The government’s current, decades-old guidance says that any exposure to harmful radiation is a cancer risk. And critics say the proposed change could lead to higher levels of exposure for workers at nuclear installations and oil and gas drilling sites, medical workers doing X-rays and CT scans, people living next to Superfund sites and any members of the public who one day might find themselves exposed to a radiation release.

The Trump administration already has targeted a range of other regulations on toxins and pollutants, including coal power plant emissions and car exhaust, that it sees as costly and burdensome for businesses. Supporters of the EPA’s proposal argue the government’s current model that there is no safe level of radiation — the so-called linear no-threshold model — forces unnecessary spending for handling exposure in accidents, at nuclear plants, in medical centers and at other sites.

At issue is Environmental Protection Agency’s proposed rule on transparency in science.

EPA spokesman John Konkus said Tuesday: “The proposed regulation doesn’t talk about radiation or any particular chemicals. And as we indicated in our response, EPA’s policy is to continue to use the linear-no-threshold model for population-level radiation protection purposes which would not, under the proposed regulation that has not been finalized, trigger any change in that policy.”

But in an April news release announcing the proposed rule the agency quoted Edward Calabrese, a toxicologist at the University of Massachusetts who has said weakening limits on radiation exposure would save billions of dollars and have a positive impact on human health.

The proposed rule would require regulators to consider “various threshold models across the exposure range” when it comes to dangerous substances. While it doesn’t specify radiation, the release quotes Calabrese calling the proposal “a major scientific step forward” in assessing the risk of “chemicals and radiation.”

Konkus said the release was written during the tenure of former EPA Administrator Scott Pruitt. He could not explain why Calabrese was quoted citing the impact on radiation levels if the agency does not believe there would be any.

Calabrese was to be the lead witness at a congressional hearing Wednesday on the EPA proposal.

Radiation is everywhere, from potassium in bananas to the microwaves popping our popcorn. Most of it is benign. But what’s of concern is the higher-energy, shorter-wave radiation, like X-rays, that can penetrate and disrupt living cells, sometimes causing cancer.

As recently as this March, the EPA’s online guidelines for radiation effects advised: “Current science suggests there is some cancer risk from any exposure to radiation.”

“Even exposures below 100 millisieverts” — an amount roughly equivalent to 25 chest X-rays or about 14 CT chest scans — “slightly increase the risk of getting cancer in the future,” the agency’s guidance said.

But that online guidance — separate from the rule-change proposal — was edited in July to add a section emphasizing the low individual odds of cancer: “According to radiation safety experts, radiation exposures of … 100 millisieverts usually result in no harmful health effects, because radiation below these levels is a minor contributor to our overall cancer risk,” the revised policy says.

Calabrese and his supporters argue that smaller exposures of cell-damaging radiation and other carcinogens can serve as stressors that activate the body’s repair mechanisms and can make people healthier. They compare it to physical exercise or sunlight.

Mainstream scientific consensus on radiation is based on deceptive science, says Calabrese, who argued in a 2014 essay for “righting the past deceptions and correcting the ongoing errors in environmental regulation.”

EPA spokesman Konkus said in an email that the proposed rule change is about “increasing transparency on assumptions” about how the body responds to different doses of dangerous substances and that the agency “acknowledges uncertainty regarding health effects at low doses” and supports more research on that.

The radiation regulation is supported by Steven Milloy, a Trump transition team member for the EPA who is known for challenging widely accepted ideas about manmade climate change and the health risks of tobacco. He has been promoting Calabrese’s theory of healthy radiation on his blog.

But Jan Beyea, a physicist whose work includes research with the National Academies of Science on the 2011 Fukushima nuclear power plant accident, said the EPA science proposal represents voices “generally dismissed by the great bulk of scientists.”

The EPA proposal would lead to “increases in chemical and radiation exposures in the workplace, home and outdoor environment, including the vicinity of Superfund sites,” Beyea wrote.

At the level the EPA website talks about, any one person’s risk of cancer from radiation exposure is perhaps 1 percent, Beyea said.

“The individual risk will likely be low, but not the cumulative social risk,” Beyea said.

“If they even look at that — no, no, no,” said Terrie Barrie, a resident of Craig, Colorado, and an advocate for her husband and other workers at the now-closed Rocky Flats nuclear-weapons plant, where the U.S. government is compensating certain cancer victims regardless of their history of exposure.

“There’s no reason not to protect people as much as possible,” said Barrie.

U.S. agencies for decades have followed a policy that there is no threshold of radiation exposure that is risk-free.

The National Council on Radiation Protection and Measurements reaffirmed that principle this year after a review of 29 public health studies on cancer rates among people exposed to low-dose radiation, via the U.S. atomic bombing of Japan in World War II, leak-prone Soviet nuclear installations, medical treatments and other sources.

Twenty of the 29 studies directly support the principle that even low-dose exposures cause a significant increase in cancer rates, said Roy Shore, chief of research at the Radiation Effects Research Foundation, a joint project of the United States and Japan. Scientists found most of the other studies were inconclusive and decided one was flawed.

None supported the theory there is some safe threshold for radiation, said Shore, who chaired the review.

If there were a threshold that it’s safe to go below, “those who profess that would have to come up with some data,” Shore said in an interview.

“Certainly the evidence did not point that way,” he said.

The U.S. Food and Drug Administration, which regulates electronic devices that emit radiation, advises, broadly, that a single CT scan with a dose of 10 millisieverts may increase risks of a fatal cancer by about 1 chance in 2,000.

Supporters of the proposal say it’s time to rethink radiation regulation.

“Right now we spend an enormous effort trying to minimize low doses” at nuclear power plants, for example, said Brant Ulsh, a physicist with the California-based consulting firm M.H. Chew and Associates. “Instead, let’s spend the resources on minimizing the effect of a really big event.”

The San Francisco institution was founded during the height of the AIDS crisis, a time when sick men were left to die alone in the hallways of county hospitals because staff were afraid to touch them. Buddhist practitioners bought the Victorian on Page Street to create a place where men could get compassionate care and die with dignity.

Now, after 30 years of caring for people with all kinds of illnesses, the house is closing its doors. The organization no longer has enough money to keep the program going.

“It’s a little chaotic in here,” says George Kellar, the executive director of the last two and a half years, as we walk through the foyer of the house. “It’s in total transition.”

All the furniture is gone. The floors are covered with canvas tarps. Blue tape lines the perimeter of the living room. Men in jumpsuits and face masks are painting the fireplace, tearing up the carpet on the stairway and power washing the windows.

When the hospice issued its press release last week about this turn in the nonprofit’s fortunes, I noted the careful wording — that the guest house was “suspending” caregiving services, that they hoped they could “offer them again, at some point.” The implication was clear: Maybe a local tech billionaire could step in with a Hail Mary donation.

But this is a house that’s being primed for a realtor to stage it and put it up for sale.

“Five bedrooms, three bathrooms. It has a boarding house feel to it,” Kellar says as he gives me a tour of the upstairs. “It probably has that kind of history.”

Before the beds were cleared out, before all the nurses were laid off, the guest house had room for six residents. They called them “residents” not “patients.” This was their home, not a hospice. And they came here not to die, but to live fully until the end of their lives.

A corps of volunteers would sit with patients, sometimes for hours — just holding their hand, telling stories, singing songs. Kitchen staff prepared three meals a day to order for each resident, even when they could no longer eat.

“They can smell it, they can see it, if they want to taste that they can,” Kellar says, adding that it’s about letting the residents know “they’re not discarded and ignored and not important.”

The organization became a pioneer in what it means to die well. It helped shape a national movement away from sterile hospital deaths — hooked up to machines — to a mindful, aesthetic end that emphasized being present with what was happening.

Donors loved the mission and they were generous. Until the 2016 election.

“We’ve been struggling through 2017,” Kellar says.

This year, they’re more than $1 million short on their $2 million annual budget. Donors have been telling Kellar they have to cut back on their gifts to the hospice because they need to support issues that have come under attack during the Trump administration.

“Voting rights, or women in politics, or immigration help,” Kellar lists the other causes drawing donations instead of his organization. “And homeless, there’s a lot of interest in helping the homeless situation.”

Nationally, philanthropy experts are waiting to see if this is a broader trend. The economy is strong right now and charitable giving has increased since the 2016 election, says Stacy Palmer, editor of the Chronicle of Philanthropy. But it’s unclear if people are giving more overall or shifting their dollars to issues that are in the news a lot.

“People really have to make choices about which charities they care about the most,” Palmer says, and in a time of shifting priorities, it can be harder to get people to open their wallets when it comes to end-of-life issues.

“People don’t really like to hear about death, even though what hospices do is really make death so much easier. It’s a tough conversation,” she says. “Sometimes really important causes are the ones that suffer just because they are dealing with difficult subjects.”

But some of the blame sits with the Zen Hospice Project itself. It relied too much on loyal donors, and didn’t cultivate enough new ones, Kellar says. And, for all these years, the hospice has declined to get licensed under the government’s Medicare and Medicaid programs, closing the door on a steady stream of reimbursement payments.

“We don’t want to compromise our commitment to this compassionate model,” Kellar explains. “And if that commitment is compromised by the reporting requirements or by the regulatory requirements, we don’t want to go there.”

But idealism doesn’t pay the bills. And that’s one of the reasons Kellar was brought in four years ago: to bring some business savvy to the nonprofit. He’s a Zen Buddhist, and he’s also a Silicon Valley guy — a software engineer with a background in sales and operations.

At first, he became right-hand man to the executive director at the time, BJ Miller, a doctor and a charismatic visionary who put the Zen Hospice Project in the national conscience through a high-profile New York Times interview and a TED talk that’s been viewed more than 7.5 million times. In it, Miller talks about the importance of “sensuous, aesthetic gratification” at the end of life and how the Zen Hospice Project wants to help people enjoy the last of their time by way of the five senses.

“Seriously, with all the heavy-duty stuff happening under our roof, one of the most tried and true interventions we know of is to bake cookies,” he said, the smell providing sustenance on so many levels. “As long as we have our senses — even just one — we have at least the possibility of accessing what makes us feel human, connected.”

Kellar, on the other hand, talks about marketing and distribution and “scaling” operations.

“I am using businesslike terms to talk about it, but I think you have to,” he says.

When he took over the executive director position, the budget troubles were officially his responsibility.

One strategy he pursued was negotiating a partnership with some private insurance companies to have them reimburse for some of the hospice’s services. It’s an appealing value proposition for insurers: It costs $850 a day to care for each patient at the hospice, compared to the thousands and thousands of dollars in daily costs for someone to die in an ICU.

But after 18 months, there was still no agreement.

“We could no longer wait,” Kellar says.

Kellar presented the numbers to the board of directors, and they agreed they could no longer afford to keep the guest house going.

“As difficult and sad as it is, which it is, we’re letting it go,” Kellar says. “And that will create another space for something else to present itself. And maybe that something else is this massive opportunity.”

That could be an opportunity presented by the 43 million informal caregivers in the U.S. — people taking care of their own ailing parents, spouses, or children — who need help. Kellar says if Zen Hospice Project sells the guest house, the organization can reinvest that money into its other programs: the volunteer program, which sends people to sit with the dying in the hospice floor of Laguna Honda Hospital, and theMindful Caregiver Education program, which emphasizes caregivers taking care of themselves so they can take better care of others.

“Our mission is to transform the experience of dying and caregiving,” Kellar says. “And while we started at the bedside and continue at the bedside at Laguna Honda, it is now a time to focus on helping other people at the bedside by training and education.”

But selling this iconic San Francisco institution to as a private residence for 5 or 6 million dollars?

“It’s not what I expected,” Kellar says, shifting from business guy to Zen guy. “I guess it’s a lesson in impermanence. And a lesson in ‘things change’ and to not get as attached as we are because everybody here is very attached to this.”

Marshall unloaded a few items from a shoulder bag onto a two-top table in front of her, including a nasal sprayer of the drug Narcan – the brand name for naloxone, a drug that reverses opioid overdoses.

Typically, Marshall educates an audience of people who use drugs. But as the opioid crisis continues to devastate communities, Marshall and her colleagues from the Harm Reduction Coalition are getting more creative in their approach to saving lives. At this training, Marshall’s assembled a group of bartenders and club and festival employees.

Immediately, Marshall fielded a question about a famous scene from the movie “Pulp Fiction,” in which actress Uma Thurman’s character overdoses on drugs and is dramatically revived. Instead of naloxone, her rescuers stab her directly in the heart with a large needle full of adrenaline.

“Two things,” Marshall said to the group. “Adrenaline doesn’t work to reverse an opioid overdose, and please don’t stab anybody in the heart with anything.”

The audience laughed as Marshall raised her hand in a fist and yelled, “Quentin Tarantino!” in a feigned rage.

Marshall then moved into more serious territory, speaking from her years of experience working at a needle exchange and sometimes administering naloxone to reverse an overdose.

She described telltale signs of what it looks like when someone is overdosing on opioids, such as heroin or fentanyl.

“Unable to maintain consciousness,” Marshall said. “Or they’re gonna be real hard to wake up, especially if alcohol is involved. And they’re not going to be breathing enough.”

A person’s body will droop, their skin will become ashen or bluish gray, she said.

Marshall instructed her pupils to call 911 as soon as they suspect an opioid overdose, and to use pain to try to wake an overdosing individual, like a knuckle rub to the sternum.

“If they go right back out or they just are not responsive, the next thing is the Narcan,” she instructed while picking up her Narcan nasal sprayer.

“Then you’re going to take this all the way up their nose,” Marshall said, pointing to a white plastic tip at the top of the tool. “One click. That’s it.”

Each attendee left with a box of Narcan to take to their next work shift.

This training was Marshall’s tenth for the nightlife industry, including one for the entire staff of HUSH Concerts, a music production company in San Francisco. The initiative is funded by San Francisco’s Department of Public Health.

At the HUSH offices on Treasure Island, creative director Robbie Kowal pointed to a photo on the wall of a good friend and DJ he worked with a lot.

“You can just see how effervescent a person he was,” Kowal said.

Kowal’s friend died three years ago, and his colleagues still don’t know the cause.

After Kowal took a Narcan training, however, he began to suspect his friend died from an opioid overdose.

The signs were really all there, Kowal said. “Had people on that site had that kind of training, they might have been able to intervene.”

At many events, Kowal’s employees are often the only sober people present, working the after-hours shift from midnight to six or seven in the morning. Lots of patrons experiment with new substances, sometimes not knowing what’s in them.

That’s why Kowal had Kristen Marshall train his company. He hopes that someday, if needed, they can save a life.

HUSH Concerts has always sent emergency bags to each event they staff. Inside, there are adapters, plugs, anything a DJ may forget. Now, the first aid kit they carry includes two doses of Narcan.

“We, who are of the after-hours community, who live this beautiful life that’s very undersung, can actually make a difference for people,” Kowal said.

Beau Gertz, who owns Denver-based lab-testing and nutraceutical companies, will buy 26-bed Surprise Valley Community Hospital in Cedarville, Calif., taking over its debt of at least $4 million. Another out-of-town investor had managed it for a few months then “abandoned” it, according to bankruptcy documents. Gertz’s offer, already accepted by the district hospital’s board and approved by a federal bankruptcy judge, required the approval of local residents in Tuesday’s election.

Nearly 84 percent of those who voted backed the deal, although turnout was light.

The woes of Surprise Valley exemplify the brutal environment faced by America’s rural hospitals, which are disappearing by the dozens due to declining populations, economic troubles, corporate consolidation and, sometimes, self-inflicted wounds.

Some Surprise Valley voters felt they had little choice but to approve the sale: Had they rejected it, the hospital almost certainly would have closed immediately, since no other “white knight” has come forward with a plan to rescue it.

Bonnie Madrigal, a former certified nursing assistant at the hospital, said Gertz convinced her that he could help.

“Now that I have children, keeping the hospital is the most important thing to me,” said Madrigal, 26, of nearby Eagleville. “I know how much improvement the hospital needs … but once I listened to Beau, I heard hope. I feel like with Beau, the debt is going to be off our shoulders, and we’ll work together as a community to make things better.”

Gertz has told residents he wants to create a “wellness center” offering vitamin infusions, genetic testing, personalized medicine and other health services for well-heeled patients. He has promised to keep the hospital’s nursing home wing open and preserve its emergency room and ambulance services.

But some in the community worry that his plans will fail and the local residents will be responsible for even more debt. Gertz said that to help Surprise Valley Community pay for it all, he would bill for lab tests on patients who’ve never set foot in the hospital. He said they will be treated through telemedicine, by doctors who connect with them through video and other technology.

“We felt that to vote yes would be to bail out the [hospital] board and forgive it for all the mistakes it’s made,” said Ray March, 83, of Cedarville, who owns a trade and travel publishing company with his wife, Barbara. “It’s much better in our opinion to shut the hospital down, start clean and listen to some other good advice, which they never did. Now it’s a marriage and they’ve got to figure out how in hell they are going to make it work.”

Some experts contend that, in general, lab billing for faraway patients is legally questionable — and the practice has drawn lawsuits and government scrutiny in other states.

Gertz, who has not faced such suits, did not respond to a request for comment.

In worn blue jeans and an untucked shirt, the bearded entrepreneur from Denver pledged at this town hall meeting in March to revive the Surprise Valley Community Hospital — a place many in the audience counted on to set their broken bones, stitch up cattle-tagging cuts and tend to aging loved ones.

Gertz said that if they vote June 5 to let him buy their tiny public hospital, he will retain vital medical services. Better still, he said, he’d like to open a “wellness center” to attract well-heeled outsiders — one that would offer telehealth, addiction treatment, physical therapy, genetic testing, intravenous vitamin infusions, even massage. Cedarville’s failing hospital, now at least $4 million in debt, would not just bounce back but thrive, he said.

Gertz, 34, a former weightlifter who runs clinical-lab and nutraceutical companies, unveiled his plan to pay for it: He’d use the 26-bed hospital to bill insurers for lab tests regardless of where patients lived. Through telemedicine technology, doctors working for Surprise Valley could order tests for people who’d never set foot there.

To some of the 100 or so people at the meeting that night, Gertz’s plan offered hope. To others, it sounded suspiciously familiar: Just months before, another out-of-towner had proposed a similar deal — only to disappear.

Outsiders “come in and promise the moon,” said Jeanne Goldman, 72, a retired businesswoman. “The [hospital’s] board is just so desperate with all the debt, and they pray this angel’s going to come along and fix it. If this was a shoe store in Surprise Valley, I could care less, but it’s a hospital.”

Looking For Salvation

The woes of Surprise Valley Community Hospital reflect an increasingly brutal environment for America’s rural hospitals, which are disappearing by the dozens amid declining populations, economic troubles, corporate consolidation and, sometimes, self-inflicted wounds.

Nationwide, 83 of 2,375 rural hospitals have closed since 2010, according to the North Carolina Rural Health Research Program. These often-remote hospitals — some with 10, 15, 25 beds — have been targeted by management companies or potential buyers who promise much but often deliver little while lining their own pockets, according to allegations in court cases, a Missouri state audit and media reports.

Enticed by such outsiders, some struggling rural hospitals around the country have embraced lab billing for faraway patients as a rescue plan. That’s because Medicare and commercial insurers tend to pay more for tests to sustain endangered rural hospitals compared with urban hospitals and especially outpatient labs. In general, this kind of remote billing is controversial and legally murky, and it recently has resulted in allegations of fraud in several states, according to government documents and media reports.

Rural hospital boards, however, tend not to have expertise in the health care business. The president of Surprise Valley Community’s board, for instance, is a rancher. Another board member owns a local motel; a third, a construction company. That lack of experience “leaves them vulnerable in many cases,” said Terry Hill of the nonprofit National Rural Health Resource Center, based in Duluth, Minn.

Seeking to distinguish himself from other would-be rescuers who ran into legal trouble, Gertz described his proposal to residents as perfectly legal — a legitimate use of telemedicine, essentially remote treatment via electronic communication such as video. “If you do it correctly,” he said in an interview with Kaiser Health News, “there is a nice profit margin. There [are] extra visits you can get from telemedicine but … it has to be billed correctly and it can’t be abused.”

Gertz runs several companies — founded within the last four years — including two labs, SeroDynamics and Cadira Labs, as well as a wellness company called CadiraMD.

He pledged in court documents to buy the bankrupt hospital for $4 million and cover its debts, saying he had lined up a $4 billion New York company as a financial backer. Kaiser Health News was unable to locate the company under the name Gertz cited, Next Genesis Development Group. He did not respond to emails seeking clarification on the issue.

Gertz, who acknowledged that he had never before run a hospital, was asked at the same gathering whether he had disclosed his “financials” to the hospital board. “As a private entity, I don’t have to show my financials and I have not provided my financials to the board,” he replied.

It was not clear whether board members had ever asked. Surprise Valley Health Care District board President John Erquiaga declined to comment.

A Sad Decline

Surrounded by the Warner and Modoc mountains and forests in California’s northeastern corner, Surprise Valley is home to four small communities. The largest is Cedarville, population 514, at last count.

The valley, covered in sagebrush and greasewood, is part of Modoc County, one of California’s poorest, with a median income of about $30,000. The closest hospital with an emergency room is roughly 25 miles away, over a mountain pass.

One of hundreds of rural hospitals built with help from the 1946 federal Hill-Burton Act, the Surprise Valley hospital opened in 1952 to serve a thriving ranching community. But it has struggled since, closing in 1981, reopening as a health clinic in 1985, then reconverting to a hospital in 1986.

A county grand jury report in 2014-15 found that “mismanagement of the [hospital district] has been evident for at least the past five years.”

By last summer, those in charge didn’t seem up to the task of running a modern hospital. By then, it was hardly a hospital at all. Crushed by debt, it primarily offered nursing home care, an emergency room, a volunteer ambulance service and just one acute care bed, with three others available if needed.

When state inspectors arrived last June, they found chaos. The hospital’s chief nursing officer resigned during the inspection. Staffers reported unpaid checks to vendors hidden in drawers. Inspectors learned that the hospital had sent home temporary nurses because it couldn’t pay them, according to their report.

The hospital’s then-chief administrator, Richard Cornwell — who staffers said had instructed them to hide the checks, according to the report — had taken a leave of absence and was nowhere to be found. Cornwell, a health care accountant from Montana, was later fired and replaced with the hospital’s lab director, who in turn resigned, according to public records. Reached by Kaiser Health News, Cornwell declined to comment.

Federal regulators suspended Medicare and Medicaid payments to the hospital — a rarely invoked financial penalty — over concerns about patient care. Those payments have since been reinstated, but a follow-up state inspection in November 2017 identified more patient care concerns.

Infighting ensued, with some residents fiercely committed to keeping the hospital open and others favoring closure, perhaps replacing it with a small clinic. Local journalist Jean Bilodeaux, 74, said board members often kept the public in the dark, failing to show up for their own meetings and sometimes making decisions outside public view.

When Bilodeaux raised questions about the hospital’s finances in the Modoc County Record, a weekly newspaper, she recalled, board members “started screaming at me,” she said. Now “I don’t even step foot in that hospital.”

Ben Zandstra, 65, a pastor in Cedarville, said that while Cornwell was in charge, he too got a chilly reception at the hospital, where he had long played guitar for patients on Christmas Eve. “I became persona non grata. It’s the most divisive thing I’ve seen in the years I’ve lived here.”

A White Knight, Vanished

Even residents who say they have experienced poor care at Surprise Valley Community believe its continued existence in some form is crucial — for its 50 or so jobs, for its ER, and because it puts the region on the map.

Eric Shpilman, 61, a retired probation officer, said his now-deceased wife received “unspeakable” treatment at Surprise Valley. But to shut it down? “It would take out the heart of Surprise Valley, the heart out of Cedarville.”

Last summer, the board turned to an outside management company for help.

Jorge Perez, CEO of Kansas City-based EmpowerHMS — which promises on its website to “rescue rural hospitals” — agreed to take over Surprise Valley’s debt and operate the hospital for three years, according to a management agreement with the board.

In the two months after EmpowerHMS took over management, Surprise Valley’s revenue more than doubled, according to financial documents provided by the hospital.

Then, according to hospital officials’ public statements, the company stopped making the promised payments, and they haven’t been able to contact EmpowerHMS or Perez since. In January, when Surprise Valley filed for bankruptcy, documents filed in court said EmpowerHMS had “abandoned” the hospital.

Around the time Perez took over, he and companies with which he was involved were dogged by allegations of improper laboratory billing at facilities in Mississippi, Florida, Oklahoma and Missouri, according to ongoing lawsuits by insurers and others, a state audit and media reports. Missouri’s attorney general in May opened an investigation into one of the hospitals Perez managed, and Sen. Claire McCaskill (D-Mo.) recently called for a federal investigation into lab billing practices at one of the hospitals.

Medicare rules and commercial insurance contracts, with some exceptions, require people to be treated on an inpatient or outpatient basis by the hospitals that are billing for their lab tests. But insurers have alleged in court documents that hospitals Perez was involved with billed for tests — to the tune of at least $175 million — on patients never seen at those facilities. Perez has maintained that what he is doing is legal and that it generates revenue that rural hospitals desperately need, according to Side Effects Public Media.

Experts say insurers are catching on to voluminous billing by hospitals in communities that typically have generated a tiny number of tests. At one Sonoma County district hospital not associated with Perez, an insurer recently demanded repayment for $13.5 million in suspect billings, forcing the hospital to suspend the lucrative program and put itself up for sale.

Lab tests for out-of-town patients have “been a growing scheme in the last year, slightly longer,” said Karen Weintraub, executive vice president of Healthcare Fraud Shield, which consults for insurers. “There’s an incentive to bill for things not necessary or even services not rendered. It also may not be proper based on contracts with insurers. The dollars are getting large.”

Some residents were aware of controversy surrounding Perez and his companies and said they tried to warn the hospital district board. “All they wanted to hear was, ‘We will pay the bills,’” Bilodeaux said.

Neither Perez nor EmpowerHMS returned requests for comment. However, Michael Murtha, president of the National Alliance of Rural Hospitals, said in an email that he was responding on behalf of Perez, who chairs the coalition’s board.

“The mission to rescue rural hospitals and set them on a path of sustainability is a difficult undertaking, and it would be a disservice to their communities to preclude struggling facilities from availing themselves of every legal and regulatory means to generate badly needed revenue,” Murtha wrote, in part.

“Such pioneering efforts are not always welcomed by those who have benefited from the status quo,” he said.

Regarding Perez’s role at Surprise Valley, Murtha wrote that Perez tried to help save the facility by “effectively” donating over $250,000 but then discovered it faced “more challenges than had been initially realized.” Murtha said Perez worked to attract others who might be better able to help the hospital.

A New Savior?

One of those “others” in Perez’s orbit was Gertz, the Denver entrepreneur, who arrived in Surprise Valley several months ago.

The Denver executive told residents and Kaiser Health News that he operated a lab that previously performed tests for hospitals owned or managed by Perez’s companies. At one hospital board meeting, Gertz also said he had handled marketing for Perez companies for 1½ years.

However, he said he had parted ways with Perez after learning of his controversial dealings in other states, and Gertz said Perez now owes him more than $14 million. (Gertz and his companies have not been named as defendants in lawsuits reviewed by Kaiser Health News involving Perez and his companies.)

“I come in with a certain guilt by association,” he told the Modoc County Board of Supervisors in April, according to a recording of the meeting. But Gertz sought to assuage any concerns, telling the supervisors he had a “passion” for rural life. He’d grown up on a farm, he said, where he “hung out with the chickens” and cleaned the stables every morning.

Gertz said his plan was different from Perez’s and legal because the hospital and one of his Denver labs, SeroDynamics, had become one business. With the hospital board’s approval earlier this year, he loaned the district $2.5 million for it to buy SeroDynamics — effectively an advance on the hospital’s purchase price of $4 million, according to bankruptcy court documents. SeroDynamics’ website now proclaims the lab a “wholly-owned subsidiary” of the Surprise Valley hospital, with “national reach.”

Robert Michel, a clinical laboratory management consultant who learned of the terms of the transaction from a reporter, offered a critical assessment. “The essence of this arrangement is to use the hospital’s existing managed-care contracts with generous payment terms for lab tests as a vehicle to bill for claims in other states,” said Michel, editor-in-chief of a trade magazine for the lab industry. This arrangement “should ring all sorts of bells” for the hospital board, he said.

For now, Gertz has said, dollars are flowing in. According to the journalist Jean Bilodeaux, Gertz phoned in to a Surprise Valley hospital board meeting last month to report that the lab billing so far had netted about $300,000. According to bankruptcy court documents, 80 percent of the profits will go to his companies, 20 percent to the hospital.

Those are terms some in Surprise Valley are willing to live with.

The next step, for Gertz, is taking ownership of Surprise Valley’s entire operation. For the 1,500 district residents, voting no on Tuesday almost certainly means closure, leaving taxpayers with potentially more debt, including any money they may owe Gertz.

That is good enough reason to go with the Denver entrepreneur, said acting hospital administrator Bill Bostic.

“He’s got something we haven’t got — which is money,” Bostic said.

Preliminary numbers show California’s overdose deaths from the synthetic opioid fentanyl increased by 57% in 2017, according to the state’s Opioid Overdose Surveillance Dashboard.

Fentanyl overdoses claimed 373 Californians, according to the Dashboard, an online tool that gathers data from the California Department of Public Health, the Office of Statewide Health Planning and Development, and the Controlled Substance Utilization Review and Evaluation System.

Fentanyl is up to 50 times more powerful than heroin and can be 100 times more potent than morphine. It’s often added to other street drugs, and can overwhelm and kill someone who has no tolerance.

The number of overdose deaths last year could rise, however, according to Dr. Phillip Coffin of the San Francisco Department of Public Health. He said determinations on causes of death are still being closed in some 2017 cases.

Fentanyl has long been behind high rates of opioid deaths in the eastern U.S., but the potent drug has not brought the same crisis to the West, including California, Coffin said. But that’s changing.

“We’re definitely seeing a change in the market. We definitely are seeing fentanyl sold as fentanyl on the street. And that’s new over the last couple of years,” Coffin said.

The number of total opioid deaths — including from heroin, prescription pain medication, morphine and fentanyl — is down slightly from 2016.

Coffin attributes this to prevention efforts across the state, which include distribution of naloxone, a drug that reverses opioid overdoses, fentanyl test strips, and safer prescribing practices by doctors.

The number of overdose deaths from fentanyl has been changed to reflect the latest information released from the California Department of Public Health. Their original numbers erroneously stated that 746 people had died from fentanyl overdoses. The actual number is 373. 

But the social significance of the vote finally burst into view this Jan. 1, when eager customers — who had lined up in the darkness outside medical marijuana dispensaries across the state — streamed through the doors at the stroke of midnight.

But the change hasn’t been confined to the cannabis cash register. Everyone has seen the advertising or heard the chatter — and that includes minors, although marijuana remains illegal for those under 21.

“Coming out of SFO airport, there are billboards for Eaze that say ‘Marijuana is here,’ ” said Danielle Ramo, a psychologist who conducts research at UCSF on adolescent drug use.

“I’m not sure parents were expecting to see so many images of cannabis all over,” she said.

Public schools in California are required by law to provide anti-drug abuse education, although experts say the quality of the instruction varies widely from district to district, and there’s little enforcement.

I was curious to know how marijuana legalization was being discussed in schools, so I embedded with Being Adept, an evidence-based curriculum that has been used in about 20 schools in the Bay Area.

To my surprise, I discovered that the rollout of legal recreational marijuana in California and other states hasn’t led to any big changes in substance abuse prevention. Drug educators have always covered both legal substances (alcohol, tobacco, prescription drugs) and illicit ones (pot, ecstasy, cocaine, LSD, heroin, meth … ). Students have accessed, and abused, both categories of drugs for decades.

But I was more struck by the evolution of drug education since the 1980s. Today, drug abuse education is an advanced pedagogy, drawing on decades of rigorous effectiveness research and the newest teaching techniques.

The “Just Say No” approach, popularized by Nancy Reagan, has been discredited. The PSAs that Gen-Xers may remember — the egg in a frying pan (“this is your brain on drugs”), or the boy calling out his dad’s drug use (“I learned it by watching you!”) — live on as memes, but they’re no longer used as messages.

“Those scare-tactic-based programs have tended to quite clearly not work, based on most of the research that evaluated its effectiveness,” Ramo said. “Today there is an entirely different mindset about school-based prevention.”

In a nutshell, the focus now is on facts, not fear. Also conspicuously absent are simplistic dictates like “just say no.” Instead, teachers spur students to examine data, speculate on motives, discuss risks, and deliberate on their own goals and values.

Ashley Brady, a Being Adept instructor, was completely open about her method when she stood in front of the eighth-graders at Marin Primary and Middle School, a private school in Larkspur.

“I’m not here to tell you what to do today. Not at all,” she began. “I’m here to give you the most up-to-date information possible so that you can make your own healthy, informed decisions.”

Brady then jump-started a fast-paced, fact-filled discussion on brain chemistry and physiology. There was an animated video about how marijuana affects dopamine pathways in the brain. Then a discussion about marijuana “edibles” and how they are metabolized by the liver.

“It can take up to 30 minutes to maybe even an hour or two before it really hits you,” she said. “When somebody eats an edible and they don’t really feel the effects, what do you think happens?”

“They eat more!” a student called out.

“They eat more,” Brady nodded. “Yeah, an hour, an hour and a half later? Boom! Like a freight train, they’ve been hit, and, you know, can barely move or can barely talk. That kind of thing. So they may have to go to the hospital.”

True, that sounds a little scary, but it’s presented neutrally, as a consequence at the end of a sequence of decisions.

Where the legalization of the marijuana industry has affected the content of these lessons is on the subject of potency. Brady tells the students that legalization has spurred competition and innovation among suppliers, to the point where they’re now churning out extremely potent and precisely calibrated forms of pot called “concentrates,” which comes in various forms.

Brady runs through their names: oil, bubble, shatter, wax and dabs.

“They call it a ‘dab’ because one tiny little nail head [of it] — I mean I’m talking like the end of my pinky — one tiny little nail head is the same as three joints hitting the system all at once. So it’s a lot stronger than it used to be.”

Tests of THC levels in marijuana samples over the years back this up. Whereas a typical joint in the ’70s probably had a THC level of 4-5 percent, at best, growers are now breeding strains of cannabis that produce buds with THC levels as high as 20-30 percent.

But the concentrates are in another category altogether. Processed concentrates sold at dispensaries now regularly test at 80, even 90 percent.

“It’s not the same drug,” Brady tells them. People sometimes vomit from concentrates. Some people hallucinate and have even become psychotic.

And yes, she adds, it can be addictive. Not just psychologically, but physically. People do go into THC withdrawal and do go to rehab for pot addiction.

Still, as she describes the transformation of marijuana from a relatively mild intoxicant to a potentially debilitating one, Brady never once says “that’s why you shouldn’t” or even “so please be careful.”

Afterward, the students applauded this approach.

“It made you feel more mature, and that you’re in control,” said Devon Soofer, 13. “This [class] was actually telling you the long-term effects and what it can actually do to you. So it actually made you feel like ‘Wow, this is actually really bad,’ and not just being forced not to do it.”

Later units in the Being Adept curriculum give students concrete tools: They rehearse what to do or say at parties, and talk about better ways to cope than using cannabis — or any substance.

Ramo, who serves as a scientific advisor to Being Adept, decried “the overwhelming stress, anxiety, depression, suicidality that is so pervasive among teens in the United States today, especially in high-intensity educational areas, like a lot of schools in the Bay Area are.”

“Addressing that problem is key,” she added, as is “having teens come up with solutions to manage their stress, that they actually would use.”

“Delay, Delay, Delay”

So if drug educators aren’t telling students “Don’t!” anymore, what exactly are they telling them to do? As I observed, they’re not overtly telling them to do anything, because teens are naturally resistant to the authoritarian approach — and some of them may resist to the point of doing the opposite.

The underlying goal of drug education remains the same as before: keep children safe. The dangers of intoxicated driving, sexual assault, academic or athletic failure, social humiliation, social media embarrassment — all of these do come up in the lessons.

But the instructors put a special emphasis on a less visible risk: the potential damage to their brains. And the science backs them up.

“More research is coming out looking at the ways in which all different kinds of substances can hijack normal brain functioning, and particularly so in adolescence,” Danielle Ramo explained.

“In heavily cannabis-using teens, there are some particularly important implications of using cannabis on the frontal lobe, and that interrupts a type of thinking called ‘executive functioning.’ ”

Also worrisome is a substantial body of research showing that using any potentially addictive substance while the brain is still developing — whether alcohol, marijuana, nicotine, or other drug — triggers neurological changes that can lead to addiction.

“The earlier teens start using, the more heavily they use in adolescence, the more likely it is that they’ll go on to have problems throughout their adulthood,” said Ramo.

Being Adept instructors don’t say it outright, but the message is clear: If you’re not going to abstain, just push it off for a while. Your brain is too vulnerable right now.

Jennifer Grellman, a psychotherapist in Kentfield and the founder of Being Adept, sums up the strategy in three words, just like the “Just Say No” campaign: “Delay, delay, delay.”

“The way to handle that with your kids is to say: ‘You know, you don’t have to use this now. Maybe you want to use it someday, but not today, not now. It will always be there.’ Just tell them to wait.”

Grellman said that advice may be more palatable for some teens, and therefore easier for parents to deliver.

They’re not forbidding something (and possibly making it more enticing). They’re not saying “never.”

The Role of Parents

Grellman said parents should talk about drugs and alcohol with their kids often — as early as fourth grade. Use the new billboards or marijuana ads as an excuse to bring up the topic. Broach the subject obliquely: What do people at your school think about those ads? Do any of your friends know what a dab actually is? Did you see this article on the seventh-grader getting expelled for pot in his locker? What do you think about that?

Listen to what they say and discuss it. Don’t lecture, but be clear about your expectations, and your values around drugs and alcohol.

At every school where Being Adept is taught, Grellman offers a “Parents Night” where parents can learn how to navigate those conversations. Some are encouraged when Grellman tells them that seemingly taboo subjects should be aired:

“Don’t hide Uncle Harry, who is the old drinker, you know? Don’t be ashamed to talk. You talk about Uncle Harry all the time,” Grellman said.

“Because these kids need to know ‘If I have alcohol, it could be, like, I may have the alcoholic gene,’ ” she added. “It doesn’t mean they’re going to for sure, but they sure need a heads-up about that.”

The same approach can be used for mental illness: “You know, I have anxiety. Your father has this issue. So chances are you might be a little anxious at times, so how are you going to deal with this?”

But it’s not just what parents say, it’s what they do, according to Grellman. Children are always watching how their parents use substances.

“Don’t glamorize it,” she advised. “It doesn’t mean you have to become a monk and never have a drop of alcohol, but please drink responsibly. Never use it for stress control.”

“This idea of coming home from the office and saying ‘I’ve got to have my glass of wine’ … if you want to have your glass of wine, have your glass of wine, but don’t announce it! That you’re just at wit’s end, and you have to have this drink. “

Grellman said the modeling part becomes tricky when kids ask parents about their past: Did you party? What drugs did you use?

When she led the Parents Night in March at Marin Primary and Secondary, she advised the parents to get ready for that moment, and have answers prepared.

But what if we did party in high school? Several parents ask. Should we lie?

Absolutely not, Grellman said, because if a kid senses dishonesty or hypocrisy, they’ll shut down. The most important thing is to keep the conversations going. If your child knows they can talk to you, no matter what, they will create a “safety plan” with you. They will reach out to you when trouble comes.

But what do we tell them then? How can we be honest, without encouraging them?

“You don’t have to tell the full story,” Grellman said. “You could say: ‘You know, I did smoke and I did drink when I was 13.’ And if you loved it, I don’t know if I would advertise that.

“You could say, ‘I did smoke, or I did drink, when I was 13. And you know, frankly? It was too early for me, man. I made some stupid decisions and I got in trouble.’ You can give them the consequences of it.”

Afterward, parents said they felt relieved to have concrete suggestions about how to talk with their kids, and how much was OK to bring up.

“It’s much more prevalent than it was when I was growing up in the ’80s,” said Joseph Sullivan, a physician from Larkspur.

“This is a different time, and so it’s nice to hear that we’re almost given permission to be talking about these different aspects of drug experimentation at different ages,” he added.

His wife, Dr. Sara Sullivan, said she’s glad that the “Just Say No” paradigm is dead.

“Just to give the kids more information, I think, is such a different way to approach it and I really appreciate that. And we’ve kind of started to have conversations in our family because of that,” she explained. “To really kind of take that approach and not be like ‘You’re kind of out there on your own.’ ”

“Generally speaking the driver is kind enough to assist some of these women in exiting the vehicle and grabbing some of their belongings,” Adams said. “The patient or client enters in through our door sometimes bewildered and confused as to why they’re here.”

Many of the women are elderly. Some have never been to A Woman’s Place before the taxi drops them off, while others are regulars. Whatever the case, the center just isn’t prepared to take in medically fragile patients straight from the hospital, according to Adams. It’s not a clinic, and it’s not even a shelter. Women and families can stop in to take showers, do laundry or get counseling. There aren’t any beds, just a television set and lots of chairs.

A bill under consideration in Sacramento aims to address this practice, which some advocates call “patient dumping.” They say hospitals commonly discharge homeless patients by sending them to social service agencies or other nonprofits, and they do this without contacting those locations first.

Adams said this “dumping” happens at least once a week at A Woman’s Place. One of the cases that haunts her involves an elderly woman who has a serious mental illness. Recently, the client had deteriorated so much that she couldn’t use the toilet alone.

“She wasn’t leaving the building under her own accord,” Adams said. “She wasn’t accessing food or water without the assistance of other people. She tried to pay me a dollar the other day to go buy her some ramen so that she could eat.”

Adams sent the woman to the hospital, hoping psychiatric services would help.

“Unfortunately, less than 24 hours later, she returned here,” Adams said.

The same client was resting at the center on the day a KQED reporter visited, sitting in a black chair that she favors. Adams said the woman’s mental illness still wasn’t well-controlled, so she couldn’t speak coherently or consent to an interview.

“In an ideal world, she would be transferred to a ‘board and care’ or an assisted living facility, where they could manage her mental health as well as her medical health in a fashion that we simply don’t have the infrastructure for,” Adams said.

The legislation moving through the state Senate would require that patients be discharged to one of four “safe and appropriate” locations:  their primary dwelling (as identified by the homeless patient), another health center or hospital, a nonprofit or social service agency that has given written consent to accept the patient, or an alternative spot that the patient has consented to go to, in writing. 

Sen. Ed Hernandez, D-West Covina, introduced the bill. He said hospitals, as part of society, have obligations to homeless Californians.

“If they fall down and have a heart attack, and somebody sends them to the hospital, we’re required by law — which is the humane thing to do — to treat those individuals,” said Hernandez, who is an optometrist and chair of the Senate Health Committee. He was referring to a federal law called EMTALA, which mandates that emergency rooms accept and treat everyone, regardless of ability to pay.

But EMTALA doesn’t address how patients are discharged from ERs. “Once they’re treated, the humane thing is to figure out where we’re going to place them, as opposed to just leaving them out in the street immediately,” Hernandez said.

His bill would require some additional work on the part of ER staffers at California hospitals, such as getting consent from a shelter where the hospital wants to send the patient. 

“I can’t imagine that it’s going to be that costly to pick up the phone,” Hernandez said.

The legislation also lays out a checklist of things to do before discharge. For example, the patient must be hydrated, have recently eaten and be dressed in weather-appropriate clothing.

But hospitals are pushing back, saying the list is too specific, and doesn’t give hospital workers enough flexibility to decide what’s right for each patient.

Peggy Wheeler is the vice president for rural health and governance for the California Hospital Association. She said the bill would put yet another burden on emergency care.

“Hospital ERs are overcrowded,” Wheeler said. “If we had to hold on to a patient in a bed in the ER, that’s one less bed, two less beds, three less beds that would be available for other members of the community that need to come in and use the ER.”

Adams, the psychologist at A Woman’s Place, thinks the bill is a good step. But she said it doesn’t get at the root problem, which is that the Bay Area doesn’t have enough options for patients who still need help after they leave the hospital. There aren’t enough nursing homes, rehabilitation units or assisted care programs for elderly, low-income or disabled patients.

“It’s a health insurance issue, it’s an aging issue, it’s a lack of infrastructure and funding,” Adams said.

Until that gets fixed, Adams fears many patients will continue to shuttle between hospitals, the shelter system and the street.

Ayala, an Oakland-based AIDS advocate, does not want the conference in his own city — or anywhere else in the United States, for that matter.

His statement of opposition and a second one drafted by colleagues at other AIDS organizations have been co-signed by hundreds of organizations and individuals in the United States and around the world.

Their biggest concern: long-standing U.S. visa policies will prevent many of the people most affected by AIDS and HIV, including drug users and sex workers who live in other countries, from attending the conference. They also worry about new restrictions affecting travel from Muslim countries.

“In this day and age, I have to wonder why we support big international AIDS conferences happening in places that bar anyone,” said Ayala, executive director of the Global Forum on MSM [Men who have Sex with Men] & HIV.

HIV/AIDS is far more prevalent in many countries, especially in Sub-Saharan Africa, than in the United States. Almost 19 percent of people ages 15 to 49 in South Africa are infected with HIV, as are more than 20 percent in some neighboring countries.

In the U.S., prevalence among the same demographic group hovers around a half of 1 percent — although that masks some stark disparities. Last year, the Centers for Disease Control and Prevention projected that 1 in 2 black men in the U.S. who have sex with men were at risk of contracting HIV. Globally, nearly 37 million people are living with HIV.

Ayala and other critics of the Bay Area location raise broader questions about the cost and frequency of a biennial event they say is enormously expensive and often excludes the very people it purports to represent.

The organizers of the conference and others who support the decision to bring it to the Bay Area say they understand these worries.

“Travel restrictions to the U.S. remain a significant concern for us,” said Mandy Sugrue, spokeswoman for the International AIDS Society, which organizes the conference.

However, Sugrue and other proponents of a San Francisco-Oakland conference venue argue that the politically liberal Bay Area offers a perfect platform for rebuking the Trump administration’s exclusionary immigration policies and its perceived retreat from leadership on AIDS policy.

In December, the administration fired all remaining members of the Presidential Advisory Council on HIV/AIDS, six months after a half-dozen others had resigned in protest. Trump officials have also proposed cutting national HIV/AIDS spending by more than $100 million and reducing the U.S. contribution to global funding by more than $1 billion.

“If there is any place in the U.S. where people can come and protest and rise up and have their voices heard … Oakland is it,” said Cynthia Carey-Grant, executive director of the Oakland-based group Women Organized to Respond to Life-Threatening Disease. She penned a statement in support of the conference location that has been signed by nearly a dozen individuals and groups.

Carey-Grant believes the contrast between upscale, predominantly white San Francisco and its decidedly poorer neighbor across the Bay offers a window on the disparities that pervade AIDS treatment and funding around the world – to the detriment of low-income communities of color.

Sofia Tobar (Courtesy of Sofia Tobar)

Sofia Tobar, a 50-year-old transgender woman from Oakland who was diagnosed with HIV in 1998, said the conference is an opportunity “for Oakland’s diverse humans to embrace people from other countries … and to also highlight what we’re lacking.” She is especially interested in speaking out against federal cuts to AIDS services and violence targeting the transgender community, she said.

Others say they are eager to honor San Francisco’s long history of battling AIDS.

Joe Hollendoner, CEO of San Francisco AIDS Foundation, noted that the conference organizers have secured use of the Moscone Center, the central conference venue, free of charge. They will use the money they save to help more people attend, he said. His foundation, along with the San Francisco Travel Association, led the committee that submitted the successful conference bid.

The planners of the International AIDS Conference usually try to alternate venues between affluent and lower-income countries. The conference was last held in the United States in 2012 in Washington, D.C. In 2014, it was in Melbourne, Australia, and in 2016, in Durban, South Africa. This year, the conference will be in Amsterdam.

Conference organizers said they reached out to a number of lower-income countries to host the 2020 conference, but none submitted a bid. As many as 20,000 people, perhaps more, are expected to attend the conference — and many cities cannot accommodate such a large gathering, they said. Sugrue, the International AIDS Society spokeswoman, said they are not considering changing the venue.

She said the location of major conference donors was not a factor in the 2020 venue decision.

Gilead Sciences Inc., which is based 20 miles from San Francisco and makes the HIV prevention drug Truvada, is one of the top sponsors of this year’s conference, as it was in 2016. Other big industry donors are not located in the Bay Area, including Johnson & Johnson, Merck and ViiV Healthcare, which specializes in HIV drugs. Funding for the 2020 conference has not yet been confirmed, Sugrue said.

Naina Khanna, the executive director of the Oakland-based Positive Women’s Network, said the fact that no developing countries submitted a bid isn’t enough to assuage her concern for the people who will likely be excluded. Khanna helped draft a separate statement demanding that the conference be relocated outside the U.S. More than 100 organizations and nearly as many individuals have signed the statement.

“Where is our commitment to actually holding the conference where the most people are impacted?” asked Ruth Morgan Thomas, global coordinator of the Global Network of Sex Work Projects, which includes 305 organizations representing sex workers in 85 countries.

Prior to the Washington, D.C., conference, the U.S. had lifted a ban on people with HIV entering the country, and many were hopeful that similar prohibitions against sex workers and drug users would also end. But they didn’t, and sex workers scrambled to organize a parallel conference in Kolkata, India, Morgan Thomas said. Drug users convened one in Kiev.

Khanna, of the Positive Women’s Network, said that the high cost of accommodations in the Bay Area will also make the conference inaccessible to many people within the United States — especially low-income African-Americans in the South, who are disproportionately burdened with the virus.

Marsha Martin, coordinating director of the Global Network of Black People Working in HIV, said she would have been happy had Bangkok or South America or even Atlanta been chosen to host the conference. “But if venues don’t submit bids, there’s nothing to do about it,” she said. So she’s treating the Bay Area conference as an opportunity to grapple with the big disparities in AIDS funding and to reinvigorate efforts in the U.S. to combat the disease.

“If we do bring it [to the Bay Area] and make it the best conference we can make it, then we win,” Martin said. “We show the world we are not giving up.”