Lorena let the nurse's call go to voicemail on her cell phone as she sold Mexican candies and trinkets out of an apartment in northwest Houston. She deleted the message, once again ignoring the words "urgent" and "please come in."

There would be more calls in the days to come. All erased.

The possibility of cancer has gnawed at Lorena since she was diagnosed with abnormal cells in the cervix a little over two years ago. She has missed seven appointments from September through November, deferring medical treatment that could prevent the condition from developing into cervical cancer.

An undocumented mother of two, Lorena fears what she considers a more immediate threat. She says she doesn't want to go to the hospital. She is afraid that if she does, someone will call immigration and she will be taken away from her daughters.

Lorena, 26, who asked that her surname not be used, is like numerous other undocumented immigrants in Houston, weighing health care needs against the increased odds of deportation, according to interviews with dozens of patients, medical professionals and health care administrators.

The Harris Health System, one of the largest public healthcare systems in the nation, has yet to record a significant decline in patient numbers across its network of clinics and its two major public hospitals, Ben Taub and Lyndon B. Johnson, president and CEO George Masi said.

But he acknowledges that it's a hard to prove a negative and says this is an issue that's tricky to quantify.

There is anecdotal evidence on the streets and at clinics and non-profit advocacy agencies across Greater Houston that the Trump administration's immigration crackdown has led undocumented immigrants — and some legal residents — to avoid seeking medical care to stay out of reach of immigration authorities.

"The city with the largest medical center in the world shouldn't have people afraid of seeking medical care," said Francisco Arguelles, executive director of the Living Hope Wheelchair Association, a non-profit that supplies wheel chairs and other medical hardware to the infirm, regardless of immigration status.

Immigration and Customs Enforcement classifies medical facilities as "sensitive locations" where raids are prohibited. But fear among the city's 600,000 undocumented immigrants that leads to delayed or deferred care has potentially significant public health implications for all Houstonians.

Lorena, still holding off on seeing a doctor for her cervical condition, spent a fall Sunday morning in her northeast Houston home, breast feeding her 4-month-old while her 5-year-old cooed at her baby sister. The lights on their white Christmas tree dimly lit the room.

Lorena's mother, Alma, peeked in from the kitchen now and then.

She has pleaded with Lorena to get treatment for her condition, if not for her own sake, then for the girls. Undocumented herself, Alma understands her only child's reservations.

"Immigration officers," Alma said, "are more terrifying than an illness."

***

A New America Aggressive federal enforcement, controversial laws and heated political rhetoric are pushing Houston's immigrants – documented and undocumented – deeper into the shadows. Click here to read more stories that show why immigration matters in Houston.

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At Centro de Corazon, a longtime resource for Houston's immigrant community, nurses reported a near 50 percent drop in the number of undocumented prenatal care patients in August.

The six Houston clinics run by the Ibn Sina Foundation, a nonprofit that provides free or low-cost medical care, reported a more than 50 percent decline in undocumented patients since September.

A NEW AMERICA: Five storylines that show why the immigration debate matters in Houston

Even private practice clinics that specifically cater to cash-paying undocumented patients saw an initial dip in no-shows around May, clinicians said.

"The health of a community is only as good as the weakest link in the health care chain," said Masi, the Harris Health CEO.

Policies that drive the undocumented underground and away from treatment need to be reassessed, he says, "if not out of compassion, it's out of good public health policy."

A Kaiser Family Foundation study released this month found evidence of decreased participation in Medicaid and the federal Children's Health Insurance Program nationwide. In some cases, legal residents worry of backlash in accepting government aid. In others, undocumented parents fear their citizen children's information could be used against them.

The Kaiser study also found that children in immigrant households face the risk of anxiety, depression and other mental health issues as their parents' fears grow.

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While much of the focus has been on physical health, Glenn Urbach, executive director of National Alliance on Mental Health of Greater Houston, is also worried for the untold numbers of undocumented immigrants who are reluctant to begin or continue psychiatric treatment.

"It's a chronic and lifelong condition that is treatable and needs to be treated," he said. His staff and volunteers are already hearing from families who are skipping medication or therapy for fear that the paperwork will somehow create a roadmap for immigration officers.

Providers and patients point to aggressive federal immigration enforcement this year, as well as Senate Bill 4, which allows local law enforcement officers to question a detained person's legal status.

In Texas, the Children's Health Insurance Program experienced a decline in new enrollment between June and July, dropping to 29,106 from 37,523. Because SB4 had only just been passed, it is unclear if the decline was triggered by the legislation, or was a one-time anomaly.

Missing even routine appointments can lead to costlier treatments down the line when patients can no longer avoid a hospital and arrive in the emergency room, said Karen Mountain, CEO of the national Migrant Clinicians Network based in Austin.

"If we catch it earlier, in a non-emergency primary care setting, the cost of care is less and the treatments are often more successful, and patients will be more likely and able to pay their co-pay, return to work, and lead healthy and productive lives wherein they can contribute to our local communities," she said. "The hospitals and clinics, in turn, aren't stuck with costly procedures for which the patient is unable to pay."

Many conservatives, worried about what they see as a strain on the nation's services, say health care for those in this country illegally is simply too expensive and legal residents should not have to foot the bill.

But it remains unclear just how expensive such health care is. Studies have shown that undocumented residents tend to use less health care services than U.S.-born citizens.

Elena Marks, president and CEO of Houston's Episcopal Health Foundation, said that those without legal status pay sales and property taxes, and often income and payroll taxes, which in turn not only contributes to the overall economy but also supports federal and local health care services.

Many undocumented immigrants rely on low-cost or free community health clinics. But such services groan under the weight of demand. By some estimates there is only one low-cost community clinic for every 85,000 unauthorized residents.

Or they go to emergency room.

Under the 1986 Emergency Medical Treatment and Active Labor Act, by law emergency room doctors and nurses must assess and stabilize all patients regardless not only of ability to pay but also legal status.

Porfirio Villareal, a spokesman for Houston Health Department, cautions that delayed or skipped treatments could have effects far beyond immigrant communities.

Communicable diseases, like tuberculosis or even childhood ailments like measles, are easily treatable and contained as long as people seek treatment. If not, they can worsen quickly for the patient but also spread across wide swaths of the community. Consider, he and others said, child care workers, fast food employees, or simply the person standing in line at the store. If that person skips or has no access to vaccinations or is too fearful to follow-up after a diagnosis, it becomes everyone's problem, he said.

"This is not just an immigration issue. This is a public health issue," Villareal said.

At the Association for the Advancement of Mexican Americans, or AAMA, there is concern over the potential of spreading HIV in Houston. The advocacy organization partners with the Ryan White HIV/AIDS program to provide treatment and medicine for those who qualify, including undocumented immigrants.

Clients already receiving care haven't shied away from services, similar to patients at Harris Health's dialysis center that treats many undocumented immigrants. But the HIV program has hit a snag in recruitment.

In previous years, AAMA would typically register five to eight new HIV patients a month, said Steven Vargas, a program coordinator. Since the presidential election, the range is now 0 to 2.

Through conversations with existing registered patients and a review of their numbers, Vargas attributed the drop-off to increased fear among Latino and African undocumented immigrants who do not wish to share any personal information for a federally funded program.

HIV patients can die or spread the disease if they don't keep to a strict schedule of medication and doctor visits, Vargas said.

If fear of laws such as SB4 keep HIV positive immigrants from being tested or treated, he added, they may put sexual partners at risk of contracting the disease.

After Arizona passed its own "show me your papers" law, Mexican teen mothers avoided seeking preventative care for themselves and their infants.

Prenatal care is critical for HIV prevention, Vargas said, since most Latinas learn their status during those visits.

If forcibly removed from the country, Vargas added, HIV patients are essentially given a death sentence.

***

When Noe Ramirez came to Houston from Mexico 20 years ago as an undocumented immigrant, the plan was to work for one year. He would buy a car and drive it back home, where he could work as a taxi driver.

Then one early morning, as he rode his bike on a quiet street, a car kept swerving behind him. One second he sat upright, hands on the handlebars. The next, a car tire pressed down onto his chest.

He remembers the driver telling him to get up. He remembers someone yanking at his arms, a pool of his own blood forming around him. By the time he gained full consciousness, he was speaking to a doctor, and was a quadriplegic.

Shortly afterward, his wife, also undocumented, came to Houston to care for him. Later, they sent for their daughter and planted roots.

'LIVING IN FEAR': Immigrants pen powerful thoughts on postcards

Today, Ramirez teaches guitar lessons at his home and is co-founder of Living Hope Wheelchair Association, the non-profit that provides wheelchairs, catheters and other items to the medically needy, including many undocumented immigrants.

Recently, more than 20 association members, all in wheelchairs and of mixed immigration statuses, gathered at the non-profit's northwest Houston office and warehouse for a meeting. Francisco Argüelles, the executive director, passed out a draft letter describing their affiliation with the group and their ties to their work in community for use in court, should they become involved in immigration proceedings.

If they are deported, Arguelles said, what awaits them is a life with no access to public transport, no rights to challenge venues without wheelchair accessibility, and a limited supply of proper medication.

***

There is no blanket protection from deportation for individuals with chronic conditions, immigration lawyers say. One attorney, Mana Yegani, cited one case last year in which a cancer patient was held in an immigration jail.

Under an executive order President Trump signed in January, all undocumented immigrants are now the priority for detention and deportation.

"Humanitarian factors are given very little consideration," Yegani said.

The case of 10-year-old Rosa Maria Hernandez has recently become a potent national symbol of how far immigration enforcement has gone.

The undocumented minor with cerebral palsy was detained at an immigration checkpoint earlier this year on her way to Corpus Christi for gallbladder surgery.

U.S. Border Patrol followed her to Driscoll Children's Hospital and kept guard outside her room until she was discharged, according to the American Civil Liberties Union. The agents then detained the girl and took her to a children's detention facility, away from her family in Laredo.

Though the ACLU won a lawsuit to free her from custody, the girl's case has just begun.

"It's had a chilling effect," said Nancy Vera, a leading advocate for Hispanic and other immigrant groups in Corpus Christi. "I'm hearing they don't trust any hospital, not just Driscoll. They don't trust anybody. This is just inhumane."

"How is it that people who live here, people who pay taxes, who are helping to rebuild our communities after the hurricane are too afraid to get health care?"

***

After enough prodding from her mother, Lorena finally stopped deleting calls on her cell phone and returned for a check-up on Dec. 1. She underwent a biopsy.

Whether she will actually go in to learn the results, she can't say.

For now, she occupies herself with her small candies and trinkets business, selling her wares Monday through Saturday, often choosing to sleep in the rented space with her daughters, who she calls the loves of her life.

One recent morning, she tucked the girls into their car seats while her mother secured the coolers of food they would sell at an immigration rights function.

As she adjusted her rearview window, she fought to suppress a coughing fit.

"Today, I'm fine," she says. "Tomorrow, who knows."

***

Ileana Najarro is a business reporter at the Houston Chronicle. She can be reached by email at Ileana.Najarro@chron.com or you can follow her on Twitter: @IleanaNajarro.

Jenny Deam writes about how the changes in today's health care touches patients, doctors, hospitals and insurers on a personal level and in business. She also writes about the burgeoning medical/tech industry in Houston. Contact Jenny by email here or follow her on Twitter at @jenny_deam.