But inside, the store is a welcoming oasis. Twinkly string lights adorn racks of donated clothing. Shelves and bins overflow with children’s books, allergy medications, and toiletries. Curtains cordon off one side of the room, where there’s a stage for musicians and a neon sign depicting roller skates for weekly free skate nights.

The space is part free thrift store, part over-the-counter pharmacy, part punk show venue — and wholly “a radical community center,” said Dan Bingler, who runs the place.

Bingler is a waiter and bartender in the city who founded a mutual-aid organization called the . He said the building owners allow him to use the space as long as he pays the water, electricity, and trash bills.

On Monday evenings, volunteers from other community organizations show up — some used to set up in the parking lot before Bingler opened the store. They offer free testing for sexually transmitted infections, basic medical care, hot meals, and sterile syringes and other supplies for people who use drugs.

The purpose of the space is simple, Bingler said: “We’re going to make sure we provide for the community.”

Although it’s been open for a few years now, the space has become even more crucial to this community in recent months, with the Trump administration slashing funding for many social service organizations and taking an aggressive approach to homelessness and drug use. In Washington, D.C., the administration has to push people living on the street to . Nationally, it has called for people who use drugs to be . It has — practices that public health experts say keep people who use drugs safe and alive but that critics say promote illegal drug use.

The community space in New Orleans — named the Fred Hampton Free Store after the known for bringing together diverse groups to fight for social reforms — aims to be a haven among this sea of changes.

It doesn’t receive federal funding, state or local grants, or money from foundations, Bingler said. It’s simply neighbors helping neighbors, he said, tearing up and adding, “It’s a really beautiful thing to be able to share all this space.”

All items inside are provided by people or organizations in the community. Bingler said one time a local hotel undergoing renovations donated 50 flat-screen TVs.

On nights the store is open, often more than 100 people visit, Bingler said.

One fall evening, dozens of people browsed for free clothing and over-the-counter medications. Others sat on the grass outside, chatting while keeping an eye on their bicycles or grocery carts full of possessions.

James Beshears stopped by the harm reduction group in the parking lot to get sterile supplies he uses to inject heroin and fentanyl. He said he’d been in treatment for years but relapsed after his doctor moved away and he was referred to a clinic that charged $250 a day. Street drugs were cheaper than treatment, he said.

He wants to stop. But until he can find affordable care, places like the free store keep him going. Without it, he said, he’d have “one foot in the grave.”

Another man in the parking lot was waiting for the arrival of Aquil Bey, a paramedic and former Green Beret well known for helping people overcome obstacles to getting health care. As soon as the man spotted Bey’s black Jeep, he ran up.

“I’ve got stage 4 kidney disease,” the man said, adding that he was scheduled for treatments at a hospital but was struggling to get there.

“Do me a favor,” Bey said as he unloaded folding tables and medical equipment from his car. “When our team gets here, come and see us. Maybe we can get you transportation.”

Bey is the founder of , a volunteer-run organization that provides free basic medical care and referrals for people who are homeless, using drugs, or part of other vulnerable communities. The group has a steady presence at the free store.

That day, Bey and his team connected the man needing kidney disease treatment to reduced-cost transit programs. They also did blood pressure and blood sugar checks for anyone who wanted them, cleaned infected wounds, and called clinics to make appointments for patients without phones.

A man with a leg injury mentioned he was sleeping on the concrete floor of an abandoned naval base. Bey noticed the free store’s furniture section had a mattress. He and another volunteer hauled it out, strapped it to the top of a car, and delivered it to where the man was sleeping.

“We’re just trying to find all these barriers” that people face and “find ways to fix them,” Bey said.

The clinic at the free store helped Stephen Wiltz connect with addiction care. He grew up in the Lower 9th Ward and had been using drugs since he was 10.

Fed up with discrimination from doctors who blamed him for his addiction, Wiltz said, he was reluctant to go to any treatment facility. But after years of knowing the volunteers at the free store, he trusted them to point him in the right direction.

At 56, Wiltz was in sustained recovery for the first time in his life, he said during a phone interview in the fall.

Those volunteers “cared for people who didn’t have nobody to care for them,” he said.

As the sun went down that fall evening at the store, a punk band started setting up for a show across the room from the medical clinic. Lights dimmed and music blared — a reminder that this was not your everyday clinic or community center.

Bey continued consulting with a patient who had gout.

“I get used to the sound,” Bey said of the rapid drums and loud power chords. “I like it sometimes.”

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They grabbed canned food, fruit and vegetables, and a grocery store gift card. And then Basu spotted a row of tables in the parking lot staffed by county social service workers helping people apply for food assistance and health coverage. Her mother-in-law, also a Medicaid recipient, might qualify for food assistance, she was told.

“It would be less money for me that I would have to put aside,” said Basu, who has been the sole breadwinner for the family from Anaheim since her husband suffered a stroke. “Maybe I can use that extra money to cover other expenses.”

Basu was among the more than 3,000 people who turned up at a November CalOptima event in one of California’s most affluent counties. It marked the start of a $20 million campaign by the Medicaid health insurer to help low-income residents get and maintain health coverage and food benefits as federal restrictions under President Donald Trump’s One Big Beautiful Bill Act take effect.

The law cuts more than for Medicaid, known in California as Medi-Cal. It also slashes around $187 billion from the Supplemental Nutrition Assistance Program, or SNAP, known as CalFresh in California. That’s about 20% of the program’s budget over the next 10 years. As a result, up to 3.4 million Medi-Cal recipients and almost 400,000 CalFresh beneficiaries could lose benefits. (Most CalFresh beneficiaries .)

Republican representatives say the changes, some of which have already taken effect, will prevent waste, fraud, and abuse through expanded eligibility checks and work requirements. Yet, Medicaid health plans across the nation are bolstering outreach to low-income households in a bid to not lose enrollees, many of whom are already struggling with high grocery and medical costs.

In Los Angeles County, L.A. Care Health Plan launched community information sessions this month to educate the public about upcoming changes to Medi-Cal. Hawaii’s AlohaCare is mobilizing a to help mitigate the impact of Medicaid coverage losses. And Community Behavioral Health, a Medicaid managed-care plan for behavioral health in Philadelphia, plans to host a series of summits starting next year to get the word out about the changes.

“We know that these changes will affect a lot of our members,” said Michael Hunn, CEO of CalOptima, one of about two dozen Medi-Cal managed-care plans paid monthly based on their number of enrollees. “We have a great responsibility to make sure that they understand and can navigate these changes as they are implemented.”

CalOptima, a public entity whose board is appointed by county supervisors, has allocated up to $2 million through the end of 2028 to pay for county eligibility workers at events like the food giveaway to provide on-the-spot assistance. It’s funding that An Tran, head of Orange County’s Social Services Agency, said can help pay for critical outreach the county otherwise wouldn’t be able to afford.

Orange County has about 1,500 eligibility workers to handle reenrollments and verification checks for around 850,000 Medi-Cal members and over 300,000 CalFresh recipients.

“We are talking about families who desperately need help especially at a time when food costs and inflation is high and they’re barely able to make it,” Tran said.

In addition to funding county workers, CalOptima intends to provide grants to community organizations to conduct Medi-Cal outreach and run a public awareness campaign in multiple languages to make enrollees aware of new requirements, Hunn said.

U.S. Rep. Young Kim, a Republican who represents part of Orange County, did not respond to a request seeking comment but has said Trump’s signature budget law, which she voted for, “takes important steps to ensure federal dollars are used as effectively as possible and to strengthen Medicaid and SNAP for our most vulnerable citizens who truly need it.” She and other Republicans have said it will provide tax relief for working Americans.

After nearly an hour with an eligibility worker, Basu learned she earned too much for her mother-in-law, who lives with the family, to qualify for CalFresh. Now, Basu said, she’s worried about Medi-Cal eligibility changes for immigrants, which she fears could affect her mother-in-law, who obtained lawful permanent residency about a year and a half ago.

“Before having that, we were paying cash for cardiology, for labs, everything. It was very pricey,” Basu said. “I’m thinking I will have to, in a few months, pay again out-of-pocket. It’s a lot on me. It’s a burden.”

In most of the nation, people who’ve had a green card for less than five years generally for federally funded Medicaid. However, California has provided state-funded Medi-Cal coverage for them and low-income immigrants without legal status.

But even those benefits are being rolled back amid state budget pressures. In July, the state will eliminate full-scope dental benefits for some enrollees who have had a green card for less than five years, as well as certain other immigrant enrollees. A year later, this group will start being charged monthly premiums.

And starting in January, California will freeze enrollment for people 19 or over without legal status, as well as some lawfully present immigrants. It will also reinstate an asset limit for all older enrollees.

Meanwhile, the state is drafting guidance for counties on how to implement the federal Medicaid eligibility changes, said Tony Cava, a spokesperson for California’s Department of Health Care Services. The federal work rules and twice-yearly eligibility checks are slated to take effect by the start of 2027, applying to enrollees under the Affordable Care Act coverage expansion.

The California Department of Social Services, which manages CalFresh, has already changed how home utility costs are calculated and imposed a cap on benefits for very large households. It is still developing guidance for the federal work requirements and changes that disqualify some noncitizens, agency Chief Deputy Director David Swanson Hollinger said at a recent hearing.

The Department of Health Care Services has developed a “” webpage about the state and federal Medicaid changes. It’s also leveraging a network of Medi-Cal “” to provide information and updates in communities across the state in multiple languages. And it’s collaborating with counties and Medi-Cal managed-care plans to support community-based enrollment assistance, including at local events, Cava said.

Aquilino and Fidelia Salazar, a husband and wife getting help with a CalFresh application, said they didn’t expect to be affected by the work requirements and Medi-Cal eligibility changes. That’s because they are both permanent U.S. residents who have chronic health conditions and can’t work, they said. People considered physically or mentally unable to work can be exempted from work requirements. But the couple are concerned other immigrants in their community could lose care.

“It’s not fair because a lot of people really need it,” Fidelia Salazar said in Spanish. “People earn so little and then medicines and going to the doctor is extremely expensive.”

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In some ways, he has. 

When layoffs were set to hit the Indian Health Service — the federal agency responsible for providing health care to Native Americans and Alaska Natives — Kennedy’s department . 

In April, while visiting Arizona’s Navajo Nation, Kennedy told Â鶹ŮÓÅ Health News he was making sure broader budget cuts and layoffs at HHS do not affect Native American communities. 

But tribal leaders expressed skepticism. They said they’ve already seen fallout from the sweeping reorganization across federal health agencies. Public health data is incomplete and agency communication has become less reliable. Tribes have also lost at least $6 million in grants from other HHS agencies, the National Indian Health Board sent to Kennedy in May. 

“There may be a misconception among some of the administration that Indian Country is only impacted by changes to the Indian Health Service,” said Liz Malerba, a tribal policy expert and citizen of the Mohegan Tribe. “That’s simply not true.” 

Native Americans face higher rates of chronic diseases and die younger than other populations. Those inequities stem from . The Indian Health Service has been chronically underfunded and understaffed, leading to gaps in care. 

Janet Alkire, chairperson of the Standing Rock Sioux Tribe in the Dakotas, said that the canceled grants paid for community health workers, vaccinations, data modernization, and other public health efforts. 

Other programs — including ones aimed at and — were slashed after the government said they violated the Trump administration’s ban on “diversity, equity, and inclusion.” 

Native leaders and organizations have , a legal process required when federal agencies consider changes that would affect tribal nations. Alkire and other tribal leaders at the Senate committee hearing said federal officials had not responded. 

“This is not just a moral question of what we owe Native people,” Sen. Brian Schatz (D-Hawaii) said at the hearing. “It is also a question of the law.”Ìý

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But the area housing the regional office of the Department of Health and Human Services was eerily quiet.

In March, HHS announced it would close as part of a broad restructuring to consolidate the department’s work and reduce the number of staff by 20,000, to 62,000. The HHS Region 2 office in New York City, which has served New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands, was among those getting the ax.

Public health experts and advocates say that , like the one in New York City, form the connective tissue between the federal government and many locally based services. Whether ensuring local social service programs like Head Start get their federal grants, investigating Medicare claims complaints, or facilitating hospital and health system provider enrollment in Medicare and Medicaid programs, regional offices provide a key federal access point for people and organizations. Consolidating regional offices could have serious consequences for the nation’s public health system, they warn.

“All public health is local,” said Georges Benjamin, executive director of the American Public Health Association. “When you have relative proximity to the folks you’re liaising to, they have a sense of the needs of those communities, and they have a sense of the political issues that are going on in these communities.”

The other offices slated to close are in Boston, Chicago, San Francisco, and Seattle. Together, the five serve 22 states and a handful of U.S. territories. Services for the shuttered regional offices will be divvied up among the remaining regional offices in Atlanta, Dallas, Denver, Kansas City, and Philadelphia.

The elimination of regional HHS offices has already had an outsize impact on Head Start, a long-standing federal program that provides free child care and supportive services to children from many of the nation’s poorest families. It is among the examples cited against the federal government challenging the HHS restructuring brought by New York, 18 other states, and the District of Columbia, which notes that, as a result, “many programs are at imminent risk of being forced to pause or cease operations.”

The HHS site included a regional Head Start office that was closed and laid off staff last month. The Trump administration had sought for Head Start, according to a draft budget document that outlines dramatic cuts at HHS, which Congress would need to approve. indicate the administration may be stepping back from this plan; however, other childhood and early-development programs could still be on the chopping block.

Bonnie Eggenburg, president of the New Jersey Head Start Association, said her organization has long relied on the HHS regional office to be “our boots on the ground for the federal government.” During challenging times, such as the covid-19 pandemic or Hurricanes Sandy and Maria, the regional office helped Head Start programs design services to meet the needs of children and families. “They work with us to make sure we have all the support we can get,” she said.

In recent weeks, payroll and other operational payments have been delayed, and employees have been asked to justify why they need the money as part of a new “” initiative instituted by the Elon Musk-led Department of Government Efficiency, created by President Donald Trump through an executive order.

“Right now, most programs don’t have anyone to talk to and are unsure as to whether or not that notice of award is coming through as expected,” Eggenburg said.

HHS regional office employees who worked on Head Start helped providers fix technical issues, address budget questions, and discuss local issues, like the city’s growing population of migrant children, said Susan Stamler, executive director of . Based in New York City, the organization represents dozens of neighborhood settlement houses — community groups that provide services to local families such as language classes, housing assistance, and early-childhood support, including some Head Start programs.

“Today, the real problem is people weren’t given a human contact,” she said of the regional office closure. “They were given a website.”

To Stamler, closing the regional Head Start hub without a clear transition plan “demonstrates a lack of respect for the people who are running these programs and services,” while leaving families uncertain about their child care and other services.

“It’s astonishing to think that the federal government might be reexamining this investment that pays off so deeply with families and in their communities,” she said.

Without regional offices, HHS will be less informed about which health initiatives are needed locally, said Zach Hennessey, chief strategy officer of Public Health Solutions, a nonprofit provider of health services in New York City.

“Where it really matters is within HHS itself,” he said. “Those are the folks that are now blind — but their decisions will ultimately affect us.”

Dara Kass, an emergency physician who was the HHS Region 2 director under the Biden administration, described the job as being an ambassador.

“The office is really about ensuring that the community members and constituents had access to everything that was available to them from HHS,” Kass said.

, division offices for the Administration for Community Living, the FDA’s Office of Inspections and Investigations, and the Substance Abuse and Mental Health Services Administration have already closed or are slated to close, along with several other division offices.

HHS did not provide an on-the-record response to a request for comment but has maintained that shuttering regional offices will not hurt services.

Under the reorganization, many HHS agencies are either being eliminated or folded into other agencies, including the recently created Administration for a Healthy America, under HHS Secretary Robert F. Kennedy Jr.

“We aren’t just reducing bureaucratic sprawl. We are realigning the organization with its core mission and our new priorities in reversing the chronic disease epidemic,” Kennedy said announcing the reorganization.

Regional office staffers were laid off at the beginning of April. Now there appears to be a skeleton crew shutting down the offices. On a recent day, an Administration for Children and Families worker who answered a visitor’s buzz at the entrance estimated that only about 15 people remained. When asked what’s next, the employee shrugged.

The Trump administration’s downsizing effort will also eliminate six of 10 regional outposts of the HHS Office of the General Counsel, a squad of lawyers supporting the Centers for Medicare & Medicaid Services and other agencies in beneficiary coverage disputes and issues related to provider enrollment and participation in federal programs.

Unlike private health insurance companies, Medicare is a federal health program governed by statutes and regulations, said Andrew Tsui, a partner at Arnall Golden Gregory about the regional office closings.

“When you have the largest federal health insurance program on the planet, to the extent there could be ambiguity or appeals or grievances,” Tsui said, “resolving them necessarily requires the expertise of federal lawyers, trained in federal law.”

Overall, the loss of the regional HHS offices is just one more blow to public health efforts at the state and local levels.

State health officials are confronting the “total disorganization of the federal transition” and cuts to key federal partners like the Centers for Disease Control and Prevention, CMS, and the FDA, said James McDonald, the New York state health commissioner.

“What I’m seeing is, right now, it’s not clear who our people ought to contact, what information we’re supposed to get,” he said. “We’re just not seeing the same partnership that we so relied on in the past.”

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He pulled to the side of the road and cried at the sight of residents trying to save their homes.

“I could see people standing on the roof, watering it, trying to protect it from the fire, and they just looked so hopeless,” said Ramirez, a community outreach worker with the Pasadena Public Health Department.

That evening, the 49-year-old volunteered for a 14-hour shift at the city’s evacuation center, as did colleagues who had also been activated for emergency medical duty. Running on adrenaline and little sleep after finding shelter for homeless people all day, Ramirez spent the night circulating among more than a thousand evacuees, offering wellness checks, companionship, and hope to those who looked distressed.

Local health departments, such as Ramirez’s, have become a key part of governments’ response to wildfires, floods, and other extreme weather events, which scientists say are becoming due to climate change. The emotional toll of fleeing and possibly losing a home can help cause or exacerbate mental health conditions such as anxiety, depression, post-traumatic stress disorder, suicidal ideation, and substance use, according to health and climate experts.

Wildfires have become a recurring experience for many Angelenos, making it difficult for people to feel safe in their home or able to go about daily living, said Lisa Wong, director of the Los Angeles County Department of Mental Health. However, with each extreme weather event, the county has improved its support for evacuees, she said.

For instance, Wong said the county deployed a team of mental health workers trained to comfort evacuees without retraumatizing them, including by avoiding asking questions likely to bring up painful memories. The department has also learned to better track people’s health needs and redirect those who may find massive evacuation settings uncomfortable to other shelters or interim housing, Wong said. In those first days, the biggest goal is often to reduce people’s anxiety by providing them with information.

“We’ve learned that right when a crisis happens, people don’t necessarily want to talk about mental health,” said Wong, who staffed the evacuation site Jan. 8 with nine colleagues.

Instead, she and her team deliver a message of support: “This is really bad right now, but you’re not going to do this alone. We have a whole system set up for recovery too. Once you get past the initial shock of what happened — initial housing needs, medication needs, all those things — then there’s this whole pathway to recovery that we set up.”

The convention center in downtown Pasadena, which normally hosts home shows, comic cons, and trade shows, was transformed into an evacuation site with hundreds of cots. It was one of at least 13 shelters opened to serve under evacuation orders.

The January wildfires have burned an estimated 64 square miles — an area larger than the city of Paris — and destroyed at least 12,300 buildings since they started Jan. 7. AccuWeather estimates the region will likely face more than from the blazes, surpassing the estimates from the state’s record-breaking 2020 wildfire season.

Lisa Patel, executive director of the , said she’s most concerned about low-income residents, who are less likely to access mental health support.

“There was a mental health crisis even before the pandemic,” said Patel, who is also a clinical associate professor of pediatrics at Stanford School of Medicine, referring to the covid-19 pandemic. “The pandemic made it worse. Now you lace in all of this climate change and these disasters into a health care system that isn’t set up to care for the people that already have mental health illness.”

Early research suggests exposure to large amounts of wildfire smoke can damage the brain and increase the risk of developing anxiety, she added.

At the Pasadena Convention Center, Elaine Santiago sat on a cot in a hallway as volunteers pulled wagons loaded with soup, sandwiches, bottled water, and other necessities.

Santiago said she drew comfort from being at the Pasadena evacuation center, knowing that she wasn’t alone in the tragedy.

“It sort of gives me a sense of peace at times,” Santiago said. “Maybe that’s weird. We’re all experiencing this together.”

She had been celebrating her 78th birthday with family when she fled her home in the small city of Sierra Madre, east of Pasadena. As she watched flames whip around her neighborhood, she, along with children and grandkids, scrambled to secure their dogs in crates and grabbed important documents before they left.

The widower had leaned on her husband in past emergencies, and now she felt lost.

“I did feel helpless,” Santiago said. “I figured I’m the head of the household; I should know what to do. But I didn’t know.”

Donny McCullough, who sat on a neighboring green cot draped in a Red Cross blanket, had fled his Pasadena home with his family early on the morning of Jan. 8. Without power at home, the 68-year-old stayed up listening for updates on a battery-powered radio. His eyes remained red from smoke irritation hours later.

“I had my wife and two daughters, and I was trying not to show fear, so I quietly, inside, was like, ‘Oh my God,’” said McCullough, a music producer and writer. “I’m driving away, looking at the house, wondering if it’s going to be the last time I’m going to see it.”

He saved his master recording from a seven-year music project, but he left behind his studio with all his other work from a four-decade career in music.

Not all evacuees arrived with family. Some came searching for loved ones. That’s one of the hardest parts of his shift, Ramirez said. The community outreach worker helped walk people around the building, cot by cot.

A week in, at least two dozen people had been killed in the wildfires.

The work takes a toll on disaster relief workers too. Ramirez said many feared losing their homes in the fires and some already had. He attends therapy weekly, which he said helps him manage his emotions.

At the evacuation center, Ramirez described being on autopilot.

“Some of us react differently. I tend to go into fight mode,” Ramirez said. “I react. I run towards the fire. I run towards personal service. Then once that passes, that’s when my trauma catches up with me.”

Need help? Los Angeles County residents in need of support can call the county’s mental health helpline at 1-800-854-7771. The national Suicide & Crisis Lifeline, 988, is also available for those who’d like to speak with someone confidentially, free of charge.

This article was produced by Â鶹ŮÓÅ Health News, which publishes , an editorially independent service of the .Ìý

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Beneath the Caesars Palace hotel and casino, Johnson found one of them stretched out on a plywood bed. Jay Flanders, 49, had sores across his back, up his arms, and into his fingers. The homeless man acknowledged occasional meth use and mental health concerns. He couldn’t recall exactly how long he’d lived underground, but it had been several years.

“Why don’t you come inside,” asked Johnson, trying to persuade Flanders to leave the tunnels. “Come get treatment.”

It’s Johnson’s job to coax homeless people out of drainage tunnels that stretch beneath Las Vegas, a perilous grid where people hide from law enforcement and shelter from extreme weather but risk being swept away by floodwaters. Drugs and alcohol are prevalent. Johnson tells clients they have a better shot at recovery above ground, where they can get medical care to treat chronic illnesses, such as diabetes, depression, and heart disease, and start drug and alcohol treatment programs.

Street medicine providers and homeless outreach workers who travel into the tunnels said they have noticed an uptick in the number of people living underground as housing costs have skyrocketed and local officials have adopted a zero-tolerance approach to homelessness. Caseworkers are also confronting a level of drug addiction that’s making it harder to get people, many suffering from mental illness and health conditions, to come aboveground for care.

“It’s meth. It’s fentanyl. It’s opioids. We’re seeing it more and more,” said Rob Banghart, vice president of community integration for the nonprofit homeless outreach organization Shine a Light, who lived in the tunnels for 2½ of the five years he was homeless, often using drugs.

Now sober for more than six years, Banghart recalled the tunnels providing a respite. “In that state of mind, I said to myself, ‘It’s got a roof; it’s out of the sun.’ It’s a little twisted, but it was a community.”

Outreach workers say more people are retreating underground. Though dark and damp, the tunnels provide cover from the harsh desert sun, warmth when temperatures drop, and privacy from society’s judgment above ground.

Constructed and measuring some 600 miles, the tunnels provide flood control for the city and outlying communities. Homeless outreach workers said 1,200 to 1,500 people live in them. Many have constructed elaborate shelters, often out of plywood and scraps of metal or brick below the casinos that define the Strip.

Tunnel living is not limited to Nevada. Across California’s Central Valley and its southern deserts, people unable to afford housing are retreating into , often dug into flood control berms, riverbanks, or along drainage canals, where people can escape the heat and law enforcement. In San Antonio, homeless people have , and in New York, homeless people have long retreated into subterranean existence in tunnels and .

In Las Vegas, some tunnel dwellers said they hide to avoid constant encampment sweeps, which have since the U.S. Supreme Court that local authorities have a right to enforce sleeping or camping bans in public spaces, even when no shelter or housing is available.

Others said they go down to escape the unbearable weather. Triple digits are common in the summer; this year, Las Vegas climbed as high as 120 degrees. And the tunnels provide protection when temperatures drop into the 30s in the winter. It even snows there.

Street medicine providers are also trying to persuade homeless people to leave the tunnels to receive care. In addition to more drug and alcohol use, they have seen new problems with wounds and skin disorders associated with the street drug known as “tranq,” slang for the animal tranquilizer xylazine, which is often mixed with fentanyl or meth.

Tranq causes deep skin infections that, left untreated, can lead to bone infections and require amputation.

Flanders, the homeless man in the tunnels, had several of these skin sores, which he referred to as spider bites — a euphemism for the deep skin wounds caused by tranq. He estimated he has been to the emergency room at least 10 times this year, several times requiring hospitalization.

“One time I was there for six days; I almost lost a finger,” Flanders said, holding up the index finger that had been warped from a deep infection, as he started to tear up. Despite the risks, Flanders said, he still felt safer living in the tunnels than aboveground.

Las Vegas’ population boom has contributed to rising housing costs. The market rent for southern Nevada rose 20% from 2022 to 2023, according to a Clark County — higher than the .

As more people get displaced, more retreat underground. And often, outreach workers say, it’s not just locals who can’t afford the rising cost of living who wind up homeless, but also out-of-towners. Some come to make it in the city’s booming entertainment industry, while others become homeless after losing it all at the casinos.

“People come here on vacation to gamble or try and make it, and they lose everything,” said Johnson, who works for Shine a Light, one of two organizations in Las Vegas that provide substantial outreach, housing referrals, and drug treatment services for homeless people in the tunnels.

“The housing market is insane; rents keep going up. A lot of people wind up down here,” said Johnson, who lived in the tunnels until he got sober with help from Shine a Light. “People just get stuck.”

Still, Nevada’s and rains and monsoons pose a major threat to those living in the tunnels, though it’s unclear exactly how deadly life in them can be.

But Louis Lacey, homeless response director for the nonprofit Help of Southern Nevada, said homeless people living belowground put their lives at risk, often in the monsoon season when the tunnels flood. His organization coordinates with the city of Las Vegas and Clark County to get as many people as possible into shelters before the start of the rainy season, which from June to September.

“We go into the tunnels to make sure people who want to get out are out, but not everyone leaves, often because they don’t want to leave their belongings,” he said. “People die every year.”

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The mountains of western North Carolina have been known to flood: The area is bursting with creeks and rivers and enjoys an abundance of rain. There are occasionally wildfires. But the ravages of the climate crisis’s worst impacts — including increasingly powerful hurricanes — felt like a problem for another place. Asheville sits almost 250 miles from the nearest coastline.

After Hurricane Helene roared across the state, causing historic flooding, downing trees, snapping power lines, decimating water infrastructure, and leading to the deaths of at least 72 people in Buncombe County alone, communities are still shaking off the shock of a storm they never thought could touch these mountains.

“People relocate to Asheville not just because it’s beautiful, but because it isn’t prone to natural disasters,” said Katie Gebely, an artist in Asheville. “But that sense of safety is gone.”

I live in Beech, a historic community in Weaverville, North Carolina, at the eastern end of a two-lane road called Reems Creek, which is named after the waterway running parallel to it. The town of Weaverville, just north of Asheville, is five miles down the road.

Helene’s destruction created a major problem for people dependent on insulin, power wheelchairs, oxygen CPAP machines for sleep apnea, or home dialysis equipment. Without electricity, their health is at risk.

To get to Weaverville from Beech in the days immediately after the storm, cars had to thump over dozens of downed power lines. Other lines were propped up with large, downed tree limbs or tied up with rope so cars could get under them. Utility poles were snapped in two. A transformer lay on the side of the road, as did a rather large boat, washed up from who knows where. Just last week, power crews arrived on Reems Creek Road, but there’s still no word on when everyone will regain electricity.

Jackie Martin of Canton, North Carolina, relies on supplemental oxygen for chronic obstructive pulmonary disease and emphysema. When the storm hit, she had four hours’ worth left. Because of her condition, Martin and her husband, David, have an electrical generator, which David checks every month to make sure it works.

“We keep enough gas to run about eight hours,” Jackie Martin said. But the Martins were without power for nearly a week. When they ran out of gasoline, their neighbors gave them the gas from their lawn mower. Then another neighbor evacuated and offered his propane generator. The Martins’ daughter came through with four tanks of propane.

“We went through tons of gas and propane,” Jackie Martin said. “Never did I think I would need every drop and then some. Thank goodness we got power back after a week.”

In Buncombe County, population 275,000, there were still more than 50,000 customers without electricity almost two weeks after the storm. Duke Energy reported that outages were in the Asheville area as of Wednesday.

In most places, the debris that littered the road has been cleared. Cars, trucks, and military vehicles can make their way through. But huge piles of trash still line the roadways. Buncombe County is asking residents not to burn it out of concern for air quality.

In a scene out of biblical end-times, yellow jackets swarmed in the days after the storm — displaced after falling trees and floodwaters destroyed their nests. Three or four days after the storm hit, an EMT drove through my neighborhood looking for Benadryl. My husband handed over what we had: a half-full bottle.

Overhead, helicopters fly day and night. The Federal Emergency Management Agency arrived in my neighborhood two Sundays ago to deliver bottled water and food rations. Potable water in some areas of western North Carolina, including Asheville, may take weeks or months to restore.

Weaverville’s residents were under a boil-water advisory until Oct. 11.

“We had sewer and water line breaks,” said Patrick Fitzsimmons, Weaverville’s mayor. “We had a lot of infrastructure destruction.”

Households with wells have fared no better. Well pumps don’t work without electricity. And storm-damaged or flooded wells may be compromised. Officials are urging residents to disinfect their wells before consuming water. The federal Environmental Protection Agency has given residents kits to test their well water.

A physical therapist at Asheville Specialty Hospital, who asked not to be identified out of concern for losing their job, told me that in the first days after the storm, crews hauled trash cans full of water into the facility so that staff could flush toilets with buckets.

“The water got shut off and we managed. We took care of people the best we could,” the therapist said. “But the amount of water that it takes to run a hospital is unsustainable for the length of time they think we’ll be out of water.”

The hospital is a 34-bed long-term acute care facility down the street from Asheville’s Mission Hospital. Nancy Lindell, a spokesperson for Mission Health, which operates both hospitals, said in a statement that fewer than 100 “low acuity patients in stable condition” at the organization’s facilities were transferred “to hospitals outside of the areas hardest hit by this disaster.”

“This decision, which was made in collaboration with more than 50 physicians and nursing leaders, helps ensure we have the capacity to meet the most critical needs of our region,” she said. “It also provides relief for our caregivers, who have been working around the clock in the wake of the storm.”

U.S. Rep. Chuck Edwards, who represents North Carolina’s 11th District, said FEMA has shipped 6 million liters of water and 4 million individual meals to western North Carolina. FEMA has promised 120 truckloads a day of food and water with no specified end date, .

The Biden administration has also for uninsured North Carolinians to replace lost prescriptions and medical equipment.

Fitzsimmons, Weaverville’s mayor, said he’s concerned about the impact of the storm on mental health. “People are going for an extended period of time without power or water,” he said. “Their nerves are frayed.”

Richard Zenn, chief medical officer at North Carolina-based Vaya Health, said the recovery will be long.

“We’re now in the phase where we have to deal with the effects of this ongoing trauma we’ve all suffered,” Zenn said. “Connect with others. Don’t get too isolated. Eat. Sleep. Try to get back into a normal routine. Do whatever reduces stress for you.”

For me, that has always been hiking or running through these ancient mountains. But there are too many uprooted trees to safely do that now. Instead I take solace on my porch and give thanks that I still have a porch to sit on. It’s a near-perfect day in Appalachia. The sky is painfully blue. I listen for the songs of birds, but all I can hear are generators.

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Farms in Colorado had of chickens in recent months to stem the transmission of bird flu. Organizers filled out the spread with hot dogs.

No matter the menu, some dairy workers at the event said they don’t exactly feel appreciated. They said they haven’t received any personal protective equipment beyond gloves to guard against the virus, even as they or colleagues have come down with conjunctivitis and flu-like symptoms that they fear to be bird flu.

“They should give us something more,” one dairy worker from Larimer County said in Spanish. He spoke on the condition of anonymity out of fear he’d lose his job for speaking out. “What if something happens to us? They act as if nothing is wrong.”

Agricultural health and safety experts have been trying to get the word out about how to protect against bird flu, including through on TikTok showing the proper way to gear up with respirators, eye protection, gloves, and coveralls. And Colorado’s health and agriculture departments have of protective equipment to any producer who requests it.

But so far, many farms aren’t taking them up on it: According to numbers provided by the state health department in late August, fewer than 13% of the had requested and received such PPE.

The virus is known to infect mammals — from skunks, bears, and cows to people and . It began showing up in dairy cattle in recent months, and Colorado has been in the thick of it. Ten of the 13 confirmed human cases in the U.S. this year have occurred in Colorado, where it among dairy cows. It isn’t a risk in cooked meat or pasteurized milk but is risky for those who come into contact with infected animals or raw milk.

Weld County, where the farmworker event was held, is one of the nation’s , supplying enough milk each month this year to fill about 45 Olympic-size swimming pools, according to . Neighboring counties are notable producers, too.

Concerns are growing about undiagnosed illness among farmworkers because of a lack of testing and safety precautions. One reason for concern: Bird flu and seasonal flu are capable of , so if they ended up in the same body at the same time, bird flu might end up with genes that boost its contagiousness. The virus doesn’t appear to be spreading easily between people yet. That could change, and if people aren’t being tested then health officials may be slow to notice.

Strains of seasonal flu already in the U.S. a year. Public health officials fear the havoc a new form of the flu could wreak if it spreads among people.

The Centers for Disease Control and Prevention recommends that dairy workers don a respirator and goggles or a face shield, , whether they are working with sick animals or not.

A found that not all infected cows show symptoms, so workers could be interacting with contagious animals without realizing it. Even when it is known that animals are infected, farmworkers often still have to get in close contact with them, sometimes under grueling conditions, such as during a recent heat wave when Colorado poultry workers collected hundreds of chickens by hand for culling because of the outbreak. At least six of the workers became infected with bird flu.

One dairy worker in Weld County, who spoke on the condition of anonymity for fear of losing his job, said his employer has not offered any protective equipment beyond gloves, even though he works with sick cows and raw milk.

His bosses asked the workers to separate sick cows from the others after some cows produced less milk, lost weight, and showed signs of weakness, he said. But the employer didn’t say anything about the bird flu, he said, or suggest they take any precautions for their own safety.

He said he bought protective goggles for himself at Walmart when his eyes became itchy and red earlier this summer. He recalled experiencing dizziness, headaches, and low appetite around the same time. But he self-medicated and pushed through, without missing work or going to a doctor.

“We need to protect ourselves because you never know,” he said in Spanish. “I tell my wife and son that the cows are sick, and she tells me to leave, but it will be the same wherever I go.”

He said he’d heard that his employers were unsympathetic when a colleague approached them about feeling ill. He’d even seen someone affiliated with management remove a flyer about how people can protect themselves from the bird flu and throw it in a bin.

The dairy worker in neighboring Larimer County said he, too, has had just gloves as protection, even when he has worked with sick animals — close enough for saliva to wipe off on him. He started working with them when a colleague missed work because of his flu-like symptoms: fever, headache, and red eyes.

“I only wear latex gloves,” he said. “And I see that those who work with the cows that are sick also only wear gloves.”

He said he doesn’t have time to wash his hands at work but puts on hand sanitizer before going home and takes a shower once he arrives. He has not had symptoms of infection.

Such accounts from dairy workers echo those from farmworkers in Texas, as reported by Â鶹ŮÓÅ Health News in July.

“Employers who are being proactive and providing PPE seem to be in the minority in most states,” said with the National Center for Farmworker Health, a not-for-profit organization based in Texas that advocates for improving the health of farmworkers and their families. “Farmworkers are getting very little information.”

But , CEO of the Colorado Livestock Association, said he thinks such scenarios are the exception, not the rule.

“You would be hard-pressed to find a dairy operation that isn’t providing that PPE,” he said. Riley said dairies typically have a stockpile of PPE ready to go for situations like this and that, if they don’t, it’s easily accessed through the state. “All you have to do is ask.”

Producers are highly motivated to keep infections down, he said, because “milk is their life source.” He said he has heard from some producers that “their family members who work on the farm are doing 18-to 20-hour days just to try to stay ahead of it, so that they’re the first line between everything, to protect their employees.”

Colorado’s health department is that ill dairy workers can call for help getting a flu test and medicine.

, an organization that emerged early in the covid-19 pandemic to promote farmworker health across Colorado, is distributing PPE it received from the state so promotoras — health workers who are part of the community they serve — can distribute masks and other protections directly to workers if employers aren’t giving them out.

Promotora Tomasa Rodriguez said workers “see it as another virus, another covid, but it is because they don’t have enough information.”

She has been passing out flyers about symptoms and protective measures, but she can’t access many dairies. “And in some instances,” she said, “a lot of these workers don’t know how to read, so the flyers are not reaching them, and then the employers are not doing any kind of talks or trainings.”

The CDC’s said during an Aug. 13 call with journalists that awareness about bird flu among dairy workers isn’t as high as officials would like it to be, despite months of campaigns on social media and the radio.

“There’s a road ahead of us that we still need to go down to get awareness on par with, say, what it might be in the poultry world,” he said. “We’re using every single messenger that we can.”

Â鶹ŮÓÅ Health News correspondents Vanessa G. Sánchez and Amy Maxmen contributed to this report.

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An art deco sign still marks the main entrance, but the front doors are locked, and the parking lot is empty. These days, a convenience store across North Edwards Avenue is far busier than the old Taborian Hospital, which first shut down more than 40 years ago.

Myrna Smith-Thompson, who serves as executive director of the civic group that owns the property, lives 100 miles away in Memphis, Tennessee, and doesn’t know what’s to become of the deteriorating building.

“I am open to suggestions,” said Smith-Thompson, whose grandfather led a Black fraternal organization now called the Knights and Daughters of Tabor. In 1942, that group established Taborian Hospital, a place staffed by Black doctors and nurses that exclusively admitted Black patients, during a time when Jim Crow laws barred them from accessing the same health care facilities as white patients.

“This is a very painful conversation,” said Smith-Thompson, who was born at Taborian Hospital in 1949. “It’s a part of my being.”

A similar scenario has played out in hundreds of other rural communities across the United States, where over the past 40 years. In that regard, the story of Mound Bayou’s hospital isn’t unique.

But there’s more to this hospital closure than the loss of inpatient beds, historians say. It’s also a tale of how hundreds of Black hospitals across the U.S. fell casualty to social progress.

The Civil Rights Act of 1964 and the enactment of Medicare and Medicaid in 1965 benefited millions of people. The federal campaign to desegregate hospitals, culminating in a out of Charleston, South Carolina, guaranteed Black patients across the South access to the same health care facilities as white patients. No longer were Black doctors and nurses prohibited from training or practicing medicine in white hospitals. But the end of legal racial segregation precipitated the demise of many Black hospitals, which were a major source of employment and a center of pride for Black Americans.

“And not just for physicians,” said Vanessa Northington Gamble, a medical doctor and historian at George Washington University. “They were social institutions, financial institutions, and also medical institutions.”

In Charleston, staff members at a historically Black hospital on Cannon Street started publishing a monthly journal in 1899 called The Hospital Herald, which focused on hospital work and public hygiene, among other topics. When Kansas City, Missouri, opened a hospital for Black patients in 1918, people held a parade. Taborian Hospital in Mound Bayou included two operating rooms and state-of-the-art equipment. It’s also where famed civil rights activist Fannie Lou Hamer died in 1977.

“There were Swedish hospitals. There were Jewish hospitals. There were Catholic hospitals. That’s also part of the story,” said Gamble, author of “Making a Place for Ourselves: The Black Hospital Movement, 1920-1945.”

“But racism in medicine was the main reason why there was an establishment of Black hospitals,” she said.

By the early 1990s, Gamble estimated, there were only eight left.

“It has ripple effects in a way that affect the fabric of the community,” said Bizu Gelaye, an epidemiologist and program director of Harvard University’s Mississippi Delta Partnership in Public Health.

Researchers have largely concluded that hospital desegregation improved the health of Black patients over the long term.

One 2009 study focusing on motor vehicle accidents in Mississippi in the ’60s and ’70s found that Black people were less likely to die after hospital desegregation. They could access hospitals closer to the scene of a crash, reducing the distance they would have otherwise traveled by approximately 50 miles.

An , published in 2006 by economists at the Massachusetts Institute of Technology, found that hospital desegregation in the South substantially helped close the mortality gap between Black and white infants. That’s partly because Black infants suffering from illnesses such as diarrhea and pneumonia got better access to hospitals, the researchers found.

A new analysis, recently accepted for publication in the Review of Economics and Statistics, suggests that racism continued to harm the health of Black patients in the years after hospital integration. White hospitals were compelled to integrate starting in the mid-1960s if they wanted to receive Medicare funding. But they didn’t necessarily provide the same quality of care to Black and white patients, said Mark Anderson, an economics professor at Montana State University and co-author of the paper. His that hospital desegregation had “little, if any, effect on Black postneonatal mortality” in the South between 1959 and 1973.

Nearly 3,000 babies were born at Taborian Hospital before it closed its doors in 1983. The building remained vacant for decades until 10 years ago, when a $3 million federal grant helped renovate the facility into a short-lived urgent care center. It closed again only one year later amid a legal battle over its ownership, Smith-Thompson said, and has since deteriorated.

“We would need at least millions, probably,” she said, estimating the cost of reopening the building. “Now, we’re back where we were prior to the renovation.”

In 2000, the hospital was listed as one of the most endangered historic places in Mississippi by the Mississippi Heritage Trust. That’s why some people would like to see it reopened in any capacity that ensures its survival as an important historical site.

Hermon Johnson Jr., director of the Mound Bayou Museum, who was born at Taborian Hospital in 1956, suggested the building could be used as a meeting space or museum. “It would be a huge boost to the community,” he said.

Meanwhile, most of the hospital’s former patients have died or left Mound Bayou. The city’s population has dropped by roughly half since 1980, U.S. Census Bureau records show. Bolivar County ranks among the poorest in the nation and life expectancy is a decade shorter than the national average.

A community health center is still open in Mound Bayou, but the closest hospital is in Cleveland, Mississippi, a 15-minute drive.

Mound Bayou Mayor Leighton Aldridge, also a board member of the Knights and Daughters of Tabor, said he wants Taborian Hospital to remain a health care facility, suggesting it might be considered for a new children’s hospital or a rehabilitation center.

“We need to get something back in there as soon as possible,” he said.

Smith-Thompson agreed and feels the situation is urgent. “The health care services that are available to folks in the Mississippi Delta are deplorable,” she said. “People are really, really sick.”

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WALL, S.D. — Stacey Schulz parks in a rear lot to avoid the crowded Main Street entrances to her local pharmacy.

“During the summer, it’s kind of hectic,” she said after greeting the pharmacist and technician by name.

That’s because Schulz’s pharmacy is tucked inside Wall Drug, a tourist attraction that takes up almost an entire block and draws more than 2 million visitors a year to a community of fewer than 700 residents.

The business is named after the town of Wall, which is just off Interstate 90 near Badlands National Park. Colorful, hand-painted billboards dot the roadside for hundreds of miles, telling motorists how far they are from Wall Drug’s free ice water, 5-cent coffee, and homemade doughnuts. Visitors can pan for gold, listen to singing animatronic cowboys, try on Western wear, and shop for souvenirs, including plush jackalopes — mythical jackrabbits with antelope horns.

Despite being part of a booming tourist attraction, Wall Drug’s pharmacy faces challenges common to independent rural pharmacies.

It’s the lone pharmacy in Wall, serving locals year-round. Some, like Schulz, live in town, while others live on ranches as far as 60 miles away. The next-nearest pharmacy is a 30-minute drive northeast.

Wall Drug also serves tourists who forget their prescriptions at home, get sick while roaming the country in their RVs, or hurt themselves while hiking through the otherworldly rock formations of the scorching Badlands, said Cindy Dinger, its sole pharmacist.

Wall has no hospital, but a clinic is open four days a week. Schulz, a medical assistant there, said she and her co-workers see a lot of summer tourists. They send them to Wall Drug to pick up prescriptions.

“And then we tell them to get fudge before they leave,” Schulz said.

Rural pharmacies, especially independent ones, closed at a higher rate from 2003 to 2021 than pharmacies in other areas, according to a By 2021, the institute found, nearly 8% of rural counties were . The Wall Drug pharmacy has fewer customers than a typical city pharmacy, which can mean less profit, Dinger said.

She said some of its prices are higher because the store can’t negotiate discounts as steep as the deals suppliers grant chain pharmacies. Rural drugstores also lack leverage with insurers, and they face increasing competition from mail-order pharmacies.

Another challenge is staffing. When Dinger needs time off, she finds a fill-in from Rapid City, nearly an hour’s drive away.

“It’s a challenge getting relief if I want to go on vacation or if I need a cover so that I can go to a doctor’s appointment,” she said. “You take what you can get and try to schedule around it.”

Dinger said her pharmacy would struggle without the rest of Wall Drug.

“All this stuff around us — the poster and print shop, the boot shop, the fudge shop, the café — they pay our bills,” she said.

The pharmacy’s white facade, with stained-glass signs and windows, is modeled after that of the original drugstore, which was across the street. The window displays and top shelves inside the store are filled with vintage pharmacy supplies, including manuals, glass medicine bottles, and a suppository-making machine.

Tourists carrying shopping bags and sporting new cowboy hats stop to look at the displays. “It’s a real pharmacy,” a woman said, sounding surprised.

Dinger and Sylvia Smith, the store’s only pharmacy tech, ring customers up below a Tiffany-style light fixture and retrieve prescriptions stored behind a wooden desk and wall.

Customer Will Lovitt said a friend advised him and his wife to stop at Wall Drug during their drive from Indiana to the Black Hills in western South Dakota. Lovitt developed a rash on the trip and ended up using the visit to get Dinger’s advice on treating it.

He said it can be difficult for tourists to know where to find medical help, especially when driving through rural states like South Dakota.

“I think it’s time that America gets back to the grass roots of the small-town doctor and the small-town pharmacist,” Lovitt said.

Alex Davis and a friend decided to visit Wall Drug on their road trip from Kansas to Yellowstone National Park.

“Then, when I saw there was a little pharmacy, I thought I’d grab something that I needed,” she said.

Davis bought Dramamine to treat car sickness on the long drive.

Dinger said she occasionally sees unusual situations, like the time several years ago when a park ranger needed antibiotics after getting bitten by a prairie dog.

“You never know what kind of diseases they might be carrying,” she said of the animals, which recently were hit with

Rick Hustead is the chairman of Wall Drug. The store was opened in 1931 by his grandfather, pharmacist Ted Hustead. Ted’s wife, Dorothy, had the idea to advertise its soda fountain and free ice water to tourists traveling along unpaved roads during the hot years of the Dust Bowl era. Rick’s father, pharmacist Bill Hustead, began expanding the store in the ’50s, turning it into the tourist magnet it is today.

Rick Hustead didn’t follow his father and grandfather’s path to pharmacy school, so he had to recruit pharmacists from elsewhere.

Hustead found Dinger in 2010 after writing a letter to each pharmacist in the state.

Dinger said she was living at the time in Sioux Falls, South Dakota’s most populous city. But she and her husband were interested in raising their kids in a small town, the way she grew up. Dinger was also attracted by the store’s limited hours: She’d be done working by 5 p.m. on weekdays and have the weekends off.

Hustead said his family has never considered closing the pharmacy, even though it’s not the main attraction for most visitors.

“We can’t be Wall Drug without being a drugstore,” he said.

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But inside, the store is a welcoming oasis. Twinkly string lights adorn racks of donated clothing. Shelves and bins overflow with children’s books, allergy medications, and toiletries. Curtains cordon off one side of the room, where there’s a stage for musicians and a neon sign depicting roller skates for weekly free skate nights.

The space is part free thrift store, part over-the-counter pharmacy, part punk show venue — and wholly “a radical community center,” said Dan Bingler, who runs the place.

Bingler is a waiter and bartender in the city who founded a mutual-aid organization called the . He said the building owners allow him to use the space as long as he pays the water, electricity, and trash bills.

On Monday evenings, volunteers from other community organizations show up — some used to set up in the parking lot before Bingler opened the store. They offer free testing for sexually transmitted infections, basic medical care, hot meals, and sterile syringes and other supplies for people who use drugs.

The purpose of the space is simple, Bingler said: “We’re going to make sure we provide for the community.”

Although it’s been open for a few years now, the space has become even more crucial to this community in recent months, with the Trump administration slashing funding for many social service organizations and taking an aggressive approach to homelessness and drug use. In Washington, D.C., the administration has to push people living on the street to . Nationally, it has called for people who use drugs to be . It has — practices that public health experts say keep people who use drugs safe and alive but that critics say promote illegal drug use.

The community space in New Orleans — named the Fred Hampton Free Store after the known for bringing together diverse groups to fight for social reforms — aims to be a haven among this sea of changes.

It doesn’t receive federal funding, state or local grants, or money from foundations, Bingler said. It’s simply neighbors helping neighbors, he said, tearing up and adding, “It’s a really beautiful thing to be able to share all this space.”

All items inside are provided by people or organizations in the community. Bingler said one time a local hotel undergoing renovations donated 50 flat-screen TVs.

On nights the store is open, often more than 100 people visit, Bingler said.

One fall evening, dozens of people browsed for free clothing and over-the-counter medications. Others sat on the grass outside, chatting while keeping an eye on their bicycles or grocery carts full of possessions.

James Beshears stopped by the harm reduction group in the parking lot to get sterile supplies he uses to inject heroin and fentanyl. He said he’d been in treatment for years but relapsed after his doctor moved away and he was referred to a clinic that charged $250 a day. Street drugs were cheaper than treatment, he said.

He wants to stop. But until he can find affordable care, places like the free store keep him going. Without it, he said, he’d have “one foot in the grave.”

Another man in the parking lot was waiting for the arrival of Aquil Bey, a paramedic and former Green Beret well known for helping people overcome obstacles to getting health care. As soon as the man spotted Bey’s black Jeep, he ran up.

“I’ve got stage 4 kidney disease,” the man said, adding that he was scheduled for treatments at a hospital but was struggling to get there.

“Do me a favor,” Bey said as he unloaded folding tables and medical equipment from his car. “When our team gets here, come and see us. Maybe we can get you transportation.”

Bey is the founder of , a volunteer-run organization that provides free basic medical care and referrals for people who are homeless, using drugs, or part of other vulnerable communities. The group has a steady presence at the free store.

That day, Bey and his team connected the man needing kidney disease treatment to reduced-cost transit programs. They also did blood pressure and blood sugar checks for anyone who wanted them, cleaned infected wounds, and called clinics to make appointments for patients without phones.

A man with a leg injury mentioned he was sleeping on the concrete floor of an abandoned naval base. Bey noticed the free store’s furniture section had a mattress. He and another volunteer hauled it out, strapped it to the top of a car, and delivered it to where the man was sleeping.

“We’re just trying to find all these barriers” that people face and “find ways to fix them,” Bey said.

The clinic at the free store helped Stephen Wiltz connect with addiction care. He grew up in the Lower 9th Ward and had been using drugs since he was 10.

Fed up with discrimination from doctors who blamed him for his addiction, Wiltz said, he was reluctant to go to any treatment facility. But after years of knowing the volunteers at the free store, he trusted them to point him in the right direction.

At 56, Wiltz was in sustained recovery for the first time in his life, he said during a phone interview in the fall.

Those volunteers “cared for people who didn’t have nobody to care for them,” he said.

As the sun went down that fall evening at the store, a punk band started setting up for a show across the room from the medical clinic. Lights dimmed and music blared — a reminder that this was not your everyday clinic or community center.

Bey continued consulting with a patient who had gout.

“I get used to the sound,” Bey said of the rapid drums and loud power chords. “I like it sometimes.”

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They grabbed canned food, fruit and vegetables, and a grocery store gift card. And then Basu spotted a row of tables in the parking lot staffed by county social service workers helping people apply for food assistance and health coverage. Her mother-in-law, also a Medicaid recipient, might qualify for food assistance, she was told.

“It would be less money for me that I would have to put aside,” said Basu, who has been the sole breadwinner for the family from Anaheim since her husband suffered a stroke. “Maybe I can use that extra money to cover other expenses.”

Basu was among the more than 3,000 people who turned up at a November CalOptima event in one of California’s most affluent counties. It marked the start of a $20 million campaign by the Medicaid health insurer to help low-income residents get and maintain health coverage and food benefits as federal restrictions under President Donald Trump’s One Big Beautiful Bill Act take effect.

The law cuts more than for Medicaid, known in California as Medi-Cal. It also slashes around $187 billion from the Supplemental Nutrition Assistance Program, or SNAP, known as CalFresh in California. That’s about 20% of the program’s budget over the next 10 years. As a result, up to 3.4 million Medi-Cal recipients and almost 400,000 CalFresh beneficiaries could lose benefits. (Most CalFresh beneficiaries .)

Republican representatives say the changes, some of which have already taken effect, will prevent waste, fraud, and abuse through expanded eligibility checks and work requirements. Yet, Medicaid health plans across the nation are bolstering outreach to low-income households in a bid to not lose enrollees, many of whom are already struggling with high grocery and medical costs.

In Los Angeles County, L.A. Care Health Plan launched community information sessions this month to educate the public about upcoming changes to Medi-Cal. Hawaii’s AlohaCare is mobilizing a to help mitigate the impact of Medicaid coverage losses. And Community Behavioral Health, a Medicaid managed-care plan for behavioral health in Philadelphia, plans to host a series of summits starting next year to get the word out about the changes.

“We know that these changes will affect a lot of our members,” said Michael Hunn, CEO of CalOptima, one of about two dozen Medi-Cal managed-care plans paid monthly based on their number of enrollees. “We have a great responsibility to make sure that they understand and can navigate these changes as they are implemented.”

CalOptima, a public entity whose board is appointed by county supervisors, has allocated up to $2 million through the end of 2028 to pay for county eligibility workers at events like the food giveaway to provide on-the-spot assistance. It’s funding that An Tran, head of Orange County’s Social Services Agency, said can help pay for critical outreach the county otherwise wouldn’t be able to afford.

Orange County has about 1,500 eligibility workers to handle reenrollments and verification checks for around 850,000 Medi-Cal members and over 300,000 CalFresh recipients.

“We are talking about families who desperately need help especially at a time when food costs and inflation is high and they’re barely able to make it,” Tran said.

In addition to funding county workers, CalOptima intends to provide grants to community organizations to conduct Medi-Cal outreach and run a public awareness campaign in multiple languages to make enrollees aware of new requirements, Hunn said.

U.S. Rep. Young Kim, a Republican who represents part of Orange County, did not respond to a request seeking comment but has said Trump’s signature budget law, which she voted for, “takes important steps to ensure federal dollars are used as effectively as possible and to strengthen Medicaid and SNAP for our most vulnerable citizens who truly need it.” She and other Republicans have said it will provide tax relief for working Americans.

After nearly an hour with an eligibility worker, Basu learned she earned too much for her mother-in-law, who lives with the family, to qualify for CalFresh. Now, Basu said, she’s worried about Medi-Cal eligibility changes for immigrants, which she fears could affect her mother-in-law, who obtained lawful permanent residency about a year and a half ago.

“Before having that, we were paying cash for cardiology, for labs, everything. It was very pricey,” Basu said. “I’m thinking I will have to, in a few months, pay again out-of-pocket. It’s a lot on me. It’s a burden.”

In most of the nation, people who’ve had a green card for less than five years generally for federally funded Medicaid. However, California has provided state-funded Medi-Cal coverage for them and low-income immigrants without legal status.

But even those benefits are being rolled back amid state budget pressures. In July, the state will eliminate full-scope dental benefits for some enrollees who have had a green card for less than five years, as well as certain other immigrant enrollees. A year later, this group will start being charged monthly premiums.

And starting in January, California will freeze enrollment for people 19 or over without legal status, as well as some lawfully present immigrants. It will also reinstate an asset limit for all older enrollees.

Meanwhile, the state is drafting guidance for counties on how to implement the federal Medicaid eligibility changes, said Tony Cava, a spokesperson for California’s Department of Health Care Services. The federal work rules and twice-yearly eligibility checks are slated to take effect by the start of 2027, applying to enrollees under the Affordable Care Act coverage expansion.

The California Department of Social Services, which manages CalFresh, has already changed how home utility costs are calculated and imposed a cap on benefits for very large households. It is still developing guidance for the federal work requirements and changes that disqualify some noncitizens, agency Chief Deputy Director David Swanson Hollinger said at a recent hearing.

The Department of Health Care Services has developed a “” webpage about the state and federal Medicaid changes. It’s also leveraging a network of Medi-Cal “” to provide information and updates in communities across the state in multiple languages. And it’s collaborating with counties and Medi-Cal managed-care plans to support community-based enrollment assistance, including at local events, Cava said.

Aquilino and Fidelia Salazar, a husband and wife getting help with a CalFresh application, said they didn’t expect to be affected by the work requirements and Medi-Cal eligibility changes. That’s because they are both permanent U.S. residents who have chronic health conditions and can’t work, they said. People considered physically or mentally unable to work can be exempted from work requirements. But the couple are concerned other immigrants in their community could lose care.

“It’s not fair because a lot of people really need it,” Fidelia Salazar said in Spanish. “People earn so little and then medicines and going to the doctor is extremely expensive.”

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In some ways, he has. 

When layoffs were set to hit the Indian Health Service — the federal agency responsible for providing health care to Native Americans and Alaska Natives — Kennedy’s department . 

In April, while visiting Arizona’s Navajo Nation, Kennedy told Â鶹ŮÓÅ Health News he was making sure broader budget cuts and layoffs at HHS do not affect Native American communities. 

But tribal leaders expressed skepticism. They said they’ve already seen fallout from the sweeping reorganization across federal health agencies. Public health data is incomplete and agency communication has become less reliable. Tribes have also lost at least $6 million in grants from other HHS agencies, the National Indian Health Board sent to Kennedy in May. 

“There may be a misconception among some of the administration that Indian Country is only impacted by changes to the Indian Health Service,” said Liz Malerba, a tribal policy expert and citizen of the Mohegan Tribe. “That’s simply not true.” 

Native Americans face higher rates of chronic diseases and die younger than other populations. Those inequities stem from . The Indian Health Service has been chronically underfunded and understaffed, leading to gaps in care. 

Janet Alkire, chairperson of the Standing Rock Sioux Tribe in the Dakotas, said that the canceled grants paid for community health workers, vaccinations, data modernization, and other public health efforts. 

Other programs — including ones aimed at and — were slashed after the government said they violated the Trump administration’s ban on “diversity, equity, and inclusion.” 

Native leaders and organizations have , a legal process required when federal agencies consider changes that would affect tribal nations. Alkire and other tribal leaders at the Senate committee hearing said federal officials had not responded. 

“This is not just a moral question of what we owe Native people,” Sen. Brian Schatz (D-Hawaii) said at the hearing. “It is also a question of the law.”Ìý

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But the area housing the regional office of the Department of Health and Human Services was eerily quiet.

In March, HHS announced it would close as part of a broad restructuring to consolidate the department’s work and reduce the number of staff by 20,000, to 62,000. The HHS Region 2 office in New York City, which has served New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands, was among those getting the ax.

Public health experts and advocates say that , like the one in New York City, form the connective tissue between the federal government and many locally based services. Whether ensuring local social service programs like Head Start get their federal grants, investigating Medicare claims complaints, or facilitating hospital and health system provider enrollment in Medicare and Medicaid programs, regional offices provide a key federal access point for people and organizations. Consolidating regional offices could have serious consequences for the nation’s public health system, they warn.

“All public health is local,” said Georges Benjamin, executive director of the American Public Health Association. “When you have relative proximity to the folks you’re liaising to, they have a sense of the needs of those communities, and they have a sense of the political issues that are going on in these communities.”

The other offices slated to close are in Boston, Chicago, San Francisco, and Seattle. Together, the five serve 22 states and a handful of U.S. territories. Services for the shuttered regional offices will be divvied up among the remaining regional offices in Atlanta, Dallas, Denver, Kansas City, and Philadelphia.

The elimination of regional HHS offices has already had an outsize impact on Head Start, a long-standing federal program that provides free child care and supportive services to children from many of the nation’s poorest families. It is among the examples cited against the federal government challenging the HHS restructuring brought by New York, 18 other states, and the District of Columbia, which notes that, as a result, “many programs are at imminent risk of being forced to pause or cease operations.”

The HHS site included a regional Head Start office that was closed and laid off staff last month. The Trump administration had sought for Head Start, according to a draft budget document that outlines dramatic cuts at HHS, which Congress would need to approve. indicate the administration may be stepping back from this plan; however, other childhood and early-development programs could still be on the chopping block.

Bonnie Eggenburg, president of the New Jersey Head Start Association, said her organization has long relied on the HHS regional office to be “our boots on the ground for the federal government.” During challenging times, such as the covid-19 pandemic or Hurricanes Sandy and Maria, the regional office helped Head Start programs design services to meet the needs of children and families. “They work with us to make sure we have all the support we can get,” she said.

In recent weeks, payroll and other operational payments have been delayed, and employees have been asked to justify why they need the money as part of a new “” initiative instituted by the Elon Musk-led Department of Government Efficiency, created by President Donald Trump through an executive order.

“Right now, most programs don’t have anyone to talk to and are unsure as to whether or not that notice of award is coming through as expected,” Eggenburg said.

HHS regional office employees who worked on Head Start helped providers fix technical issues, address budget questions, and discuss local issues, like the city’s growing population of migrant children, said Susan Stamler, executive director of . Based in New York City, the organization represents dozens of neighborhood settlement houses — community groups that provide services to local families such as language classes, housing assistance, and early-childhood support, including some Head Start programs.

“Today, the real problem is people weren’t given a human contact,” she said of the regional office closure. “They were given a website.”

To Stamler, closing the regional Head Start hub without a clear transition plan “demonstrates a lack of respect for the people who are running these programs and services,” while leaving families uncertain about their child care and other services.

“It’s astonishing to think that the federal government might be reexamining this investment that pays off so deeply with families and in their communities,” she said.

Without regional offices, HHS will be less informed about which health initiatives are needed locally, said Zach Hennessey, chief strategy officer of Public Health Solutions, a nonprofit provider of health services in New York City.

“Where it really matters is within HHS itself,” he said. “Those are the folks that are now blind — but their decisions will ultimately affect us.”

Dara Kass, an emergency physician who was the HHS Region 2 director under the Biden administration, described the job as being an ambassador.

“The office is really about ensuring that the community members and constituents had access to everything that was available to them from HHS,” Kass said.

, division offices for the Administration for Community Living, the FDA’s Office of Inspections and Investigations, and the Substance Abuse and Mental Health Services Administration have already closed or are slated to close, along with several other division offices.

HHS did not provide an on-the-record response to a request for comment but has maintained that shuttering regional offices will not hurt services.

Under the reorganization, many HHS agencies are either being eliminated or folded into other agencies, including the recently created Administration for a Healthy America, under HHS Secretary Robert F. Kennedy Jr.

“We aren’t just reducing bureaucratic sprawl. We are realigning the organization with its core mission and our new priorities in reversing the chronic disease epidemic,” Kennedy said announcing the reorganization.

Regional office staffers were laid off at the beginning of April. Now there appears to be a skeleton crew shutting down the offices. On a recent day, an Administration for Children and Families worker who answered a visitor’s buzz at the entrance estimated that only about 15 people remained. When asked what’s next, the employee shrugged.

The Trump administration’s downsizing effort will also eliminate six of 10 regional outposts of the HHS Office of the General Counsel, a squad of lawyers supporting the Centers for Medicare & Medicaid Services and other agencies in beneficiary coverage disputes and issues related to provider enrollment and participation in federal programs.

Unlike private health insurance companies, Medicare is a federal health program governed by statutes and regulations, said Andrew Tsui, a partner at Arnall Golden Gregory about the regional office closings.

“When you have the largest federal health insurance program on the planet, to the extent there could be ambiguity or appeals or grievances,” Tsui said, “resolving them necessarily requires the expertise of federal lawyers, trained in federal law.”

Overall, the loss of the regional HHS offices is just one more blow to public health efforts at the state and local levels.

State health officials are confronting the “total disorganization of the federal transition” and cuts to key federal partners like the Centers for Disease Control and Prevention, CMS, and the FDA, said James McDonald, the New York state health commissioner.

“What I’m seeing is, right now, it’s not clear who our people ought to contact, what information we’re supposed to get,” he said. “We’re just not seeing the same partnership that we so relied on in the past.”

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He pulled to the side of the road and cried at the sight of residents trying to save their homes.

“I could see people standing on the roof, watering it, trying to protect it from the fire, and they just looked so hopeless,” said Ramirez, a community outreach worker with the Pasadena Public Health Department.

That evening, the 49-year-old volunteered for a 14-hour shift at the city’s evacuation center, as did colleagues who had also been activated for emergency medical duty. Running on adrenaline and little sleep after finding shelter for homeless people all day, Ramirez spent the night circulating among more than a thousand evacuees, offering wellness checks, companionship, and hope to those who looked distressed.

Local health departments, such as Ramirez’s, have become a key part of governments’ response to wildfires, floods, and other extreme weather events, which scientists say are becoming due to climate change. The emotional toll of fleeing and possibly losing a home can help cause or exacerbate mental health conditions such as anxiety, depression, post-traumatic stress disorder, suicidal ideation, and substance use, according to health and climate experts.

Wildfires have become a recurring experience for many Angelenos, making it difficult for people to feel safe in their home or able to go about daily living, said Lisa Wong, director of the Los Angeles County Department of Mental Health. However, with each extreme weather event, the county has improved its support for evacuees, she said.

For instance, Wong said the county deployed a team of mental health workers trained to comfort evacuees without retraumatizing them, including by avoiding asking questions likely to bring up painful memories. The department has also learned to better track people’s health needs and redirect those who may find massive evacuation settings uncomfortable to other shelters or interim housing, Wong said. In those first days, the biggest goal is often to reduce people’s anxiety by providing them with information.

“We’ve learned that right when a crisis happens, people don’t necessarily want to talk about mental health,” said Wong, who staffed the evacuation site Jan. 8 with nine colleagues.

Instead, she and her team deliver a message of support: “This is really bad right now, but you’re not going to do this alone. We have a whole system set up for recovery too. Once you get past the initial shock of what happened — initial housing needs, medication needs, all those things — then there’s this whole pathway to recovery that we set up.”

The convention center in downtown Pasadena, which normally hosts home shows, comic cons, and trade shows, was transformed into an evacuation site with hundreds of cots. It was one of at least 13 shelters opened to serve under evacuation orders.

The January wildfires have burned an estimated 64 square miles — an area larger than the city of Paris — and destroyed at least 12,300 buildings since they started Jan. 7. AccuWeather estimates the region will likely face more than from the blazes, surpassing the estimates from the state’s record-breaking 2020 wildfire season.

Lisa Patel, executive director of the , said she’s most concerned about low-income residents, who are less likely to access mental health support.

“There was a mental health crisis even before the pandemic,” said Patel, who is also a clinical associate professor of pediatrics at Stanford School of Medicine, referring to the covid-19 pandemic. “The pandemic made it worse. Now you lace in all of this climate change and these disasters into a health care system that isn’t set up to care for the people that already have mental health illness.”

Early research suggests exposure to large amounts of wildfire smoke can damage the brain and increase the risk of developing anxiety, she added.

At the Pasadena Convention Center, Elaine Santiago sat on a cot in a hallway as volunteers pulled wagons loaded with soup, sandwiches, bottled water, and other necessities.

Santiago said she drew comfort from being at the Pasadena evacuation center, knowing that she wasn’t alone in the tragedy.

“It sort of gives me a sense of peace at times,” Santiago said. “Maybe that’s weird. We’re all experiencing this together.”

She had been celebrating her 78th birthday with family when she fled her home in the small city of Sierra Madre, east of Pasadena. As she watched flames whip around her neighborhood, she, along with children and grandkids, scrambled to secure their dogs in crates and grabbed important documents before they left.

The widower had leaned on her husband in past emergencies, and now she felt lost.

“I did feel helpless,” Santiago said. “I figured I’m the head of the household; I should know what to do. But I didn’t know.”

Donny McCullough, who sat on a neighboring green cot draped in a Red Cross blanket, had fled his Pasadena home with his family early on the morning of Jan. 8. Without power at home, the 68-year-old stayed up listening for updates on a battery-powered radio. His eyes remained red from smoke irritation hours later.

“I had my wife and two daughters, and I was trying not to show fear, so I quietly, inside, was like, ‘Oh my God,’” said McCullough, a music producer and writer. “I’m driving away, looking at the house, wondering if it’s going to be the last time I’m going to see it.”

He saved his master recording from a seven-year music project, but he left behind his studio with all his other work from a four-decade career in music.

Not all evacuees arrived with family. Some came searching for loved ones. That’s one of the hardest parts of his shift, Ramirez said. The community outreach worker helped walk people around the building, cot by cot.

A week in, at least two dozen people had been killed in the wildfires.

The work takes a toll on disaster relief workers too. Ramirez said many feared losing their homes in the fires and some already had. He attends therapy weekly, which he said helps him manage his emotions.

At the evacuation center, Ramirez described being on autopilot.

“Some of us react differently. I tend to go into fight mode,” Ramirez said. “I react. I run towards the fire. I run towards personal service. Then once that passes, that’s when my trauma catches up with me.”

Need help? Los Angeles County residents in need of support can call the county’s mental health helpline at 1-800-854-7771. The national Suicide & Crisis Lifeline, 988, is also available for those who’d like to speak with someone confidentially, free of charge.

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Beneath the Caesars Palace hotel and casino, Johnson found one of them stretched out on a plywood bed. Jay Flanders, 49, had sores across his back, up his arms, and into his fingers. The homeless man acknowledged occasional meth use and mental health concerns. He couldn’t recall exactly how long he’d lived underground, but it had been several years.

“Why don’t you come inside,” asked Johnson, trying to persuade Flanders to leave the tunnels. “Come get treatment.”

It’s Johnson’s job to coax homeless people out of drainage tunnels that stretch beneath Las Vegas, a perilous grid where people hide from law enforcement and shelter from extreme weather but risk being swept away by floodwaters. Drugs and alcohol are prevalent. Johnson tells clients they have a better shot at recovery above ground, where they can get medical care to treat chronic illnesses, such as diabetes, depression, and heart disease, and start drug and alcohol treatment programs.

Street medicine providers and homeless outreach workers who travel into the tunnels said they have noticed an uptick in the number of people living underground as housing costs have skyrocketed and local officials have adopted a zero-tolerance approach to homelessness. Caseworkers are also confronting a level of drug addiction that’s making it harder to get people, many suffering from mental illness and health conditions, to come aboveground for care.

“It’s meth. It’s fentanyl. It’s opioids. We’re seeing it more and more,” said Rob Banghart, vice president of community integration for the nonprofit homeless outreach organization Shine a Light, who lived in the tunnels for 2½ of the five years he was homeless, often using drugs.

Now sober for more than six years, Banghart recalled the tunnels providing a respite. “In that state of mind, I said to myself, ‘It’s got a roof; it’s out of the sun.’ It’s a little twisted, but it was a community.”

Outreach workers say more people are retreating underground. Though dark and damp, the tunnels provide cover from the harsh desert sun, warmth when temperatures drop, and privacy from society’s judgment above ground.

Constructed and measuring some 600 miles, the tunnels provide flood control for the city and outlying communities. Homeless outreach workers said 1,200 to 1,500 people live in them. Many have constructed elaborate shelters, often out of plywood and scraps of metal or brick below the casinos that define the Strip.

Tunnel living is not limited to Nevada. Across California’s Central Valley and its southern deserts, people unable to afford housing are retreating into , often dug into flood control berms, riverbanks, or along drainage canals, where people can escape the heat and law enforcement. In San Antonio, homeless people have , and in New York, homeless people have long retreated into subterranean existence in tunnels and .

In Las Vegas, some tunnel dwellers said they hide to avoid constant encampment sweeps, which have since the U.S. Supreme Court that local authorities have a right to enforce sleeping or camping bans in public spaces, even when no shelter or housing is available.

Others said they go down to escape the unbearable weather. Triple digits are common in the summer; this year, Las Vegas climbed as high as 120 degrees. And the tunnels provide protection when temperatures drop into the 30s in the winter. It even snows there.

Street medicine providers are also trying to persuade homeless people to leave the tunnels to receive care. In addition to more drug and alcohol use, they have seen new problems with wounds and skin disorders associated with the street drug known as “tranq,” slang for the animal tranquilizer xylazine, which is often mixed with fentanyl or meth.

Tranq causes deep skin infections that, left untreated, can lead to bone infections and require amputation.

Flanders, the homeless man in the tunnels, had several of these skin sores, which he referred to as spider bites — a euphemism for the deep skin wounds caused by tranq. He estimated he has been to the emergency room at least 10 times this year, several times requiring hospitalization.

“One time I was there for six days; I almost lost a finger,” Flanders said, holding up the index finger that had been warped from a deep infection, as he started to tear up. Despite the risks, Flanders said, he still felt safer living in the tunnels than aboveground.

Las Vegas’ population boom has contributed to rising housing costs. The market rent for southern Nevada rose 20% from 2022 to 2023, according to a Clark County — higher than the .

As more people get displaced, more retreat underground. And often, outreach workers say, it’s not just locals who can’t afford the rising cost of living who wind up homeless, but also out-of-towners. Some come to make it in the city’s booming entertainment industry, while others become homeless after losing it all at the casinos.

“People come here on vacation to gamble or try and make it, and they lose everything,” said Johnson, who works for Shine a Light, one of two organizations in Las Vegas that provide substantial outreach, housing referrals, and drug treatment services for homeless people in the tunnels.

“The housing market is insane; rents keep going up. A lot of people wind up down here,” said Johnson, who lived in the tunnels until he got sober with help from Shine a Light. “People just get stuck.”

Still, Nevada’s and rains and monsoons pose a major threat to those living in the tunnels, though it’s unclear exactly how deadly life in them can be.

But Louis Lacey, homeless response director for the nonprofit Help of Southern Nevada, said homeless people living belowground put their lives at risk, often in the monsoon season when the tunnels flood. His organization coordinates with the city of Las Vegas and Clark County to get as many people as possible into shelters before the start of the rainy season, which from June to September.

“We go into the tunnels to make sure people who want to get out are out, but not everyone leaves, often because they don’t want to leave their belongings,” he said. “People die every year.”

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The mountains of western North Carolina have been known to flood: The area is bursting with creeks and rivers and enjoys an abundance of rain. There are occasionally wildfires. But the ravages of the climate crisis’s worst impacts — including increasingly powerful hurricanes — felt like a problem for another place. Asheville sits almost 250 miles from the nearest coastline.

After Hurricane Helene roared across the state, causing historic flooding, downing trees, snapping power lines, decimating water infrastructure, and leading to the deaths of at least 72 people in Buncombe County alone, communities are still shaking off the shock of a storm they never thought could touch these mountains.

“People relocate to Asheville not just because it’s beautiful, but because it isn’t prone to natural disasters,” said Katie Gebely, an artist in Asheville. “But that sense of safety is gone.”

I live in Beech, a historic community in Weaverville, North Carolina, at the eastern end of a two-lane road called Reems Creek, which is named after the waterway running parallel to it. The town of Weaverville, just north of Asheville, is five miles down the road.

Helene’s destruction created a major problem for people dependent on insulin, power wheelchairs, oxygen CPAP machines for sleep apnea, or home dialysis equipment. Without electricity, their health is at risk.

To get to Weaverville from Beech in the days immediately after the storm, cars had to thump over dozens of downed power lines. Other lines were propped up with large, downed tree limbs or tied up with rope so cars could get under them. Utility poles were snapped in two. A transformer lay on the side of the road, as did a rather large boat, washed up from who knows where. Just last week, power crews arrived on Reems Creek Road, but there’s still no word on when everyone will regain electricity.

Jackie Martin of Canton, North Carolina, relies on supplemental oxygen for chronic obstructive pulmonary disease and emphysema. When the storm hit, she had four hours’ worth left. Because of her condition, Martin and her husband, David, have an electrical generator, which David checks every month to make sure it works.

“We keep enough gas to run about eight hours,” Jackie Martin said. But the Martins were without power for nearly a week. When they ran out of gasoline, their neighbors gave them the gas from their lawn mower. Then another neighbor evacuated and offered his propane generator. The Martins’ daughter came through with four tanks of propane.

“We went through tons of gas and propane,” Jackie Martin said. “Never did I think I would need every drop and then some. Thank goodness we got power back after a week.”

In Buncombe County, population 275,000, there were still more than 50,000 customers without electricity almost two weeks after the storm. Duke Energy reported that outages were in the Asheville area as of Wednesday.

In most places, the debris that littered the road has been cleared. Cars, trucks, and military vehicles can make their way through. But huge piles of trash still line the roadways. Buncombe County is asking residents not to burn it out of concern for air quality.

In a scene out of biblical end-times, yellow jackets swarmed in the days after the storm — displaced after falling trees and floodwaters destroyed their nests. Three or four days after the storm hit, an EMT drove through my neighborhood looking for Benadryl. My husband handed over what we had: a half-full bottle.

Overhead, helicopters fly day and night. The Federal Emergency Management Agency arrived in my neighborhood two Sundays ago to deliver bottled water and food rations. Potable water in some areas of western North Carolina, including Asheville, may take weeks or months to restore.

Weaverville’s residents were under a boil-water advisory until Oct. 11.

“We had sewer and water line breaks,” said Patrick Fitzsimmons, Weaverville’s mayor. “We had a lot of infrastructure destruction.”

Households with wells have fared no better. Well pumps don’t work without electricity. And storm-damaged or flooded wells may be compromised. Officials are urging residents to disinfect their wells before consuming water. The federal Environmental Protection Agency has given residents kits to test their well water.

A physical therapist at Asheville Specialty Hospital, who asked not to be identified out of concern for losing their job, told me that in the first days after the storm, crews hauled trash cans full of water into the facility so that staff could flush toilets with buckets.

“The water got shut off and we managed. We took care of people the best we could,” the therapist said. “But the amount of water that it takes to run a hospital is unsustainable for the length of time they think we’ll be out of water.”

The hospital is a 34-bed long-term acute care facility down the street from Asheville’s Mission Hospital. Nancy Lindell, a spokesperson for Mission Health, which operates both hospitals, said in a statement that fewer than 100 “low acuity patients in stable condition” at the organization’s facilities were transferred “to hospitals outside of the areas hardest hit by this disaster.”

“This decision, which was made in collaboration with more than 50 physicians and nursing leaders, helps ensure we have the capacity to meet the most critical needs of our region,” she said. “It also provides relief for our caregivers, who have been working around the clock in the wake of the storm.”

U.S. Rep. Chuck Edwards, who represents North Carolina’s 11th District, said FEMA has shipped 6 million liters of water and 4 million individual meals to western North Carolina. FEMA has promised 120 truckloads a day of food and water with no specified end date, .

The Biden administration has also for uninsured North Carolinians to replace lost prescriptions and medical equipment.

Fitzsimmons, Weaverville’s mayor, said he’s concerned about the impact of the storm on mental health. “People are going for an extended period of time without power or water,” he said. “Their nerves are frayed.”

Richard Zenn, chief medical officer at North Carolina-based Vaya Health, said the recovery will be long.

“We’re now in the phase where we have to deal with the effects of this ongoing trauma we’ve all suffered,” Zenn said. “Connect with others. Don’t get too isolated. Eat. Sleep. Try to get back into a normal routine. Do whatever reduces stress for you.”

For me, that has always been hiking or running through these ancient mountains. But there are too many uprooted trees to safely do that now. Instead I take solace on my porch and give thanks that I still have a porch to sit on. It’s a near-perfect day in Appalachia. The sky is painfully blue. I listen for the songs of birds, but all I can hear are generators.

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Farms in Colorado had of chickens in recent months to stem the transmission of bird flu. Organizers filled out the spread with hot dogs.

No matter the menu, some dairy workers at the event said they don’t exactly feel appreciated. They said they haven’t received any personal protective equipment beyond gloves to guard against the virus, even as they or colleagues have come down with conjunctivitis and flu-like symptoms that they fear to be bird flu.

“They should give us something more,” one dairy worker from Larimer County said in Spanish. He spoke on the condition of anonymity out of fear he’d lose his job for speaking out. “What if something happens to us? They act as if nothing is wrong.”

Agricultural health and safety experts have been trying to get the word out about how to protect against bird flu, including through on TikTok showing the proper way to gear up with respirators, eye protection, gloves, and coveralls. And Colorado’s health and agriculture departments have of protective equipment to any producer who requests it.

But so far, many farms aren’t taking them up on it: According to numbers provided by the state health department in late August, fewer than 13% of the had requested and received such PPE.

The virus is known to infect mammals — from skunks, bears, and cows to people and . It began showing up in dairy cattle in recent months, and Colorado has been in the thick of it. Ten of the 13 confirmed human cases in the U.S. this year have occurred in Colorado, where it among dairy cows. It isn’t a risk in cooked meat or pasteurized milk but is risky for those who come into contact with infected animals or raw milk.

Weld County, where the farmworker event was held, is one of the nation’s , supplying enough milk each month this year to fill about 45 Olympic-size swimming pools, according to . Neighboring counties are notable producers, too.

Concerns are growing about undiagnosed illness among farmworkers because of a lack of testing and safety precautions. One reason for concern: Bird flu and seasonal flu are capable of , so if they ended up in the same body at the same time, bird flu might end up with genes that boost its contagiousness. The virus doesn’t appear to be spreading easily between people yet. That could change, and if people aren’t being tested then health officials may be slow to notice.

Strains of seasonal flu already in the U.S. a year. Public health officials fear the havoc a new form of the flu could wreak if it spreads among people.

The Centers for Disease Control and Prevention recommends that dairy workers don a respirator and goggles or a face shield, , whether they are working with sick animals or not.

A found that not all infected cows show symptoms, so workers could be interacting with contagious animals without realizing it. Even when it is known that animals are infected, farmworkers often still have to get in close contact with them, sometimes under grueling conditions, such as during a recent heat wave when Colorado poultry workers collected hundreds of chickens by hand for culling because of the outbreak. At least six of the workers became infected with bird flu.

One dairy worker in Weld County, who spoke on the condition of anonymity for fear of losing his job, said his employer has not offered any protective equipment beyond gloves, even though he works with sick cows and raw milk.

His bosses asked the workers to separate sick cows from the others after some cows produced less milk, lost weight, and showed signs of weakness, he said. But the employer didn’t say anything about the bird flu, he said, or suggest they take any precautions for their own safety.

He said he bought protective goggles for himself at Walmart when his eyes became itchy and red earlier this summer. He recalled experiencing dizziness, headaches, and low appetite around the same time. But he self-medicated and pushed through, without missing work or going to a doctor.

“We need to protect ourselves because you never know,” he said in Spanish. “I tell my wife and son that the cows are sick, and she tells me to leave, but it will be the same wherever I go.”

He said he’d heard that his employers were unsympathetic when a colleague approached them about feeling ill. He’d even seen someone affiliated with management remove a flyer about how people can protect themselves from the bird flu and throw it in a bin.

The dairy worker in neighboring Larimer County said he, too, has had just gloves as protection, even when he has worked with sick animals — close enough for saliva to wipe off on him. He started working with them when a colleague missed work because of his flu-like symptoms: fever, headache, and red eyes.

“I only wear latex gloves,” he said. “And I see that those who work with the cows that are sick also only wear gloves.”

He said he doesn’t have time to wash his hands at work but puts on hand sanitizer before going home and takes a shower once he arrives. He has not had symptoms of infection.

Such accounts from dairy workers echo those from farmworkers in Texas, as reported by Â鶹ŮÓÅ Health News in July.

“Employers who are being proactive and providing PPE seem to be in the minority in most states,” said with the National Center for Farmworker Health, a not-for-profit organization based in Texas that advocates for improving the health of farmworkers and their families. “Farmworkers are getting very little information.”

But , CEO of the Colorado Livestock Association, said he thinks such scenarios are the exception, not the rule.

“You would be hard-pressed to find a dairy operation that isn’t providing that PPE,” he said. Riley said dairies typically have a stockpile of PPE ready to go for situations like this and that, if they don’t, it’s easily accessed through the state. “All you have to do is ask.”

Producers are highly motivated to keep infections down, he said, because “milk is their life source.” He said he has heard from some producers that “their family members who work on the farm are doing 18-to 20-hour days just to try to stay ahead of it, so that they’re the first line between everything, to protect their employees.”

Colorado’s health department is that ill dairy workers can call for help getting a flu test and medicine.

, an organization that emerged early in the covid-19 pandemic to promote farmworker health across Colorado, is distributing PPE it received from the state so promotoras — health workers who are part of the community they serve — can distribute masks and other protections directly to workers if employers aren’t giving them out.

Promotora Tomasa Rodriguez said workers “see it as another virus, another covid, but it is because they don’t have enough information.”

She has been passing out flyers about symptoms and protective measures, but she can’t access many dairies. “And in some instances,” she said, “a lot of these workers don’t know how to read, so the flyers are not reaching them, and then the employers are not doing any kind of talks or trainings.”

The CDC’s said during an Aug. 13 call with journalists that awareness about bird flu among dairy workers isn’t as high as officials would like it to be, despite months of campaigns on social media and the radio.

“There’s a road ahead of us that we still need to go down to get awareness on par with, say, what it might be in the poultry world,” he said. “We’re using every single messenger that we can.”

Â鶹ŮÓÅ Health News correspondents Vanessa G. Sánchez and Amy Maxmen contributed to this report.

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An art deco sign still marks the main entrance, but the front doors are locked, and the parking lot is empty. These days, a convenience store across North Edwards Avenue is far busier than the old Taborian Hospital, which first shut down more than 40 years ago.

Myrna Smith-Thompson, who serves as executive director of the civic group that owns the property, lives 100 miles away in Memphis, Tennessee, and doesn’t know what’s to become of the deteriorating building.

“I am open to suggestions,” said Smith-Thompson, whose grandfather led a Black fraternal organization now called the Knights and Daughters of Tabor. In 1942, that group established Taborian Hospital, a place staffed by Black doctors and nurses that exclusively admitted Black patients, during a time when Jim Crow laws barred them from accessing the same health care facilities as white patients.

“This is a very painful conversation,” said Smith-Thompson, who was born at Taborian Hospital in 1949. “It’s a part of my being.”

A similar scenario has played out in hundreds of other rural communities across the United States, where over the past 40 years. In that regard, the story of Mound Bayou’s hospital isn’t unique.

But there’s more to this hospital closure than the loss of inpatient beds, historians say. It’s also a tale of how hundreds of Black hospitals across the U.S. fell casualty to social progress.

The Civil Rights Act of 1964 and the enactment of Medicare and Medicaid in 1965 benefited millions of people. The federal campaign to desegregate hospitals, culminating in a out of Charleston, South Carolina, guaranteed Black patients across the South access to the same health care facilities as white patients. No longer were Black doctors and nurses prohibited from training or practicing medicine in white hospitals. But the end of legal racial segregation precipitated the demise of many Black hospitals, which were a major source of employment and a center of pride for Black Americans.

“And not just for physicians,” said Vanessa Northington Gamble, a medical doctor and historian at George Washington University. “They were social institutions, financial institutions, and also medical institutions.”

In Charleston, staff members at a historically Black hospital on Cannon Street started publishing a monthly journal in 1899 called The Hospital Herald, which focused on hospital work and public hygiene, among other topics. When Kansas City, Missouri, opened a hospital for Black patients in 1918, people held a parade. Taborian Hospital in Mound Bayou included two operating rooms and state-of-the-art equipment. It’s also where famed civil rights activist Fannie Lou Hamer died in 1977.

“There were Swedish hospitals. There were Jewish hospitals. There were Catholic hospitals. That’s also part of the story,” said Gamble, author of “Making a Place for Ourselves: The Black Hospital Movement, 1920-1945.”

“But racism in medicine was the main reason why there was an establishment of Black hospitals,” she said.

By the early 1990s, Gamble estimated, there were only eight left.

“It has ripple effects in a way that affect the fabric of the community,” said Bizu Gelaye, an epidemiologist and program director of Harvard University’s Mississippi Delta Partnership in Public Health.

Researchers have largely concluded that hospital desegregation improved the health of Black patients over the long term.

One 2009 study focusing on motor vehicle accidents in Mississippi in the ’60s and ’70s found that Black people were less likely to die after hospital desegregation. They could access hospitals closer to the scene of a crash, reducing the distance they would have otherwise traveled by approximately 50 miles.

An , published in 2006 by economists at the Massachusetts Institute of Technology, found that hospital desegregation in the South substantially helped close the mortality gap between Black and white infants. That’s partly because Black infants suffering from illnesses such as diarrhea and pneumonia got better access to hospitals, the researchers found.

A new analysis, recently accepted for publication in the Review of Economics and Statistics, suggests that racism continued to harm the health of Black patients in the years after hospital integration. White hospitals were compelled to integrate starting in the mid-1960s if they wanted to receive Medicare funding. But they didn’t necessarily provide the same quality of care to Black and white patients, said Mark Anderson, an economics professor at Montana State University and co-author of the paper. His that hospital desegregation had “little, if any, effect on Black postneonatal mortality” in the South between 1959 and 1973.

Nearly 3,000 babies were born at Taborian Hospital before it closed its doors in 1983. The building remained vacant for decades until 10 years ago, when a $3 million federal grant helped renovate the facility into a short-lived urgent care center. It closed again only one year later amid a legal battle over its ownership, Smith-Thompson said, and has since deteriorated.

“We would need at least millions, probably,” she said, estimating the cost of reopening the building. “Now, we’re back where we were prior to the renovation.”

In 2000, the hospital was listed as one of the most endangered historic places in Mississippi by the Mississippi Heritage Trust. That’s why some people would like to see it reopened in any capacity that ensures its survival as an important historical site.

Hermon Johnson Jr., director of the Mound Bayou Museum, who was born at Taborian Hospital in 1956, suggested the building could be used as a meeting space or museum. “It would be a huge boost to the community,” he said.

Meanwhile, most of the hospital’s former patients have died or left Mound Bayou. The city’s population has dropped by roughly half since 1980, U.S. Census Bureau records show. Bolivar County ranks among the poorest in the nation and life expectancy is a decade shorter than the national average.

A community health center is still open in Mound Bayou, but the closest hospital is in Cleveland, Mississippi, a 15-minute drive.

Mound Bayou Mayor Leighton Aldridge, also a board member of the Knights and Daughters of Tabor, said he wants Taborian Hospital to remain a health care facility, suggesting it might be considered for a new children’s hospital or a rehabilitation center.

“We need to get something back in there as soon as possible,” he said.

Smith-Thompson agreed and feels the situation is urgent. “The health care services that are available to folks in the Mississippi Delta are deplorable,” she said. “People are really, really sick.”

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WALL, S.D. — Stacey Schulz parks in a rear lot to avoid the crowded Main Street entrances to her local pharmacy.

“During the summer, it’s kind of hectic,” she said after greeting the pharmacist and technician by name.

That’s because Schulz’s pharmacy is tucked inside Wall Drug, a tourist attraction that takes up almost an entire block and draws more than 2 million visitors a year to a community of fewer than 700 residents.

The business is named after the town of Wall, which is just off Interstate 90 near Badlands National Park. Colorful, hand-painted billboards dot the roadside for hundreds of miles, telling motorists how far they are from Wall Drug’s free ice water, 5-cent coffee, and homemade doughnuts. Visitors can pan for gold, listen to singing animatronic cowboys, try on Western wear, and shop for souvenirs, including plush jackalopes — mythical jackrabbits with antelope horns.

Despite being part of a booming tourist attraction, Wall Drug’s pharmacy faces challenges common to independent rural pharmacies.

It’s the lone pharmacy in Wall, serving locals year-round. Some, like Schulz, live in town, while others live on ranches as far as 60 miles away. The next-nearest pharmacy is a 30-minute drive northeast.

Wall Drug also serves tourists who forget their prescriptions at home, get sick while roaming the country in their RVs, or hurt themselves while hiking through the otherworldly rock formations of the scorching Badlands, said Cindy Dinger, its sole pharmacist.

Wall has no hospital, but a clinic is open four days a week. Schulz, a medical assistant there, said she and her co-workers see a lot of summer tourists. They send them to Wall Drug to pick up prescriptions.

“And then we tell them to get fudge before they leave,” Schulz said.

Rural pharmacies, especially independent ones, closed at a higher rate from 2003 to 2021 than pharmacies in other areas, according to a By 2021, the institute found, nearly 8% of rural counties were . The Wall Drug pharmacy has fewer customers than a typical city pharmacy, which can mean less profit, Dinger said.

She said some of its prices are higher because the store can’t negotiate discounts as steep as the deals suppliers grant chain pharmacies. Rural drugstores also lack leverage with insurers, and they face increasing competition from mail-order pharmacies.

Another challenge is staffing. When Dinger needs time off, she finds a fill-in from Rapid City, nearly an hour’s drive away.

“It’s a challenge getting relief if I want to go on vacation or if I need a cover so that I can go to a doctor’s appointment,” she said. “You take what you can get and try to schedule around it.”

Dinger said her pharmacy would struggle without the rest of Wall Drug.

“All this stuff around us — the poster and print shop, the boot shop, the fudge shop, the café — they pay our bills,” she said.

The pharmacy’s white facade, with stained-glass signs and windows, is modeled after that of the original drugstore, which was across the street. The window displays and top shelves inside the store are filled with vintage pharmacy supplies, including manuals, glass medicine bottles, and a suppository-making machine.

Tourists carrying shopping bags and sporting new cowboy hats stop to look at the displays. “It’s a real pharmacy,” a woman said, sounding surprised.

Dinger and Sylvia Smith, the store’s only pharmacy tech, ring customers up below a Tiffany-style light fixture and retrieve prescriptions stored behind a wooden desk and wall.

Customer Will Lovitt said a friend advised him and his wife to stop at Wall Drug during their drive from Indiana to the Black Hills in western South Dakota. Lovitt developed a rash on the trip and ended up using the visit to get Dinger’s advice on treating it.

He said it can be difficult for tourists to know where to find medical help, especially when driving through rural states like South Dakota.

“I think it’s time that America gets back to the grass roots of the small-town doctor and the small-town pharmacist,” Lovitt said.

Alex Davis and a friend decided to visit Wall Drug on their road trip from Kansas to Yellowstone National Park.

“Then, when I saw there was a little pharmacy, I thought I’d grab something that I needed,” she said.

Davis bought Dramamine to treat car sickness on the long drive.

Dinger said she occasionally sees unusual situations, like the time several years ago when a park ranger needed antibiotics after getting bitten by a prairie dog.

“You never know what kind of diseases they might be carrying,” she said of the animals, which recently were hit with

Rick Hustead is the chairman of Wall Drug. The store was opened in 1931 by his grandfather, pharmacist Ted Hustead. Ted’s wife, Dorothy, had the idea to advertise its soda fountain and free ice water to tourists traveling along unpaved roads during the hot years of the Dust Bowl era. Rick’s father, pharmacist Bill Hustead, began expanding the store in the ’50s, turning it into the tourist magnet it is today.

Rick Hustead didn’t follow his father and grandfather’s path to pharmacy school, so he had to recruit pharmacists from elsewhere.

Hustead found Dinger in 2010 after writing a letter to each pharmacist in the state.

Dinger said she was living at the time in Sioux Falls, South Dakota’s most populous city. But she and her husband were interested in raising their kids in a small town, the way she grew up. Dinger was also attracted by the store’s limited hours: She’d be done working by 5 p.m. on weekdays and have the weekends off.

Hustead said his family has never considered closing the pharmacy, even though it’s not the main attraction for most visitors.

“We can’t be Wall Drug without being a drugstore,” he said.

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