “If you are homeless, your body ages faster from living outside,” Gregerson said.

In Los Angeles County, the average age of death for homeless people was 48 for women and 51 for men. The for women in California in 2016 was 83 and 79 for men — among the best longevity statistics in the nation.

Over the five-year period in L.A. County, there also was a sharp increase in deaths of younger adults who were homeless. For instance, the deaths of adults under 45 more than doubled.

The data does not include information about mental illnesses, which Elias of the coroner’s office said could be a contributing factor in some of the deaths.

Stephen Rosenstein, 59, was walking across the street in Panorama City, an L.A. neighborhood, when a car struck and killed him one night early last year, said his sister, Cindy Garcia. He had spent years bouncing from the streets to shelters to board-and-care homes, she said.

Rosenstein had been diagnosed with schizophrenia and manic depression, Garcia said, and often resisted help — behavior she attributed to his mental illness. “Most people would want to have a roof over your head,” she said. “He just fought it all the way.”

Rosenstein’s cause of death was listed as “traumatic injuries.” Deaths by trauma or violence were common among the homeless in the period analyzed: At least 800 people died from trauma, and of those, about 200 were shot or stabbed.

“They are ready for bad luck to happen,” King said.

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La iniciativa, financiada con unos $8 millones por los Centros para el Control y la Prevención de Enfermedades (CDC), se lleva a cabo en 50 centros en esos dos estados.

Este novedoso enfoque reconoce que las súper bacterias no se mantienen aisladas en un hospital o en una residencia para mayores, sino que se diseminan con rapidez en toda la comunidad, señaló el doctor John Jernigan, quien dirige la investigación de los CDC sobre infecciones adquiridas durante la atención de la salud.

“Ningún centro de salud es una isla”, dijo Jernigan. “Todos formamos parte de esta complicada red”.

En los Estados Unidos, cada año, al menos dos millones de personas se infectan con bacterias resistentes a los antibióticos, y unas 23,000 mueren por esas infecciones, indican los CDC.

En los hospitales, los pacientes son vulnerables a estas bacterias, pero las personas mayores que viven en hogares lo son más. Un son portadores de microorganismos resistentes a los medicamentos, aunque no todos ellos desarrollarán una infección, explicó la doctora Susan Huang, especialista en enfermedades infecciosas en la Universidad de California-Irvine.

“Las súper bacterias son aterradoras y no se detienen”, explicó Huang. “No se van”.

Algunas de las bacterias más comunes en hospitales son el Staphylococcus aureus resistente a la meticilina (SARM), y las Enterobacterias resistentes a los carbapenemes (), a menudo llamadas “bacterias de pesadilla”. E. coli y Klebsiella pneumoniae son dos gérmenes comunes que pueden entrar en esta categoría cuando se vuelven resistentes a los antibióticos de último recurso conocidos como . Según los CDC, las ERC causan un estimado de 600 muertes cada año.

Las ERC se han “extendido ampliamente” por los hospitales del área de Chicago, señaló el , especialista en enfermedades infecciosas de Rush University Medical Center, que encabeza la iniciativa de los CDC en esa región. “Si el SARM es una súper bacteria, esta es la súper bacteria extrema”.

El control de las bacterias peligrosas ha sido un desafío para hospitales y hogares de adultos mayores. Como parte de la iniciativa de los CDC, médicos y trabajadores de la salud en Chicago y el sur de California usan jabón antimicrobiano con clorhexidina, que en pacientes que lo usan para bañarse. Aunque la clorhexidina se utiliza con frecuencia en las unidades de cuidados intensivos de los hospitales y como enjuague bucal para infecciones dentales, no se usa mucho en las duchas de los hogares.

En Chicago, los investigadores trabajan con 14 residencias y hospitales de cuidado a largo plazo, donde hacen pruebas de detección de la bacteria ERC en el momento del ingreso y usan clorhexidina para los baños.

La iniciativa de Chicago, que comenzó en 2017 y termina en septiembre, incluye una campaña para promover lavarse las manos, y una mayor comunicación entre los hospitales sobre los pacientes portadores de microorganismos resistentes a los medicamentos.

El trabajo de control de infecciones es algo nuevo para muchas residencias, que no tienen los mismos recursos que los hospitales, señaló Lin.

De hecho, tres cuartas partes de las residencias para mayores en los Estados Unidos recibieron citaciones por problemas de control de infecciones durante un período de cuatro años, según un análisis de Kaiser Health News, y los centros con citaciones reiteradas casi nunca recibieron multas. Con frecuencia, los residentes deben regresar al hospital a causa de infecciones.

En California, funcionarios de salud monitorean la bacteria ERC, que es menos prevalente allí que en otras partes del país, y tratan de evitar que se afiance, señaló el doctor Matthew Zahn, director de epidemiología de la Orange County Health Care Agency. “No tenemos mucho tiempo”, dijo Zahn. “Intentar marcar una diferencia en la trayectoria de la ERC ahora es crucial”.

El proyecto financiado por los CDC en California tiene su sede en el condado de Orange, donde 36 hospitales y residencias para mayores utilizan el lavado antiséptico con un hisopo nasal a base de yodo. El objetivo es evitar el contagio de bacterias resistentes a los medicamentos y conseguir que quienes tienen la bacteria en la piel o en otros lugares no desarrollen infecciones, dijo Huang, quien dirige el proyecto.

Huang inició el proyecto estudiando el movimiento de pacientes entre los diferentes hospitales y residencias en Orange, y lo que descubrió provocó una pregunta clave: “¿Qué podemos hacer no sólo para proteger a nuestros pacientes, sino también para cuidarlos cuando empiezan a moverse por todas partes?”

Sus investigaciones anteriores demostraron que los pacientes con la bacteria SARM que usaban clorhexidina para bañarse y como enjuague bucal, y que se aplicaban un antibiótico nasal, podían reducir el riesgo de desarrollar una infección SARM en un 30%. Pero todos los pacientes de ese estudio, publicado en febrero en el , ya habían sido dados de alta de los hospitales.

Ahora, el objetivo es llegar a pacientes que aún se encuentran en hospitales o en residencias para mayores y extender el trabajo a las ERC. Los hospitales que participan en el nuevo proyecto se centran en los pacientes de las unidades de cuidados intensivos y en aquellos que ya eran portadores de bacterias resistentes a los medicamentos, mientras que los hogares y los hospitales de cuidados a largo plazo realizan el baño, también llamado “descolonización”, en todos los residentes.

Una mañana, en Coventry Court Health Center, una residencia para mayores en Anaheim, California, Neva Shinkle, de 94 años, estaba sentada en su silla de ruedas. La enfermera Joana Bartolome le limpió la nariz con un hisopo y le preguntó si recordaba para qué lo hacía.

“Para matar gérmenes”, respondió Shinkle. “Así es, esto te protege de las infecciones”.

En otra sala, la coordinadora del proyecto, Raveena Singh, de UC-Irvine, conversaba con Caridad Coca, de 71 años, quien acababa de llegar al hogar. Singh le explicó que debía bañarse con clorhexidina en lugar de jabón común. “Si tienes una herida o un corte abierto, evita que contraigas una infección”, le dijo. “Y así no sólo te estamos protegiendo a ti. Protegemos a todos los residentes”.

Coca contó que tenía un primo que había pasado meses en el hospital después de contraer SARM. “Por suerte, yo nunca lo he tenido”, dijo.

El gerente de Coventry Court, Shaun Dahl, dijo que deseaba participar en el proyecto porque había personas que llegaban a la residencia con SARM u otras súper bacterias. “Estaban enfermos entonces y están enfermos ahora”, dijo Dahl.

A la espera de los resultados del proyecto de Chicago, los resultados preliminares del condado de Orange, que finaliza en mayo, son positivos, según Huang. Después de 18 meses, los investigadores observaron una disminución del 25% en bacterias resistentes a medicamentos entre los residentes mayores, del 34% en los pacientes de los hospitales de atención a largo plazo y del 9% en los pacientes de los hospitales tradicionales. La mayor reducción se vio en las ERC, aunque eran menos los pacientes con este tipo de bacterias.

Los datos preliminares también muestran un prometedor efecto dominó en los centros que no son parte de la iniciativa, una señal que el proyecto podría estar comenzando a hacer una diferencia en el condado, señaló Zahn de la Orange County Health Care Agency.

“En nuestra comunidad, hemos visto un aumento de la fármaco-resistencia”, dijo. “Esto nos ofrece la oportunidad de intervenir y movernos en la dirección correcta”.

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The efforts — funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention — are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC.

People in hospitals are vulnerable to these bugs, and people in nursing homes are particularly vulnerable. Up to harbor drug-resistant organisms, though not all of them will develop an infection, said Dr. Susan Huang, who specializes in infectious diseases at the University of California-Irvine.

“Superbugs are scary and they are unabated,” Huang said. “They don’t go away.”

Some of the most common bacteria in health care facilities are methicillin-resistant Staphylococcus aureus, or MRSA, and carbapenem-resistant Enterobacteriaceae, or , often called “nightmare bacteria.” E. coli and Klebsiella pneumoniae are two common germs that can fall into this category when they become resistant to last-resort antibiotics known as . CRE bacteria cause an estimated 600 deaths each year, according to the CDC.

CREs have “basically spread widely” among health care facilities in the Chicago region, said , an infectious-diseases specialist at Rush University Medical Center, who is heading the CDC-funded effort there. “If MRSA is a superbug, this is the extreme — the super superbug.”

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes.

In Chicago, researchers are working with 14 nursing homes and long-term acute care hospitals, where staff are screening people for the CRE bacteria at admission and bathing them daily with chlorhexidine.

The Chicago project, which started in 2017 and ends in September, includes a campaign to promote handwashing and increased communication among hospitals about which patients carry the drug-resistant organisms.

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.

In California, health officials are closely watching the CRE bacteria, which are less prevalent there than elsewhere in the country, and they are trying to prevent CRE from taking hold, said Dr. Matthew Zahn, medical director of epidemiology at the Orange County Health Care Agency. “We don’t have an infinite amount of time,” he said. “Taking a chance to try to make a difference in CRE’s trajectory now is really important.”

The CDC-funded project in California is based in Orange County, where 36 hospitals and nursing homes are using the antiseptic wash along with an iodine-based nose swab. The goal is to prevent new people from getting drug-resistant bacteria and keep the ones who already have the bacteria on their skin or elsewhere from developing infections, said Huang, who is leading the project.

Huang kicked off the project by studying how patients move among different hospitals and nursing homes in Orange County, and discovered they do so far more than imagined. That prompted a key question: “What can we do to not just protect our patients but to protect them when they start to move all over the place?” she recalled.

Her previous research showed that patients with the MRSA bacteria who used chlorhexidine for bathing and as a mouthwash, and swabbed their noses with a nasal antibiotic, could reduce their risk of developing a MRSA infection by 30%. But all the patients in that study, published in February in the , already had been discharged from hospitals.

Now the goal is to target patients still in hospitals or nursing homes and extend the work to CRE. The traditional hospitals participating in the new project are focusing on patients in intensive care units and those who already carried drug-resistant bacteria, while the nursing homes and the long-term acute care hospitals perform the cleaning — also called “decolonizing” — on every resident.

One recent morning at Coventry Court Health Center, a nursing home in Anaheim, Calif., 94-year-old Neva Shinkle sat patiently in her wheelchair. Licensed vocational nurse Joana Bartolome swabbed her nose and asked if she remembered what it did.

“It kills germs,” Shinkle responded.

“That’s right — it protects you from infection.”

In a nearby room, senior project coordinator Raveena Singh from UC-Irvine talked with Caridad Coca, 71, who had recently arrived at the facility. She explained that Coca would bathe with the chlorhexidine rather than regular soap. “If you have some kind of open wound or cut, it helps protect you from getting an infection,” Singh said. “And we are not just protecting you, one person. We protect everybody in the nursing home.”

Coca said she had a cousin who had spent months in the hospital after getting MRSA. “Luckily, I’ve never had it,” she said.

Coventry Court administrator Shaun Dahl said he was eager to participate because people were arriving at the nursing home carrying MRSA or other bugs. “They were sick there and they are sick here,” Dahl said.

Results from the Chicago project are pending. Preliminary results of the Orange County project, which ends in May, show that it seems to be working, Huang said. After 18 months, researchers saw a 25% decline in drug-resistant organisms in nursing home residents, 34% in patients of long-term acute care hospitals and 9% in traditional hospital patients. The most dramatic drops were in CRE, though the number of patients with that type of bacteria was smaller.

The preliminary data also shows a promising ripple effect in facilities that aren’t part of the effort, a sign that the project may be starting to make a difference in the county, said Zahn of the Orange County Health Care Agency.

“In our community, we have seen an increase in antimicrobial-resistant infections,” he said. “This offers an opportunity to intervene and bend the curve in the right direction.”

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Patients heavily sedated or shackled to gurneys for days while awaiting placement in a specialized psychiatric hospital, their symptoms exacerbated by the noise and chaos of emergency medicine. Long wait times in crowded ERs for people who show up with serious medical emergencies. High costs for taxpayers, insurers and families as patients languish longer than necessary in the most expensive place to get care.

“If you are living with schizophrenia or bipolar disorder, that is a really tough way to begin that road to recovery,” said Dr. Jack Rozel, president of the American Association for Emergency Psychiatry.

In pockets across the country, hospitals are trying something new to address the unique needs of psychiatric patients: opening emergency units specifically designed to help stabilize and treat patients and connect them to longer-term resources and care. These psychiatric ERs aim to address the growing number of patients with mental health conditions who end up hospitalized because traditional emergency rooms don’t have the time or expertise to treat the crisis.

The rate of ER visits involving psychoses, bipolar disorder, depression or anxiety from 2006 to 2013, according to the federal Agency for Healthcare Research and Quality. Roughly 1 in 8 emergency department visits now stem from mental illness or substance use disorders, the data show.

The psychiatric ERs, staffed with nurses, social workers and psychiatrists, work to treat and release patients in under 24 hours, much as traditional emergency rooms handle physical ailments. Those who are well enough to go home get discharged, while those who need more treatment are admitted to the hospital or transferred to an inpatient facility.

There are now roughly 100 such units across the country, said Dr. Scott Zeller, vice president of acute psychiatry at Vituity, a physician-led organization that provides staffing and consulting services to medical centers nationwide.

Zeller pioneered the approach while working as chief of psychiatric emergency services at John George Psychiatric Hospital in Alameda County, Calif. Over time, he transformed the center from a traditional ward where restraints were common into one that treated patients in a more supportive, living-room like setting. The results — in terms of both patient outcomes and cost-savings — made Zeller a believer.

He is helping design 10 , including in California, Florida, Illinois and Tennessee. Each is distinct, accepting patients in somewhat different circumstances and offering a slightly different range of services.

Patients who arrive at an emergency room for psychiatric or substance use disorders are more than twice as likely to be admitted than other patients, federal data show. And yet about 80 percent of the time, Zeller said, patients’ mental health crises can be resolved without a costly inpatient hospital stay. A patient may be having a psychotic episode because he fell off his medications, for example, or having drug-induced hallucinations.

“We need to treat people at the emergency level of care,” he said. “The vast majority of psychiatric emergencies can be resolved in less than 24 hours.”

Nowhere To Hide

Wearing a hospital gown, Rachel Diamond lay back in her recliner in a spacious room in a relatively new ward at Providence Little Company of Mary Medical Center San Pedro, a hospital near the Port of Los Angeles. Nearby, a few patients slept on identical recliners, draped in soft blankets. Others communed at a kitchen table over microwaved meals. A nurse walked through the locked unit with a rolling cart, dispensing medications.

Except for a nursing station in the middle of the room, the unit didn’t look much like a health care facility. The room was divided into men’s and women’s sides, with separate TVs. A few smaller rooms — where patients could meet with a psychiatrist or social worker — lined the unit’s edge.

Anya Price, interim clinical supervisor and a nurse, said the unit was designed to feel more like a home than a hospital. “We’re operating from an understanding that they’re coming here to get better,” Price said.

The open design of the unit, known as the “Outpatient Behavioral Health Center,” allows patients to move freely. Staff said it also helps reduce problems because they can quickly spot a patient who may be getting agitated. Dr. Herbert Harman, a psychiatrist and medical director for the facility, said violence and the need for restraints are rare.

The unit is in a building a short walk from the medical center emergency room. It opened in 2017 and accepts patients from emergency rooms across Los Angeles County once they are deemed stable medically. So far this year, its staff has treated about 400 patients, Price said.

One recent morning, the patients included a man in his 40s found on the railroad tracks after an alcohol binge, and a woman with a history of schizophrenia who said she was seeing spirits. Some were there on involuntary holds because authorities had decided they were at risk of hurting themselves or others because of their illness.

Diamond, 30, said she has been diagnosed with depression and anxiety and has landed in multiple ERs over the past decade when her symptoms spiked out of control. During those stays, she said, she often felt isolated and in the dark about her treatment. Doctors typically numbed her with medications and consigned her to a guarded room. “No one really talked to me,” said Diamond, who lives in Torrance, Calif. “It was like I was a caged animal.”

She had been living in a car and fighting with her boyfriend in late February when she decided she wanted to end her life. She tried jumping out of a moving car, and when that didn’t work, she grabbed a bottle of pills. She gets help for her mental health issues, but sometimes, she said, the stress becomes too much. This time, she was taken to a hospital emergency room in Torrance before being transferred to the San Pedro unit.

During her time in the behavioral health center — about 26 hours — she slept, received medications and met with nurses, a social worker and a psychiatrist. She said it was calmer than a regular ER, and the staff had time to talk, listen and help her through the worst of the crisis.

“I genuinely feel better enough to leave,” she said. “I haven’t been able to say that in a while.”

A Return On Investment

Zeller argues that the use of emergency psychiatric clinics is both humane and cost-effective. on the Alameda County model found such units can dramatically reduce how long patients spend in medical emergency rooms, and that about three-quarters of patients treated in the units can be discharged to the community rather than to inpatient care. That, Zeller said, can lessen the overwhelming demand for inpatient psychiatric beds and preserve available spots for those who truly require them. The model saves money for hospitals in part because the patients spend less time in emergency care.

“The return on investment is exponential,” he said.

In Montana, the Billings Clinic opened a psychiatric stabilization unit last April across the street from the traditional ER. Dr. Eric Arzubi, psychiatry department chair, said nearly 10 percent of the visits in the Billings Clinic emergency room involve people in psychiatric crisis. Since the new unit opened, wait times for psychiatric patients have dropped from about 10 hours to four hours, and fewer patients are being admitted to the inpatient unit. Arzubi said his staff isn’t trying to cure people of their mental illness but rather stabilize them and get them the care they need.

“Just like in the emergency room, you don’t get comprehensive care,” Arzubi said. “But you can stop the bleeding, you stabilize the patient and get them to the right level of care.”

In some cases, that means a transfer to an inpatient facility.

Staff at the San Pedro unit decided soon after Chantelle Unique arrived that she would be one of those patients. Unique, who is 23, has been diagnosed with bipolar disorder and schizophrenia. She had been dancing on the roof and speaking gibberish when her mother called 911.

Unique said she has had a hard time in regular emergency rooms. “There are a million people,” she said. For most of a morning at the San Pedro facility, she sat calmly watching TV, talking to nurses and eating spaghetti. But at one point, she started pacing and yelling at other patients. Nurses and security guards quickly surrounded her and persuaded her to return to her recliner and take additional medication.

Finding an inpatient bed for a patient like Unique with more progressed mental illness is not always easy, said clinical social worker Mark Tawfik. But he’s committed to finding a way. “We have to make sure we find them adequate resources,” he said. “Otherwise, they will come right back.”

For Price, the clinical supervisor, even when a patient requires a transfer for more intensive care, there’s satisfaction in knowing that person is headed in the right direction. If Unique hadn’t been brought in, Price said, she would have been out in the community, lost to her delusions, putting herself at risk of accident or arrest.

In the unit, staff made sure she was safe, Price said, in addition to providing “a warm bed, some food and some compassion.”

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Pero este campamento de personas sin hogar en una rampa de la autopista de Hollywood, en California, a menudo está lleno de agujas y basura, y empapado en orina. Las ratas se escapan ocasionalmente y Millar teme las consecuencias.

“Me preocupan todas esas enfermedades”, aseguró Millar, de 43 años, quien dijo que ha estado sin hogar la mayor parte de su vida.

Enfermedades infecciosas, algunas que devastaron a las poblaciones en la Edad Media, están resurgiendo en California y en todo el país, y están afectando especialmente a las personas sin techo.

Los Ángeles registró recientemente un brote de tifus, una enfermedad que se contagia por pulgas infectadas que portan ratas y otros animales, en las calles del centro. Las autoridades cerraron brevemente parte del Ayuntamiento después de informar que roedores habían invadido el edificio.

En el hubo infecciones con la bacteria Shigella, que se transmite a través de las heces y causa una enfermedad diarreica llamada shigelosis y con Bartonella quintana, que se propaga a través de los piojos del cuerpo y causa la fiebre de las trincheras.

La hepatitis A también se propagó principalmente a través de las heces, infectando a más de 1,000 personas en el sur de California en los últimos dos años. La enfermedad en Nuevo México, Ohio y Kentucky, principalmente entre personas sin hogar o usuarios de drogas.

Funcionarios y oficiales de salud pública están utilizando términos como “desastre” y “crisis de salud pública” para describir los brotes, y advierten que estas enfermedades pueden diseminarse fácilmente más allá de la población sin hogar.

“Nuestra crisis de personas sin techo se está convirtiendo cada vez más en una crisis de salud pública”, dijo el gobernador de California Gavin Newsom en su discurso sobre la situación del estado en febrero, citando brotes de hepatitis A en el condado de San Diego, sífilis en el condado de Sonoma y tifus en el condado de Los Ángeles.

“Tifus”, dijo. “Una enfermedad medieval. En California. En 2019”.

Estas enfermedades se han disparado a medida que creció en los últimos dos años: aproximadamente 553,000 personas se quedaron sin hogar a fines de 2018, y casi una cuarta parte de las personas sin hogar vive en California.

Las enfermedades se propagan rápida y ampliamente entre las personas que viven a la intemperie o en refugios, alimentadas por aceras contaminadas con heces humanas, condiciones de hacinamiento, sistemas inmunológicos debilitados y acceso limitado a la atención médica.

“La situación de higiene es simplemente horrible” para las personas que viven en las calles, dijo el doctor Glenn López, médico del St. John’s Well Child & Family Center, que atiende a pacientes sin hogar en el condado de Los Ángeles. “Se convierte en un entorno del Tercer Mundo, las heces humanas contaminan las áreas donde comen y duermen”.

Esas enfermedades infecciosas no se limitan a las poblaciones sin hogar, advirtió López. “Incluso alguien que cree que está protegido contra estas infecciones no lo está”.

Al menos dijo que contrajo tifus en el Ayuntamiento el otoño pasado. Y funcionarios del condado de San Diego advirtieron en 2017 que personas que habían comido en un famoso restaurante estuvieron en riesgo de contraer hepatitis A.

Hubo 167 casos de tifus desde el 1 de enero de 2018 hasta el 1 de febrero de este año, comparado con 125 en 2013 y 13 en 2008, según el .

El tifus es una infección bacteriana que puede causar fiebre alta, dolor de estómago y escalofríos, pero se puede tratar con antibióticos. Los brotes son más comunes en áreas superpobladas y llenas de basura que atraen ratas.

El reciente brote de tifus comenzó el otoño pasado, cuando los funcionarios de salud informaron sobre grupos de enfermedades transmitidas por pulgas en el centro de Los Ángeles y Compton. También se registraron en Pasadena, donde es probable que los problemas se deban a que las personas alimentan a gatos callejeros con pulgas.

En febrero, el condado anunció otro brote en el centro de Los Ángeles que infectó a nueve personas, seis de las cuales estaban sin hogar. Después que los trabajadores de la ciudad dijeron que vieron excrementos de roedores en el ayuntamiento, el presidente del Concejo Municipal de Los Ángeles, Herb Wesson, cerró brevemente su oficina para romper las alfombras, y también pidió una investigación y más limpieza.

La hepatitis A es causada por un virus que generalmente se transmite cuando las personas entran en contacto con las heces de las personas infectadas. La mayoría de las personas se recuperan solas, pero la enfermedad puede ser muy grave para aquellos con afecciones hepáticas subyacentes. Hubo 948 casos de hepatitis A en 2017, y 178 en 2018 y 2019, dijo el departamento de salud pública del estado. como resultado del brote de 2017-18.

Las infecciones en todo el país no son una sorpresa, dada la falta de vivienda y de atención de salud para las personas sin hogar, y la escasez de baños y lugares para lavarse las manos, dijo el doctor Jeffrey Duchin, oficial de salud de , Washington.

“Es un desastre de salud pública”, dijo.

Duchin dijo que en su área ha visto shigelosis, fiebre de las trincheras e infecciones de la piel entre las poblaciones sin hogar.

En la ciudad de Nueva York, donde las personas sin hogar viven más en albergues que en las calles, no ha habido los mismos brotes de hepatitis A y tifus, dijo la doctora Kelly Doran, médica de emergencia y profesora asistente en la Escuela de Medicina de la Universidad de Nueva York. Pero Doran dijo que se producen diferentes infecciones en los refugios, incluida la tuberculosis, una enfermedad que se transmite por el aire y por lo general infecta los pulmones.

Las enfermedades a veces reciben el apodo de “medievales” porque las personas en esa época vivían en condiciones miserables sin agua limpia o tratamiento de aguas residuales, explicó el doctor Jeffrey Klausner, profesor de medicina y salud pública en UCLA.

Las personas que viven en las calles o en albergues son vulnerables a estos brotes porque su sistema inmunológico debilitado se ve agravado por el estrés, la desnutrición y la falta de sueño. Muchos también tienen enfermedades mentales y adicciones, por lo que les puede resultar más difícil mantenerse saludables o recibir atención médica.

Una tarde reciente de febrero, Negeen Farmand, asistente médica de la Clínica Comunitaria Saban, caminó por los campamentos de personas sin hogar en Hollywood con una mochila con suministros médicos. Se detuvo para hablar con un hombre que barría las aceras. Dijo que ve “todo y cualquier cosa” en las cunetas y espera que no se enferme.

Se presentó con algunos otros y les preguntó si tenían algún problema de salud que fuera necesario revisar. Cuando vio a Millar, Farmand le tomó la presión, le preguntó sobre su asma y la instó a que fuera a ver a un médico para que le tratara la hepatitis C, una infección viral que se transmite a través de la sangre contaminada y que puede provocar un daño grave en el hígado.

“Lograr que estas personas ingresen a una clínica es algo muy importante”, dijo. “Muchos de ellos desconfían del sistema de salud”.

Otro día, Karen Mitchell, de 53 años, esperó a que la clínica de salud móvil del St. John’s Well Child & Family Center la tratara por una tos persistente. También necesitaba una prueba de tuberculosis, según lo exige el refugio donde vivía en Bellflower, California.

Mitchell, quien dijo que desarrolló alcoholismo después de una carrera en ventas de productos farmacéuticos, dijo que contrajo neumonía de gérmenes de otros residentes del refugio. “Todo el mundo está siempre enfermo, no importa qué precauciones tomen”.

Durante el brote de hepatitis A, los funcionarios de salud pública administraron vacunas ampliamente, limpiaron las calles con cloro y agua e instalaron estaciones de lavado de manos y baños portátiles cerca de altas concentraciones de personas sin hogar.

Pero los funcionarios de salud y los defensores de las personas sin techo dijeron que se necesita hacer más, incluyendo ayudar a las personas a acceder a la atención médica y a viviendas asequibles.

“Realmente es inconcebible”, dijo Bobby Watts, CEO de National Health Care for the Homeless Council, una organización de defensa. “Todas estas enfermedades son prevenibles”.

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But this homeless encampment off a Hollywood freeway ramp is often littered with needles and trash, and soaked in urine. Rats occasionally scamper through, and Millar fears the consequences.

“I worry about all those diseases,” said Millar, 43, who said she has been homeless most of her life.

Infectious diseases — some that ravaged populations in the Middle Ages — are resurging in California and around the country, and are hitting homeless populations especially hard.

Los Angeles recently experienced an outbreak of typhus — a disease spread by infected fleas on rats and other animals — in downtown streets. Officials briefly closed part of City Hall after reporting that rodents had invaded the building.

People have been infected with Shigella bacteria, which is spread through feces and causes the diarrheal disease shigellosis, as well as Bartonella quintana, which spreads through body lice and causes trench fever.

Hepatitis A, also spread primarily through feces, infected more than 1,000 people in Southern California in the past two years. The disease in New Mexico, Ohio and Kentucky, primarily among people who are homeless or use drugs.

Public health officials and politicians are using terms like “disaster” and “public health crisis” to describe the outbreaks, and they warn that these diseases can easily jump beyond the homeless population.

“Our homeless crisis is increasingly becoming a public health crisis,” California Gov. Gavin Newsom said in his State of the State speech in February, citing outbreaks of hepatitis A in San Diego County, syphilis in Sonoma County and typhus in Los Angeles County.

“Typhus,” he said. “A medieval disease. In California. In 2019.”

The diseases have flared as the nation’s has grown in the past two years: About 553,000 people were homeless at the end of 2018, and nearly one-quarter of homeless people live in California.

The diseases spread quickly and widely among people living outside or in shelters, fueled by sidewalks contaminated with human feces, crowded living conditions, weakened immune systems and limited access to health care.

“The hygiene situation is just horrendous” for people living on the streets, said Dr. Glenn Lopez, a physician with St. John’s Well Child & Family Center, who treats homeless patients in Los Angeles County. “It becomes just like a Third World environment where their human feces contaminate the areas where they are eating and sleeping.”

Those infectious diseases are not limited to homeless populations, Lopez warned. “Even someone who believes they are protected from these infections are not.”

At least one said she contracted typhus in City Hall last fall. And San Diego County officials warned in 2017 that diners at a well-known restaurant were at risk of hepatitis A.

There were 167 cases of typhus from Jan. 1, 2018, through Feb. 1 of this year, up from 125 in 2013 and 13 in 2008, according to the .

Typhus is a bacterial infection that can cause a high fever, stomach pain and chills but can be treated with antibiotics. Outbreaks are more common in overcrowded and trash-filled areas that attract rats.

The recent typhus outbreak began last fall, when health officials reported clusters of the flea-borne disease in downtown Los Angeles and Compton. They also have occurred in Pasadena, where the problems are likely due to people feeding stray cats carrying fleas.

Last month, the county announced another outbreak in downtown Los Angeles that infected nine people, six of whom were homeless. After city workers rodent droppings in City Hall, Los Angeles City Council President Herb Wesson briefly shut down his office to rip up the rugs, and he also called for an investigation and more cleaning.

Hepatitis A is caused by a virus usually transmitted when people come in contact with feces of infected people. Most people recover on their own, but the disease can be very serious for those with underlying liver conditions. There were 948 cases of hepatitis A in 2017 and 178 in 2018 and 2019, the state public health department said. Twenty-one as a result of the 2017-18 outbreak.

The infections around the country are not a surprise, given the lack of attention to housing and health care for the homeless and the dearth of bathrooms and places to wash hands, said Dr. Jeffrey Duchin, the health officer for , Wash.

“It’s a public health disaster,” he said.

In his area, Duchin said, he has seen shigellosis, trench fever and skin infections among homeless populations.

In New York City, where more of the homeless population lives in shelters rather than on the streets, there have not been the same outbreaks of hepatitis A and typhus, said Dr. Kelly Doran, an emergency medicine physician and assistant professor at NYU School of Medicine. But Doran said different infections occur in shelters, including tuberculosis, a disease that spreads through the air and typically infects the lungs.

The diseases sometimes get the “medieval” moniker because people in that era lived in squalid conditions without clean water or sewage treatment, said Dr. Jeffrey Klausner, a professor of medicine and public health at UCLA.

People living on the streets or in homeless shelters are vulnerable to such outbreaks because their weakened immune systems are worsened by stress, malnutrition and sleep deprivation. Many also have mental illness and substance abuse disorders, which can make it harder for them to stay healthy or get health care.

One recent February afternoon, Saban Community Clinic physician assistant Negeen Farmand walked through homeless encampments in Hollywood carrying a backpack with medical supplies. She stopped to talk to a man sweeping the sidewalks. He said he sees “everything and anything” in the gutters and hopes he doesn’t get sick.

She introduced herself to a few others and asked if they had any health issues that needed checking. When she saw Millar, Farmand checked her blood pressure, asked about her asthma and urged her to come see a doctor for treatment of her , a viral infection spread through contaminated blood that can lead to serious liver damage.

“To get these people to come into a clinic is a big thing,” she said. “A lot of them are distrustful of the health care system.”

On another day, 53-year-old Karen Mitchell waited to get treated for a persistent cough by St. John’s Well Child & Family Center’s mobile health clinic. She also needed a tuberculosis test, as required by the shelter where she was living in Bellflower, Calif.

Mitchell, who said she developed alcoholism after a career in pharmaceutical sales, said she has contracted pneumonia from germs from other shelter residents. “Everyone is always sick, no matter what precautions they take.”

During the hepatitis A outbreak, public health officials administered widespread vaccinations, cleaned the streets with bleach and water and installed hand-washing stations and portable toilets near high concentrations of homeless people.

But health officials and homeless advocates said more needs to be done, including helping people access medical and behavioral health care and affordable housing.

“It really is unconscionable,” said Bobby Watts, CEO of the National Health Care for the Homeless Council, a policy and advocacy organization. “These are all preventable diseases.”

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These and other health and safety problems were detailed in two reports released Tuesday. The reports, produced by state Attorney General Xavier Becerra and California , found that the inadequate medical care, along with other health and safety risks, posed a serious danger to immigration detainees.

Becerra and Howle blamed the federal and local governments for failing to oversee the detention centers, allowing the health and safety violations to persist.

“Everyone in this country has constitutional rights, and everyone at the end of the day, child and adult, deserves to be treated in a humane way,” Becerra said at a news conference in San Francisco where he announced his findings.

U.S. Immigration and Customs Enforcement is committed to “ensuring all detainees are treated in a humane and professional manner,” spokeswoman Lori Haley countered in a written statement. “The safety, rights and health of detainees in ICE’s care are of paramount concern and all ICE detention facilities are subject to stringent, regular inspections.”

Haley’s statement didn’t discuss the specific findings in the reports.

Becerra described his as an initial look at conditions in the 10 California centers that housed immigration detainees in 2017, when his review began. The centers, overseen by ICE, hold people awaiting immigration hearings or deportation.

The federal centers have come under increased scrutiny as President Donald Trump has stepped up immigration enforcement, with reports of deaths, abuse and substandard medical care.

The reports landed on the same day as a on the detention of immigrants and family separation. During the hearing, Democrats questioned White House officials about the policy of taking children from their parents at the Mexican border.

Over the past three years, nearly 75,000 immigrant detainees were housed in the 10 California facilities. The immigrants, who stayed an average of more than 50 days, were held in civil, not criminal, detention.

The federal also examined detention facilities and revealed health and safety problems such as nooses in cells and “improper and overly restrictive segregation.” The inspector general also that the federal immigration agency’s own inspections are not consistent or thorough.

“The standards are so low for these detention centers, and they are not regulated the way that they should be,” said Angelica Salas, executive director of the Coalition for Humane Immigrant Rights.

In addition to one-day visits to all of the facilities, Becerra’s Department of Justice conducted more comprehensive investigations of three: the Yolo County Juvenile Detention Facility, Theo Lacey Facility in Orange County and the West County Detention Facility in Contra Costa County. Contra Costa County no longer to house immigrant detainees in the West County facility.

The department found a number of health and safety problems in the centers:

• Staff at the Yolo facility did not adequately address the mental health needs of detainees and overused psychotropic medications. One youth had been cutting himself but wasn’t put under a special watch.
• Providers conducted superficial medical examinations that failed to rule out serious injuries or health conditions, including one case in which a detainee complained of testicular pain.
• A shortage of bilingual medical staff compromised the confidentiality of medical care and made it more difficult to access care.
• Unqualified personnel, including detention officers, deputies and licensed vocational nurses, made medical decisions.
• Dental services were often delayed, including one case in which a detainee needed urgent care for a probable “tooth eruption.” Other detainees were denied fillings and root canal procedures.

Noheli Sandoval, 32, entered the U.S. in March from Venezuela seeking asylum, and spent four months at the West County Detention Facility in Richmond.

It wasn’t easy accessing medical services there, said Sandoval, who lives in Berkeley. “You have to be practically dying for them to treat you.”

To get dental care, you had to be in pain, and the waiting list for mental health help was months long, she added.

Becerra said the federal government is not ensuring its own standards are met. And while some of the facilities already have made changes, he said he will continue monitoring them to ensure they adequately address their shortcomings. He didn’t rule out legal action.

“Our work is not done,” Becerra said. “We are prepared to do whatever we must to make sure that the laws of this country and this state … are not only protected but enforced.”

A separate but equally damning report by the state auditor concluded that California cities that contract with ICE to house immigration detainees are not providing adequate oversight, putting the detainees’ health and safety at risk.

The report highlights health care at three detention centers: Adelanto Detention Facility in Adelanto, Mesa Verde Detention Facility in McFarland and Imperial Regional Detention Facility in Holtville.

Those cities subcontract with private businesses to manage and operate the detention facilities, but they provided “little or no oversight of the private operators and simply passed federal payments from ICE to these subcontractors,” Howle wrote in a letter to the legislature.

Most of the health concerns raised in her report occurred during an unannounced federal inspection in May at the Adelanto Detention Facility, where inspectors found that detainees had hung bedsheets, which could be used to attempt suicide. In 2017, a detainee died after staff found him hanging from his sheets. The report said there had been three other suicide attempts by hanging as well.

The inspection also revealed that medical providers at the Adelanto facility did not conduct face-to-face medical assessments of detainees in segregation, but instead performed “cursory walk-throughs.” Nor did the facility provide proper interpretation services for people seeking care, or adequate dental services. No detainees had received fillings in the last four years, the report said.

“The city takes the findings contained in the report seriously and appreciates the recommendations,” said Adelanto city spokeswoman Michelle Van Der Linden in an emailed statement. The city, she added, is in the process of forming a committee to oversee the operation of the facility.

The city of McFarland it will not renew its contract with ICE.

During the five-year period covered by the auditor, the cities did not review complaints or inspection reports, the report said.

These cities have done little “to ensure that they are living up to their responsibilities in ensuring the safety and well-being of the detainees there,” said Michael Kaufman, senior staff attorney of the ACLU of Southern California.

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

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