Tuesday, November 21, 2017

Skin Cancers Rise, Along With Questionable Treatments

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John Dalman was told he would need surgery on at least a half-dozen nonlethal cancerous lesions, as well as radiation for several weeks. Credit Josh Ritchie for The New York Times
John Dalman had been in the waiting room at a Loxahatchee, Fla., dermatology clinic for less than 15 minutes when he turned to his wife and told her they needed to leave. Now.
“It was like a fight or flight impulse,” he said.
His face numbed for skin-cancer surgery, Mr. Dalman, 69, sat surrounded by a half-dozen other patients with bandages on their faces, scalps, necks, arms and legs. At a previous visit, a young physician assistant had taken 10 skin biopsies, which showed slow growing, nonlethal cancerous lesions. Expecting to have the lesions simply scraped off at the next visit, he had instead been told he needed surgery on many of them, as well as a full course of radiation lasting many weeks.
The once sleepy field of dermatology is bustling these days, as baby boomers, who spent their youth largely unaware of the sun’s risk, hit old age. The number of skin cancer diagnoses in people over 65, along with corresponding biopsies and treatment, is soaring. But some in the specialty, as well as other medical experts, are beginning to question the necessity of aggressive screening and treatment, especially in frail, elderly patients, given that the majority of skin cancers are unlikely to be fatal.
“You can always do things,” said Dr. Charles A. Crecelius, a St. Louis geriatrician who has studied care of medically complex seniors. “But just because you can do it, does that mean you should do it?”
Mr. Dalman’s instinct to question his treatment plan was validated when he went to see a dermatologist in a different practice. The doctor dismissed radiation as unnecessary, removed many of the lesions with a scrape, applied small Band-Aids, and was finished in 30 minutes.
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Dermatology — a specialty built not on flashy, leading edge medicine but on thousands of small, often banal procedures — has become increasingly lucrative in recent years. The annual dermatology services market in the United States, excluding cosmetic procedures, is nearly $11 billion and growing, according to IBISWorld, a market research firm. The business potential has attracted private equity firms, which are buying up dermatology practices around the country, and installing crews of lesser-trained practitioners — like the physician assistants who saw Mr. Dalman — to perform exams and procedures in even greater volume.
The vast majority of dermatologists care for patients with integrity and professionalism, and their work has played an essential role in the diagnosis of complex skin-related diseases, including melanoma, the most dangerous form of skin cancer, which is increasingly caught early.
But while melanoma is on the rise, it remains relatively uncommon. The incidence of basal and squamous cell carcinomas of the skin, which are rarely life-threatening, is 18 to 20 times higher than that of melanoma. Each year in the United States more than 5.4 million such cases are treated in more than 3.3 million people, a 250 percent rise since 1994.
The New York Times analyzed Medicare billing data for dermatology from 2012 through 2015, as well as a national database of medical services maintained by the American Medical Association that goes back more than a decade. Nearly all dermatologic procedures are performed on an outpatient, fee-for-service basis.
The Times analysis found a marked increase in the number of skin biopsies per Medicare beneficiary in the past decade; a sharp rise in the number of physician assistants, mostly unsupervised, performing dermatologic procedures; and large numbers of invasive dermatologic procedures performed on elderly patients near the end of life.
In 2015, the most recent year for which data was available, the number of skin biopsies performed on patients in the traditional Medicare Part B program had risen 55 percent from a decade earlier — despite a slight decrease in the program’s enrollment over all.
Skin cancers are more common in older people, which means Medicare pays for much of the treatment. In 2015, 5.9 million skin biopsies on Medicare recipients were performed.
More than 15 percent of the biopsies billed to Medicare that year were performed by physician assistants or nurse practitioners working independently. In 2005, almost none were, said Dr. Brett Coldiron, a former president of the American Academy of Dermatology, who has studied the use of clinicians who are not physicians in medical practices.
Dr. Coldiron, a dermatologist in Cincinnati, said he was skeptical of the growing use of such clinicians in the specialty. “Ads will say ‘See our dermatology providers,’” he said. “But what’s really going on is these practices, with all this private equity money behind them, hire a bunch of P.A.’s and nurses and stick them out in clinics on their own. And they’re acting like doctors.”

Dermatology on Wheels

Bedside Dermatology, a mobile practice in Michigan, sends clinicians to 72 nursing homes throughout the state for skin checks and treatment.
Dr. Steven K. Grekin, a dermatologist, said that when he founded Bedside, many of the nursing home patients had not been examined by a dermatologist for several years.
“We were seeing a real unmet need,” he said.
In 2015, Bedside Dermatology’s traveling crews performed thousands of cryosurgeries — spraying liquid nitrogen on precancerous lesions with an instrument that resembles a blowtorch. Other spots on the nursing home patients’ skin were injected with steroids, or removed with minor surgery.
Examining the 2015 Medicare billing codes of three physician assistants and one nurse practitioner employed by Bedside Dermatology, The Times found that 75 percent of the patients they treated for various skin problems had been diagnosed with Alzheimer’s disease. Most of the lesions on these patients were very unlikely to be dangerous, experts said, and the patients might not even have been aware of them.
“Patients with a high level of disease burden still deserve and require treatment,” Dr. Grekin said. “If they are in pain, it should be treated. If they itch, they deserve relief.”
Dr. Eleni Linos, a dermatologist and epidemiologist at the University of California, San Francisco, who has argued against aggressive treatment of skin cancers other than melanomas in the frail elderly, said that if a lesion was bothering a patient, “of course we would recommend treatment.” However, she added, many such lesions are asymptomatic.
Dr. Linos added that physicians underestimate the side effects of skin cancer procedures. Complications such as poor wound healing, bleeding and infection are common in the months following treatment, especially among older patients with multiple other problems. About 27 percent report problems, her research has found.
“A procedure that is simple for a young healthy person may be a lot harder for someone who is very frail,” she said.
The work of Bedside Dermatology reflects a wider tendency to diagnose and treat patients for skin issues near the end of life. Arcadia Healthcare Solutions, a health analytics firm, analyzed dermatologic procedures done on 17,820 patients over age 65 in the last year of life, and found that skin biopsies and the freezing of precancerous lesions were performed frequently, often weeks before death.
Arcadia found that the same was true for Mohs surgery, a sophisticated procedure for basal and squamous cell skin cancers that involves slicing off a skin cancer in layers, with microscopic pathology performed each time a layer is excised until the growth has been entirely removed. Each layer taken is reimbursed separately.
In 2015, one out of every five Mohs procedures reimbursed by Medicare was performed on a patient 85 or older, The Times found.
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A doctor removing suspected cancerous skin cells from a patient in Ohio during a Mohs surgery. Credit Luke Sharrett for The New York Times

Rise of Physician Assistants

Bedside Dermatology is owned by Advanced Dermatology and Cosmetic Surgery, the largest dermatology practice in the country, with a database of four million active or recently established patients. Last year, Harvest Partners, a private equity firm, invested a reported $600 million in the practice, known as ADCS.
ADCS has its headquarters in Maitland, Fla., in a sleek suite of offices and cubicles the size of a football field. One morning early this year, the buzz of corporate expansion was everywhere. A delivery crew wheeled in a stack of cubicle partitions. Employees at a large phone bank scheduled appointments around the country. A transition team was preparing to visit a newly acquired practice in Pennsylvania, and Dr. Matt Leavitt, ADCS’s founder and chief executive, was congratulating his director of business development on snagging a sought-after recruit.
In an email last week, Dr. Leavitt said the company currently has 192 physicians, but declined to confirm other numbers because ADCS is privately held. The company’s website advertises “180+ locations.” The website also lists 124 physician assistants. That is a 400 percent increase from 2008, according to web pages preserved by the Internet Archive’s Wayback Machine. ADCS offers a six-month fellowship program for physician assistants to provide additional training in dermatology.
“My number one goal would be to have people take skin cancer much more seriously than they have, especially baby boomers,” said Dr. Leavitt, a dermatologist. “And we’ve got to continue to work at getting better access for patients.”
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The call center of Advanced Dermatology and Cosmetic Surgery in Maitland, Fla. A private equity firm invested in the company in a deal worth some $600 million last year. Credit Jennifer Sens for The New York Times
While health care experts agree that access to care is of growing importance, there is an ongoing debate over whether practitioners who are not physicians are qualified to make diagnoses, identify skin cancers and decide when to perform biopsies — skills dermatologists acquire through extensive training — particularly among the elderly.
The frequency with which physician assistants and nurse practitioners take skin biopsies — compared with M.D.’s — was the subject of a 2015 study at the University of Wisconsin, Madison. Based on 1,102 biopsies from 743 patients, researchers found that physician assistants and nurse practitioners performed nearly six biopsies for every skin cancer found — more than twice the number performed by physicians.
Riley Wood, age 82, arrived one morning last February at an ADCS clinic in Heathrow, Florida, for a skin check with David Fitzmaurice, a physician assistant.
For Mr. Fitzmaurice, the exam was routine; Mr. Wood was one of a few dozen patients he sees each day. On the day a reporter observed him, Mr. Fitzmaurice moved quickly through the visits, many of which entailed procedures like biopsies and cryosurgery.
Mr. Wood had already had two other cancers — kidney and throat. Mr. Fitzmaurice decided Mr. Wood needed two biopsies — one on his scalp, for a suspected squamous cell carcinoma, and a second on his neck, for a spot that might be a melanoma.
The bleeding from the biopsy wound to Mr. Wood’s neck persisted for several minutes, leaving the patient worried and depleted.
“I don’t like needles,” said Mr. Wood, in a voice close to a whisper, adding that the word cancer frightened him. Still, Mr. Wood said, he usually goes with the recommendations of Mr. Fitzmaurice, whom he called “Dr. David.” “I like him. He’s very thorough and cordial.”
With Mr. Wood’s permission, a reporter photographed the area Mr. Fitzmaurice biopsied for a suspected melanoma, and sent the image to nine physician-dermatologists. A few dismissed the biopsied lesion as nothing, while others said it was hard to tell from the photograph. None said the spot had the telltale signs of melanoma.
Yet all nine dermatologists, with no prompting, pointed to an adjacent lesion that had gone unremarked by Mr. Fitzmaurice, saying it looked like a skin cancer that was not melanoma.
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Dr. Matt Leavitt at the corporate headquarters of ADCS, of which he is founder and chief executive. Credit Jennifer Sens for The New York Times
Two months later in a telephone interview, the reporter asked Dr. Leavitt about Mr. Fitzmaurice’s apparent oversight. Dr. Leavitt defended his employee, saying Mr. Fitzmaurice had probably seen the spot but his higher priority was the suspected melanoma.
The morning after the interview, Mr. Wood received a call from ADCS, telling him to come in for a second look. The spot Mr. Fitzmaurice biopsied for melanoma turned out to be benign. The one next to it, which Mr. Fitzmaurice did not flag, was in fact a squamous cell carcinoma in situ, Dr. Leavitt said in a follow-up email.
While Dr. Leavitt pointed out that “routine skin checks are a great way to catch potential problems early,” Dr. Coldiron said he was wary of clinicians who are not physicians doing basic skin checks, given the evidence that those often lead to unnecessary biopsies.
Arielle Rought, a physician assistant with ADCS who is in her late 20s, called skin checks “our bread and butter.” On the day a reporter visited, Ms. Rought biopsied a spot on a patient’s hand to rule out melanoma. Her supervising physician was standing out in the hall, yet she did not ask him to take a look. Asked why she had not called him into the room, she said she did not consider it necessary. The biopsy was negative.
In an emailed statement, the president of the American Academy of Dermatology, Dr. Henry W. Lim, said: “The AAD believes the optimum degree of dermatologic care is delivered when a board-certified physician dermatologist provides direct, on-site supervision to all non-dermatologist personnel.”
Ms. Rought said it was not unusual for a skin check to lead her to to freeze as many as 30 precancerous lesions called actinic keratoses on a patient during a single visit. Actinic keratoses are called precancerous because they can sometimes turn into squamous cell carcinoma. Ms. Rought said her “rule of thumb” was that 20 percent of actinic keratoses progress to cancer.
While that might once have been the popular understanding, research now suggests otherwise. Dr. Martin A. Weinstock, a professor of dermatology and epidemiology at Brown University, reported in a 2009 study of men with a history of two or more skin cancers that were not melanomas that the risk of an actinic keratosis progressing to skin cancer was about 1 percent after a year, and 4 percent after four years. More than 50 percent of the lesions went away on their own.
Dr. Lim said the dermatology academy’s position is that actinic keratoses should be treated, as it is impossible to know which ones will turn into cancer, but some specialists are questioning whether that’s necessary.
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Riley Wood, 82, had two biopsies during an examination at ADCS. When nine outside dermatologists examined a photograph of a lesion on his neck, none flagged it as melanoma, but all pointed to an adjacent lesion, saying it looked like skin cancer. Credit Jacob Langston for The New York Times

The Doctor Is Not In

The experience of Mr. Dalman, the patient who fled the waiting room, began in January, when he made an appointment as a new patient at the clinic of Dr. Joseph Masessa, believing he would be seen by the dermatologist. Instead, he was seen by a young woman in a lab coat, whom he assumed was a physician, though she did not identify herself as one. She biopsied 10 different lesions.
At his next visit in February, he was seen by another young woman, whom he also took to be a physician. As it turned out, both women were physician assistants.
The second physician assistant told Mr. Dalman that he would need radiation on basal cell carcinomas on his temple, shoulder and ear. He said he tried to argue with her, explaining that he’d had many similar lesions in the past that were removed with a simple scrape.
He said she countered that if she attempted to remove the lesion above his right eye, he might end up unable to blink that eye. And without superficial radiation on his ear, he was in danger of losing the entire ear. She said he would also need Mohs surgery on several of the basal cell carcinomas. She did not respond to requests from The New York Times to speak about the case.
Although Dr. Masessa signed Mr. Dalman’s chart, Mr. Dalman never met him. This could be because the clinic he went to, northwest of West Palm Beach, Fla., is one of more than a dozen clinics scattered across three states associated with Dr. Masessa, who is based in New Jersey but licensed in Florida. Supervision of physician assistants is required by state law. The Florida Department of Health website lists Dr. Masessa as supervising four physician assistants in the state.
Dr. Masessa did not respond to repeated requests for comment. An associate, who identified himself as Jeff Masessa, returned a call and asked for questions by email. Neither he nor Dr. Masessa responded to a detailed list of questions, despite repeated follow-up emails from The Times.
On the day of Mr. Dalman’s surgery, the same physician assistant injected a local anesthetic, then instructed Mr. Dalman to return to the waiting room, Mr. Dalman said.
Then something dawned on him. Since he had not laid eyes on a physician in several visits, he worried that the physician assistant would be doing the procedure. The prospect made him nervous and he decided to make a swift exit.
Mr. Dalman later went to see Dr. Joseph Francis, a dermatologist near West Palm Beach. Dr. Francis said there was no indication for superficial radiation, a treatment of which the American Academy of Dermatology has voiced skepticism. Moreover, Dr. Francis decided, many of the basal cell carcinomas could be scraped off.
Dr. Francis said he was shocked not only by the number of biopsies that had been taken at once, but also by the aggressive treatment proposed.
Moreover, when he reviewed Mr. Dalman’s records from Dr. Masessa’s clinic, he saw four skin exams documented over the four-month period. But when he examined the patient, Dr. Francis noticed a pigmented, asymmetrical spot slightly bigger than a pencil eraser on Mr. Dalman’s shoulder.
It turned out to be a malignant melanoma, not documented by the physician assistant. Dr. Francis removed it before it had a chance to spread.

Monday, November 20, 2017

In Mexico, Not Dead. Not Alive. Just Gone.


XALAPA, Mexico — At 5 a.m., the couple stirred to the buzz of a cellphone alarm. They had hardly slept — Carlos Saldaña had been in the hospital the night before, betrayed by his fragile stomach.  He had prayed that the pain would subside, that God would give him strength. Today was the raid, the culmination of years of tracking the cartels, of lonely reconnaissance missions to find where they had discarded his daughter.

For so long, he had begged officials to do something, anything. Now, he wondered if he could even walk.

“Why tonight, God?” he had murmured in the hospital, doubled over. “I’ve been waiting so many years for this.”

He had spent the last six years searching for his daughter Karla, charging through every obstacle with an obsession that bordered on lunacy — cartel threats, government indifference, declining health, even his other children, who feared that his reckless hunt had put them in danger.




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Mr. Saldaña with a shrine created in memory of his and Ms. Delgadillo’s missing children in the bedroom of their home. Credit Daniel Berehulak for The New York Times
Vicky Delgadillo watched as he eased out of bed and grabbed a cane. She had a missing girl as well, Yunery, whom Mr. Saldaña now thought of as his own. For the last two years, the couple had shared a home, a life and a love born of loss.

She understood the raw fixation that defined his life. It defined hers too.
Before dawn, their prayers were answered. If not fully recovered, Mr. Saldaña was at least well enough to get to his feet. Sheer will and adrenaline would do the rest, allowing him to go on the raid of the ranch where he knew, deep down, both girls were buried — two bodies among the thousands lost in the state of Veracruz, among the tens of thousands nationwide.

The couple moved in silence, checking and rechecking their bags. Ms. Delgadillo packed a lunch — apples, carrots and a stew made of vegetables to avoid upsetting his stomach.

She heated water for instant coffee and made toast as Mr. Saldaña searched for his essentials: binoculars, gloves, boots and a battery charger.

Mrs. Delgadillo’s grandchildren — Yunery’s little girls — slept in the second bedroom. After making breakfast, she applied mascara in front of a mirror on the living room wall as Mr. Saldaña finished packing.

“I don’t think we will need this today,” he said, grabbing a long metal spike from behind their vinyl sofa, a crude tool they often used to find mass graves. “I think others will bring theirs for the search.”

They left before sunrise that humid June morning, carrying four bags and a familiar ambivalence, hopeful and afraid of what they might find.




‘The Entire State Is a Mass Grave’

Officially, the Mexican government acknowledges the disappearances of more than 30,000 people — men, women and children trapped in a liminal abyss — neither dead nor alive, silent victims of the drug war.
But the truth is no one knows how many people are missing in Mexico.
Not the government, which does not have a national registry of the missing. Not the families caught in emotional purgatory. Not the authorities in states like Veracruz, where both Karla and Yunery disappeared in a single 24-hour stretch.
When the new governor of Veracruz began his term last December, the state’s official figure for the number of missing was in the low hundreds. Upon the most basic review, the governor revised it — to nearly 2,600.
In the last year alone, the remains of nearly 300 bodies have been unearthed from clandestine graves in Veracruz, unidentified fragments that only begin to tell the story of what has transpired in the state, and more broadly the nation, over the last decade.
“There are an infinite number of people who are too scared to even say anything, whose cases we know nothing about,” said the state’s attorney general, Jorge Winckler.
Not that the state could handle many more. In March, Veracruz announced that it didn’t have money to do DNA tests on the remains that had already been found, leaving parents like Mr. Saldaña to panhandle in the street to raise it themselves.
Overwhelmed, the state also decided to temporarily halt all new searches for clandestine graves. There was simply nowhere else to put the bodies.
“The entire state is a mass grave,” the attorney general said.
For more than a decade, cartels across Mexico have taken out their rivals with utter impunity, tossing their remains into unmarked graves across the country. Soldiers and law enforcement officers often adopt the same approach, leaving many families too terrified to ask for help from a government they see as complicit.
It is both highly efficient and cruel: Without a body, there can be no case. And the disappearances inflict a lasting torture on enemies — robbing them of even the finality of death.
“The cruelest thing about a disappearance is that it leaves you with this desperate hope that your child might actually still be alive somewhere,” said Daniel Wilkinson, a managing director at Human Rights Watch. “You’re trapped in this horrific limbo where you can’t mourn or move on because that feels like betrayal, like you’re killing off your own child.”





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“How could I stop looking for her?” Mr. Saldaña says. “She is my daughter.” Credit Daniel Berehulak for The New York Times

Loss, and Then Love

In the summer of 2013, Mr. Saldaña’s love life was falling apart, which was hardly new for him. Only, he wasn’t recklessly careering from woman to woman, as he did when he was a younger man.
This time, his marriage was being torn apart by loss.
In the two years since Karla’s disappearance, he had become a man consumed by rage, impotence — and purpose. He spent every day planning his next search for his daughter, his next interview with her friends, his next stakeout of the men he thought responsible.
His wife at the time, who was not Karla’s mother, couldn’t take it. His single-mindedness was creating another hole in their home. After more than a decade together, they split.
On the walls of his new apartment, he taped up pictures of his daughter, a shrine of sorts. He loved her deeply, but theirs had been a troubled relationship, volatile. Karla viewed him as a part-time father, an accusation that stung all the more because it was true.
In a life ruled by urges, he had fathered nine children, with multiple women. He was short, with a heavy paunch and a square mustache, and he pursued women like some people devour food, to the point of addiction. To support his families, he gave up any chance of going to college and became a driver, leaving a trail of bitterness.
Finding Karla, in some way, would be his redemption.
She had disappeared with one of his estranged children, Jesus. The half brother and sister were close, though Mr. Saldaña rarely saw him, thanks to an ugly separation with his mother.
Jesus and Karla had gone out together that night, Nov. 28, 2011, to a party. They enjoyed the night life, though the clubs and bars were often populated with members of organized crime. The two were last seen in her car. It was recovered two days later in the possession of an off-duty policeman.
Mr. Saldaña wonders whether some cartel member hit on Karla at a bar that night, or whether she and Jesus witnessed something they weren’t supposed to. But as with so many other cases, the circumstances of their disappearance are unknown.
From that moment, Mr. Saldaña’s life was re-centered on a single mission — finding Karla and, with her, Jesus. He joined a collective of families and began attending meetings.
To search for a missing loved one in Mexico is to inhabit a life of desperate entrepreneurialism. Families, resigned to looking on their own, build coalitions, pressure and cajole officials, and cling to every shred of hope.
Mr. Saldaña threw himself into it, combing areas where criminals may have murdered people, organizing free DNA tests and raising money to pay for it all.
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A birthday party for a grandson offered a brief respite from grief, but Mr. Saldaña says he cannot give his family the attention it deserves. Credit Daniel Berehulak for The New York Times
He and others scouted out suspicious plots of land, looking for signs of slightly upturned earth. When they found one, they hammered long metal crosses six feet into the ground, then wrenched them out to sniff for the smell of decay. This is how the poor search for their dead.
During his first year with the collective, he met Ms. Delgadillo, a 43-year-old mother of four with luminous brown skin and green eyes. She graciously welcomed him.
Like him, she showed up at every meeting, every fund-raiser and every media campaign, denouncing the government for its inaction or inefficiency. She was warm, too, bringing a calming presence to a group often seized with rage.
She and Mr. Saldaña had an especially haunting bond. Their children had disappeared less than a day apart — abducted, they believed, by the same group of criminals. To them, it seemed inevitable that their children would be buried in the same place.
Mr. Saldaña had scoured Veracruz for details of the criminal operation: where it conducted business, where it buried its enemies. A friend of Karla’s told him of a ranch where cartel members were believed to dissolve their victims in acid. He felt, somehow, that this was where their children had been taken.
He shared his suspicions, the fruit of his one-man investigation, with Ms. Delgadillo. They folded their individual searches into one, meeting over coffee to compare notes, and sometimes just to be in each other’s company. Slowly, the friendship became something more, a love wrought from the inescapable forces shaping their lives.
“We were friends and companions in this fight,” Mr. Saldaña said. “But we decided to spend our lives together and live this struggle united.”
On his birthday — May 24, 2015 — he moved in with her, shifting his modest belongings into the two-bedroom cinder block flat where she lived with Yunery’s two children.
Their life moves to the same rhythm these days, an odd cadence that is both comforting and isolating. Their friends, even their other children, are afraid of the course they have taken — the endless chase, the constant pressure on state authorities, the media campaigns.
They don’t tell people anymore when they find threatening letters on the windshield of their Volkswagen. Or when strangers call their phones with cryptic, menacing messages, ordering them to stop their crusade. The traumas have drawn them closer as a couple, but farther from their families.
“It just leaves you with so little time to raise and be a parent to the rest of your kids,” said Ms. Delgadillo, whose contact with her two other children tapered off in recent years.
Mr. Saldaña nodded. “One of my daughters called me up recently and said she wanted to chat. We went to a coffee shop and she told me: ‘Dad, please, I want to ask you to stop doing what you are doing. I am scared, scared for you, scared for me and for all of us. Please, just stop.’”
“I told her: ‘How could I stop looking for her? She is my daughter, she is your sister,’” he said. “I will never ever stop looking for her.”
He wiped away a stray tear and cleared his throat.
“It’s like you lose your other children as well,” he said.
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Members from the Colectivo Solecito, a group of women whose children are missing, found more than 250 skulls at this site near Veracruz. Credit Daniel Berehulak for The New York Times

The Dirty War Then — and Now

To disappear has a particular meaning in Latin America, a vocabulary shared by nations that have suffered its tragic distinction. It is not simply to vanish, but to be vanished: forcibly abducted and, often, never seen again.
In the 20th century, the authoritarian governments of Argentina and Chile disappeared thousands of supposed opposition members, robbing spouses, parents and children of closure. Guatemala and El Salvador razed communities of accused sympathizers, both before and during their ultraviolent civil wars.
Mexico took part in the campaign, amassing some 1,200 disappearances during the 1960s and 1970s at the hands of the Institutional Revolutionary Party, which ruled for nearly 70 years and governs again today. Historians call this period of disappearances the dirty war.
But unlike Argentina, Chile or Uruguay, Mexico never really investigated its atrocities. While truth commissions and exhumations of mass graves sought to exorcise the sins of past regimes elsewhere in the region, government responsibility in Mexico largely stayed buried. Attempts in the early 2000s fell apart, leading to few arrests or prosecutions.
As the nation wrestled with that mysterious chapter of Mexican history, another was already starting.
The disappearances continued, in a new form. The numbers were small, the cases isolated and the purpose distinct from earlier iterations. It was not political but criminal.
This time, the disappearances were carried out by organized crime as it battled for territory in the lucrative drug trade. Along the border with Texas, the numbers slowly ticked higher. The government eventually launched a war against organized crime in 2006. And as the violence mounted, so did the disappearances.
The cartels are not the only ones responsible. In hundreds of cases, the military and the police have been accused of disappearing individuals across Mexico’s coasts, deserts and mountains.
The families of victims in Baja California have meticulously documented 95 cases involving the authorities and delivered them to the International Criminal Court with a plea to investigate. Five hundred cases have been recorded in Coahuila and sent to the court as well. Similar disappearances in Chihuahua and Guerrero have also been brought to the attention of international bodies.
Until recently, the disappearances were largely ignored by a government neither willing nor capable of effectively confronting the atrocities. But as families have become more organized, their plight has become harder to ignore.
In 2012, leaked documents showed that the government believed there to be a total of 25,000 people missing across the country, perhaps the first time any official recognition of the problem surfaced. This year, the tally climbed to nearly 33,000.
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The cartel ranch in Veracruz state where Mr. Saldaña and Ms. Delgadillo accompanied officials on a search. Credit Daniel Berehulak for The New York Times

The Search at the Ranch

The convoy left at 6:30 a.m. sharp, a procession of camouflage trucks bearing marines, police officers and officials. Mr. Saldaña and Ms. Delgadillo trailed in a small van transporting the families.
After countless phone calls beseeching the government for help, hundreds of hours chasing down leads, years of rallying other families and stalking officials with a megaphone of grief, Mr. Saldaña and Ms. Delgadillo were getting a shot. Maybe their only shot.
They drove for nearly an hour, slowing in the town of Cosautlán de Carvajal, the last population center before the ranch Mr. Saldaña had heard about. Like many places taken over by organized crime in rural Mexico, the property was scarcely discussed in town. Locals knew not to ask what the armed men were doing up there. They began to whisper as the convoy passed through the narrow streets, wondering what was happening.
Past a creek flowing over an unpaved road, the vehicles came to an entrance. The marines got out and began a clearing operation that lasted three hours.
The ranch, meandering over expansive terrain, had been abandoned. But only recently. The team — a mix of forensic scientists, police officers and investigators — discovered healthy horses, cattle and well-tended sheep roaming around when they arrived.
The couple wandered the grounds in a dream state, led more by instinct than clues. They stumbled on a large metal bin filled with dirt and random pieces of clothing, perhaps, they thought, the belongings of captives.
Having been the engine behind the entire raid, Mr. Saldaña tried to take control, barking orders.
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Ms. Delgadillo and Mr. Saldaña preparing to leave home to search the ranch. Credit Daniel Berehulak for The New York Times
The officials grew weary of his commands. He was pointing to undisturbed earth, where the police dogs caught no scent.
“I’m not simply looking for the remains,” he shouted. “I know you want to find body parts, but I have information that our kids were probably dissolved in acid or burned.”
“I’m looking for buried clothing,” he said, “and ashes.”
A woman from the federal prosecutor’s office intervened.
“All authorities are here to listen to the requests of these two,” she instructed the others.
The next day, they continued searching but came away with more questions than answers. A cinder block room contained a soiled mattress and chains — some grisly torture chamber, the couple imagined. Nearby, a stack of women’s undergarments — bras and panties — tied together.
What other use could this room have had than torturing and imprisoning people, Mr. Saldaña wondered. “No one would even hear if someone was screaming at the top of their lungs from here,” he said.
He and Ms. Delgadillo continued down the hill for another kilometer. He carried a metal stick with a hook fixed on its end, to pry loose items from the soft earth. His hook snagged a piece of clothing, and then another, and another. He laid them in a pile at his feet and called for help.
The forensic specialists took over, drawing a circle around the spot. They dug. An hour later, a pile of 500 items sat before them: baby outfits, women’s blouses, worn-out jeans and shoes.
A profound sadness settled over Mr. Saldaña. He took no comfort in finding the clothes that he had chastised officials to look for, no comfort in being right. It only reminded him how far they were from finding Karla, Jesus and Yunery.
“I wonder if this clothing might be as close as we ever get to our children,” he said to Ms. Delgadillo. “That its very existence means we may never reach them.”
The authorities gave the families one more day to search the property, a stretch of land that would take 10 times that many people a week to cover.
They found nothing else.
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Relatives of missing persons gathered to give DNA samples at a church in Veracruz. Credit Daniel Berehulak for The New York Times

‘A Body, Any Body’

In Veracruz, the missing are not only buried in secret graves. They are also recorded in small black books, where their names and details are lost to the modern age.
The state’s forensic laboratory chief, Rita Adriana Licea Cadena, pulled out a ledger. In it, she said, were the names of thousands of individuals who had turned over their DNA in the hope that it might match some of the remains disinterred from mass graves across the state.
But no one had been able to computerize the records, which were drawn from 2010 to 2013, some of the most violent years in the state. In notebook form like this, the data was virtually useless. No one could realistically search the DNA samples to find a match.
“We just don’t have enough people to do the work,” she said this March.
Outside her offices, a family sat quietly in the lobby, hoping for some news. The families come often, asking questions no one can answer.
“One woman came into my office crying, asking me to give her a body, any body, so she could bury it as her son,” said Mario Valencia, the official in charge of all forensics in the state. “I told her I could not: ‘How can I take someone else’s child to satisfy your grief? What about their grief?’”
The cause of the disappeared was often a forgotten one — until 43 college students vanished at once on Sept. 26, 2014, forcing a national reckoning in Mexico.
The students, who were preparing to become teachers, were heading to a protest in Mexico City. They had commandeered a fleet of buses to get there, a practice more or less accepted over the years.
But that night, the police opened fire, creating a panic that left at least six people dead. The remaining 43 students, frozen in fear, were rounded up by the police and turned over to a criminal gang that the officers were working for.
The motive for the attack has never been fully explained, and after more than three years, only one of the student’s remains has been positively identified.
After the mass abduction, hundreds of thousands of Mexicans poured into the streets in protest. The entire world was shocked. Mexican officials had not only failed to find the students. Some were clearly complicit in the crime.
Scenes of relatives hunting in the forested mountains of Guerrero for mass graves, equipped with little more than picks, shovels and blind resolve, reinforced the extent of the phenomenon.
The public pressure helped lead to a new law, enacted this month, to combat disappearances. Its passage has given some hope that the proper resources and attention might be paid to an issue long bled of both.
“It will not solve the problem, but it’s a start,” said Juan Pedro Schaerer, the director of the International Committee of the Red Cross in Mexico, who helped shape the legislation. “The challenge will be implementing the law.”
On paper, the Law Against Forced Disappearances creates a national registry of the missing, something that is currently maintained piecemeal across multiple lists, by multiple agencies. It should also bring more resources, for forensic investigations and the management of precious DNA information.
“Attending to the disappeared is my main priority, both as a public official and as a human,” said Roberto Campa, the subsecretary for human rights in the country’s interior ministry.
But in Mexico, laws are seldom the issue; on paper, they are often perfect. Rather, change hinges on the will and capacity to enforce them. On this score, advocates for the disappeared have tempered their hopes.
A highly touted legal overhaul, completed last year to replace an antiquated system, is facing an attack from the government that put it into practice.
Amid new laws to protect the nation’s media, more journalists have been killed this year than in any other in recent history.
Meanwhile, anti-corruption efforts passed with great fanfare this year have been met with scandal after scandal and a refusal to investigate.
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Forty-seven skulls were found at the mass burial site in Arbolillo. Credit Daniel Berehulak for The New York Times

Raised Hopes, and Dashed Ones

The couple’s next target — another ranch, this one tucked into the verdant hillsides of central Veracruz — was abandoned when they arrived in late September.
A local lawyer from the prosecutor’s office had agreed to join the pair, out of a sense of solidarity. As they climbed a hill, Mr. Saldaña looked over at the young prosecutor and asked him where his gun was.
The man pulled a bible out of his pocket and said it was all the protection he needed.
Mr. Saldaña told him he was stupid.
Locals living nearby had whispered to Mr. Saldaña that the suspects in his daughter’s disappearance were using the place a few times a month, to conduct business and throw parties.
Mr. Saldaña had decided to take a look. But he agonized over whether to tell Ms. Delgadillo. Even as he packed his bags, walking stick and binoculars, he had still not made up his mind. Feeling guilty, he gave in.
As he had suspected, she immediately began packing her things, waving away his protests. They both knew he couldn’t deny her, not after the last few months she had endured.
In April, the couple had been scouring the state, as usual, asking to review case files, poring over the descriptions and pictures of missing persons. Suddenly, they got a hit.
The girl was short, with the same hair color and complexion as Yunery. Ms. Delgadillo could barely breathe. She begged the authorities to exhume the body for a DNA test.
“It wasn’t my daughter,” she said, sobbing lightly. “But still I feel a sense of peace, that another family has their daughter back, that they can stop looking.”
After that, Mr. Saldaña knew he couldn’t tell Ms. Delgadillo to stay home while he went out on his missions. With the prosecutor in tow, the couple searched the ranch for three hours that fall day, making their way through heavy brush before coming across a set of stables. The entrance was locked. Mr. Saldaña scaled the wall and jumped inside. A flock of bats stirred.
Once again, scattered throughout, were clothes belonging to a mishmash of ages and sexes. Some had been burned, and others were puzzling — like the stack of heavy coats in a state where the temperatures range from hot to infernal.
Further on they found what looked like tombs.
“It could be something,” Mr. Saldaña said, beaming.
They didn’t have the tools needed to open the covers, so they moved on. Later, they heard the sound of all-terrain vehicles, a favorite mode of transport for cartel lookouts.
The three fled, racing down the hill and back to the car.
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Mr. Saldaña and Ms. Delgadillo traveled home by bus after a meeting in Mexico City, last month. Credit Daniel Berehulak for The New York Times

Dreams of the Dead

A crowd of portraits lined the esplanade, taped down against the fierce harbor wind. A woman paused to study them, as if to remember every detail. But most bore only two: the names of missing people and the dates they disappeared, simple facts anchored in mystery.
“I loved you before I knew you, and I will love you to the end of my days,” read one poster with the faces of more than a dozen missing children, arrayed along the branches of a tree.
Mr. Saldaña, watching from the shade, sheepishly approached the woman to ask for help. His daughter was among those faces, he explained, pointing to a portrait of Karla.
“The government is out of money to buy the materials for DNA testing,” he told the stranger, lifting a straw hat from his head and mopping his brow. “So we are raising the money ourselves to pay for it.”
Dozens of other relatives of Mexico’s missing had joined him in the port city of Veracruz that bright Saturday in October, all to raise money for a government that, in their eyes, seemed incapable of helping them — or unwilling to. When told of their campaign, the federal government denied that it was necessary, saying it provides all the resources needed for DNA testing.
“My brother disappeared, too,” the woman told Mr. Saldaña, nodding tightly. A year of searching had produced no leads, she said, not in a state bankrupted by its previous governor, who has been charged with stealing millions of dollars.
“This is our government,” the woman concluded, fishing a small bill from her pocket and putting it into a slotted tin. “They took it all for themselves.”
The sun cast an acid wash over the port as Mr. Saldaña returned to the shade. Cargo vessels trudged in and out of the channels. Shipping cranes lined the sky like origami birds.
The other families waded into the blistering heat to approach passers-by, or to give chase when the breeze blew away the portraits of their children.
Everyone except for Ms. Delgadillo, who remained in the sun for most of the day, tending to all the portraits as if each one were her child.
It was humbling work. Most pedestrians slid past without a word. A few even picked up the pace when they saw a parent approaching.
“You sometimes wonder how it is that someone can’t even give one dollar,” Mr. Saldaña said, after being blown off by a Frenchman on holiday. “I guess they just don’t know what we are living.”
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Ms. Delgadillo cried after flipping through a photo album of her missing daughter, Yunery. Credit Daniel Berehulak for The New York Times
Kindness surfaced in unexpected places. Christian Carrillo Rios, an employee at the state victim’s assistance program, arrived with the parents shortly after 9 a.m., wearing a collared shirt and starched jeans in the stifling heat.
He crawled on the ground to tape down the portraits and chased spare change as if he, too, had lost someone. Ashamed that his office had refused to pay for refreshments for the families, he bought water and snacks on his own dime.
“I’ve always cared about this issue, but when I had a son last year it all changed,” he said, his voice breaking. He cleared his throat and shook his head. “If someone were to take my child from me, I don’t know how I could go on living.”
Two young brothers were so moved by the stories of loss that they raced home to retrieve the contents of their piggy bank. They returned with a bag full of change covered in bits of smashed clay.
A father who heard about the campaign on the radio took his entire family. He listened to a mother talk about her lost son while holding the hand of his own, weeping. Before he left, he emptied his wallet into the collection box.
“Most of the time we feel impotent and powerless, but when you see the goodness of people it gives you strength,” Mr. Saldaña said.
The families stood outside for 10 hours that day, until sunset, earning a little less than $600 — the equivalent of three DNA tests.
As a couple, Mr. Saldaña and Ms. Delgadillo have decided to adopt a new approach to mourning. Instead of learning to live without their children, they are trying to live with them. To celebrate them every day.
This October, the couple decided to throw their daughters a joint birthday party, with cake, candles and balloons. The girls’ birthdays were only days apart.
Mr. Saldaña and Ms. Delgadillo wanted to invite their extended family — the other parents, husbands and wives who had lost someone.
“We wanted to do something happy with them,” Mr. Saldaña explained.
“This way, until we find them, we will keep them present in our lives,” Ms. Delgadillo added.
But their plans soon gave way to reality, and there was no party. Between the trips up and down the state and basic necessities, they had no money for it.
Despite everything, Mr. Saldaña said he was filled with more hope these days than ever. He dreamed about Karla, felt her close to him, as if the end was near.
In a recent dream, he confronted the men responsible for Karla’s abduction. With an arsenal of automatic weapons, he fought them like an action hero, leaving no survivors.
In the dream, he said, it was up to him and no one else. No failing system, numb to his pleas. No crooked cops or courts that so often failed to reach convictions in Mexico. Only justice.
“If you kill them,” he said, “at least it’s over.”
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Ms. Delgadillo and Mr. Saldaña in front of their home. “We decided to spend our lives together and live this struggle united,” he says. Credit Daniel Berehulak for The New York Times