In the three decades he’s lived in Oakland, Ian Simmons has watched family members struggle with obesity and type 2 diabetes, including a close relative he feels will die because she consumes only sugary drinks, never water. He watched a high school friend go cold turkey to break a two- or three-soda-a-day habit.

“It was like he was going through heroin withdrawal. It was insane,” Simmons said. “People drink soda as their only liquid intake and that’s scary.”

For the last few months, he’s been watching ads on Twitter and receiving mailings at home that call Measure HH a “regressive” tax on groceries—meaning it will affect the poor more than others. The measure, as written, is a proposed one-cent-per-ounce tax on sugar-sweetened beverages in Oakland paid by the distributors of those beverages.

Simmons plans to open a grocery store in Oakland by the end of the year. Even as someone who would have to deal with the tax if Measure HH passes on November 8, he still isn’t buying into the $5.4 million No on HH campaign that says the measure would increase in the price of groceries for all his customers.

“Anyone who has the money to do that only cares about their own interests. They don’t care about the poor. They don’t care about Oakland. They don’t care about the community,” Simmons said. “Anyone who sends me something in the mail every day, it’s hard for me to believe you.”

Instead, he believes Measure HH would increase the cost of sodas, making them less affordable to people who overconsume them and develop diseases because of it. “It should affect the poor,” he said. “It’s not a bad thing if it affects them health-wise.”

Modern science is slowly unraveling the link between sugar and preventable diseases, and many health professionals say it is more detrimental to human health than it’s been sold for decades. Overconsumption of sugar can lead to tooth decay and loss, type 2 diabetes, heart disease, certain types of cancer, and, among other related problems, obesity. These conditions also affect the health of minorities, the young and the poor more than anyone else.

A person’s health in Oakland, much like the rest of the country, is often highly dependent on a person’s means. People who earn the least often live in “food deserts,” or neighborhoods with few grocery stores that offer fresh produce, leaving them to rely on corner stores and smaller markets for food. According to a 2014 report on obesity in Alameda County, there were five times as many fast food restaurants and convenience stores than supermarkets and produce vendors across the county in 2007, the latest figures available. These are the places where sugary drinks are at eye-level or standard with fries in a combo meal.

In a study released last year by the U.S. Centers for Disease Control and Prevention, one-fifth of Bay Area students reported drinking a sugar-sweetened beverage during school lunch, half which were purchased on their way to school.

Dr. Nora Garcia-Zepeda, a pediatrician at Kaiser Permanente’s La Clinica Salud en Espanol, says numerous environmental factors—such as income level and lack of access to healthy food—can increase a person’s likelihood of becoming diabetic or obese.

“It’s a huge problem,” she said. “It’s as if the new norm is to be a little overweight.”

Another factor, she said, is that food assistance programs—like WIC benefits—cover sugar-sweetened beverages, including apple and other juices that contain the same amount of sugar as soda. “It’s really just concentrated sugars with no nutritional value,” she said referring to apple juice, adding it’s most often the biggest surprise to people who drink it.

The Alameda County report found more than half of adults and a third of children in fifth, seventh, or ninth grade were overweight or obese. It also found diabetes and nutrition-related disorders were among the 10 most common reasons children were hospitalized in 2011.

According to a 2016 study of nearly 8,000 children at obesity intervention programs at Kaiser Permanente locations in Northern California, including Oakland, obese children of color tend to have higher rates of unhealthy behaviors, like daily consumption of multiple sugary beverages, than white children. African American children ages 6 to 11 were 1.8 times more likely to drink two or more sugary drinks a day than white children, researchers found.

“Nearly two-thirds and three-fourths of black and Hispanic school-aged children and adolescents reported excess consumption of [sugar-sweetened beverages]/juices on a daily basis,” the study, published in the Journal of Obesity, concluded.

Statewide, about 40 percent of all Californians are either diabetic or pre-diabetic, according to the UCLA Center for Health Policy Research. These conditions are highest among young adult Pacific Islanders, African Americans, American Indians, multiracial Californians and Latinos.

In Alameda County, according to the 2014 figures, fewer than 5 percent of white people have diabetes. Among Latinos, it’s nearly 10 percent. For African Americans, it’s nearly 13 percent. The neighborhoods with the highest obesity rates—greater than 27 percent of the population—are in East and West Oakland, areas historically home to large African American and Latino populations.

While living below the poverty line—which U.S. Census Bureau data shows nearly a third of Oakland children do—used to be associated with starving, it now means a person is more likely to be obese and have related health conditions, because the food they can afford is often higher in calories and lower in essential nutrients.

Dr. Cecily Wait is pediatrician and an internist—a medical interest that tracks a person from infancy to adulthood—at La Clinica de la Raza in Fruitvale. There, she sees teenage mothers feeding their infant children orange soda. She once had a 42-year-old obese patient suffer a heart attack. For her, it seems disease onset has shifted 20 years earlier, meaning that diseases doctors once saw in the elderly and middle aged are now turning up in young people.

“When I see a 7-year-old approaching my weight, that’s when I have a problem,” Wait, an athletic woman who eats vegetarian tacos and then runs five miles, said. “When it becomes normal for people to have heart attacks in their 40s, that’ll be a come-to-Jesus moment.”

One major problem, Wait said, is that too often people don’t pay any attention to the calories they consume through beverages. A 20-ounce soda typically contains about nine teaspoons of sugar. Juices, sports drinks, and energy drinks typically contain between five to 12 teaspoons per 12-ounce serving. These can add up, especially if you’re not counting.

“It’s hard to get people to stop drinking sodas,” she said. “Everyone wants their kids to be happy, so they give them a soda because it makes them happy.”

Another thing Wait sees on some of her obese patients is a dark patch of skin that accumulates on the back of a child’s neck, an outward sign of the body’s inability to produce enough insulin to combat the levels of sugar being consumed. Its appearance means a child could be either pre-diabetic or has already developed type 2 diabetes.

“It’s not dirt. You can’t scrub it off,” Wait tells parents.

Obesity and diabetes are the cornerstone conditions on which proponents of Measure HH have built their campaign, hoping to raise prices on sodas, the way other “sin” taxes are applied to tobacco and alcohol, and using the money to fund city health measures.

This year, Oakland, San Francisco, Albany, and Boulder, Colorado, have taxes on their ballots modeled after the one that passed in Berkeley in 2014, the only successful ballot initiative in the U.S. to tax drinks based on sugar volume, or the one from Philadelphia, which passed a tax through its city council in 2015. In the Berkeley model, the tax goes into the city’s general fund. A panel of experts and community members oversee where those funds are spent; in Berkeley, the funds have gone to public health initiatives, including those to reduce obesity and diabetes rates through nutrition and exercise programs.

These taxes are supported—in policy and sometimes in funding—by major medical groups like the World Health Organization, which announced this week that price increases of 20 percent on sugary drinks would discourage consumption and lower the rates of diseases associated with them. The Cook County, Illinois, Board of Commissioners is also considering a sugary drink tax.

But some local market owners and representatives of soda makers fear the tax would spill over to other items, arguing that raising the price of things people buy on a daily basis would make an already expensive city that much harder to live in. Joe Arrellano, a San Francisco-based consultant and spokesman for the No on HH campaign, called Measure HH “a grocery tax” that will raise the high cost of living in Oakland, “and we have higher priorities to deal with.”

Arrellano wrote in an e-mail that HH is “a money grab.”

“Not a cent goes directly to health or wellness programs and that’s because Oakland politicians wrote the measure so the funds go into the city’s general fund, where they can use it for whatever they want,” he wrote.

To earmark funds specifically for health initiatives, the measure would have been written to require a two-thirds vote. Instead, the measure needs a simple majority vote and creates a committee to oversee the funds, much like Berkeley’s measure.

Campaigns against sugary beverage taxes typically center on arguing that they are taxes on groceries. They say that the costs paid by the distributors will be handed down to the store owners, who, in turn, will raise the costs of all their items, including groceries. Last month, an Alameda County judge ruled that the language used on the ballot measure, stating that the tax “is not paid by your local grocer,” is accurate.

Ads and mailers sent to Oakland residents feature grocery store owners of color saying how the taxes will hurt their businesses. “Shame on billionaires and politicians for trying to raise the price of groceries just so they can feel good about themselves,” Abdul Taleb, owner of Mi Carnal Market in East Oakland, says in the latest ad.

Another ad urges voters to “do the research for yourself” by going to a beverage trade group-funded website that lists, among other things, that “out-of-state billionaires are running misleading ads to pass Measure HH.”

According to a report by the Center for Science in the Public Interest released last month, what they label “Big Soda”—the American Beverage Association, Coca-Cola, and PepsiCo—has spent $67 million from 2009 through August 2016 to oppose public health measures aimed at reducing soda consumption. Of that, more than $2.4 million was spent on Berkeley’s measure. That report, released September 21, counted $747,268 spent against Measure HH in Oakland. It’s increased more than seven-fold since then.

Of the $5.4 million in disclosed contributions in opposition to the tax filed as of October 17—most of which has been spent on advertising, mailers, and consultants—all has come from the American Beverage Association’s California political action committee, which has previously funded anti-tax or warning label campaigns at the state and local level. The American Beverage Association is a trade group representing major producers of sugar-sweetened beverages.

In other Bay Area cities that attempted soda taxes or warning labels—including Richmond and San Francisco—soda makers funded campaigns against the taxes calling themselves citizens’ groups in favor of “beverage choice.”

According to the nonprofit Ninjas for Health, leaked emails allegedly show Coca-Cola employees engaging in “coalition-building work” as early as February to mount “coalitions” against potential sugary beverages taxes in Oakland, San Francisco, and Watsonville, California. The group based their piece, published on Medium, on emails obtained by the “hacktivist” group DCLeaks.

This is on top of the millions that, according to a 2015 New York Times investigation, Coca-Cola has spent on influencing academics in obesity and diabetes research who conduct soda-related research. It’s a practice that dates back to the 1960s, when the sugar industry paid researchers, including those from institutions like Harvard University, to shift the dietary culprit of coronary heart disease from sugar to fat, according to research led by Cristin Kearns, a researcher at the Philip R. Lee Institute for Health Policy Studies, at UC San Francisco.

From 2011 to 2015, Coke and Pepsi sponsored 96 health organizations while simultaneously lobbying against 29 public health bills aimed at reducing sugary drink consumption of improving nutrition standards, according to a study published in the October, 2016, edition of the American Journal of Preventative Medicine.

Katherine Schermerhorn, director of public affairs and communications for Coca-Cola North America, said Coca-Cola no longer uses health experts “to place responses in media, either directly or through our PR agencies, and we have not done so for some time.”

Since 2010, Coca-Cola has provided $135.4 million in funding to scientific research, and health-related programs and professionals. To support transparency, Coca-Cola released a searchable database of those contributions, Schermerhorn said.

“Even though we stressed the transparency of these relationships in the past, we realized in some instances it was causing some confusion and we wanted to remove any questions or concerns regarding those relationships,” she said.

Schermerhorn says Coca-Cola believes in working with government and the rest of society about calorie reductions goals and other measures, which are “more effective than discriminatory taxes.”

“We are listening and learning from leading experts in the public health community on our journey to becoming a more helpful and credible partner in this effort,” she said.

Schermerhorn declined to comment on the leaked emails regarding early “coalition-building” efforts in cities like Oakland, referring the question to the American Beverage Association.

William Dermody, the American Beverage Association’s vice president of policy, did not respond to questions regarding the influence of the soda industry on medical research by press time.

While measures aimed at taxing soda have been dwarfed by large-scale campaigns funded by the American Beverage Association, there’s increasing financial support from media billionaire Michael Bloomberg, who unsuccessfully tried to restrict sugary beverages over 16 ounces in New York City while mayor there in 2012. Since then, he’s invested millions in local and nationwide efforts to tax sugary drinks by the ounce. He’s backed taxes not only in Berkeley, but also Philadelphia and a nation-wide tax in Mexico.

In Oakland, the pro-HH side has raised $4.9 million as of October 17, the majority of which has come from Bloomberg. Recent smaller donations have come from the California Dental Association, dentists, doctors, Oakland residents and professional health organizations.

While spending to rally votes for or against Measure HH now exceeds $10.3 million, funding for public health programs to prevent or treat these diseases pales in comparison. The Alameda Public Health Department’s diabetes program, for example, was allotted $505,712 this year. The education and support-based diabetes program serves between 125 and 140 people a year, mainly seniors.

The head of that program is Brenda Yamashita, who has been working in diabetes care for 19 years. She said during that time cases of childhood diabetes have increased, although the condition used to primarily affect seniors. She, too, says that her patients do not always know how much added sugar in their diets come from juices and sodas. When Yamashita was young, in her family, those beverages were for special occasions and parties. “Our usage of the drinks have changed,” she said.

Part of that usage is because of the sheer amount of advertising food and beverage makers leverage towards the young, poor and people of color. From celebrities like Beyoncé and LeBron James appearing in ad campaigns for soda to beverage makers offering schools money for exclusive distribution rights, African American children and teenagers see, on average, twice as many ads for sugary and energy drinks on television than their white counterparts, according to a report released in September by the Union of Concerned Scientists (UCS). Spanish-speaking children’s televisions shows also feature more fast food ads than English speaking ones, according to the report.

“Children of color and low-income children are put at particular risk, victims of a one-two punch of being targets of junk food marketing campaigns and having less access to healthy food options,” the UCS report states. “By targeting children of color disproportionately, food companies are knowingly exacerbating health disparities in the United States in order to boost their bottom lines.”

The UCS report did mention one specific measure that helped improve nutrition to the poor without a ballot initiative: the Alameda County Community Food Bank, which began providing healthier options, like fresh fruits and vegetables, to those who use their services. During fiscal year 2015, they distributed 17.8 million pounds of fresh produce to its patrons, making up more than half of all food they distributed that year, according to their annual report.

At both La Clinica offices, doctors like Wait and Garcia-Zepeda work with patients on an individual and familial level. They want parents to model healthy behavior for their children, although they recognize many of the families they serve have parents working long hours at multiple jobs, common among Oakland’s working class.

“As a nation, we’re bad with how we subvert our stress, so we eat,” Wait said.

“It’s way cheaper to eat fast food,” Garcia-Zepeda said.

And that’s the reality for many people in Oakland: Their health is dependent on what’s available to them, and too often what’s available isn’t healthy.

Simmons, the future grocer, wants to change that, at least for the people living in North Oakland where he plans to open his store. Simmons, who is currently working as a landscaper, envisions it as part general store, part space to host community events—a place where people can go to see some familiar faces.

There will be fresh produce, he says. But there will most likely be sodas, too—even though, as he’s seen with family and friends, Simmons believes soda can be bad for people’s health. After all, he knows stores have to make money to stay open.

Maybe, he said, they will be local brands, rather than those whose names you might already know. And if the tax passes, the sodas in his coolers will be more expensive and people may think twice about buying them. That’s the point of it, he says.

“You have to be realistic and know your customers,” Simmons said. “I am not technically a grocer yet, but I’m for this tax.”