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by Bianca Fortis

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In a stunning shift, Columbia University announced on Monday a sweeping series of changes to address the school’s failures to protect patients who were sexually assaulted by a Columbia doctor.

A ProPublica investigation, published in collaboration with New York Magazine, found that Columbia had failed to act on years of warnings as Robert Hadden, an OB-GYN, abused at least hundreds of patients during his 25-year career at the university. In 2012, administrators allowed Hadden to continue seeing patients even after he was arrested for assaulting a patient.

The story prompted waves of criticism toward Columbia. State Assembly members held a press conference on campus. A unanimous resolution by the university senate said that the Hadden revelations have “shaken our community to the core.”

In Monday’s announcement, the university said it would commit to an external investigation to examine systemic failures that allowed Hadden’s abuse to continue. It also said it would notify nearly 6,500 former Hadden patients about his crimes. Columbia will also open a $100 million survivors’ settlement fund for those who don’t want to go through the court system.

The university had long sought to distance itself from the scandal, placing blame solely on Hadden. Columbia had refused demands from survivors that the school notify all of Hadden’s patients. It hadn’t commissioned an external investigation and had aggressively fought lawsuits filed by survivors.

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Hadden was convicted in federal court of sex crimes in January, and he is now serving a 20-year prison sentence. More than 600 patients have so far come forward to allege abuse.

“Columbia failed these survivors, and for that we are deeply sorry,” President Minouche Shafik and Columbia University Irving Medical Center CEO Katrina Armstrong said in a statement on Monday.

Columbia’s announcement comes just ahead of a looming deadline for survivors to file suit against the university. The Adult Survivors Act, put into law in New York last year, opened a one-year lookback window, during which survivors can file civil suits against perpetrators of sexual abuse, or institutions that protected them, even if they are past the statute of limitations. The deadline closes on Nov. 23.

The university has previously settled civil suits with 226 patients for $236.5 million.

Marissa Hoechstetter, a former Hadden patient who pushed for the Adult Survivors Act, said she was glad Columbia finally acted.

“This is what we’ve been asking them to do,” Hoechstetter said. “This is good. But we need to continue to hold them accountable and see what comes of this and continue to support survivors.”

Still, Hoechstetter said, the $100 million figure will likely be too low. “We don’t yet know the full extent of his crimes,” she said.

by Joshua Kaplan, Justin Elliott, Brett Murphy and Alex Mierjeski

Update, Nov. 13, 2023: This story has been updated throughout.

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The Supreme Court on Monday released a code of conduct governing the behavior of the country’s most powerful judges for the first time in its history. But experts said it was unclear if the new rules, which do not include any enforcement mechanism, would address the issues raised by recent revelations about justices’ ethics and conduct.

The nine-page code, with an accompanying five pages of commentary, was signed by all the sitting justices and covers everything from the acceptance of gifts, to recusal standards, to avoiding improper outside influence on the justices. The step followed months of reporting by ProPublica detailing undisclosed gifts to Supreme Court justices from wealthy political donors.

The code does not specify who, if anyone, could determine whether the rules had been violated.

The new Supreme Court code’s lack of any apparent enforcement process is “the elephant in the room,” said Stephen Vladeck, a law professor at the University of Texas who studies the court. “Even the most stringent and aggressive ethics rules don’t mean all that much if there’s no mechanism for enforcing them. And the justices’ unwillingness to even nod toward that difficulty kicks the ball squarely back into Congress’ court.”

Nevertheless, some leading observers of the court described the creation of an explicit, written code as a landmark in the court’s 234-year history.

“The Supreme Court’s promulgation of a code of conduct today is of surpassing historic significance,” former federal appellate judge J. Michael Luttig told ProPublica. “The court must lead by the example that only it can set for the federal judiciary, as it does today.”

A statement released by the court on Monday accompanying the code said it was formulated to dispel “the misunderstanding that the Justices of this Court, unlike all other jurists in this country, regard themselves as unrestricted by any ethics rules.” It said the code “largely represents a codification of principles that we have long regarded as governing our conduct.”

A series of ProPublica stories this year detailed a pattern of behavior by Supreme Court justices that legal ethics experts said was far outside the norms of conduct for other federal judges. ProPublica disclosed that Justice Clarence Thomas has accepted undisclosed luxury travel from Dallas billionaire Harlan Crow and a coterie of other ultrawealthy men for decades. Crow purchased Thomas’ mother’s home and paid private school tuition for a relative Thomas was raising as his son. Thomas also spoke at donor events for the Koch network, the powerful conservative activist group. Separately, ProPublica revealed that Justice Samuel Alito accepted a private jet trip to Alaska from a hedge fund billionaire and did not recuse himself when that billionaire later had a case before the court.

Reporting from other outlets, including The Washington Post and The Associated Press, has added to the picture. The New York Times revealed that Thomas received a loan from a wealthy friend to purchase an expensive RV. A Senate investigation later found Thomas did not repay the loan in full.

Federal judges below the Supreme Court have long been subject to a written code of conduct, the foundations of which were set down a century ago following a major ethics scandal in the judiciary. Lower court judges are subject to oversight by panels of other judges, who review allegations of misconduct.

The high court’s new code of conduct is separate from an existing federal law that requires all federal judges including the justices on the Supreme Court to annually report income, assets and most gifts on a publicly available disclosure form. The law, which passed after the Watergate scandal, has been at the center of the controversies involving Thomas’ undisclosed gifts. Thomas and Alito have argued they were not required to disclose the luxury travel, and Thomas’ lawyer has said that “any prior reporting errors were strictly inadvertent.”

The new document largely echoes the code that applies to lower court judges. Many of its prescriptions are lofty but vague. It requires the justices to “act at all times in a manner that promotes public confidence in the integrity and impartiality of the judiciary.” It prohibits justices from soliciting gifts, practicing law or sitting on cases where their “impartiality might reasonably be questioned.” It states that the justices should not engage in “political activity,” but it does not define what that means.

Court observers are likely to spend weeks parsing the differences between the new code and that of the lower courts. Small changes were made without explanation. For instance, lower court judges are prohibited from lending “the prestige of the judicial office to advance” their own private interests. The justices are merely prohibited from “knowingly” doing so.

Whether any of the conduct that sparked the push for a formal ethics code would now be prohibited seems to remain open for interpretation. Take Thomas’ appearances at Koch network events. A federal judge told ProPublica that if he’d done the same as a lower court judge, it would’ve violated prohibitions against fundraising and political activity and he would’ve been subject to a disciplinary proceeding. It’s unclear if the high court’s new code would bar such activities or if each justice would answer such questions for him or herself.

Sen. Sheldon Whitehouse, D-R.I., who has introduced a bill that would require the Supreme Court to adopt an enforceable code of conduct, said in a statement that the new code fell short of what is needed.

“The honor system has not worked for members of the Roberts Court,” he said. “This is a long-overdue step by the justices, but a code of ethics is not binding unless there is a mechanism to investigate possible violations and enforce the rules.”

Whitehouse’s bill advanced out of the Senate Judiciary Committee in July, but it has since stalled in the face of GOP opposition. It would create an enforcement mechanism for the court’s code of conduct and set up a process where panels of appellate judges would investigate potential ethics violations.

It’s unclear whether the court’s release of the code will affect the ongoing Senate investigations into justices’ relationships with businessmen and others involved in undisclosed travel and gifts. For months, the Senate Judiciary Committee has been seeking information from Crow and others about undisclosed gifts to Thomas.

Last week, Senate Judiciary Democrats deferred an effort to subpoena Crow in the face of intense Republican opposition on the committee. Sen. Dick Durbin, D-Ill., the panel’s chair, said last week the committee would continue its efforts to authorize subpoenas in the near future.

The court’s new ethics standards are in many ways more lenient than those governing employees of the executive and legislative branches. There are still few restrictions on what gifts the justices can accept. Members of Congress are generally prohibited from taking gifts worth $50 or more and would need preapproval from an ethics committee to take many of the gifts Thomas and Alito have accepted.

Jeremy Fogel, a retired federal judge in California who had publicly called for the Supreme Court to adopt an ethics code, said Monday that he was “heartened to see that the justices unanimously have recognized the need for an explicit code of conduct.”

“Whether it will make a difference in the justices’ day-to-day actions or in public perceptions of the court remains to be seen,” Fogel said.

by Melissa Sanchez and Maryam Jameel

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When dairy workers die on farms across the country, the circumstances are often similar: They drown in manure lagoons, get crushed by skid steers, are trampled by cows.

But whether the government investigates their deaths depends on factors that advocates for worker safety say seem arbitrary: the state where they died, the size of the farm where they worked or whether they lived in employer-provided housing.

For decades, Congress has banned the federal Occupational Safety and Health Administration from investigating worker deaths, injuries and complaints on farms with fewer than 11 workers unless those farms have employer-provided housing known as a temporary labor camp. How this exemption for small farms plays out looks different in the country’s dairy states.

In New York and Vermont, for instance, worker advocates say they don’t bother calling OSHA when workers die or get hurt on small farms because they’re so used to the agency saying it can’t investigate.

In Wisconsin, OSHA has sometimes investigated dairy worker deaths on small farms when those farms provide housing to immigrant workers. In such cases, the agency has called that housing a temporary labor camp that gives it jurisdiction to inspect.

And in California, which has a more robust occupational safety and health plan than the federal program, inspectors look into dairy workers’ deaths and injuries no matter how many workers a farm employs. The question of whether there’s worker housing is irrelevant.

This patchwork of enforcement, in which some deaths are investigated and others are ignored, is fundamentally unfair, advocates say.

“It’s unjust and it’s inhumane,” said Crispin Hernández, a former dairy worker and a member of the Workers’ Center of Central New York, a nonprofit focused on workplace and economic justice. “It is on small farms that workers get injured the most.”

Last month, ProPublica reported on how OSHA has inconsistently labeled farm housing for immigrant dairy workers in Wisconsin as a temporary labor camp. Our reporting identified three worker deaths on small farms over the past decade, including the March drowning of an undocumented Mexican immigrant in a manure lagoon, that OSHA said it couldn’t investigate even though workers lived in farm housing.

OSHA officials declined interview requests but have said the agency has a consistent national policy on how it views temporary labor camps.

Since 2005, OSHA offices said they couldn’t investigate 44 safety incidents on dairy farms — including deaths, injuries, complaints and referrals from local agencies such as medical examiner’s offices — because of the small-farms exemption, records show. It’s unknown how many of those farms provided housing to immigrant workers, something common on dairy farms across the country.

None of this is as clear cut as many advocates and farmers would like, and the issue has received scant attention. More than a dozen farm safety advocates, farm worker attorneys and dairy worker researchers from a number of states — including Wisconsin — told us they had no idea it was even possible for OSHA to look into deaths and injuries on small dairy farms that provided housing to immigrant workers.

“We end up in these granular arguments over what counts as temporary or seasonal or what’s a labor camp,” said Hannah Gordon, an attorney with the Farmworker Law Project of the Legal Aid Society of Mid-New York.

One of the key factors in OSHA’s approach to deciding if a dairy farm has a temporary labor camp is whether it considers the workers themselves to be temporary or permanent. The answer is not immediately obvious because cows are milked year-round. Agricultural jobs such as picking apples or blueberries are more clearly seasonal.

In addition, dairy farms can’t use a federal guest worker program to bring in immigrants on temporary visas. Instead, the industry by and large relies on undocumented immigrant workers whose ability to stay permanently in this country — and, by that logic, stay permanently on a job — is precarious.

“Being undocumented and constantly facing the risk of deportation” is one reason these workers could be considered temporary, said Maggie Gray, an associate professor of political science at Adelphi University who studies New York farm workers. “They have permanent homes in their home country where they intend to return.”

OSHA doesn’t ask workers whether they’re in the U.S. legally. But in Wisconsin, OSHA inspectors have described some immigrant workers who live on dairy farms as temporary workers because they are hired with the understanding that they may go back and forth to their home countries to visit their families.

The prospect of OSHA taking a similar view of dairy workers in New York — where an estimated 80% live and work on small farms — led to pushback from a group of seven members of Congress from that state in late 2013.

At the time, OSHA was preparing to launch a program to improve safety on New York’s dairy farms. The program would allow the agency to conduct random inspections, something it typically doesn’t do.

But the representatives wrote to OSHA’s top official, asking for it to be delayed and to discourage the agency from considering immigrant dairy workers as temporary when deciding whether a small farm was eligible for inspections.

“A dairy farmer hires an employee with the understanding and intent that the employee will be here long term,” the lawmakers wrote. “A dairy farm employer does not embrace the cultural assumption that an employee of a foreign ethnicity or whose primary language is not English is seeking work as a temporary or seasonal worker when they accept a permanent position on a farm.”

OSHA conceded the point. David Michaels, then the assistant secretary of labor for OSHA, wrote back to the lawmakers and said the agency had decided to limit the scope of the program to “dairy farms with eleven or more employees, so the definition of temporary labor camp is no longer relevant.”

Outside of the New York effort, Michaels wrote, the agency would not inspect small farms that provided housing to their workers if the employers had offered them permanent jobs.

In a recent interview, Michaels said he did not recall the controversy around temporary labor camps. He also said he wasn’t aware that OSHA officials in Wisconsin had concluded that housing for immigrant workers on dairy farms was a temporary labor camp so they could investigate deaths on small farms.

But he said he was “glad to hear that” and thought that the agency’s work in Wisconsin should be more widely known. That way, he said, perhaps more advocates would call OSHA when workers die or get injured “in situations where OSHA could actually answer.”

Erica Sweitzer-Beckman, an attorney and the legal director of the Farmworker Project at the nonprofit Legal Action of Wisconsin, said that when a farm “asserts an exemption, OSHA could thoroughly investigate to determine if the exemption actually applies.”

Not every state relies on federal OSHA; more than 20 states have their own safety and health workplace programs. At least three of those states, California, Oregon and Washington, use state funds to inspect farms of all sizes, regardless of whether there’s housing for workers.

“There is no small-employer exception,” said Garrett Brown, a retired field compliance officer and senior official with the California Division of Occupational Safety and Health. “If you have one employee, that’s it; you’re an employer and you fall under Cal/OSHA’s jurisdiction the same as United Airlines or Coca-Cola.”

Some research has shown that the fatality rate for farm workers is significantly lower in California, Oregon and Washington than in states where the small-farms exemption is observed. Dairy farms on the West Coast tend to be larger operations than those in the Midwest and East Coast, and there are far fewer of them, which may also contribute to the difference in fatality rates. California is the nation’s biggest dairy producer. Wisconsin ranks second; New York is fifth.

Matthew Keifer, an occupational medicine physician and researcher who lives in Washington state and previously ran the National Farm Medicine Center in Wisconsin, said small farms in states that rely on federal OSHA don’t always put a priority on safety issues because they know “they’re not likely to be investigated, fined or found culpable if someone is seriously injured.”

He added that in Washington, by contrast, “there is a healthy preoccupation about the possibility of being inspected.”

Other states, including Vermont, have state OSHA plans that mirror the federal OSHA when it comes to the small-farms exemption. Vermont hasn’t considered employer-provided housing for dairy workers a temporary labor camp.

In December 2009, a worker named José Obeth Santiz Cruz died on a small Vermont dairy farm after he was pulled into a piece of machinery and strangled by his own clothing. The state OSHA sent two inspectors to the farm. Santiz, an immigrant from Mexico, lived in farm housing, according to interviews and records.

But the agency determined it couldn’t investigate because the farm employed too few workers.

In an email to ProPublica, Dirk Anderson, the director of the Vermont OSHA, said his general understanding was that dairy work was not “of a seasonal or temporary nature.” However, he said, “it is certainly something I will discuss with both our legal counsel and my commissioner in the near future.”

Santiz’s death helped lead to the creation of Migrant Justice, a dairy worker-led human rights organization in Vermont. Marita Canedo, the group’s program coordinator, said nearly all of the 1,000 or so immigrant dairy workers in the state live on the farms where they work.

Canedo and her colleagues routinely hear about workers who get hurt on the job. But they rarely call the state agency for a number of reasons, including its hands-off approach to small farms. Recently, when a worker lost several toes after the heavy metal bucket of a skid steer crushed them, Canedo said she didn’t bother to contact OSHA.

“We don’t even think about OSHA,” she said.

Mariam Elba contributed research.

by Isabelle Taft, Mississippi Today

This article was produced for ProPublica’s Local Reporting Network in partnership with Mississippi Today. Sign up for Dispatches to get stories like this one as soon as they are published.

Fourteen years ago, Mississippi legislators passed a law requiring county jails to be certified by the state if they held people awaiting court-ordered psychiatric treatment.

Today, just one jail in the state is certified.

And yet, from July 2022 to June 2023, more than 800 people awaiting treatment were jailed throughout the state, almost all in uncertified facilities, according to state data.

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Mississippi Today and ProPublica have been reporting on county officials’ practice of jailing people with mental illness, most of whom haven’t been charged with a crime, as they await treatment under the state’s civil commitment law. After the news organizations started asking about the 2009 law earlier this year, the state attorney general’s office concluded that it is a “mandatory requirement” that the Mississippi Department of Mental Health certify the facilities where people are held after judges have ordered them into treatment.

The Department of Mental Health, which oversees the state’s behavioral health system and has no other responsibility for jails, responded by sending letters to county officials across the state encouraging them to stop holding people in uncertified jails. But the law provides no funding to help counties comply and no penalties if they don’t.

Caption: Wendy Bailey, executive director of the Mississippi Department of Mental Health, sent a letter in October to officials in all 82 counties encouraging them to stop holding people awaiting mental health treatment in uncertified jails. According to the department’s data, more than 800 people were held in jail before being admitted to a state hospital through the civil commitment process in the 12 months ending in June. (Obtained by Mississippi Today and ProPublica, highlighting by ProPublica)

Under state law, counties are responsible for housing people going through the commitment process until they are admitted to a state hospital. Counties are allowed to put them in jail before their court hearings if there’s “no reasonable alternative.”

The last time the Department of Mental Health tried to ensure those jails met state standards, more than a decade ago, it had little success. After the law passed, the agency got to work to inform counties about the new rules. Some didn’t respond. Others expressed interest but didn’t follow through. By 2013, just two jails had been certified. (One of them no longer is.) After that, the effort apparently petered out, according to a review of state documents.

To be certified, a jail must offer on-call crisis care by a physician or psychiatric nurse practitioner and must have a supply of medications. Staff must be trained in crisis intervention and suicide prevention. People detained during the commitment process must be housed separately from people charged with crimes, in rooms free of fixtures or structures that could be used for self-harm, according to Department of Mental Health standards that took effect in 2011.

“If they’re going to be held in jail, they have to receive some kind of treatment in a semi-safe environment,” a department attorney told The Clarion-Ledger at the time.

Until recently, many county officials weren’t even aware of those requirements, according to interviews across the state — even though they were routinely jailing people solely because they might need mental health treatment. Mississippi appears to be the only state in the country where people awaiting treatment are commonly jailed without charges for days or weeks at a time.

Mississippi jails are subject to no statewide health and safety standards. Many jails treat people going through the civil commitment process virtually the same as those who have been charged with crimes, Mississippi Today and ProPublica found. They’re shackled and given jail uniforms. They’re often held in the same cells as criminal defendants. They receive minimal medical care. Some said they couldn’t access prescribed psychiatric medications. Since 1987, at least 18 people going through the commitment process for mental illness and substance abuse have died after being jailed, most of them by suicide.

Colett Boston, left, and Everlean Boston hold a photograph of their mother, Mae Evelyn Boston, in Oxford, Mississippi. In 1987, when Colett was a newborn and Everlean was 12 years old, their mother died in the Lafayette County jail as she waited for a mental health evaluation. (Eric J. Shelton/Mississippi Today)

Some local officials say getting certified could be expensive. Sheriffs worry it could codify their role as their county’s de facto mental health care provider.

“It looks like the state wants the sheriff to be the chief mental health officer,” said Will Allen, attorney for the Mississippi Sheriffs’ Association. “This is coming down to the state stuffing the cost of this down to the counties, and frankly I just think that’s wrong.”

“Are You Going to Shut the Jail Down? No.”

The genesis of the 2009 law was a conversation state Sen. Joey Fillingane had with his girlfriend at the time, a social worker who worked with troubled youth. She told him that Mississippians going through the commitment process in some counties were locked in jail cells like criminals, while in other counties they were held in hospitals like patients, according to a 2011 news story in The Clarion-Ledger.

Fillingane’s bill addressed that. “Shouldn’t there be some kind of minimum standard where you’re holding people who haven’t committed a crime?” the Republican from Sumrall, near Hattiesburg, said in that story about his legislation.

His bill passed with little fanfare. It made it “illegal for individuals committed to a DMH behavioral health program to be held in jail unless it had been certified” as a holding facility, an agency staffer wrote in a timeline of the law’s implementation obtained by Mississippi Today and ProPublica.

The board overseeing the Department of Mental Health set detailed standards for those facilities. Department staff surveyed counties to see whether they could meet them.

Ed LeGrand was head of the department when the law passed. He said he viewed it as a progressive effort that could spur counties to stop holding mentally ill people in jail. And even if that didn’t happen, the law would improve jail conditions — at least somewhat.

“I didn’t think that everybody would be able to meet those standards. I thought they would give it a try,” he said in a recent interview. “A lot of them did, but some of them didn’t.”

Department staff met with county officials and toured jails to offer assistance. Those visits, which records show mostly took place in 2011 and 2012, were the first time the Department of Mental Health had tried to get a comprehensive look at the local facilities where Mississippians awaited psychiatric treatment in state hospitals, LeGrand said.

Many jails were poorly equipped to care for these people, according to notes by agency staff.

“Toured the current jail (scary),” reads a status update written after staff visited Tishomingo County, in the northeast corner of the state, shortly before the county opened a new jail. In Jones County in south Mississippi, where the jail had 180 inmates and only four staff: “The holding cells are not safe for violent behavior. Too much cement.”

Jones County Sheriff Joe Berlin said the cells have not changed since then, though now detainees are monitored with cameras.

In early 2011, LeGrand told county officials who hadn’t already begun the certification process that they had six months to find a certified provider to house people awaiting treatment.

Sheriffs were frustrated. Some objected to being told they had to upgrade their jails and train guards so they could care for mentally ill people they didn’t think they should be responsible for in the first place.

“What do they expect of me?” one sheriff was quoted as saying in the 2011 news story. “What they need to do is turn around and certify some places that are under Mental Health’s control so they can be responsible for it, not me.”

In 2011, The Clarion-Ledger reported that sheriffs were frustrated by a law requiring the Department of Mental Health to certify their jails if people were detained there as they awaited admission to a state psychiatric hospital. Sheriffs worried that the law would force them to spend time and resources on a job they didn’t sign up for. (Hattiesburg American via newspapers.com. Blurred by ProPublica for emphasis.)

Some county officials concluded there was little the state could do if they didn’t comply. Mike Harlin, the jail administrator in Lamar County, discussed the standards with a Department of Mental Health staffer in 2012, according to an agency memo. In an interview this year, Harlin said he remembered thinking, “What are you going to do? Are you going to shut the jail down? No.”

By June 2013, jails in just two of the state’s 82 counties had been certified, according to the department’s tally. (A hospital was certified in another county, and a different type of facility was certified in a fourth.)

Six counties said they couldn’t meet the standards. Another 23 had received guidance from the department on how to meet them. Thirty, including a few of the counties that had received advice, eventually said they didn't jail people, some because they had contracts with providers. Twenty-one never responded.

Mississippi Today and ProPublica requested all Department of Mental Health records since 2010 related to enforcement of the certification law and correspondence with counties. Documents through 2013 included standards, correspondence, memos describing visits to county facilities and a log summarizing contact with each county. After that, the records released show no statewide outreach.

The final entry in the department’s timeline of the law’s implementation reads: “June 2013 was the last attempt to update the information about DMH Designated Mental Health Holding Facilities due to lack of additional responses from the counties.” That timeline is undated, but a department spokesperson said data in the file shows that it was created in January 2015 by a staffer who held positions in the certification and behavioral health divisions.

LeGrand, who served until 2014, said he doesn’t recall any decision to stop contacting counties about the law.

Katie Storr, the current chief of staff at the Department of Mental Health, told Mississippi Today and ProPublica it’s possible staff did communicate with counties beyond what the records indicate. “After more than a decade, a lack of correspondence, email, or other documentation is not indicative that communication and follow-ups did not take place,” she wrote in an email. However, she said the department had no additional records that would show this.

During this time, Storr wrote, the department was focused on trying to get counties to hold people going through the commitment process in short-term crisis stabilization units rather than jail.

Department Can’t “Boss Counties Around”

The recent effort to implement the certification law stems from inquiries by Mississippi Today and ProPublica.

In January, the news organizations asked the head of the Department of Mental Health, Wendy Bailey, if the department certifies jails where people are held as they await admission to a state hospital. Bailey, who handled communications for the department when the certification law passed, initially said it didn’t apply to jails. In March, after reviewing documents showing prior efforts to certify jails, she said she didn’t believe the law was intended to apply to them.

After our inquiries, Bailey sought an opinion from the attorney general. (Such opinions are not binding, but officials who request and abide by them are protected from liability.)

Around the same time, the Department of Mental Health contacted the four facilities it had previously certified to schedule inspections. The department’s standards say such inspections will happen annually, but this was the first year in which staff had sought to visit all of them since 2017. (Storr said the inspection effort was planned before inquiries by Mississippi Today and ProPublica.)

In March, staffers inspecting the Chickasaw County jail in rural northeastern Mississippi found serious violations. Inmates and people awaiting mental health treatment were housed together in the same cells, where beds were anchored with long bolts that “could be used by a person to harm themselves,” the reviewers recorded.

The department suspended the jail’s certification in August, but reinstated it after the county submitted a compliance plan that included shortening the bolts and providing mental health training for staff.

Lafayette County told the state it didn’t want its jail to be certified anymore. The certification for a holding facility in Warren County, home to Vicksburg, was suspended. A hospital in Alcorn County in northeast Mississippi maintained its certification.

In 2021 and again early this year, Lafayette County Sheriff’s Department staff told the state Department of Mental Health that they no longer wanted their jail to be certified. In an interview conducted before the department notified counties about the certification law this fall, Sheriff Joey East, pictured here, said he believes people in his jail waited longer to be admitted to a state hospital because the state prioritizes those waiting in uncertified jails. “There was not a lot of benefit” to being certified, he said. DMH director Wendy Bailey said people held in any jail get priority for psychiatric treatment. (Eric J. Shelton/Mississippi Today)

In August, the attorney general’s office confirmed that the department must “ensure that each county holding facility, including but not limited to county jails,” meets its standards. If they don’t, an assistant attorney general wrote, the law allows the department to require counties to contract with a county that does have a certified facility.

When Bailey informed county officials about the opinion in her October letter, she instructed that if a county holds someone in an uncertified facility, including a jail, officials should contact the department to seek certification or work with local community mental health centers. These are publicly funded, independent providers set up to ensure that poor, uninsured people can access mental health care.

Several counties, including Lamar, have taken up the matter in public meetings or have contacted the department to begin the certification process.

Storr told Mississippi Today and ProPublica that the department asked counties to initiate the certification process because the law says it’s up to counties to determine which facility they use.

But the Department of Mental Health already knows which counties have held people in uncertified jails. Starting in July 2021, in response to a federal lawsuit over the state’s mental health system, department staff have tracked how many people come to state hospitals directly from jails for psychiatric treatment.

The tally for the year ending in June breaks down all 71 jails, only one of which is certified, where a total of 812 people who had been civilly committed were held before being admitted to a state hospital. (The tally doesn’t include anyone who was jailed and released without being admitted to a state hospital.)

For the past two years, the Mississippi Department of Mental Health has gathered data on how many people are admitted to a state hospital directly from jail and how long they wait in jail after commitment hearings. (Obtained by Mississippi Today and ProPublica)

In Lauderdale County, on the Alabama line: 83. Across the state in DeSoto County: 76. A couple hundred miles down the Mississippi River in Adams County: 33.

Storr and Bailey have emphasized that they have limited authority over counties and no way to force them to do anything. The department’s only means of enforcement, Storr wrote, is to put a jail on probation, then revoke certification — if the jail in question even was certified in the first place — and require the county to contract with another provider.

LeGrand said a law without teeth is effectively optional. "The department’s not really in a good position to boss counties around,” he said.

James Tucker, an attorney and the director of the Alabama Disabilities Advocacy Program, which has sued that state over its civil commitment process, said the agency has a responsibility to make sure counties are treating people properly. “You don’t discharge that duty by sitting on your hands and waiting for every local sheriff to report in,” he said.

Bailey’s department encourages counties to connect families with outpatient services in order to avoid the commitment process. If someone does need to be committed, the department said, counties should hold people in crisis stabilization units operated by community mental health centers.

“I do not believe jails are an appropriate location to hold someone who is not charged with a crime and is awaiting admission to a treatment bed,” Bailey told Mississippi Today and ProPublica in an email. “The person should be in a safe location, receiving treatment.”

Adams County Sheriff Travis Patten said he doesn’t think the county jail, pictured here, could meet state standards. Due to deteriorating conditions, most people facing charges — but not those awaiting court-ordered mental health treatment — are now sent to another jail. Lacey Robinette Handjis died in another part of the jail in August while she was awaiting mental health treatment. (Eric J. Shelton/Mississippi Today)

But there are only 180 crisis beds in the state, and crisis stabilization units frequently turn people away because they are full, can’t provide the needed care, or deem a patient too violent. Storr said the agency is working to reduce denials and plans to use one-time federal pandemic funding to expand capacity.

Allen, the sheriffs’ association attorney, said the state will need more crisis beds if officials want to keep people out of jail as they await mental health care. He said he’s been meeting with sheriffs and county officials since the guidance was issued.

“This has catalyzed the county governments and law enforcement to do something,” he said. Sheriffs agree on the need for “certified centers, just not in the county jail.”

Mollie Simon contributed research.

by Rose Lundy, The Maine Monitor

This article was produced for ProPublica’s Local Reporting Network in partnership with The Maine Monitor. Sign up for Dispatches to get stories like this one as soon as they are published.

One lunchtime in 2021, a longtime resident at Woodlands Memory Care of Rockland started throwing up. His fingernails turned purple, and his skin became red all over. He was lethargic and fidgety, and his breathing grew shallow, according to the facility’s daily care notes.

The resident was well known at this residential care facility in Maine’s Midcoast region. Former facility employees told The Maine Monitor and ProPublica that he was a nationally renowned concert pianist who continued to play a portable keyboard in his room even as his Alzheimer’s disease advanced.

It wasn’t until a family member arrived and asked if the resident had eaten peanuts that employees realized that he was having an allergic reaction to the peanut butter sandwich that he had been served for lunch, according to the facility care notes. Staff used an EpiPen to treat his anaphylactic shock and took him to the hospital. He died days later, though no official records were made available that show the cause of his death.

The employee who gave the sandwich to the resident wrote in the facility care notes the day after the incident that they “didn’t know” that the resident “was allergic to peanuts.”

In interviews with the Monitor and ProPublica, however, four former employees said the resident’s severe peanut allergy had been documented throughout the facility: in his resident profile, in his room and posted in the kitchen.

“It said it everywhere you looked around him that he was allergic to peanut butter,” said Stacy Peterson, who served as the human resources coordinator at Woodlands of Rockland from 2018 to 2020.

So it was a mystery to the former employees how the resident had been served a peanut butter sandwich that day for lunch.

After receiving an anonymous complaint, the Maine Department of Health and Human Services investigated the incident and cited Woodlands of Rockland for two resident rights violations — first by failing to protect the resident from a severe allergic reaction and the second time by not reporting the case to the state. (The citations do not identify the resident.)

Under state regulations, the health department had the power to impose a fine of up to $10,000 or issue a conditional license that would bar Woodlands of Rockland from accepting new residents for up to 12 months. But it did neither. Instead, it simply required the facility to submit a report, called a plan of correction, stating how it intended to address the deficiencies.

In that plan, Woodlands of Rockland acknowledged that the resident’s allergy had been documented but disputed the health department’s characterization that the facility violated the resident’s rights in the incident. Still, it promised to discipline the employee who served the sandwich and to retrain others on how to handle allergies and to report incidents.

The Maine Department of Health and Human Services found that Woodlands Memory Care of Rockland violated a resident’s right to be free “from abuse, neglect or exploitations” by serving him a peanut butter sandwich despite his documented peanut allergy. (Obtained by The Maine Monitor and ProPublica. Highlighted by ProPublica.)

The health department’s modest response to the peanut allergy incident exemplifies its approach to oversight, an investigation by the Monitor and ProPublica found. The health department rarely imposes fines or issues conditional licenses against the state’s roughly 190 largest residential care facilities, classified as Level IV, which provide less medical care than nursing homes but offer more homelike assisted living alternatives for older Mainers.

From 2020 to 2022, the health department issued “statements of deficiencies” against these facilities for 59 resident rights violations and about 650 additional violations — involving anything from medication and record-keeping errors to unsanitary conditions and missed mandatory trainings. Despite these violations, however, it imposed a fine only once: a $265 penalty against a facility for failing to comply with background check rules for hiring employees. And it issued four conditional licenses: three in response to administrative or technical violations and one in response to a variety of issues, including a violation of a resident’s privacy rights.

By contrast, Massachusetts, which has 269 assisted living facilities, doesn’t shy away from imposing stiff sanctions. From 2020 to 2022, the state suspended eight facilities’ operations for regulatory violations.

The paucity of sanctions in Maine comes at a time when Level IV facilities like Woodlands of Rockland — which are similar to what are known generally as assisted living facilities in other states — are expanding their presence in the state. The share of Maine’s population that is 65 or older, 21.7%, is the highest percentage in the country.

As the Monitor and ProPublica have reported, the state’s decision in the mid-1990s to tighten the requirement to qualify for nursing home placement helped spur thousands of older Mainers, many with significant medical needs, to move to these nonmedical facilities — which are subject only to state regulations that hold them to much lower minimum staffing, nursing and physician requirements than nursing homes, which face both state and federal scrutiny.

In stark contrast to how rarely Level IV facilities face sanctions, nursing homes in Maine are often hit with considerable fines for regulatory violations.

Health department spokesperson Jackie Farwell said that plans of correction are often sufficient for improving conditions at facilities. She added that as part of an effort to improve the long-term care system in Maine, the state has been considering rules changes to “establish fines and sanctions as more meaningful deterrents.” But she declined to elaborate on the specifics.

Dan Cashman, spokesperson for Woodlands Senior Living, which runs 14 Maine facilities including the one in Rockland, said the company has “a zero-tolerance policy” and has taken disciplinary actions against any employees who were found to have violated residents’ rights.

Cashman added that the company is in favor of stronger state action against individuals found to have violated residents’ rights to prevent them from working in residential care settings again.

But long-term care advocates say the health department is not doing enough to crack down on facilities, as opposed to individuals, and is allowing poor conditions to persist for vulnerable residents.

Richard Mollot, executive director of the Long Term Care Community Coalition, a national advocacy group focused on improving nursing homes and assisted living facilities, said stiff sanctions should be imposed more, so that there’s a “meaningful ladder of sufficient penalties to ensure that facilities are properly motivated to take steps to ensure resident safety.”

Otherwise, Mollot said, facilities have no incentive to change their behavior. “To pussyfoot around resident neglect or abuse,” he said, “is essentially encouraging. It’s allowing it to happen.”

A review by the Monitor and ProPublica of state inspection records from 2020 to 2022 shows that the health department employed the lowest intervention possible, even for some of the most serious abuse and neglect incidents.

In the summer of 2021, for instance, a resident at Crawford Commons in midcoast Maine was found to have sexually abused another resident multiple times, according to the state’s investigation. The health department cited the facility for two resident rights violations but only required it to submit a plan of correction.

A year later, a resident in Jed Prouty Residential Care Home in the Penobscot Bay region was found around 6:30 a.m., naked and asleep on the floor, “soaking wet with urine,” after falling sometime after 10 p.m. Witnesses said the resident had been crying for help and complaining of thirst until medics responded. No efforts had been made by staff to move the resident from the floor or provide clothing, according to the state’s investigation. Again, the health department cited the facility for a resident rights violation but only required it to submit a plan of correction.

Similarly, in 2021 and 2022, the health department also investigated Woodlands of Rockland for two other serious incidents. In one, a certified nursing assistant at the facility slapped a resident who had spit at and attempted to bite her, according to the state’s investigation. In the other, a resident wandered out to the facility’s locked courtyard, but employees didn’t notice that she was missing until they went to give her medications nearly two hours later, according to the state’s investigation. When the resident was found outside in the snow at around 8:40 p.m., employees wrapped her in blankets and called for emergency medical care. The resident died in hospice days later, and the state investigation cited the cause as “complications of hypothermia.” In the end, both incidents also led to plans of correction.

The Maine Department of Health and Human Services cited Woodlands Memory Care of Rockland for not protecting “a resident’s health and welfare” after the resident wandered out unsupervised into the facility’s locked courtyard. (Obtained by The Maine Monitor and ProPublica. Highlighted by ProPublica.)

Woodlands of Rockland has been disputing the health department’s characterization that the facility violated the resident’s rights in the courtyard incident. But Cashman declined to elaborate on the specifics.

Edward Sedacca, CEO of Magnolia Assisted Living, which runs Jed Prouty, said his company took over the operation of the facility in August 2022, a month before the incident, and has since made it a priority to enhance its staffing and training. “The staff we inherited was lacking in overall general knowledge,“ he said. “Magnolia has built an infrastructure well beyond that required under regulation to enable us to provide a higher level of care to all of our residents.”

Crawford Commons did not respond to requests for comment.

For Maine’s nursing homes, however, the response to similar incidents has been very different.

From 2020 to 2022, more than half of nursing homes in Maine received fines — 98 penalties in all, totaling nearly $700,000 — according to U.S. Centers for Medicare and Medicaid Services reports. These fines were imposed in response to a range of violations, including not following COVID-19 infection prevention protocol, making medication errors, not reporting unexpected deaths and failing to protect residents from harm.

In 2020, for instance, an employee at Pinnacle Health & Rehab, a nursing home in Canton in western Maine, “lost it” when a resident became combative, according to CMS investigation records. The employee punched the resident, who ended up with a black eye and bruising around the eyebrow. CMS fined the facility $41,650.

A year later, a resident at Heritage Rehab and Living Center, a nursing home in central Maine, wandered off the premises at night using a walker and was found later by police by the side of a road in the rain. No one at the facility had noticed that the resident was missing, according to CMS investigation records. CMS fined the facility $71,243.

Ken Huhn, administrator of Pinnacle, said the employee was fired, and he made it clear that “that type of behavior would not be tolerated” at his facility.

Heritage did not respond to requests for comment.

Even without the involvement of CMS, which does not regulate assisted living facilities around the country, the health department has the power to adopt a tougher approach toward Level IV facilities. Under state regulations, for instance, it can impose a fine when an incident poses “a substantial probability of serious mental or physical harm to a resident.”

Long-term care advocates told the Monitor and ProPublica that under this standard, some of the egregious abuse and neglect incidents in recent years at Level IV facilities should have resulted in stiff sanctions.

“Because the incidents are so egregious and show such disregard for the well-being of residents, they would have warranted some significant penalty and not just a pro forma requirement that the facility submit a plan of correction,” said Eric Carlson, director of long-term services and support advocacy at Justice in Aging, a national legal advocacy nonprofit focused on ending poverty among seniors.

Paula Banks, who has served as the executive director of another Woodlands facility in Cape Elizabeth and as an assistant administrator of a Maine nursing home, said the fear of such sanctions would be effective. If she were still helping run a residential care facility, she said, it would spur her to take immediate action to address any problems.

“What’s the impetus to change if there’s no consequence?” said Banks, who now runs a geriatric consulting and care management firm.

But Dr. Jabbar Fazeli, who has served as medical director at multiple residential care facilities and nursing homes in Maine, said that rather than imposing sanctions, the state should require more medical attention by increasing nursing hours and requiring a medical director to be on the premises.

“If they had more medical care, I would say 50% of these issues will self-resolve,” Fazeli said.

The health department metes out sanctions in only a small percent of the incidents it hears about each year. Most of the time, it hardly does anything.

To better understand the health department’s process for looking into potential issues, the Monitor and ProPublica analyzed a database of incidents reported to the state by Level IV facilities themselves. Unlike the state inspection records, the database of facility-reported incidents gives a window into what happens earlier in the health department’s enforcement process.

Level IV facilities are required to report an incident to the state when a regulatory violation may have occurred or when a resident’s safety was put at risk. We focused particularly on reports of incidents with the potential for direct harm: the cases of abuse and neglect.

From 2020 to 2022, the state received more than 550 reports of abuse and neglect incidents from Level IV facilities, according to the Monitor and ProPublica analysis. Of those, 342 cases involved residents abusing other residents, 102 cases involved “elopement,” in which residents wandered away unsupervised, and 61 cases involved a staff member abusing a resident.

The analysis shows that in nearly 85% of these incidents, state investigators took “no action” — which, according to Farwell, means that the health department decided not to investigate. She said this could have been for a range of reasons, such as when a facility has already taken corrective action, when state investigators do not expect to find a regulatory violation, or when an incident is being investigated as part of another case or is expected to be reviewed later.

The analysis also shows that the health department did not step up its enforcement even when individual facilities repeatedly reported similar issues.

From 2020 to 2022, 13 Level IV facilities, including Woodlands of Rockland, each had at least 10 abuse and neglect incidents, collectively reporting 348 cases to the state. Even after these facilities had reported multiple cases, the health department still took no action in 91% of them, the analysis shows.

Farwell said state investigators do pay attention to repeated incidents. “If patterns are observed, specific issues may be flagged for follow-up at the next scheduled survey,” she said.

But such follow-ups might not happen for many months, depending on the timing of the next inspection required for license renewal, which takes place only once every two years.

Dionne Mills, who served as the program coordinator at Woodlands of Rockland from 2019 to 2021 and also worked at two other Level IV facilities, said she became aware of the lack of state oversight during her time at the Rockland facility. She said she reported multiple incidents to the state until eventually a state investigator told her that they were too overwhelmed with complaints and that she would have more success taking her concerns to the media.

“The state is so super busy that they only have time to look into the absolute worst-case scenario,” Mills said.

Dionne Mills outside her home in Northport, Maine (Tara Rice for ProPublica)

Farwell disputed Mills’ account, noting that state investigators made seven visits to Woodlands of Rockland from 2020 to 2022, the time period when the facility was under investigation for the courtyard, peanut allergy and slapping incidents. Mills’ account “is inconsistent with the number of onsite visits that were conducted at this facility,” she said.

According to Farwell, the health department has 13 investigators — and is in the process of hiring two more — to inspect more than 1,100 assisted housing facilities in the state for license renewals and to investigate any incidents.

Mollot, of the Long Term Care Community Coalition, said the health department needs to do more against facilities with a history of repeated incidents, such as requiring independent monitoring and, possibly, revoking licenses.

“Faced with the fact that these facilities have reported over and over and over and over and over again incidents of abuse and neglect, why have there been a paucity of enforcement acts?” Mollot said.

Several former employees told the Monitor and ProPublica that the history of repeated incidents at Woodlands of Rockland illustrates what can happen to a facility’s standards when the health department takes little enforcement action.

Stacy Peterson, a former human resources coordinator at Woodlands Memory Care of Rockland, said facility managers made little effort to address recurring problems when she worked there. (Tara Rice for ProPublica)

From 2020 to 2022, Woodlands of Rockland had the highest number of abuse incidents reported by a Level IV facility — 48 cases in all, including 38 in which a resident abused another resident, according to the health department database.

But the health department investigated only five of the incidents that Woodlands of Rockland reported, took no action on the rest and imposed no sanctions other than requiring the facility to submit one plan of correction.

With little pressure from the health department, efforts to address recurring problems “were nonexistent when I worked there,” Mills, the former program coordinator, said.

Joshua Benner, who served as a residential care aide at Woodlands of Rockland from 2018 to 2020, said he found it concerning that when the facility was cited by the health department, none of the managers at the facility shared with employees what problems had been found.

“Every other health care place that I’ve ever worked, you have interventions, usually after the state comes in, to go over what you’re dinged on and what can be improved,” said Benner, who has worked at a nursing home and two other residential care facilities.

Cashman, the Woodlands spokesperson, denied that Woodlands of Rockland had “an ongoing or systemic problem” with abuse incidents, noting that the bulk of the cases involved a small number of residents “whose progressively worsening dementia-related behaviors became more and more challenging.”

In response to these residents’ behaviors, Cashman said Woodlands of Rockland has been proactive and taken “multiple interventions,” including resident care plan updates, medication modifications, referrals for hospital treatment and discharge planning.

Cashman said Woodlands of Rockland and its employees have been doing “their best to manage what can be extremely difficult behaviors by individuals living with significant cognitive impairments.”

But Banks said something is amiss if any facility has repeated incidents, noting that she would have been alarmed to see more than one or two incidents of abuse in three years, let alone 30 or more as Woodlands of Rockland did.

“When you have people in your building and you took them in and you told their families you would take care of them and you took their money,” Banks said, “I don’t care what’s going on. I don’t care if you have a staff of three. You’ve got to take care of your people.”

Mariam Elba contributed research.

by Kyle Hopkins, Anchorage Daily News

This story details allegations of violence against Indigenous women and girls.

This article was produced for ProPublica’s Local Reporting Network in partnership with the Anchorage Daily News. Sign up for Dispatches to get stories like this one as soon as they are published.

KOTZEBUE, Alaska — On a subzero Monday morning in March 2020, police found another woman dead at the ex-mayor’s property.

Two years earlier, the body of 25-year-old Jennifer Kirk lay curled at the foot of a bed, a rifle on the floor, strangulation marks on her neck and a bullet hole beneath her chin. City police swiftly closed the case, declaring it a suicide.

Now police were back at the property, where the lifeless body of Susanna “Sue Sue” Norton, 30, was discovered in an adjacent house, beaten and strangled. An autopsy determined the cause of death to be homicide.

Kirk and Norton, both Inupiaq, had each dated sons of the former borough mayor, and the sons had previously been convicted of beating each of them. One of the sons had admitted to strangling Kirk twice before. Another pleaded guilty to kicking Norton in the stomach when she was six months pregnant.

No one has ever been charged with a crime in connection to the deaths.

In a state where women are 2.5 times more likely than the national average to be killed by a man and Alaska Native women are especially at risk, elected leaders here have repeatedly pledged action. The Department of Justice declared a rural law enforcement emergency in Alaska following a 2019 report by the Anchorage Daily News and ProPublica on glaring lapses in local policing. Two years later, the governor created a state council on Missing and Murdered Indigenous Persons, and in 2022, new investigators were hired to solve cases like Norton’s.

Unexplained holes in the investigations into the deaths of Kirk and Norton call into question this commitment, a review by the Anchorage Daily News and ProPublica found. More than that, the events leading up to the women’s deaths illustrate how police, prosecutors and judges here have regularly given pass after pass to people accused of domestic violence and strangulation.

Police records obtained by the newsrooms show that Kirk’s body revealed signs of strangulation. Her boyfriend, Anthony Richards, son of then-Mayor Clement Richards Sr., admitted to police that he had caused the marks on the day she died. After reviewing the records, former Kotzebue Police Chief Ed Ward said the 10 red flags that the Training Institute on Strangulation Prevention instructs police to look for in cases of domestic violence killings all appeared to apply to the scene of Kirk’s death. (Ward did not work at the police department at the time of her death.)

Yet the Kotzebue Police Department closed the case after a single day of investigation, labeling it a suicide before receiving the final autopsy report.

In Norton’s case, police never told her family she had been strangled, family members said. Police didn’t ask the public to help catch the suspect, as they had the prior year when a fire department dog was killed in the same neighborhood. They never interviewed key witnesses and failed to obtain a search warrant, leaving evidence uncollected.

State troopers, who took over the investigation into Norton’s death in 2022, told her family they planned to travel to Kotzebue over the summer to investigate further. Norton’s family says that didn’t happen either. (A department spokesperson said on Oct. 27 that investigators had not yet visited Kotzebue for the case but planned to do so before the end of the year. He said the agency’s Missing and Murdered Indigenous Persons unit is “taking investigative steps with the goal of finding the person responsible for Sue Sue’s tragic death and holding that person responsible for their actions through the criminal justice system.”)

Both Kirk and Norton had been victims of domestic violence at the hands of two of the Richards brothers. The Daily News and ProPublica found that state prosecutors repeatedly allowed the men to avoid felony domestic violence convictions for strangling or beating women, including Kirk and Norton. In those cases, the state offered the sons deals, allowing them to plead guilty to reduced misdemeanor charges such as “harassment” and receive slaps on the wrist, not prison sentences.

In one sexual assault case involving a different woman, state Superior Court Judge Paul Roetman granted Anthony Richards, the mayor’s youngest son, uncommonly low bail. Roetman explained his decision by saying he had worked with Anthony’s mother and knew his father held elected office.

“Fine Third Parties” Listen to state Superior Court Judge Paul Roetman describe Annette Richards and Clement Richards Sr. as “fine third parties”in a 2015 bail hearing for their son Anthony Richards, who was facing sexual assault charges. (Obtained by Anchorage Daily News and ProPublica)

Roetman and two prosecutors, now a magistrate and judge, declined to comment through a court system spokesperson. “Judicial officers cannot and do not comment on their cases, in order to maintain the integrity of their decisions and to ensure that, for fairness reasons, their thinking is reflected solely in the official court record without extraneous commentary,” the spokesperson wrote.

In the center of Kotzebue, Norton’s adoptive mother, Susanna “Mama Sue” Norton, is waiting for answers from Alaska’s criminal justice system. She lives three doors down from the house where her daughter was found strangled to death.

“My family is not going to have peace until they know that they found someone that did this to her,” she said in an interview in 2020. Three years later, as another winter begins, the case grows colder by the day.

Susanna “Mama Sue” Norton says police never talked to her about her daughter’s homicide. (Emily Mesner/Anchorage Daily News) In this overview of Kotzebue, the two green houses in the center belong to Clement Richards Sr., while Mama Sue Norton lives in the brown house in the bottom right. Kotzebue City Hall and the police station are to the left of the intersection. (Emily Mesner/Anchorage Daily News) A History of Criminal Charges

Kotzebue lies just above the Arctic Circle on a frying-pan-shaped peninsula, nearer to Russia than to Anchorage. Clement Richards Sr. was born here in 1961, two years after Alaska became a state. The city sold itself back then as the Polar Bear Capital of the World, where small planes carrying trophy hunters from across the globe parked on the sea ice. (One of the largest polar bears ever recorded was hunted here in 1963.)

In the 1970s, geologists confirmed what a local bush pilot long suspected: The red-stained creeks that veined the tundra hinted at a massive mineral deposit. In the ’80s, Kotzebue and surrounding villages voted to create a new Northwest Arctic Borough government, with the second-largest zinc mine in the world funding public services such as search and rescue.

Meantime, Clement Richards Sr. and Annette Richards were busy growing their family. The couple had two sons, Amos and Clement Jr., and another on the way in May 1989 when Clement Sr. kicked Annette in the stomach, according to charges filed in Kotzebue state Superior Court. Clement Sr. had previously struck her, Annette wrote in an earlier restraining order request. This time she was eight months pregnant.

The charges say Annette was “bleeding profusely from her genital area.” The couple’s third son, Anthony, was born the next day.

Clement Richards Sr. is sworn in to the office of mayor of Kotzebue. He also served as mayor of the Northwest Arctic Borough. (Arctic Sounder)

Clement Sr. pleaded no contest to felony domestic violence assault and received a six-month jail sentence. The conviction wasn’t mentioned by his opponents or the media a decade later when he won a seat on the city council in 1999 or still later when he became the city’s vice mayor, then mayor. Annette began working in a local office for the Alaska State Troopers where her duties involved assisting state prosecutors, including one who later served as the judge in domestic violence cases against her sons.

The sons wrestled in high school, competed in fishing derbies and sometimes worked at the nearby zinc mine. Now 34, 37 and 39, all three have listed the former mayor’s property as their home address for most of their adult lives.

All three sons have been charged with assaulting women at the mayor’s property but dodged serious punishment.

The Daily News and ProPublica reviewed 31 criminal court cases involving the three sons, including more than 800 pages of charging documents, testimony, sentencing orders and protective order requests. In 12 of those cases, one of the sons was charged with committing domestic violence. The victims — six different women — included the sons’ relatives and current and ex-girlfriends, including Kirk and Norton. (The other criminal cases involved driving while intoxicated, indecent exposure and trespassing.)

Seven of these domestic violence cases were filed while Clement Sr. held political office, from 1999 to 2018. All told, the three sons have been charged with a combined 16 counts of domestic violence, including five felonies. Yet none of the charges against them resulted in a felony domestic violence conviction.

While the details in each case differ, seven of the domestic violence cases unfolded in familiar ways:

First, one of the girlfriends or a worried neighbor called the Kotzebue police. Officers arrived to find the victim with visible wounds such as bruises, markings on her neck or a bloody nose. The girlfriend told police one of the sons punched, kicked or strangled her.

She told police the attacks began when she tried to stop the son from drinking, attempted to leave the house or refused sex. In two cases, police noted the mayor or his wife refused to cooperate with the active investigation. The Kotzebue Police Department then arrested the son but usually labeled the attack as a low-level misdemeanor rather than felony assault.

Next, the son appeared before a local judge or magistrate who was sometimes a former state prosecutor who had worked alongside the ex-mayor’s wife. The judge or magistrate agreed to set bail for the son — once even acknowledging on the record that the bail was unusually low and telling the victim that the mayor and his wife would help keep the son out of trouble until the trial.

But the cases never made it to trial. They were settled at a change-of-plea hearing where prosecutors dropped any felony charges and the son promised to do better. Within a few months, maybe a year, the cycle would begin again.

In one 2013 case, a woman said Clement Richards Jr. punched her in the face and police filed a charge of domestic violence assault. Clement Jr. eventually pleaded guilty to harassment and received a suspended sentence, scrubbing his conviction from the public record. In a sexual assault case filed the following year against Anthony Richards, Roetman reduced Anthony’s bail from $7,500 to $2,500 over the protests of the victim, who said in a quaking voice that she feared running into Anthony in the town of 2,900.

“You Dodged a Bullet” Listen to Roetman, a judge, speak to Anthony Richards, who was facing sexual assault charges. “To say that you dodged a bullet is probably an understatement on this one,” Roetman said. (Obtained by Anchorage Daily News and ProPublica)

“I know Mrs. Richards from when she used to work for the troopers,” Roetman said at Anthony’s bail hearing. “She has a lot of experience with these types of cases and knows what these are like.”

The Alaska Judicial Code of Conduct states that a judge “shall not allow family, social, political, or other relationships to influence the judge’s judicial conduct or judgment.” Roetman did not respond to questions about his remarks in court, his work relationship with Annette Richards or the cases he presided over involving her sons. A court system spokesperson provided the newsrooms with a statement saying “judicial officers cannot and do not comment on their cases.”

Although a Kotzebue grand jury indicted him on felony charges of sexual assault and attempted sexual assault, Anthony Richards eventually pleaded guilty to a single misdemeanor count of indecent exposure in the 2014 case. The deal allowed him to avoid registering as a sex offender. (The prosecutor, Rachel Ahrens, is now a state superior court judge and declined to comment through a court system spokesperson.)

“To say that you dodged a bullet is probably an understatement on this one,” Roetman told him at the change-of-plea hearing.

Increasingly Dangerous Attacks

Clement Richards Sr. won election as Northwest Arctic Borough mayor in November 2015, campaigning on his experience leading the city and his bona fides as a born-and-raised son of Kotzebue. He became chief executive of a region the size of Indiana with a population of about 7,500. As climate change threatened the nearby village of Kivalina, the Northwest Arctic moved into the national spotlight.

“What’s happening here is America’s wake-up call,” then-President Barack Obama said after flying over the village and touring Kotzebue just before Richards was elected in 2015.

Clement Sr. had been in office just a month when Kirk showed up at the local hospital. She told police that Anthony had punched her five times.

Kirk grew up in the village of Buckland, 75 miles outside of Kotzebue. She and Anthony sometimes lived in one of two teal homes that Clement Sr. and Annette Richards own on a grassy lot, one block from the police department and City Hall. Officer Nate Lecours came to the property to investigate the beating.

Former Kotzebue mayor Clement Richards Sr. lives on this multi-home lot that his sons have also listed as their home address for much of their adult lives. (Emily Mesner/Anchorage Daily News)

“Upon arrival the Borough Mayor, Clement Richards, who appeared extremely intoxicated, answered the door and stated how can I help you a total of three times speaking over me then slammed the door in my face,” Lecours wrote in a Dec. 6, 2015, affidavit. (In a brief phone interview, Lecours said he remembered that encounter but no longer works for Kotzebue police and referred all questions to the department.)

A few days later, Magistrate Judge Stephan Brady reduced Anthony’s bail in this new assault case to just $100. (Brady no longer works for the state. He did not respond to phone messages or emails.)

As the years passed, the attacks grew more dangerous. On March 14, 2017, Kirk told police Anthony strangled her until her field of vision began to shrink and she nearly passed out.

That would have been enough, under a 2005 Alaska law, to charge him with a felony for nonfatal strangulation. Alaska was one of the first states to recognize that strangulation is often a precursor to homicide and increases suicide risk, according to the Training Institute on Strangulation Prevention.

The prosecutor, Ahrens, allowed Anthony to plead guilty to a single count of misdemeanor assault.

Despite the light punishment, Magistrate Judge Aaron Michels warned Anthony he could have killed Kirk that day.

“Strangulation is a very serious thing and it’s recognized that way by the Legislature, that’s why these types of cases can be charged as felonies,” Michels said at an October 2017 change-of-plea hearing. (He declined to comment through a court system spokesperson.)

“The result of strangulation — if it’s not stopped, if a person can’t breathe — is death,” the magistrate told Anthony Richards.

“You Are Getting Away From a Felony Conviction” In a hearing where Anthony Richards pleaded guilty to misdemeanor assault as part of a deal to avoid felony charges, Magistrate Aaron Michels tells Richards that “the natural result of a punch or a kick or kind of your typical misdemeanor assault is a bruise or an injury, that sort of thing. The result of strangulation — if it’s not stopped, if a person can’t breathe — is death.” (Obtained by Anchorage Daily News and ProPublica)

On May 23, 2018, Kirk and Anthony’s final argument began on the mayor’s property.

Alerted by a neighbor, two officers came to the house around 6 p.m. They found Anthony in the bedroom holding Jennifer Kirk’s body, according to police records, his hands and clothes coated in blood.

Anthony told police he had been watching TV with two children in the living room when he heard the pop of a gunshot and discovered Kirk dying on the floor. A .22-caliber rifle lay across her feet and a gunshot wound pierced the underside of her chin.

The police department’s investigator at the time, Thomas Milliette, measured the weapon.

“I noted the length of the rifle from the tip of the barrel to the tip of the trigger as being 27 1/8 inches long,” Milliette wrote in his report. Next he measured the length of Kirk’s arm: 26 3/18 inches. In interviews, members of Kirk’s family wondered how Kirk, who was 5 feet, 5 inches tall, could have shot herself with a long gun.

Robert Shem, a retired firearm expert for the state crime laboratory, said in an interview that such measurements can be useful in determining whether a death is indeed a suicide, but in this case, more information would be needed. (Shem was the forensic scientist who first established a link among the shooting victims of Alaska serial killer James Dale Ritchie in 2016.)

“Before I would write it off as a suicide myself,” he said, “I would probably try to locate somebody of the same size and build and use that rifle, or one similar to it, with the same length barrel and configuration, demonstrate that it’s completely unloaded and see if the person can lean over and potentially get their thumb in position to pull the trigger.”

Kirk’s father, Timothy Gavin, said Kirk gave no hints she might kill herself.

“We never seen that in her. No signs, nothing,” Gavin said. “So it’s hard to believe she did that to herself.”

Tim Gavin, Jennifer Kirk’s father, has questions about whether his daughter’s death was really suicide. (Emily Mesner/Anchorage Daily News)

Gavin knows something about policing and public service. A Buckland city councilmember and the former mayor, he served 11 years as a village police officer. He’s also no stranger to gunshot deaths. His stepfather shot and killed his mother, Kirk’s grandmother. (The stepfather was convicted of manslaughter and sentenced to prison.)

Kirk’s mother, Dora Stalker, chatted with her daughter hours before the shooting and recalls that nothing seemed amiss. They even made plans. “She was trying to ask me to send diapers for her daughter,” Stalker said.

“We kind of had a plan to send each other some Native foods,” Stalker said. Kirk would trade her mother beluga muktuk in exchange for springtime smelt from Buckland.

Two days after Kirk’s death, the state medical examiner’s office phoned Kotzebue police and said her body “showed signs of strangulation,” according to the death investigation report compiled by police and obtained through a public records request.

In his first interviews with police, Anthony had not revealed that he and Kirk violently fought before she died. Once Milliette knew about the strangulation marks, Anthony admitted to causing the injuries to her neck. He said he acted in self-defense.

Anthony said Kirk slapped him and he “held her away by the neck and didn’t know how hard he was squeezing,” according to the police report. Anthony said Kirk continued to slap him so he pushed her to the ground, twice. He said he didn’t know if he knocked her unconscious.

Milliette closed the case after one day of investigation. He concluded his report with a note that the medical examiner’s office had called again and said Kirk’s death would be ruled a suicide, with the final autopsy findings to be sent to Kotzebue police when finished. Kirk’s mother, Stalker, said police never interviewed her or asked her what her daughter had said to her the day she died.

“They should have investigated a lot better, a lot more thorough before they said it was a suicide,” Stalker said. “It’s like they just rush and do whatever to get it over with.”

The Kotzebue Police Department did not answer certain questions about the death investigation, including any about what conclusions Milliette drew from the rifle measurements, referring questions to the former police chief. Milliette did not respond to interview requests. The Alaska Department of Law, which oversees state prosecutors, did not answer questions about why no charges were filed in the case.

“I would have prosecuted him for the strangulation before she died,” said Casey Gwinn, a former prosecutor and president of the Training Institute on Strangulation Prevention.

A Missing 10-Year-Old Girl

Kirk’s death never made the news. Three months passed and the city of Kotzebue, along with the rest of Alaska, became absorbed with the case of a missing child. In this time of crisis, everyone turned to Mayor Clement Richards Sr.

Hundreds of volunteers hunted for 10-year-old Ashley Johnson-Barr, who disappeared in September 2018 from a playground at the center of town. The Northwest Arctic Borough Assembly chambers, adorned with antlers and a scrimshaw walrus tusk, served as the nerve center for the search with Clement Sr. acting as spokesperson.

“We’re a small community where everyone knows everyone, so we’re trying as hard as we can to find her,” Clement Sr. told the Daily News at the time.

“I’m deeply concerned she hasn’t been found yet,” he said, explaining that as many as 50 people were looking for the child at any one time. Norton joined in, her family said, cooking her best-loved food, caribou stew with pilot bread crackers, to feed fellow searchers.

After eight days, a volunteer spotted Johnson-Barr’s body in a brushy hollow outside the city. Federal investigators and state troopers raced to Kotzebue to aid local police and soon arrested a 41-year-old man for her death by strangulation. To solve the case, law enforcement used cellphone location data, DNA evidence, search warrants, surveillance video and the advantage of the FBI, who first arrested the suspect on grounds of lying to a federal officer. The killer, Peter Wilson, pleaded guilty to first-degree murder and first-degree sexual abuse of a minor and is serving life in prison.

The response shows how cases involving missing and murdered Indigenous people can be solved when they are immediately prioritized by local authorities and when state and federal agencies give assistance. The state declared an annual Ashley Johnson-Barr Day and hired a retired Kotzebue-area trooper, Alaska Native Anne Sears, as Alaska’s first full-time Missing and Murdered Indigenous People investigator.

Ashley Johnson-Barr’s aunt holds a photo of the murdered girl at a Missing and Murdered Indigenous People event in Kotzebue this year. (Marc Lester/Anchorage Daily News)

The message: Alaska would no longer tolerate the rape and killing of Indigenous women and girls.

But as the mayor prepared to leave office, nothing appeared to change for his sons. On Nov. 17, 2018, two months after Johnson-Barr was found dead, Kotzebue police received yet another report of domestic violence.

This time the victim was Norton, who by then was six months pregnant. Police found her crying, her right eye swollen shut. She said she had tried to stop her boyfriend, Amos Richards, from drinking by pouring out his beer.

City police Sgt. Norman Hughes described the attack in a report: “Susanna said the defendant became angry and grabbed her by the hair and drug her around the house. Susanna said the defendant kicked her repeatedly in the head, face, stomach and back. Susanna showed me her forearms which were swollen and told me she was holding her arms up to protect her head when the defendant was kicking her.”

Hughes categorized the beating in a criminal complaint filed in state court as misdemeanor, fourth-degree assault, the least serious form of assault spelled out by state law. (Hughes did not respond to interview requests or written questions.)

According to medical records, Norton flew to Anchorage, where her baby was born two weeks later at the Providence Alaska Medical Center. Doctors noted she had suffered “premature rupture of membranes.” Her family said the trip to Anchorage was medically necessary and believe the premature birth was brought on by the attack.

The baby weighed 3.1 pounds. Norton named her Eden.

“She is a tough baby girl,” Norton posted that day to friends and family. “Please remember us in your prayers.”

Sue Sue Norton’s Facebook post announcing the birth of her daughter (Screenshot courtesy of Lesley Sundberg)

Doctors recommended the baby stay in Anchorage, even after leaving the hospital, because Eden had health problems unrelated to the premature birth and needed surgery to survive. Mama Sue Norton said the Office of Children’s Services became involved and planned to temporarily place Eden with a foster family so she could be closer to medical care.

Sue Sue sang to the baby in Inupiaq over FaceTime, said Lesley and Joel Sundberg, a foster family who housed Eden after she left the hospital and have since adopted her. Amos, for a time, frequently texted the foster parents to ask how Eden was feeling and discuss the upcoming adoption.

Up in Kotzebue, a new strangulation case captured the attention of City Hall and local police. Authorities did not hesitate to seek the public’s help.

“The Kotzebue Police Department suspects foul play and is pursuing all investigative leads,” said Milliette, the investigator who had closed Kirk’s case without an arrest the year before. By this time, he had become chief of police. Volunteers raised thousands of dollars in reward money and the story made statewide news for days. After police released a surveillance photo of the suspect, a tipster came forward and identified the killer, who pleaded guilty to a felony in Roetman’s courtroom.

The victim was a dog: the city fire department’s pet husky.

A Second Death

On Jan. 19, 2020, Norton changed her Facebook profile photo to display a red handprint across her closed mouth, the symbol of the Missing and Murdered Indigenous Women movement.

Sue Sue Norton commemorated missing and murdered Indigenous women in her Facebook profile photo less than two months before she was killed. (Facebook)

A few days later, Amos Richards appeared in court to face charges for kicking Norton while she was six months pregnant. Once again the magistrate was Michels, who approved a deal that allowed Amos to plead guilty to a single count of “reckless endangerment.”

Despite the plea, Norton and Amos made plans to fly to Anchorage to finalize adoption paperwork.

“I cant tell if she has me or Amos’s eyes,” Norton wrote on Jan. 30, 2020, after seeing the latest picture of Eden at the hospital. She sent the Sundbergs a selfie of her and Amos, heads together, to show the baby.

Norton sent a photo of herself and Amos Richards to the couple who adopted their daughter, Eden. (Photo courtesy of Lesley Sundberg)

Like Kirk, Norton was a Leo. (Although born years apart, Kirk and Norton shared the same Aug. 21 birthday.) Norton had a habit of cracking her knuckles and dreamed of one day taking a Caribbean cruise. Her biggest fear, she once wrote, was losing her children.

Her mother remembers her, most of all, as a helper. The last time the whole Norton family gathered with Sue Sue, she sat on a square of cardboard on the tiled floor, separating the hide from the marbled meat of a freshly killed caribou.

Five days before Norton and Amos were to sign adoption papers, Amos stopped responding to texts from the adopting family.

The timeline of Norton’s last week alive is muddled by conflicting evidence. In a 2020 email to the Daily News and ProPublica, Kotzebue police estimated her date of death as March 5 or 6. But Norton’s sister, Vera Norton, said Sue Sue helped family prepare a caribou on March 7 or 8.

At 8:32 a.m. on March 9, police were called to the former mayor’s house, where they found Norton’s body, her head covered by a jacket.

Outside, the temperature fell to 13 below. Here above the Arctic Circle, graves must be carved into the icy soil and permafrost, and as Vera Norton was leaving home to look for a burial site, she saw police placing Amos into a patrol car.

Hughes later told Sundberg that police were unable to collect certain evidence. Asked to clarify by ProPublica and the Daily News, Kotzebue Police Chief Roger Rouse said in an email that Hughes had been referring to “the rejection of a search warrant from the judge in regard to some evidence.” The police chief would not say which judge he was referring to.

Amos skipped the funeral.

Mama Sue Norton said police never spoke to her about the case. She first learned the official cause of her daughter’s death was homicide when a death certificate arrived in the mail.

Norton is buried just outside Kotzebue. (Emily Mesner/Anchorage Daily News)

The certificate listed the cause of death as “asphyxiation due to obstruction of airways and compression of neck.” The autopsy also found that Norton had suffered “multiple blunt force injuries of head, neck and extremities.”

She’d been beaten. But it was the strangling that killed her.

“We’re Not Interested”

The homes on the Richards’ property are 440 feet from the Kotzebue Police Department lobby. City Hall is even closer. A dozen domed surveillance cameras circle the various government buildings, several within view of the former mayor’s house.

One day in June 2021, I knocked on the door of the main house, the first of three visits to the property where police found Kirk and Norton’s bodies. “What’s this about?” Clement Sr. asked.

Richards was no longer borough mayor at the time, having lost reelection in 2018. Norton’s family says the deaths on his property were common knowledge and gave voters pause. Other Kotzebue residents said the election was simply more competitive, with a new crop of respected candidates. When asked about the death of Norton, he said, “I have no comment,” and shut the door.

Clement Jr., the middle son, stood outside by a four-wheeler watching the exchange. He said he knew nothing about the case because he was in Anchorage with his father when Norton died. Asked how he thinks she died, Clement Jr. said he didn’t know, hasn’t thought about it and never asked.

Maybe she killed herself, he volunteered. “It’s a common thing in Alaska.”

In 2022, Sears, the state’s Murdered and Missing Indigenous People investigator, began looking into the case and met with Eden’s foster family to learn more. But Sears soon resigned, just five months into the new job. She declined an interview request.

The Daily News and ProPublica on June 14 of this year again attempted to interview Clement Sr. and his sons about the deaths. A man who answered the door at the back house refused to comment and closed the door.

“We’re not interested,” he said.

Last month, the newsrooms sent certified letters detailing the findings of this story to members of the Richards family; we didn’t hear back. The family also didn’t respond to letters, phone calls, texts and Facebook messages.

It’s all made for a long three years for Mama Sue, a devout Christian and a retired tribal doctor who practiced traditional medicine in Inupiaq villages. She suffered a stroke months after her daughter’s death and temporarily lost her ability to speak. On a recent weekday she sat in a formation of half-filled produce boxes, silently packing everything she owns as she prepared for her house to be demolished.

Her family built the home by hand decades earlier. Now a new house is arriving on a barge, and soon Mama Sue will have indoor plumbing and running water for the first time. Builders will place the new home on the same lot, 230 feet from the house where her daughter was found strangled.

As of September, Kotzebue police had never interviewed Mama Sue about the homicide. Nor had they talked to Norton’s other relatives and potential witnesses. Nor did they ever talk to neighbors who live between Mama Sue and the former mayor’s house, who regularly visit with Amos and Anthony Richards.

The new Kotzebue police chief, Rouse, said he could not comment on Norton’s death because it remains an open investigation, although the case is now in the hands of Alaska State Troopers.

In 2021, Lesley Sundberg, who adopted Amos and Sue Sue’s child, filed a formal complaint with the state regulators against the Kotzebue Police Department, accusing the department of “dishonesty and untruthfulness.”

“One must wonder,” Sundberg wrote to the Alaska Police Standards Council in November 2021. “If there are unethical reasons why a Native Alaskan woman, mother of 3, daughter, niece, sister, aunt, and well-known community member’s murder, has been swept under the rug.” (The executive director for the council said in an email to the newsrooms that the agency “does not investigate complaints of this nature until the involved criminal investigation is completed by the law enforcement agency working on it, so that we do not interfere with the criminal investigation.”)

She never received an answer.

Correction

Nov. 11, 2023: This story originally misidentified Rachel Ahrens’ current position. She is a superior court judge, not a magistrate.

by Melissa Sanchez and Maryam Jameel

Leer en español.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. This story was co-published with the USA TODAY NETWORK-Wisconsin.

County officials in Wisconsin approved reforms this week meant to respond to a ProPublica report on the flawed investigation into the 2019 death of a Nicaraguan boy on a dairy farm. They include an $8 million fund for farmworker housing and measures to improve access to government services for people who don’t speak English.

Advocates said the housing initiative appears to be the first of its kind in Wisconsin, a state that calls itself “America’s Dairyland” but that offers few protections for the undocumented immigrants whose labor many farms depend on.

Separately, the sheriff’s office in Dane County — which investigated the boy’s death — has drafted its first-ever written policy on how to respond to residents with limited English proficiency.

The changes come in response to a February report by ProPublica that detailed the flawed law enforcement investigation into the death of Jefferson Rodríguez, an 8-year-old boy who had lived in a barn above a milking parlor on the farm where his father worked about a half-hour north of Madison.

ProPublica found that another worker had accidentally run Jefferson over with a skid steer, a piece of machinery used to clear manure off barn floors. But the deputy who interviewed the boy’s father, José María Rodríguez Uriarte, mistakenly concluded that he had been the one operating the machine. This failure, we found, was due in large part to a language barrier. Jefferson’s death was ruled an accident, but Rodríguez was publicly blamed.

In a recent interview, Rodríguez said he was glad to learn that the story of what happened to his son has led to changes that could help other immigrants. “Perhaps if all of this had happened five or six years ago, my situation would have been entirely different,” he said. “It would be much better to be able to communicate with police without the fear of calling and them not understanding.”

José María Rodríguez Uriarte and his son Jefferson in Wisconsin. (Courtesy of José María Rodríguez Uriarte)

The measures were approved Monday as part of the county budget. Joe Parisi, the county executive, can still veto the budget but is not expected to do so.

After our story was published, several members of the board and other elected officials began calling for measures to ensure that people who don’t speak English can communicate accurately with sheriff’s deputies.

When Jefferson died, the sheriff’s office had no written policy on what deputies should do when they encountered people who spoke limited English or when they should call for an interpreter. As a general practice, the department encouraged patrol deputies to ask for help from bilingual colleagues or to use a phone- or video-based interpreter, Elise Schaffer, a department spokesperson, said in a statement.

The department doesn’t test language skills of employees, who instead self-report proficiency.

The deputy who interviewed Rodríguez identified herself as a proficient Spanish speaker. When we interviewed her, however, we discovered that the words she used in Spanish to question Rodríguez didn’t mean what she thought. Rodríguez told us that he never understood the deputy was trying to ask if he was driving the machine that killed his son.

Sheriff Kalvin Barrett declined interview requests. But at a county board meeting in September, he acknowledged “shortfalls in the services that we have and we want to make sure that we’re continuing to provide individuals with the help and the services that they need, especially if they don’t speak English.”

Barrett said the department will test employees on their ability to speak a second language and that it was looking for ways to provide “additional financial support” to those who demonstrate proficiency. According to a draft policy, the department will provide training to staff on how to find qualified interpreters and ensure key documents and forms are translated.

Schaffer said she did not know when the draft policy would be adopted.

Law enforcement agencies that receive federal funding, like Dane County, are required by the Civil Rights Act to ensure that their services are accessible to people who speak limited English. ProPublica found that sheriff’s departments across Wisconsin routinely encountered language barriers when responding to 911 calls from dairy farms. Over and over, records showed, officers who couldn’t communicate with Spanish-speaking workers relied on farm supervisors, other workers, Google Translate and even children to interpret for them.

The Board of Supervisors on Monday separately approved the creation of three full-time positions and one part-time role to improve services for people who don’t speak English. Among them: a coordinator to help departments implement language access plans and engage community members with limited English proficiency.

Dana Pellebon, a member of the Board of Supervisors who chairs the county’s Equal Opportunity Commission, said the issue of language accessibility got more attention than ever this year.

“Your article started this investigation into what it is that needed to happen,” she said. “I am deeply sorry and ashamed that it had to take the death of a child for us to be aware, and we’re going to work proactively to make sure these situations never occur again.”

ProPublica’s reporting also put a spotlight on dairy worker housing, which goes largely unregulated and uninspected by state and federal authorities.

Dane County is home to more than 170 dairy farms, according to state records. It’s unknown how many provide housing to workers, but a recent statewide study on immigrant dairy workers by the University of Wisconsin-Madison’s School for Workers found that close to three-quarters of surveyed workers lived in employer-provided housing, typically on the farm.

Our reporting found that Jefferson and his father had lived in a room above a milking parlor — the place where cows are milked day and night with loud, heavy machinery. (In court filings, the farm’s owners disputed that they lived there. ProPublica spoke with more than a half-dozen people, including Jefferson’s bunkmate, who confirmed that they and other workers lived above the parlor.)

“The issue of safe housing for folks working on farms and in rural parts of the county I don’t think had been front of mind to me until hearing more about, honestly, the death of Jefferson Rodríguez,” said Heidi Wegleitner, a member of the Board of Supervisors who was the lead sponsor and author of the farm worker housing initiative. “This is a gap that existed, I think, before your important reporting, but it really gave me a sense of urgency about doing something about it.”

Wegleitner, who is also a housing attorney, said the first goal of the new initiative will be to assess the existing housing supply and needs of farm workers. The county could then purchase land and build new housing.

Advocates say there is a significant need for affordable housing for undocumented immigrant dairy workers who are excluded from existing programs due to restrictions in federal funding.

“This has always been a challenge for us,” said José Martínez, the chief operating officer of the nonprofit United Migrant Opportunity Services, which operates several affordable housing projects for agricultural workers across Wisconsin.

None of UMOS’ housing developments are accessible to people who are undocumented.

Neither is the 32-unit apartment complex for low-income agricultural workers that opened last year in Darlington, in southwest Wisconsin. Several people involved with the project said it was intended, in part, to serve immigrant dairy workers in the area, but instead the units have been mostly rented out to other kinds of agricultural and food-processing workers, including immigrants with work permits.

There are other challenges. For more than a decade, Wisconsin has barred undocumented immigrants from obtaining driver’s licenses, even though the state allows them to buy and register their vehicles. ProPublica reported earlier this year on how undocumented dairy workers are ticketed over and over for driving without a license. As a result, some workers prefer to live on the farms where they work so they can avoid having to drive.

Meanwhile, Rodríguez said he is glad somebody in Dane County is paying attention to the housing conditions immigrant workers encounter on dairy farms. It’s a subject he says comes up often when talking to friends who live and work in the area.

“The problem is you are just afraid that if you complain, there will be a negative reaction from the bosses,” he said. “That maybe they’ll tell you, ‘We don’t need you working here anymore.’ And so you just put up with the bad conditions.”

by Jessica Miller, The Salt Lake Tribune

Update, Nov. 14, 2023: Scott Owen was charged on Nov. 13 with multiple felonies related to the allegations of two men who say he touched them inappropriately during therapy. If convicted, he faces a five-years-to-life prison term on each charge. His defense attorney did not respond to a request for comment. The Salt Lake Tribune is publishing ongoing coverage of the case.

This story details allegations of sexual assault.

This article was produced for ProPublica’s Local Reporting Network in partnership with The Salt Lake Tribune. Sign up for Dispatches to get stories like this one as soon as they are published.

Former Utah therapist Scott Owen was arrested Wednesday in connection with accusations that he sexually abused patients during sessions.

The Salt Lake Tribune and ProPublica reported in August on a range of sex abuse allegations against Owen, who had built a reputation over his 20-year career as a specialist who could help gay men who were members of The Church of Jesus Christ of Latter-day Saints. He gave up his therapy license in 2018 after several patients complained to state licensers that he had touched them inappropriately. Some of the men who spoke to The Tribune said their bishop used church funds to pay for sessions where Owen allegedly also touched them inappropriately.

Owen, 64, was booked into the Utah County jail on suspicion of six counts of object rape and four counts of forcible sodomy. A Utah County judge has ordered that Owen remain in jail without the opportunity to post bail, finding that he could be a danger to the community and would likely flee if released.

Scott Owen (Obtained by The Salt Lake Tribune and ProPublica)

Owen had not been formally charged as of Friday morning. He has not responded to detailed lists of questions previously sent to him on two occasions regarding allegations that he touched his patients inappropriately. He co-founded Canyon Counseling in the late 1990s and continued to have an active role in the business until recently. The counseling center cut ties with him after sexual assault allegations became public before announcing in September that it was closing altogether.

In a probable cause statement released Wednesday, a Provo police officer wrote that the department had interviewed 12 former patients of Owen’s since August. Owen was arrested on allegations connected to two former patients, who both say Owen engaged in sexual contact with them during therapy sessions. That alleged touching included kissing, cuddling and Owen using his hand to touch their anuses. One man also alleges Owen performed oral sex on him.

Provo police allege in the statement that Owen used his position of trust as a therapist to coerce his patients into engaging in kissing, cuddling and sexual touching during therapy sessions. According to arrest records, many of the 12 former patients told officers that they began seeing Owen for treatment of “same-sex attraction.” The therapist told them their relationships with men were “broken” and that therapy could help them have “normal” relationships with men and eventually women, the men told police. From there, the patients allege, Owen would engage in touching that some say became increasingly sexual in nature.

Utah law says patients can’t consent to sexual acts with a health care professional if they believe the touching is part of a “medically or professionally appropriate diagnosis, counseling or treatment.”

Under a negotiated settlement with Utah’s licensing body, Owen was able to surrender his license without admitting to any inappropriate conduct, and the sexual nature of his patient’s allegations is not referenced in the documents he signed when he gave up his license.

Prior to the August publication of The Tribune and ProPublica article, Provo police said they had no record of anyone ever reporting Owen to law enforcement for alleged sexual misconduct.

Both state licensers and the local leaders in the LDS Church knew of inappropriate touching allegations against Owen as early as 2016, The Tribune and ProPublica reporting showed, but neither would say whether they ever reported Owen to the police. In Utah, with few exceptions, the state licensing division is not legally required to forward information to law enforcement.

The church said in response that it takes all matters of sexual misconduct seriously, and that in 2019 it confidentially annotated internal records to alert bishops that Owen’s conduct has threatened the well-being of other people or the church.

by Brandi Kellam and Louis Hansen, Virginia Center for Investigative Journalism at WHRO

This article was produced for ProPublica’s Local Reporting Network in partnership with the Virginia Center for Investigative Journalism at WHRO. Sign up for Dispatches to get stories like this one as soon as they are published.

A Virginia state representative has called for creating a legislative commission to examine public universities’ uprooting of Black neighborhoods following reports of the racial impacts of one local college’s expansion.

Delegate Delores McQuinn said in an interview that a commission is needed to research Black communities that were displaced by Virginia universities and to examine cases of families who say they were forced to sell their homes. Separate legislation sponsored by McQuinn in 2020 established a commission studying the impact of slavery and racial discrimination in Virginia, which is expected to issue a preliminary report in January.

McQuinn also urged colleges to explore potential redress for displaced families, such as free tuition. “Universities should take it upon themselves to revisit and address these inequities and injustice that occurred at monumental levels,” said McQuinn, a Democrat who represents part of the city of Richmond and adjoining counties. “Many universities have profited for years based on the injustice that prevented Black families from progressing financially.”

Along with McQuinn, other state legislators, a U.S. representative, and municipal and academic leaders said they were troubled by a recent series of articles by ProPublica and the Virginia Center for Investigative Journalism. The series detailed how Virginia universities have dislodged Black families, sometimes through the use of eminent domain, to make room for dormitories, parking lots, laboratories and other facilities, thereby exacerbating the racial gap in home ownership and the loss of Black-owned land.

For example, the city of Newport News seized the core of a middle-class Black community in the early 1960s for the site of what is now Christopher Newport University. Although less expensive locations were available, the Shoe Lane neighborhood was close to an all-white country club and residents were planning to develop more housing for Black families. Newport News leaders decided to erase what they called the “Black spot,” according to former CNU President Anthony Santoro. The city paid homeowners 20% less than the property value set by an independent appraiser. After Black families began to resettle around the university, Christopher Newport expanded its boundaries and bought most of the remaining homes. The university used eminent domain as leverage to force at least one homeowner to sell in 2005. That year, the school’s governing board approved the tactic’s use for three other properties that Christopher Newport said it ultimately acquired without resorting to eminent domain.

In a September message to faculty and staff, Christopher Newport President Bill Kelly acknowledged that the university’s progress “has come at a human cost, and we must continue to learn about and understand our complicated history.” This “important chapter … is appropriately receiving renewed attention,” he added in an apparent reference to our Sept. 5 article.

The school has erected a plaque and an exhibit chronicling the 1960s seizure of the community. In response to ProPublica and VCIJ’s reporting, Kelly, a retired rear admiral who became CNU’s president this year, will lead a neighborhood walk next week with CNU faculty and students as well as state and city leaders and law enforcement officials, according to university spokesperson Jim Hanchett. Although one purpose of the walk is to explore the university’s history, the tour will bypass two of the streets most affected by CNU’s expansion into the former Black neighborhood. “The route was chosen because it was the safest option” in terms of traffic and sidewalk width, Hanchett said. “We are listening and learning … so that actions pursued by the university are thoughtful and effective.”

As part of its “listening and learning” campaign, the university hosted a panel discussion Wednesday at its fine arts center, where faculty members, local historians and clergy spoke to an overflow crowd about the significance of the campus’s location and the effects of expansion on the surrounding community. While acknowledging the event as a first step, associate professor Johnny Finn, chair of the sociology department, said that the university should go beyond symbolic actions and consider “very real and very material things that we can do,” such as paying reparations or offering scholarships to descendants of families who were pushed out of their homes.

“I hope that this is indeed a starting point and not an ending point,” Finn said.

Christopher Newport University (Christopher Tyree/Virginia Center for Investigative Journalism at WHRO)

Several other universities in Virginia and elsewhere have sought to make amends for shattering minority communities. Part of the Lamberts Point neighborhood in Norfolk, Virginia, was leveled in the 1960s and 1970s, when it was a predominantly Black neighborhood, to make room for what is now Old Dominion University’s main campus.

ODU officials said they have long recognized the need to improve relationships with their neighbors in Lamberts Point. In the past three decades, through community outreach and changes to admissions policies, students of color have increased from 21% to 54% of ODU’s enrollment. ODU has awarded $310,000 in scholarships to 137 students from Lamberts Point and nearby neighborhoods since 1999, according to university records. The school also has run free summer camps for Lamberts Point children since 1992 and offers seasonal jobs to high school students.

The University of Virginia also has acknowledged its role in displacing Black residents, appointing two executive commissions within the last decade to study its historical support for racist policies. The school’s president, Jim Ryan, set a goal of building up to 1,500 affordable homes and apartments by 2030 for Charlottesville residents on property owned by the university or its affiliates.

Some public and private universities outside Virginia are directing scholarships to residents of communities that were diminished by campus expansions. The bustling, largely Hispanic neighborhood of Auraria in Denver was chosen in the early 1970s as the site for a satellite campus of the University of Colorado. An urban renewal project razed all but 13 cottages and a grocery store, scattering 343 families. In the 1980s, the University of Colorado at Denver set up a Displaced Aurarian Scholarship program to eliminate fees and tuition for students from families who lived there between 1955 and 1973. Last year, the university expanded the program to include all future direct descendants of the displaced families. Overall, the school has handed out more than 600 Aurarian scholarships worth $3.4 million.

Nolbert Chavez, an administrator at the University of Colorado at Denver and former Colorado state lawmaker, said community lobbying helped secure an additional $2 million in scholarship funds from the state legislature in 2022. The Aurarian community’s struggle for recognition is similar to that of other Black and Hispanic neighborhoods displaced by universities across the country, he said.

“The thread is all the same — the communities were all traumatized,” Chavez said. “Until that is dealt with, these communities can’t move on.”

One such community is seeking financial reparations. About 50 families in Linnentown, a small Black neighborhood in Athens, Georgia, were displaced when their homes were acquired, mainly through eminent domain, and razed between 1962 and 1966 to clear space for University of Georgia dormitories. The financial losses caused by the seizures cost Black families $5 million in current dollars, including $4 million in underpayments and $1 million in foregone increases in property values, according to a study by University of Georgia researchers.

In 2021, commissioners in Athens-Clarke County, where the school is located, passed a resolution supporting redress for Linnentown families through economic development projects in underserved communities. Commissioners also earmarked $2.5 million to build affordable housing and a community center.

Linnentown families who say they were paid less than fair value for their properties have sought compensation from the university. But a university spokesperson said the Georgia Constitution prohibits the school from using state funds for voluntary payments to third parties.

“However, the university leads a wide range of successful initiatives and partnerships that contribute to UGA’s nearly $500 million economic impact on the Athens-Clarke County community,” spokesperson Greg Trevor said. The school dedicates 10 need-based scholarships to residents of the county, he said.

In an interview with VCIJ, Newport News Councilperson Tina Vick raised the possibility of reparations for families uprooted by the establishment and expansion of Christopher Newport University. Scholarships for their descendants aren’t adequate compensation, she said. “If somebody disrupted my whole family, business and wealth, free tuition would not be enough for me.” She said the council has informally discussed the ProPublica/VCIJ articles but hasn’t decided what, if anything, to do.

State Delegate Jeion Ward, a Christopher Newport graduate whose General Assembly district includes part of Newport News, said Virginia universities need to enhance their investments in Black communities through scholarships, affordable housing initiatives and development programs. The treatment of Black property owners by universities highlights “how the loss of generational wealth has been systemically sustained in our society,” she said.

“It’s crucial for both our community and the universities involved to acknowledge and respect the sacrifices of the Black property owners who were unjustly evicted from their homes and businesses,” said Ward, a Democrat.

Rep. Bobby Scott, who has represented Newport News in the U.S. House of Representatives for 30 years, said that the seizure of Shoe Lane was typical of “some of the practices and policies intended to make life more difficult for Black Americans” during the Jim Crow era. “It is neither shocking nor surprising that one of the only thriving middle class Black neighborhoods in Newport News was selected for this treatment,” he said.

Scott added that he supported the Biden administration’s infrastructure bill, which passed in 2021 and included a $1 billion pool to be used for reconnecting predominantly minority communities that have been intentionally divided by major highway construction. Public and private universities are eligible for the grants, which require local matching funds.

“We cannot undo all the harm that has been done, but we can do more to ensure current policies are implemented with equity,” said Scott.

McQuinn, the state delegate who called for a commission to explore the racial impact of university expansions, was reelected this week. She said she hopes that “these efforts will result in solution oriented steps towards addressing past inequities.”

Reach Brandi Kellam at brandi@brandikellam.com or brandi.kellam@vcij.org and Louis Hansen at louis.hansen@vcij.org.

by Logan Jaffe

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

This month, in collaboration with The New Yorker, the ProPublica Films team published an animated documentary called “The Night Doctrine.” The film follows the investigative journey of reporter Lynzy Billing as she pieces together what happened to her own family members when they were murdered in Afghanistan 30 years ago. During her reporting, Billing began to learn of a series of other killings of Afghan civilians committed by the Zero Units, elite Afghan special forces groups backed by the U.S. That investigation, called “The Night Raids,” was published late last year.

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The accompanying film weaves together Billing’s personal story, the recent history of Afghanistan and the hauntingly recurrent nightly raids carried out by the Zero Units. I spoke with ProPublica visual journalist Mauricio Rodríguez Pons about the production of “The Night Doctrine,” which has so far been selected for screening by more than a dozen film festivals, including the Tribeca Film Festival, HollyShorts, the New Hampshire Film Festival and BIAF, among others. It is an incredible feat of animated journalism, and I encourage you to watch the 16-minute piece on our site or on YouTube. Now, on to the discussion, which has been edited for clarity and length.

Watch “The Night Doctrine” How did the idea to create an animated short documentary based off of this investigation come to be?

In the beginning, our plan was to create a three-minute video explainer. But when we started to work at the beginning with video that Lynzy [Billing] and another photographer, Kern Hendricks, took in Afghanistan, we saw the potential to create the story around it. Then we decided, OK, let’s do a nine-minute animated video about a single raid through the perspectives of a family and a soldier. And as we kept working with Lynzy, and with Tracy [Weber, ProPublica managing editor], and with Almudena Toral, ProPublica’s executive producer and co-director of the film, we discovered that Lynzy’s story was really, really hard — and really connected with the families, the Zero Units and the story of Afghanistan itself. So we started asking questions: What if we created a film that connects the three stories into one while trying to explain what happened in Afghanistan?

Part of the style of the film is the idea that everything is connected. It’s like an infinite journey. We wanted to create a journey that never ends — mimicking Afghanistan’s cycle of violence, loss and no accountability.

The transitions really are some of the biggest elements in the film. It’s not necessarily cuts between scenes; it’s fluid, you sort of slide into one scene and then another.

A phrase that we wrote on a storyboard is “infinite nightmare,” and we asked ourselves how we can represent that. I came up with this idea of creating an infinite sequence that connects with each sequence, and the whole film is like a connection. It’s like you’re always navigating the stories and the journey. I mean, Lynzy’s journey and Afghanistan’s journey is at the end of the day the same, right?

How would you describe the film’s style and what informed your decision to animate in the way you did?

Of course, the night is kind of the main thing here. In the night, the darkness is important. We wanted to again create that infinite nightmare — and the mood, the colors, everything is connected with the night, the shadows, the blue color is also kind of like a nightmare. Everything was driven by that idea.

From the technical perspective, it’s hard to create differences in black.That’s why we wanted some light elements present like the candle at the beginning that the little kid has next to his bed, and the lanterns, and the lights of a car.

I know you mentioned that Lynzy is a photographer as well, and the film incorporates real video footage and photographs. How did you make that decision to include the source of real elements? And how did you want those elements to relate to the animation?

The security of our sources was important for us. And the access was impossible — especially after the Taliban took over Afghanistan again. We also really wanted to add some elements to communicate that this is a true story. And that’s why we decided to add real footage elements.

For example, the image that everybody saw when the United States left Afghanistan was that plane … so we wanted to use that to remind people: Remember this image? These are the stories that were around that image you saw. And at the end we show the main characters of the piece in their actual, modern environment. It’s to give some kind of truth; that this is a true story. It’s not just a fiction animated piece. We didn’t invent this.

What are your thoughts on how visuals and animation can fill in gaps of what isn’t officially recorded? And how did you think about that as you made the film?

I think the animation gives you the power not just to fill the gaps, but to fill the gaps creatively. That creativity, that freedom that the animation gives you, allows you to present not just the facts but also the sentiments that people felt. It’s something that not only animation can do, but it’s also kind of like its main role. Especially here in ProPublica, a place where we really care about facts, and with what happened and what didn’t happen, animation is a powerful tool to represent not just what happened with the families but to represent how the families felt and how Lynzy felt.

Were there any inspirations that you drew on while you were working on the piece?

The main inspiration for me came from a soundtrack that Milad Yousufi, the musician we worked with, shared with me. It was like a soundtrack of Afghan old movies and the instruments include the main instruments, the rabab and piano, we used in the film. It was really, really dark. And I played that all day for days. I don’t remember how many months; maybe eight months. I would work with that music on and kind of allowed myself to feel that darkness and the suffering of the story, of the Afghan people. I mean, how many families suffered there? For me, that’s the main thing. It's the main inspiration.

What do you hope viewers will take away from the film?

I hope viewers take away the story, and I hope they think about what the United States is doing in places like Afghanistan, and about accountability. Like Lynzy said in the film, it happened in Afghanistan, it happened in Vietnam, it happened in Iraq. That’s why I said at the beginning that this is a never-ending story. You just can’t imagine all the sad stories that are destroying families right now. I guess I just want people to consider the families that are affected. That’s the intention of the film. That’s what we wanted to represent. And I hope we can put another voice out there to try to make change.

by Nat Lash, ProPublica, and Janet Wilson, The Desert Sun

As the Colorado River snakes through the deserts of the Southwest United States, its water is diverted to cities, states, tribes and farmers along its course.

Agriculture has always been the largest use of the Colorado River, and California’s Imperial Irrigation District, established in 1911, has among the earliest claims and by far the largest claim to the river. The district — and by extension, the farmers it serves — has access to enormous amounts of cheap water from the shrinking river. Congress and the U.S. Supreme Court have upheld the farmers’ rights to the water.

The river’s reservoirs cratered last year, with Lake Mead falling to its lowest level since it was filled in 1937. As the federal government weighs paying more than half a billion dollars to the irrigation district and its farmers to use less water, The Desert Sun and ProPublica sought to find out who was using the water and what they did with it.

The district refused to tell us and denied public record requests, saying that identifying individual customers would create “uncertainty, fear and turmoil.” So we used satellite data, combined with records on who owns and farms each field in the valley, to estimate for the first time exactly who benefits from the vast supply of water, and how they use it.

Read the full story on ProPublica’s website.

by Janet Wilson, The Desert Sun, and Nat Lash, ProPublica

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. This story was co-published with The Desert Sun.

Craig Elmore’s family history is the stuff of Westerns. His grandfather, John Elmore, a poor son of a Missouri preacher, arrived in California’s Imperial Valley in 1908 and dug ditches to deliver water to homesteaders.

Thanks to his marriage to a citrus magnate’s daughter, reputed good fortune as a gambler and business acumen, he amassed the Elmore Desert Ranch, part of roughly 12,000 acres that two branches of the family still farm.

All that land in the blazing-hot southeastern corner of California came with a huge bonanza: water from the Colorado River. In 2022, the present-day Elmores consumed an estimated 22.5 billion gallons, according to a Desert Sun and ProPublica analysis of satellite data combined with business and agricultural records. That’s almost as much as the entire city of Scottsdale, Arizona, is allotted.

That puts the Elmores in exclusive company. They are one of 20 extended families who receive fully one-seventh of the river’s flow through its lower half — a whopping 1,186,200 acre-feet, or about 386.5 billion gallons, the analysis showed.

The Colorado River system, which supplies 35 million people in seven U.S. states and Mexico, nearly collapsed last year. Even after a wet winter, it is dwindling due to overuse and climate change. But no matter how low its reservoirs sink, the historic claims of these families and all of Imperial County place them first in line — ahead of every state and major city — for whatever water remains.

How a handful of families and a rural irrigation district came to control so much of the West’s most valuable river is a story of geography and good timing, intermarrying and shrewd strategy, and a rich but sometimes ugly past when racist laws and wartime policies excluded farmers of color. Together, they winnowed the greatest access to these 20 clans, who today use more of the river than all of Wyoming, New Mexico or Nevada. A vast, laser-leveled green quilt of crops covers this naturally bone-dry valley, all of it grown with Colorado River water.

The water is held “in trust” by the Imperial Irrigation District and two smaller agencies, meaning they are legally required to deliver the water to any county landowner for use on their property.

But many farmers here see the river water as virtually their private property, though nearly all acknowledge it can’t be sold apart from their land.

“It’s not a public resource,” says Rachel Magos, executive director of the Imperial County Farm Bureau. “It’s called prior perfected rights.”

That phrase, “prior perfected rights,” is shorthand for legal decisions spanning 100 years, including three by the U.S. Supreme Court, that have perpetuated those rights since early would-be developers staked claims for the Imperial Valley that amounted to the river’s entire flow.

Blood ties, and the ceaseless buying of lands from less successful farmers or descendants who want a “windfall,” have concentrated thousands of farm fields and the water that comes with them into an ever-smaller number of hands, says county tax assessor Robert Menvielle.

Menvielle, a third-generation resident, and his extended family own about 1,700 acres that they largely lease to farmers, some of whom he’s known his entire life. “You’ve got this small group of families, and … they’ve all intermarried, and it’s almost like a feudal-type system, where we’re combining our little kingdoms,” he says.

Those fiefdoms exclude most of Imperial’s 180,000 residents. Agricultural operations — which in addition to historic farming families include universities, the Mormon Church, outside speculators and a Middle Eastern hay company — get 97% of the irrigation district’s river water, while every town, strip mall and other business combined get 3%. And the county ranks among the poorest in California, with a 2021 per capita income of $19,005. The U.S. per capita income that year was $70,480.

Irrigation district spokesperson Robert Schettler didn’t dispute the Desert Sun and ProPublica analysis showing who uses the valley’s water and what they do with it. But he said in a statement that despite distributing half of its water to 20 extended families, the district “provides equitable water delivery service to all,” including small landowners, towns and businesses.

The disparities in wealth and water disturbed Benny Andrés Jr. when he was growing up in Imperial County, and he became a historian partly to study their origins.

“How is it that a region conducive to year-round farming, with half a million acres of rich soil, plentiful and subsidized water … has bred widespread poverty and unhealthiness?” Andrés, now an associate professor at the University of North Carolina at Charlotte, asks in his book, “Power and Control in the Imperial Valley.” His research shows that outside speculators and absentee landlords also amassed huge amounts of land and water while people of color were systematically excluded, condemning most to eventual poverty.

Growers say that without agriculture, unemployment and poverty here would be even worse.

Meanwhile, outside threats to the area’s outsized water supply are looming. As federal officials force hard choices to keep the river afloat, states and cities facing water cuts are eyeing the Imperial Valley. The big farmers and their irrigation district say they know they’ve got a target on their backs.

Jay Famiglietti, an Arizona State University hydrologist who studies global water supplies, says large-scale farming in southwestern deserts like the Imperial Valley is “not sustainable, it just can’t go on.” Ultimately, production may need to shift to wetter regions.

Elmore and other farmers say that could devastate year-round food supplies in the U.S. — you can’t grow leafy greens and alfalfa in the Midwest in February. But they are striving to use far less water and to devise new ways to profit from an ancient flow.

Just Add Water

A canal carries water through Elmore Desert Ranch. (Jay Calderon/The Desert Sun)

Elmore’s grandfather arrived a year after the Southern Pacific Railroad forced the then-raging Colorado River to resume its normal course to Mexico, ending two years of flooding in the valley. For eons, the river was a wild, unpredictable force that shaped this landscape. At times, it flowed west and north into a huge trough between emerging mountain ranges. Here, the ancient river deposited millions of tons of mineral-rich soil.

In the mid-1800s, physician O.M. Wozencraft, a would-be land developer, realized that if the river could be diverted into its ancient path, the silty top coat of what was then known as “the Valley of Death” could be farmed. He persuaded California to deed him most of present-day Imperial County, but he couldn’t convince Congress to pay for a canal to carry river water to his land. A congressman called the scheme a “fantastic folly of an old man.”

But the lure of that water was irresistible. From 1895 through 1899, according to M.J. Dowd’s book, “The First 40 Years,” dreamers, schemers and agents for land barons posted notices on the river’s western bank, invoking California law protecting downstream mining claims, and filed them with the county recorder. “Each of these appropriations was for a flow of 10,000 cubic feet per second of the water of the Colorado River,” writes Dowd.

Collectively, they claimed the river’s entire flow and then some, Andres says. “They wanted it all, they didn’t want Arizona or anybody else to get a drop.”

But he and other experts note such claims had to be actively worked on, by seeking investors, building infrastructure and eventually providing water for “beneficial uses.”

By 1901, the California Development Co. had acquired rights to as much water as it could use. That year, Colorado River water was diverted via the first canal to what had been grandly christened the Imperial Valley, and by 1910, thousands of small farmers had arrived. The following year, the Imperial Irrigation District was formed, and a few years later, it bought out the private company and its rights.

Restless young men from India, Japan, Europe and the eastern U.S. arrived in the next 30 years. Many quickly went belly up and sold to more successful neighbors, like ancestors of the Elmores, Abattis, Strahms, Saikhons, Taylors, Morgans, Schaffners, Grizzles, Brandts, LaBrucheries, Rueggers and Osterkamps, all among the top 20 families using Imperial water today.

No Limits

The rose-colored vision of hardy pioneers “settling” the “virgin West” — after driving Native Americans from their ancestral lands — was enshrined in the federal Homestead Act of 1862 and Reclamation Act of 1902. Farmers were permitted to occupy and irrigate a maximum of 160 acres of free land and make it their own.

However, Imperial County landowners and complaisant U.S. Bureau of Reclamation officials ignored that limit, allowing rapid consolidation of land, says Andrés, who wrote his doctoral dissertation on the county’s early years. Thousands of formerly small holdings were now “farm units” absorbed by growing spreads like the Elmores’, a cotton syndicate, and hundreds of absentee landlords, he found. A 1924 report estimated 85% of Imperial landlords lived on the California coast or out of state.

Many farmers in the county were not white: By 1922, there were 2,200 Japanese immigrants farming 28,000 acres, and 495 people from India farmed 36,000 acres. Japanese growers, some of whom had worked on Hawaiian pineapple plantations, were often highly skilled and successful across California. Similarly, immigrants from the Punjab region of India knew how to coax vegetables from the valley’s often claylike soil in triple-digit heat. Some owned land; others farmed absentee owners’ holdings.

Japanese workers pick strawberries on an Imperial Valley farm. (Leo G. Hetzel/Hetzel Collection via Imperial County Historical Society/Pioneers’ Museum) A group portrait of Japanese members of the Imperial Valley Fencing Club in 1932. (Leo G. Hetzel/Hetzel Collection via Imperial County Historical Society/Pioneers’ Museum)

These migrants regularly endured racism. Landowners, county officials and even farmers of differing nationalities ranked migrants — Japanese, Indians, Filipinos, Mexicans and eventually Black southerners — in terms that would be familiar to white eugenicists. They classified them by their farming knowledge, ability to do backbreaking labor in searing heat and “reliability,” which meant they were unlikely to walk off the job or to demand higher wages or better living conditions.

“Like immigrants always, these groups were more desperate to succeed, so they were willing to work harder,” Andrés says.

White groups statewide decried the success of people of color. State Alien Land Laws banned Asians from owning land or leasing it long term. The U.S. Supreme Court upheld the second ban, but it was rarely prosecuted in Imperial. Still, it was not easy. Japanese families built wooden “mobile” shacks that they could carry from one set of fields to another after leases ended or if they were forcibly evacuated.

The exclusionary law drove out people of color who worked as merchants, too, and “began to depopulate the countryside,” said Andres. Many large landowners also ceased using full-time workers who lived nearby and hired contractors to bring in cheap, temporary labor from across the border.

Elmore says his grandfather operated differently than many during that era, building a school that all children from the surrounding remote area could attend. Elmore still lives in Imperial County, has about 50 full-time employees, and pays their health and life insurance benefits.

Today, instead of a vibrant local workforce, thousands of day laborers line up as early as 1 a.m. at the Mexicali-Calexico border, waiting for hours to be bused to fields, then back again. Meanwhile, Imperial had the highest unemployment rate in California in September, 19.7%, compared with 4.4% statewide.

Imperial Valley United

When the Great Depression hit, a flood of Dust Bowl “Okies” and other poor white and southern Black migrants arrived, upending the “whites first” racial caste system.

A migrant farm worker from Mexico outside his home on the edge of a pea field in the Imperial Valley in 1937. (Dorothea Lange, Library of Congress) A Dust Bowl refugee living in temporary housing in Imperial County in 1937. (Dorothea Lange, Library of Congress)

A few years later, during World War II, anti-Asian sentiment reached a fever pitch. FBI agents forced more than 100 Japanese community leaders from their homes in February 1942, including a Buddhist priest and a Christian minister. Then on two nights in May of that year, the entire Japanese population of Imperial County — hundreds of successful farmers, merchants, religious leaders and their families — was removed from their homes to be forcibly relocated to the Poston incarceration camp in Arizona. Some of the valley’s first farmers were among those imprisoned.

Their parcels, like land owned by detained Japanese farmers across the state, were likely acquired by neighbors and investors at foreclosure sales. Elmore says his grandfather and father had Japanese farmer friends who were forcibly removed. “That shouldn’t have happened,” he says. He’s not sure who acquired the local Japanese families’ land. “I know we didn’t.”

Near the end of the war, a huge anti-Japanese rally was held on the Brawley high school football field. A resolution was adopted petitioning the president, Congress and governor of California and protesting the return of any Japanese people to the Imperial Valley. Speakers at the rally condemned local churches for trying to aid their former neighbors.

There were financial motives behind the xenophobia. Powerful white shippers and growers organized the event, telling the local chamber of commerce that two people from the Poston camp “had appeared in town, announcing their intention to return to Brawley.” About 2,500 more former Imperial Valley residents of Japanese ancestry were due to be released.

A broad coalition of community groups dubbed “Imperial Valley United” vowed to permanently exclude Japanese people from the valley. Today, one Japanese-American farmer is listed on the Imperial Valley Vegetable Growers Association roster, and it’s not clear if he used any water last year.

“Prior Perfected”

Imperial officials lobbied for years for massive federal infrastructure to “tame” the Colorado and diminish the impact of drought and flooding. Growing southwestern cities wanted a steady water and power supply, too. It took until 1935 to complete what was then the world’s largest dam, in Boulder Canyon, Arizona.

In exchange for Hoover Dam, California and six other states signed a “Law of the River” compact. It divided the Colorado into upper and lower basins and set maximum amounts that each could take annually.

The Imperial Irrigation District had to agree for the first time to cap its river allocation. On paper, the era of no limits was over. But in practice, the agency would for decades order as much free river water as its farmers wanted.

There were challenges to their dominance.

As Phoenix and other cities in the Southwest grew exponentially, Arizona challenged California’s historic claim to the Colorado River. Arizona lost, but in 1960, the U.S. Supreme Court decided that California would keep 4.4 million acre-feet, Arizona would be entitled to 2.8 million acre-feet and Nevada would get 300,000 acre-feet. Imperial County came out on top, with a legal claim to three-quarters of California’s share.

An idealistic New York doctor named Ben Yellen, who had built a practice in Brawley caring for low-income residents and farmworkers, also wrote “yellow sheets,” denouncing Imperial landowners’ long-standing violation of the 160-acre homesteading limit and the irrigation district’s delivery of massive amounts of river water to them in violation of the 1902 Reclamation Act. He successfully intervened in a case challenging the water district, and California’s highest court eventually ruled the 160-acre irrigation limit had been illegally ignored.

But Elmore’s father and other major farmers fought back. In 1980, the Supreme Court ruled that the farmers could keep their large tracts and all the river water being delivered to them. The court ruled that the Imperial Irrigation District held “prior perfected” rights acquired from private irrigation companies under state law, neither of which had imposed limits on how much acreage could be irrigated. A framed copy of the decision hangs on Elmore’s ranch office wall.

U.S. Sen. Alan Cranston that year slipped language into a bill supposedly designed to reform the Bureau of Reclamation that permanently exempted Imperial County farmers from the 160-acre limit.

The number of farmers continued to shrink. From the 1960s to the 1990s, hundreds of smaller Imperial County farmers — largely descendants of Filipino migrants and other people of color — were decimated. U.S. Department of Agriculture research led to sturdier tomatoes that could be transported long distances, including from Mexico, which slashed demand for tastier but more perishable tomatoes grown by more than 500 Filipino farmers in and around Niland, in the valley. The North American Free Trade Agreement sent even more farming across the border, wiping out more small Imperial operations.

Sending Water to Cities

It was the Elmores who first cost their fellow growers some water. In 1982, Craig Elmore’s dad sued neighboring farmers and the irrigation district. The Elmores’ land sat at a lower elevation than nearly every other farmer’s fields, and they alleged that aging canals and overwatering by some had caused costly flooding on their fields.

The courts found that the irrigation district and its farmers were wasting water. The settlement agreement forced the district to partner with the urban Metropolitan Water District of Southern California, which supplies 19 million residents in coastal counties. In exchange for a cut of Imperial’s water, Metropolitan Water District funded the lining of the earthen All-American Canal and miles of side ditches.

As cities and suburbs drew millions more residents, Imperial’s power continued to erode. In 2002, President George W. Bush’s Interior secretary, Gale Norton, threatened to take some of Imperial’s water for cities; a year later, U.S. Sen. Dianne Feinstein bluntly warned Imperial Irrigation District officials that if they didn’t agree to transfer 300,000 acre-feet per year to suburban San Diego and the Coachella Valley, the U.S. Interior secretary might strip away their “senior” water rights. It would be the largest transfer of agricultural water to an urban area in the nation’s history, and the irrigation district would be paid handsomely by urban customers.

Antonio Ramos of El Centro, California, holds up a gallon-size bottle, representing Imperial County’s water, during a 2002 meeting on a proposal to transfer water from Imperial Valley farms to San Diego County. (Kevin Marty/Imperial Valley Press via AP)

A thin majority of the district’s board approved the deal. Most farmers have now accepted that they, like everyone else, have a limit on how much water they can use. But with urban areas wielding far more political power, some are not sure there will be farming here in another century.

“We Adapt”

Ralph Strahm, who with his brother and nephews used an estimated 81,000 acre-feet of water last year, the second-highest amount in the district, thinks people’s need for drinking water may win out over the need for food in most politicians’ minds.

He and other prominent growers are willing to seasonally fallow some fields for two months during the summer, if they’re paid to do so and keep their “senior” river rights. The federal government is weighing whether to award Imperial Irrigation District and local growers more than $600 million not to farm certain fields.

Andrés, the historian, says that approach is what led to most of the county’s impoverishment. He has his own vision for the valley’s future: The irrigation district and farmers should sell less-productive or unused land and pay out of their own pockets to ensure they use water efficiently. Public funds and training should instead support the diverse group of small farmers, he says.

But Elmore says hefty public subsidies and possible private investments are needed for farmers to grow crops more efficiently, then be paid to possibly transfer the conserved water elsewhere or leave it in the river’s massive reservoirs.

A tractor works a field at the Elmore Desert Ranch in 2019. (Jay Calderon/The Desert Sun)

Elmore’s son is the southwest region farm manager for Water Asset Management, a Wall Street investment firm whose mission is to tap into a potential trillion-dollar water transfer market. Elmore has spoken at WAM’s annual meetings, and like another top vegetable farmer, Jack Vessey, now leases and farms acreage that WAM has bought in the valley.

Elmore is building support in the irrigation-district for funding a $4.4 million pilot reservoir on his land, which could ultimately hold water for farming or for sale. The private sale of water outside the valley is currently prohibited, but that could change if public funding for conservation dries up.

However it shakes out, the Elmores and Imperial’s other dynasties will likely continue profiting from the Colorado River.

“I’m optimistic,” Elmore says in a throaty rumble. “Every time there’s a change, we adapt. If there’s one thing the Imperial farmer has learned how to do in these harsh conditions, it’s to adapt.”

Elmore, 66, says he’s thinking about who will benefit long term: “My grandson is 6 years old. I’d like to see him go into farming.”

Mark Olalde contributed reporting.

Janet Wilson’s reporting was supported by funding from Stanford University’s Bill Lane Center for the American West.

Correction

Nov. 10, 2023: The story originally misidentified where Jay Famiglietti works. He is at Arizona State University, not the University of Arizona.

by Robert Faturechi and Ellis Simani

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It was the kind of endorsement most companies dream of. Berkshire Hathaway CEO Warren Buffett, the legendary investor known as the Oracle of Omaha, repeatedly sang the praises of Wells Fargo in an interview with Fortune. The bank, Buffett said, “has come closer” to an effective business model “than any other big bank by some margin.” He detailed the ways in which Wells Fargo was more valuable than it seemed and compared its chair to Walmart founder Sam Walton.

The interview was published on April 20, 2009. Banks were still reeling from the financial crisis, stock markets were turbulent, and Buffett was the kindly white-haired billionaire who had assured Wall Street, the U.S. government and the public that America would be just fine. It was Buffett who had proposed the idea that turned into the $250 billion federal bailout that had propped up America’s banks (including Wells Fargo).

Berkshire was already one of Wells Fargo’s largest shareholders, and Buffett was so influential that, Fortune noted, he had “caused a 20%-plus jump in Wells shares” the previous month “simply by expressing confidence in the bank on TV.” After the Fortune interview appeared, a similar pattern ensued: Buffett’s comments rippled across financial media, eagerly lapped up by the legion of investing fans who followed his every move. By April 24, Wells Fargo shares had jumped 13%.

That day, Buffett privately sold off $20 million worth of Wells Fargo shares in his personal account.

It has long been known that Buffett keeps a personal stock portfolio, separate from his company’s holdings. But what’s inside of it has always been a closely guarded secret. Buffett’s hand-picked biographer, Alice Schroeder, told ProPublica that he gave her access to nearly everyone and everything in his life — except his personal investing records.

Over the years, Buffett has been unequivocal about one aspect of his personal portfolio: He has repeatedly said he steers clear of trading stocks that his company is trading. “I can’t be buying what Berkshire is buying,” he has said. Doing so, he stated on another occasion, would pose a “conflict” of interest. If he buys a stock before Berkshire does, for example, he could be enjoying a better stock price than his shareholders, since a big stock purchase by Berkshire will tend to increase prices.

But roughly two decades of Buffett’s personal trades were included in a leak of IRS data obtained by ProPublica. Those records show that the nation’s best known and most respected investor has sometimes said one thing in public and done another in private.

On at least three occasions, Buffett has traded stocks in his personal account in the same quarter or the quarter before Berkshire bought or sold shares of the same companies, doing so before the conglomerate’s moves were disclosed to the public.

These trades may violate Berkshire’s ethics policies, authored by Buffett himself, which require “all actual and anticipated securities transactions of Berkshire” be publicly disclosed before Berkshire employees can trade the stocks personally.

Warren Buffett answers questions during the Berkshire Hathaway annual shareholders meeting in 2021. (Daniel Acker/Bloomberg via Getty Images)

Overall, Buffett’s records show he reported at least $466 million in personal stock sales between 2000 and 2019. That’s a relatively modest sum for a person reported to be worth more than $100 billion (and indeed the records reveal vastly more trades in government and corporate bonds than in stocks). But the records include only securities he sold, not those he bought and held, so the portfolio is likely larger than ProPublica could see.

The trading records offer an unprecedented window into how America’s most iconic investor manages his personal portfolio. Buffett did not respond to detailed written questions about his personal trades.

Buffett has in the past described the process of finding a stock for his personal account in amorous terms: “It’s like finding a new girl to me.” But, at a Berkshire shareholder meeting in 2016, he waved away speculative questions about his personal trading by saying that the vast majority of his money is in shares of Berkshire, not his personal account, and that he planned to donate almost all of his billions in wealth to charity anyway.

In February 2012, Buffett was asked on CNBC why, despite his praise of JPMorgan Chase, Berkshire did not invest in the bank. “I’ll let you in on a little secret,” Buffett responded. “I own some shares of JPMorgan.” He explained that because Berkshire didn’t own any shares of the giant bank, “it’s one that I can buy without having any possible problems about conflict.”

The question came up a second time at a Berkshire shareholder meeting that year, and Buffett gave almost the same answer. He said he preferred Wells Fargo, but Berkshire was “buying Wells Fargo stock and that takes me out of the business of buying Wells Fargo,” so he bought shares of Chase for his personal account because it was his second choice.

“That’s one of the problems I have,” he said. “I can’t be buying what Berkshire is buying and I’ve got some money around and therefore I go into my second choices or into tiny little companies.”

Only a year earlier, the issue of personal trading had given rise to a rare scandal for Berkshire Hathaway. Buffett’s heir apparent at the time, David Sokol, resigned under a cloud after making personal stock trades, which Berkshire ultimately determined had violated its insider trading policy. Berkshire is a sprawling conglomerate, with $300 billion in 2022 revenues, that wholly owns some businesses and has stakes in a number of publicly traded companies. Sokol, who denied his trades were improper, had purchased shares of a chemicals company that Berkshire acquired soon after.

“Sokol episode could dent Berkshire reputation,” read one headline. “Say it ain’t so, Warren,” read another.

In the wake of such articles, Buffett defended his company’s personal trading policies and the firm’s controls to ensure those rules were followed. “I don’t think you’ll find that the problem is in the rules. The problem is in people breaking the rules,” he said. “People break rules...the job is to find them.”

He distinguished between an employee long holding a stock that Berkshire then invests in, which he defended, and making a move in a stock about the same time Berkshire did, as was the case with Sokol. Buffett was asked if there were other instances of anyone at Berkshire trading in a way that might create even the perception of potential frontrunning — the practice of investment managers trading stock with the knowledge that their employers were planning to trade the same security. “I’ve never seen it,” Buffett said. “I have no evidence of it.”

Ultimately, the Sokol episode left no permanent blemish on Buffett, whose reputation for probity is as stellar as his reputation for investing acumen. Indeed, Buffett has had a credibility no other investor could match — a homespun billionaire, with plain-spoken aphorisms and a handshake you could trust.

Buffett’s reputation in the public mind blossomed in the early 1990s after he was chosen to clean up a mess at Salomon Brothers. In the wake of the investment bank’s involvement in rigging auctions for treasury securities, Buffett was called to testify before Congress. With the cameras rolling, he assured lawmakers that ethical lapses would not be tolerated under his watch. “Lose money for the firm, and I will be understanding,” he testified. “Lose a shred of reputation for the firm, and I will be ruthless.”

Ever since, Buffett has spoken out harshly against anyone who would trade reputation for profit, repeating the adage that no one should do anything in private they don’t want to see on the front page of a newspaper.

The remarkable returns he delivered for Berkshire investors gave him his golden aura, but he also cultivated the image of a selfless and ethical billionaire. He pledged the vast majority of his wealth to charity. And he has called for higher tax rates for the wealthy, earning plaudits from President Barack Obama and others, even though the kinds of reforms he pushed would have largely left his fortune untouched.

In October 2012, Buffett made another noteworthy personal trade. Over several days, he sold $35 million worth of Johnson & Johnson shares. At that point, Berkshire had effectively revealed that it, too, had sold Johnson & Johnson shares.

Berkshire did this in the normal manner. It did not issue a press release announcing its plans to sell the shares. Instead, it filed a report (as many investment managers are required to do) listing its holdings as of the end of the quarter. The public could then compare the holdings in that filing to the holdings in the previous quarter. In that way, ardent Berkshire followers could determine that the company had sold shares at some point — no date is specified — during the quarter.

That filing did not disclose what was to come: namely, that Berkshire would sell millions more shares in the two quarters that followed. That seems to put Buffett’s personal sale at odds with Berkshire’s policy. That document states that if an employee is “aware that Berkshire has taken or altered a position in a public company’s securities or that Berkshire is actively considering such action, trading in any securities of such public company” is “expressly prohibited prior to the public disclosure by Berkshire of its actions.” The policy categorized awareness of Berkshire’s trades as “material nonpublic information,” a necessary component of an insider-trading claim.

In this instance, Buffett’s sale of Johnson & Johnson avoided a small dip in the days that followed. But over the ensuing months, the shares climbed significantly.

In another instance, in August 2009, Buffett appeared to move, in his personal portfolio, in the opposite direction of Berkshire’s portfolio. He sold $25 million of Walmart stock in his personal account, even as Berkshire almost doubled its stake (which had previously held steady for 15 quarters) during the same quarter. It’s unclear which transaction came first, but no matter the order of events, it raises the question of why Buffett made one choice for his own portfolio and the opposite choice for Berkshire’s investors. And if he knew Berkshire had or was considering making a move, and still traded, Buffett again risked violating his own insider trading policy.

The result of Buffett’s moves was anticlimactic: Walmart’s stock didn't move much in the weeks that followed this trade, but then months later rose some with the market. There’s no sign, in ProPublica’s data, that he sold Walmart shares again.

by Maya Miller, with additional reporting by Ash Ngu

If you want to request your own claim file, head to our “Claim File Helper.” If you have trouble getting your claim file back, let us know what happened at claimfile@propublica.org.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

Just outside public view, the American health insurance industry’s algorithms, employees and executives process tens of millions of claims for people seeking medical care.

Sometimes, as ProPublica has reported, insurers base decisions on what’s good for the company’s bottom line rather than what’s good for the patient’s health. Sometimes, insurers make mistakes. In one case we learned about, a company denied a child’s treatment because it based its judgment on adult guidelines instead of pediatric ones. In another, an internal reviewer misread what type of surgery the patient sought and denied coverage based on that error.

At first, these patients had no idea why they were denied treatment. But in each instance, insurance employees left a paper trail — in notes, emails or recordings of phone calls — explaining what happened. Patients and advocates used what they found in those records to craft appeals and ultimately receive the care they needed.

Federal law and regulations require insurers to hand over exactly this sort of information in response to a written request. And they have to do it fast: Most people who get insurance through an employer should get the records, called claim files, within 30 days.

There’s just one catch: Some insurers aren’t turning files over like they’re supposed to. We followed ProPublica readers through the process with five different insurers. Several companies only shared documents with patients after we reached out.

Our team discovered how useful claim files can be after a patient shared internal notes and calculations that a health insurer had made about his case. But few health insurers advertise this service or offer clear instructions for getting these records. To help fill that gap, we published a guide explaining how to submit a claim file request. We also shared resources with health care providers and patient advocates nationwide, including request letter templates.

Never miss the most important reporting from ProPublica’s newsroom. Subscribe to the Big Story newsletter.

More than 120 people have told us that they have since requested or intend to request their claim files. Though a handful say they received information that helped them understand why their health insurer denied coverage, many more have been running into challenges. They’ve told us about insurers blowing past deadlines, wrongly requiring subpoenas and — in several cases — misinterpreting their request entirely.

We shared a summary of these examples with Tim Hauser, a deputy assistant secretary with the Department of Labor. His office oversees claim file laws that cover more than 131 million people. He said insurers who fail to provide records are breaking the law. “The claimant really needs to be able to see what the relevant evidence is so that they can respond to it,” he said.

We brought our findings to five insurance companies. We presented them with details about the requests patients had made and how the company had responded, and we asked for an explanation of what happened in each case.

All of the insurers acknowledged that the patients were entitled to the material they’d asked for. Four began sending the files after our inquiry. Two, spokespeople told us, are updating policies to handle future requests. Anthem Blue Cross Blue Shield spokesperson Michael Bowman said the company needed to better train staff on the rules “to close any gaps to prevent this from occurring in the future.” Cigna spokesperson Justine Sessions admitted that patients do not need a subpoena to access their records, contrary to what the insurer had told a member. She said the company would update its “policies and communications to reflect that for future requests. We regret that we did not make these updates sooner and apologize for any frustration or confusion this has caused our customers.”

By crowdsourcing people’s experiences, we identified some patterns in health insurers’ behavior. Here are some of the most common issues people encountered — and what to watch out for if you submit your own request:

Insurers Asking for Unnecessary Subpoenas or Court Orders

Cigna and Anthem told members that they would need to obtain a court order or subpoena to access their claim file records.

“This is completely unheard of,” said Wells Wilkinson, a senior attorney with the nonprofit legal group Public Health Advocates who regularly files these requests. “It also sounds completely illegal. The consumer has the right to any information used by the health plan in the context of the denial.”

On July 12, Lisa Kays, a Maryland resident, asked Cigna for phone call records related to its decision to deny coverage for her 4-year-old son’s speech therapy. “We couldn’t afford to just give up,” Kays said.

In September, Cigna sent her a letter saying she would need to submit a subpoena to get any transcripts or recordings.

After ProPublica inquired, the company sent Kays partial transcripts of the calls. It also reimbursed her for some of the previously denied coverage. She is still waiting for the recordings.

We asked Anthem about a similar case. On July 19, a call center agent told Pamela Tsigdinos she would need a subpoena to receive her claim file records. Tsigdinos had submitted the request 50 days earlier.

Bowman, the Anthem spokesperson, told us the response was an error and apologized. The company compiled the claim file and sent it to Tsigdinos.

Insurers Confusing Claim File Requests With Appeals

At least five people told ProPublica that, after submitting a request for a claim file, their health insurer mistook the request for an appeal.

We brought three cases to UnitedHealthcare. S.J. Farris requested her claim file from the company on May 10. Five days later, she received a response stating that her request for an appeal had been received. Farris sent a clarifying letter but was met with a call from an appeals agent based in Ireland. “I asked her to send the claim files,” Farris said. “She had no idea what I was talking about.”

After ProPublica sent the company questions, Farris received a call from UnitedHealth in October. They told her that the insurer was working on her claim file and that she should expect it soon. In a statement to ProPublica, UnitedHealth spokesperson Maria Gordon Shydlo said: “We take our responsibility to provide members access to their records seriously and have processes in place to comply with the law. We are sorry for any inconvenience.”

After Beth Tolley sent Anthem a claim file request on behalf of her granddaughter, she received a letter from the health insurer stating, “We’ve received a request from Beth Tolley for an appeal.” This left Tolley confused since, in its last communication, Anthem had said all avenues of appeal with its office had been exhausted.

In early October, Anthem sent the Tolley family a check for the amount it had initially declined to cover. Bowman told ProPublica that the company would be sending the records soon.

Insurers Blowing Past the 30-Day Deadline

For most people who get insurance through their employers, insurers are required to send claim files back within 30 days, according to federal law.

Twelve of the people whose requests ProPublica followed did not receive their records within that time frame even though they had these types of plans. Five of those had been waiting for responses from their insurers for more than 70 days before ProPublica contacted the companies with questions.

Isabella Gonzalez submitted a claim file request via certified mail on Aug. 8. When she called Aetna to get an update, a representative told her they did not see it in the system and advised her to upload it onto the insurer’s online portal, which she did. She called back a few days later. A different customer service employee told her Aetna would respond in 45 days.

Alex Kepnes, the executive director of communications for Aetna, said the company at first did not recognize what Gonzalez was asking for and therefore did not respond to it.

Kepnes declined to respond to follow-up questions about why staff failed to correctly identify the request and whether the company would be taking action to ensure this does not happen again.

Other companies that failed to follow the 30-day timeline include UnitedHealth, Anthem and Cigna.

“It’s really important that these responses be timely,” said Hauser, the Department of Labor official. “If that’s not happening, it’s really contrary to the regulation.”

If you are facing a health insurance denial and want to get your claim file, check out ProPublica’s “Claim File Helper.”

If your health insurer blocks your access to a claim file, you can contact the agency that regulates your health insurance company. Find out more using our free tool. If you’d like to tell our team about your experience, you can email us at claimfile@propublica.org.

by Ash Ngu and Maya Miller

A claim file is a collection of the information your insurer used to decide whether it would pay for your medical treatment or services. Most people in the U.S. facing a denial have the right to request their claim file from their insurer. It can include internal correspondence, recordings of phone calls, case notes, medical records and other relevant information.

Information in your claim file can be critical when appealing denials. Some patients told us they received case notes showing that their insurer’s decision was the outcome of cost-cutting programs. Others have gotten denials overturned by obtaining recordings of phone calls where company staff introduced errors into their cases.

If you’ve gotten a denial and want to see your insurance company’s records, check out ProPublica’s “Claim File Helper” tool to file a request yourself.

by Molly Parker, Capitol News Illinois

This article was produced for ProPublica’s Local Reporting Network in partnership with Capitol News Illinois. Sign up for Dispatches to get stories like this one as soon as they are published.

In late December, a teenage boy with a broken arm was left to suffer alone in his cell at a youth lockup in rural southern Illinois. Staff were aware he’d been seriously injured; he told them he was in pain and asked to see a doctor. Two hours passed before staff took him to the hospital, during which they cooked and served dinner and took a group of kids for recreation, he claimed.

Almost everything had gone wrong that day, at a place where things went wrong a lot. Four months earlier, a state audit had called the Franklin County Juvenile Detention Center in rural Benton a “facility in crisis” because it was routinely keeping kids locked up for upwards of 24 hours at a time, a “significant violation” of state standards. It had failed to offer them much in the way of mental health or educational services, the audit said. An overwhelmed and undertrained staff routinely called on the sheriff’s department to help keep the youth in line, even for seemingly minor behavioral disruptions, according to additional law enforcement records obtained by Capitol News Illinois.

All of that was evident on this particular day, when the residents were told they’d get a rare treat, an hour or so inside the facility’s gymnasium.

But once in the gym, the boy got into a shouting match with another youth and staff ordered him back to his room. Devastated to lose his rare gym time, he refused to go. Deputies from the sheriff's office across the street rushed in — several men who were much bigger than the teen, according to sworn statements that several youth provided for a federal lawsuit the American Civil Liberties Union of Illinois filed against the detention center this summer.

The lawsuit alleges widespread failures, namely that the detention center had violated youths’ constitutional rights by subjecting them to excessive forms of restraint and seclusion while denying them adequate education and mental health services. The children who are confined there are “uniquely vulnerable, many having already suffered harrowing abuse and trauma” — and instead of caring for them, the lawsuit claims, the facility subjected them to “inhumane conditions” known to cause lasting harm.

Melissa Morgan, chief judge of the 2nd Judicial Circuit Court of Illinois, whose office is ultimately charged with running the facility, did not return phone calls seeking comment, though an assistant confirmed she had received the messages. In a court filing last week, Illinois Attorney General Kwame Raoul, who is representing the chief judge and other senior facility staff sued in federal court, denied the allegations of poor care leveled against the facility. The attorney general’s office declined further comment. In a separate filing on Monday, Franklin County, which was also named in the lawsuit, denied the allegations as well.

Youth at the facility said in signed statements taken under oath that the deputies took the boy to the ground, breaking his arm in the process, a claim that is backed up by law enforcement records obtained by Capitol News Illinois and ProPublica.

In a sworn statement entered as evidence by the ACLU in a federal suit against the Franklin County detention center, a youth relates how sheriff’s deputies broke his arm. (Obtained by Capitol News Illinois and ProPublica. Highlighting by ProPublica.)

“The officer asked me about my arm and I said ‘You know it’s broken. You heard it snap,’” the youth who was injured, identified only by his initials, A.B., said in his signed statement. A.B. is not a plaintiff in the suit, though his statement was included as evidence of the poor conditions alleged by the ACLU. The ACLU is seeking class-action status for the case, and that request is pending before a federal judge.

A month after the incident, the Illinois Department of Juvenile Justice returned to the detention center to see whether the “facility in crisis” had corrected any of the deficiencies cited in the August audit. It had made “some improvements” but “several” deficiencies remained and new ones were identified, the auditor wrote in a report on the visit. He also made note of the broken arm, saying that he could find no proof that anyone at the facility had conducted a review to determine whether staff or the deputies had acted appropriately. Franklin County Sheriff Kyle Bacon, who was among the law enforcement officers who restrained the youth that day, defended his department’s actions but said he could not speak to whether the facility had conducted an internal review because the sheriff’s office is not involved in its administration. Nearly a year later, a spokesperson for IDJJ said the detention center has yet to provide one.

A new analysis by Capitol News Illinois and ProPublica suggests those failures were not unusual. A review of hundreds of pages of state audits, law enforcement records, a federal lawsuit, and reports by oversight and advocacy bodies point to troubling conditions inside many of the state’s 16 juvenile detention centers, which operate much like adult jails, detaining court-involved youth with open cases when a judge determines they are at risk of fleeing or reoffending. The facilities combined can house upwards of 1,200 youth as young as age 10, though they are rarely at capacity.

The records show that youth have been Tased, pepper sprayed and roughed up by staff and law enforcement officers; forced into isolation for days at a time; denied access to their psychotropic medications and mental health treatment; and received little or no schooling, despite state and federal laws mandating that the youth receive educational services while incarcerated. Nearly two-thirds of those who are detained are Black teens.

Poor conditions in juvenile lockups across the country have recently made headlines, bringing renewed calls for reform. What makes Illinois different from many of its state peers is that no independent agency licenses or certifies the youth detention centers. Even in some states that have been heavily scrutinized for problematic conditions inside their youth facilities, such as Louisiana, Tennessee, Michigan and Pennsylvania, a licensing process is in place that allows for sanctions up to closure.

Under state law, the Illinois Department of Juvenile Justice sets standards for county detention facilities that hold youth in custody and conducts audits of them. While the department has repeatedly cited several centers for failing to meet its standards, under state law, IDJJ cannot mandate corrective action plans, issue fines or shut down detention centers found in repeated violation of the rules. Instead, the IDJJ reports are sent back to the county detention facilities’ staff and to the chief judges of each judicial circuit, under whose authority they operate. Neither the staff nor the judges are obligated to respond.

IDJJ shares oversight of the youth detention centers with the Illinois Supreme Court. The high court’s administrative arm implemented its own set of standards for facilities in 2022 and started conducting reviews later that year. In its initial review of the detention centers, the court found that about a third did not meet its standards, and action plans were developed with them to address deficiencies. Christopher Bonjean, a spokesperson for the Illinois Supreme Court, declined to provide the full reviews or any of the ongoing progress reports for facilities requiring action plans, saying that only its initial summary reports are made public. The judicial branch is not subject to the Illinois Freedom of Information Act.

Juvenile justice experts and advocates for incarcerated youth in Illinois say the weak oversight of these facilities needs the attention of lawmakers and policy experts.

And it’s the latest example the news organizations have revealed about the failures of Illinois officials to put an end to the poor treatment of vulnerable populations held in facilities, even when problems are well documented.

Capitol News Illinois spoke with six experts in the field of juvenile justice and youth development who said facilities that detain children should have robust oversight structures. This spring, Equip for Equality, Illinois’ federally designated legal aid organization for people with disabilities, called on policymakers to reform the oversight system “given the longstanding, serious and pervasive problems” inside facilities statewide.

I don’t want nursing homes operated without oversight. So to think we don’t have any kind of oversight and quality improvement for kids that are in custody in a facility, I don’t understand.

—Hunter Hurst, director of the National Center for Juvenile Justice

“Would you want nursing homes operated without any oversight? I don’t want nursing homes operated without oversight. So to think we don’t have any kind of oversight and quality improvement for kids that are in custody in a facility, I don’t understand,” said Hunter Hurst, director of the National Center for Juvenile Justice, the research arm of the National Council of Juvenile and Family Court Judges.

IDJJ Director Heidi Mueller said in an interview that she agrees that the agency is limited in what it can do if a county’s chief judge can’t or won’t enforce compliance.

“I think a lot of folks would say that that oversight mechanism isn’t what you would call best practice,” Mueller said. Only the Illinois General Assembly has the authority to change the oversight structure, she said. Mueller stopped short of making a call for lawmakers to do so, saying that’s not her role as an agency leader.

Widespread Problems

Oversight entities have identified numerous problems in facilities across the state. In a March report, Equip for Equality found widespread problems at Chicago’s youth lockup — the state’s largest — including that it had utilized “unjust and excessive use of physical restraints and seclusion, often as punishment, with a wanton disregard of state law.”

In a letter addressed to Equip for Equality, Leonard Dixon, superintendent of the Chicago facility, rebutted the findings, saying that the youth facility follows state and federal laws and that the advocacy group’s claims about unlawful restraints were “unsupported” and that physical restraints are “never used as punishment.” Dixon noted to the news organizations in a statement that recent state audits found the facility to be in compliance with restraint standards.

Concerns about excessive use of force extended beyond Chicago. In April, a youth at the Mary Davis Home in Galesburg, in central Illinois, told an IDJJ auditor of a troubling physical restraint from the day before. After watching a video of the incident, the inspector was so alarmed that he reported it to the state’s child abuse hotline, although ultimately the Department of Children and Family Services did not designate this as a case of abuse or neglect. No other governmental body is charged with reviewing whether administrative policies were properly followed in specific situations. The IDJJ audit noted that one of the staff members involved had not received the training the facility utilizes to teach staff proper restraint techniques.

Wendi Steck, superintendent of the Mary Davis Home, said the employee involved in the restraint incident no longer works there, but she declined to say whether his departure was related to this incident. “Any incidents of abuse of our clients are not tolerated and are dealt with swiftly,” she said. “All staff are trained in Handle with Care restraint and cannot be involved in any restraints until successfully trained.”

Perhaps nowhere are concerns as extensive as those documented at the 32-bed youth lockup in Benton, the only one that IDJJ labeled “in crisis.” The facility is the state’s southernmost detention center and houses youth from across 26 counties — the lower quarter of the state.

Among IDJJ’s findings in its August 2022 audit: Youth were confined to their rooms for upwards of 24 hours for behavioral infractions, though state standards limit the use of seclusion to four hours and allow it only if youths are at risk of harming themselves or others. In fact, because the facility was so short-staffed that IDJJ described the issue as “critical and unsustainable,” youth were kept in their rooms for most of their days there, even if they had not acted out. The facility has a gym and outdoor recreation area, but youth had not utilized either area for two years. The facility had no process for assessing youth to determine if they were at risk of sexual assault or of sexually assaulting a peer, a requirement of the federal Prison Rape Elimination Act. Mental health services were “minimal” and “there was an obvious lack of training” among the staff.

Staff at the Benton facility told the IDJJ auditor that at one time, it had utilized the Crisis Prevention Institute to train staff on how to try to calm situations before they escalate and how to properly use physical restraints if it can’t be avoided. But a supervisor acknowledged to the IDJJ inspector that such training had not been conducted in several years and that some newer employees may have never received it. “This poses a high risk for potential liability for the county,” IDJJ wrote in the audit.

Joseph A. Cervantez, the state’s attorney in Jackson County, one of the counties from which youth go to the Benton facility, said he was so alarmed when he read the report that he immediately stopped sending youth there. Without better services, he said, “I might as well just keep them out on the street.”

When IDJJ followed up in January, it found that many problems had not been corrected in the intervening five months. It also criticized the facility’s handling of the broken arm incident. Detention center staff told the auditor that its video system was faulty and didn’t record what happened. A senior official told the auditors that an internal review had been conducted but could produce no written record of it. While the standards do not stipulate the use of video cameras inside the facilities, any use of restraint or seclusion requires a full written report.

Bacon, the sheriff, said his office conducted an internal review consisting of a conversation between him and the chief deputy about what had transpired. “I was present and I was familiar with what was happening and the actions that we took, and there were no issues with those actions,” he said.

While IDJJ’s reports cited extensive problems, claims made by five youth who provided statements for evidence as part of the ACLU’s lawsuit, filed in July, suggested even more dire conditions. The youth said they were locked inside “very small concrete boxes” covered in black mold and that they were forced to eat their meals alone in their cells next to their toilets and sleep on wet mattresses because the windows leaked. One youth said he was experiencing a mental health crisis and cut his arm with a broken colored pencil. “Instead of getting me any mental health treatment, they just gave me a paper towel to clean up the blood,” he said.

The presence of law enforcement officers inside the facility is common, several of them said. “The crazy thing is the police don’t even just come in for fights or big things, they come in just when a kid doesn’t want to move and they do things that the staff should be doing,” said another youth.

Law enforcement records obtained by Capitol News Illinois showed that staff called on sheriff’s deputies 21 times between September 2021 and August 2023. Some of the calls were for seemingly minor incidents. For instance, on Aug. 1, staff requested backup because a youth had “stuffed snacks down his pants and won’t give them back.”

Part of a call log showing reasons why staff of the Franklin County Juvenile Detention Center called sheriff’s deputies to the facility. (Obtained by Capitol News Illinois and ProPublica)

In some cases, the arrival of deputies resulted in more aggressive restraint techniques than are typical for — or allowed in — juvenile detention centers. In October 2022, detention center staff called for backup because a different youth had refused to return to his cell. When the deputies tried to force him back to his room, the youth assumed a fighting position, the responding deputy wrote in a report, so the deputy fired his Taser.

Staff in juvenile lockups are not allowed to use stun guns on youth, according to IDJJ.

Bacon said he believes the staff call on the sheriff’s deputies because of their ability to utilize tools, such as stun guns, that the facility staff cannot.

He said that he and his staff are trained in deescalation techniques and use force only when necessary. “There are youth that can cause harm to you,” Bacon said. “And we want to use the least amount of force necessary, but at the same time we have to protect ourselves from being injured as well as the youth. That’s not our intention to hurt anyone.” He also said that as he understands the law, his office is not bound by IDJJ standards, even when officers are responding to an incident inside a facility that is under those rules.

In a statement, IDJJ said it does not consider calling for outside law enforcement alone to be a violation of any standards, though “the standards would apply to how force, if any, is used.”

The agency said it had not been aware of the stun gun incident until they were alerted to it when they returned for an audit in late September. That audit is not complete and has not yet been made public.

Oversight Breakdown

Two years ago, IDJJ updated its standards for the operation of juvenile detention centers, incorporating language that emphasizes youths’ education and mental health and stresses appropriate use of restraint and seclusion. Its reports, available online, became more robust. But while they have helped bring problems to light, said Rachel Shapiro, a managing attorney with Equip for Equality, her agency is still identifying some “horrific” conditions that never appear in IDJJ audits.

And although it can document problems it has identified, IDJJ’s authority to ensure they are fixed is limited.

The law does allow the state agency to petition a court to order a facility into compliance if it hasn’t fixed deficiencies within six months of receiving notice from IDJJ. But IDJJ said the agency is “not aware of any instances'' of agency staff initiating such a process, in part because it would have to petition the very courts that run them.

The Illinois Supreme Court is also limited in what it can do. Its standards say that the court “shall” withhold 10% of the salary reimbursements it provides to any facility that remains out of compliance 90 days after receiving notice, and another 10% monthly thereafter. But it has not financially sanctioned any facilities.

Instead, Bonjean said, a special unit within the Administrative Office of the Illinois Courts is closely monitoring any facilities that are still working through their corrective action plans.

A spokesperson for the state Supreme Court said that the Franklin County facility is making improvements but is not in compliance with its standards. (Julia Rendleman for ProPublica)

The court spokesperson declined to provide the news organizations with the court’s full review of the Benton facility, its action plans or its progress reports. He confirmed that it remains out of compliance 14 months after the review but said that it is “making progress.” The county has approved funds for needed repairs and improvements to the facility, he said, but they will “take some time.” Reducing funding, he said, “could be problematic and could hinder the progress we are trying to achieve.”

John Albright, IDJJ’s chief of performance and innovation, who conducts the audits for the agency, said he also tries to work closely with facility staff to help them understand the standards and how to meet them.

“Some facilities have been working very hard to make changes, and others maybe not as much,” he said.

When the oversight entities don’t compel action, the only option remaining for those who feel they were harmed by the system is a lawsuit, advocates say. Kevin Fee, an attorney with the ACLU of Illinois, said his organization is concerned about conditions across facilities. But those found in Benton were “far and away” the most troubling, he said.

“The Franklin County reports were pretty scathing, and we would have expected more action in response to those reports,” Fee said of the IDJJ audits. “But we didn’t see any, which is why we felt the need to bring the lawsuit.”

Jennifer Vollen-Katz, executive director of the John Howard Association of Illinois, an independent watchdog organization, agreed that even with the improved standards, there are still shortcomings with “system transparency and concerns about the treatment and conditions youth experience while in detention.”

The weak enforcement mechanisms are “a real deficiency in the state of Illinois,” she said. “We have work to do so that we’re not just inspecting these facilities and reporting on the issues. There has to be some way of holding the detention centers accountable and responsible for the treatment of youth in their custody short of litigation.”

Southern Illinois University journalism students Sarah Alli-Brown, Grayson Bittner, Carolyn Dickte, Jared Harris, Brandon Jones, Jamilah Lewis and Ethan Neir contributed research.

by Talia Buford

ProPublica’s Emerging Reporters Program, now in its ninth year, provides support and mentorships to college students who are pursuing careers in investigative journalism and need additional training and financial support to help advance their goals.

Participants receive a $9,000 stipend, a trip to the annual NICAR investigative journalism conference, occasional training and presentations by speakers. They’ll also be paired one-on-one with ProPublica journalists who can help counsel them on stories, build their connections in the industry and expose them to the varied paths for careers in investigative journalism. Past Emerging Reporters have gone on to work at The New York Times, The Atlantic, The City, Capital B and other outlets.

Our goal is to encourage the next generation of journalists who seek to shine a light on abuses of power and produce stories of moral force that provoke change. In choosing the class, we look for students who demonstrate an early dedication to journalism as a career, through internships, work at local news outlets or work at campus publications. And where those opportunities — which are often unpaid — aren’t accessible, we look for other ways the student has shown an eagerness and drive to learn the craft.

The 2023-24 academic year’s class of outstanding student journalists are from Massachusetts, Virginia, Georgia, Kansas and Washington. They represent a range of collegiate journeys, and their desire to pursue ambitious, important stories inspired us. Through their work, the students have already shown not only their dedication to the craft, but a yearning to tell stories that have impact.

Some have always wanted to be journalists, while others found their calling through campus media.

They’ve set their sights on covering issues around gender, immigration and indigenous communities, or on using data to make journalism more accessible. Some are already freelancing for local outlets on pressing community issues, while others are working for print and broadcast student media organizations.

Meet our 2023 class:

Shradha Dinesh is a senior studying data science and political journalism at William & Mary in Williamsburg, Virginia. Dinesh is the co-director of DisinfoLab, an undergraduate-run research lab; an associate data editor at The Flat Hat student newspaper; and a campus reporting fellow with the Pulitzer Center on Crisis Reporting. She previously worked at the Pew Research Center as a data journalism intern, and her interests include incorporating data in policy and accountability reporting.

Cassandra Dumay is a junior at Boston University majoring in journalism and minoring in Spanish and political science. She is the politics editor at BU’s student radio station, WTBU, and the president of her university’s chapter of the Society of Professional Journalists. Dumay has reported on her home state of Massachusetts for GBH, Boston’s local NPR station, and the Boston Globe. She previously received fellowships from Investigative Reporters and Editors’ National Institute of Computer-Assisted Reporting and the National Association of Black Journalists. Dumay is interested in data journalism and audio broadcasting.

Alyssa Noriega is a junior studying journalism and mass communications at Haskell Indian Nations University in Lawrence, Kansas. She is an anchor for “Good Morning Indian Country,” a student-led Indigenous news show and participates in the Planet Forward Indigenous Correspondents Program with a project focused on Native storytelling in journalism.

Arielle Robinson is a senior at Georgia’s Kennesaw State University majoring in international affairs with a minor in gender and women’s studies. She freelances for the Atlanta Journal-Constitution and the Cobb County Courier, where she has reported on issues ranging from race to housing to local government. Robinson previously interned for CNN, helping to edit, research and fact-check digital news and scripts for domestic and international news. She’s passionate about issues affecting women and girls and hopes to center them in her investigative work.

Jacquelyn Jimenez Romero is a senior at the University of Washington, where she is majoring in journalism and public interest communication and law, societies and justice. She is minoring in diversity and environmental studies. The daughter of immigrants from Mexico, Jimenez Romero is passionate about writing human-interest stories that focus on uplifting underrepresented communities. She has worked as the diversity beat writer for the university’s The Daily newspaper and has written for Capitol Hill Seattle and International Examiner.

by T. Christian Miller

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

In August 2018, Robert Salim and eight of his friends and relatives flew to the steamy heat of New York City to watch the U.S. Open.

The group — most of them lawyers who were old tennis buddies from college — gathered every few years to attend the championship. They raced from court to court to catch as many matches as possible. They hung out at bars, splurged on high-priced meals and caught up on each others’ lives.

But that year, Salim had trouble walking the half-mile from the subway station to the Billie Jean King National Tennis Center in Flushing Meadows without stopping two or three times to rest. Back in his hotel room, he was coughing badly, his phlegm speckled with spots of blood. Although he had kept fit for a 67-year-old, he felt ragged.

Salim, whose friends call him Skeeter, flew home to Houston, where he saw his family doctor. After dozens of tests and visits to specialists, he received his diagnosis: stage 4 throat cancer. A tumor almost an inch long was growing under the back of his tongue, lodged like a rock. It had spread to his lymph nodes. Dr. Clifton Fuller, his oncologist at the MD Anderson Cancer Center, called it “massive oral disease.”

Still, Fuller told Salim that his type of throat cancer would respond well to a treatment known as proton therapy, which focuses a tight beam of radiation on a tumor. So Fuller’s staff quickly sought approval from Salim’s health insurer, marking its fax “URGENT REQUEST”: “Please treat this request as expedited based on the patient’s diagnosis which is considered life threatening.”

The answer arrived two days later. Blue Cross and Blue Shield of Louisiana would not pay for proton therapy; the costly procedure was appropriate only after doctors had previously tried other methods for irradiating the head and neck. “This treatment is not medically necessary for you,” the rejection letter read.

Fuller told Salim that he might have to use a cheaper form of radiation that is less precise. Normally outgoing and optimistic, Salim felt his chest tighten as Fuller described the possible side effects of that other type of treatment. Because there were many critical organs near Salim’s tumor, the damage could be severe, causing loss of hearing, diminished sense of taste and smell, and brain impairment, like memory loss.

At that point, Salim seemed in danger of joining millions of other Americans denied payment for medical treatment. These patients often settle for outdated, riskier procedures or simply forgo care.

But Salim was no ordinary patient. He was, in fact, an aggressive litigator who had been named one of the 100 best trial lawyers in America. In a long career working from Natchitoches, Louisiana, a tiny city in the Creole heartland, he had helped extract settlements worth hundreds of millions of dollars from massive corporations that had harmed consumers with unsafe products, including pelvic mesh and the pain reliever Vioxx.

Salim decided to do what few people can afford to do. He paid MD Anderson $95,862.95 for his proton therapy and readied for a battle with Blue Cross, the biggest insurance company in Louisiana. As always, Skeeter Salim was determined to win.

It would be Goliath vs. Goliath.

First image: Salim in the private jet he uses to commute between his home in Houston, Texas, and his office in Natchitoches. Second image: Awards on display in Salim’s office. (Danielle Villasana for ProPublica)

“It’s not about the money for me. I’ve been blessed and we have an extremely lucrative practice,” said Salim, a broad-set man quick with jokes. “But I would like to see other people that are not in the same situation not get run over by these people. There’s no telling how many billions the insurers made by denying claims on a bogus basis.”

Blue Cross and Blue Shield of Louisiana declined to comment, citing ongoing litigation.

In his decades as a plaintiff’s lawyer, Salim had relied upon consumer protection laws and billion-dollar judgments to make companies fix their bad practices. But now he stood on different terrain, facing a 1970s-era federal law that deprived patients of tools to fight, let alone change, abuses by the insurance industry.

And interviews, court documents and previously confidential emails and records from Blue Cross, its contractors and MD Anderson would expose the inner workings of a large insurer and an unnerving truth: To overcome a system tilted heavily in favor of the insurance industry, you need money, a dogged doctor and a friend with unusual skills.

“Arbitrary and Capricious”

Salim was angry. For years, he had paid Blue Cross more than $100,000 in annual premiums to cover himself, the employees of his law firm and their family members.

In mid-October 2018, he scrawled a note on a legal pad: “Blue Cross’ denial is arbitrary and capricious and will lead to irreversible harm to my physical being.”

A note Salim wrote complaining about Blue Cross’ denial of payment for his medical care (Courtesy of Robert Salim)

And so Salim began his unusual journey to appeal an insurance company rejection. Few patients ever do so. One study of Obamacare health plans purchased on healthcare.gov found that less than 1% of people tried to overturn claim denials.

When a patient files an appeal, insurance company doctors are supposed to take a fresh look to reconsider the denial, relying on medical guidelines, their own clinical experience, scientific studies and the recommendations of professional societies.

But the insurance industry doctors who shot down Salim’s appeal did little to consult outside sources, a ProPublica review found. They cut and pasted guidelines created by a company called AIM Specialty Health: “The requested proton beam therapy is not medically necessary for this patient,” one rejection letter read.

Many insurers won’t pay for certain specialized or expensive treatments unless a patient gets approval in advance. Blue Cross and other health plans often farm out those reviews to companies like AIM. The insurance industry maintains such companies keep health care costs down and help patients by rejecting unnecessary and unproven treatments. Critics say the companies unfairly deny claims, noting that they market themselves to insurers by promising to slash costs.

In Salim’s case, AIM made decisions using its own guidelines, which it said at the time were based on medical studies and the recommendations of professional medical associations. AIM’s parent company, Anthem, renamed itself Elevance Health in 2022, and subsequently changed AIM’s name to Carelon Medical Benefits Management. In a statement, Elevance said that Carelon “uses evidence-based clinical guidelines to assess requests.”

At Blue Cross, Salim’s appeal started with a review by one of its own doctors, an ear, nose and throat specialist. He affirmed the denial using language taken directly from AIM’s guidelines.

The insurer then routed Salim’s request to an outside company called AllMed that it had hired to render expert opinions. A day later, AllMed’s doctor, a radiation oncologist, affirmed the decision to deny payment for Salim’s care. He, too, copied AIM’s guidelines in explaining his reasons. AllMed did not return requests for comment.

Not willing to give up, Fuller, Salim’s doctor, took a step physicians rarely do: He asked Blue Cross to have an independent medical review board unaffiliated with the insurer or AIM examine Salim’s claim. Louisiana’s Department of Insurance randomly selected the review company, Medical Review Institute of America.

Fuller didn’t skimp on evidence. He sent the company a 225-page request containing Salim’s medical records, MD Anderson’s evaluation and outside studies supporting the use of proton therapy.

The next day, the Medical Review Institute denied the claim. Its doctor, a radiation oncologist, not only quoted AIM’s guidelines, but also cited four studies that raised questions about the evidence for proton therapy. The Medical Review Institute did not return requests for comment.

In 19 days, five different people at four different companies had reviewed Salim’s case. Each had denied his request for treatment. Each had cited AIM’s guidelines. The appeal process was over.

Before the review was complete, Salim had decided to pay out of pocket for the proton beam therapy. “If there’s a tumor in there, and it’s growing, why are we waiting so long to do something?” he asked Fuller.

Over more than two and half months that fall and winter, Salim visited MD Anderson multiple times a week. At each radiation session, he strapped on a custom mask that covered his entire face. Nurses locked him into arm and leg restraints. Then he had to hold still for 45 minutes while the proton therapy machine thrummed around him.

In the background, he sometimes heard the nurses playing the 1977 Kansas song, “Dust in the Wind.”

“What a terrible song to play,” he thought.

On Dec. 24, he endured two sessions in a day to finish up. He had completed his treatments — a Christmas present to himself. But he wasn’t done fighting.

A Useful Friendship

A few months after recovering, Salim decided to sue Blue Cross to force them to pay.

There was one problem. Salim held a type of insurance governed by a relatively obscure federal statute: the Employee Retirement Income Security Act. The Department of Labor is charged with enforcing the law, known as ERISA.

The 1974 law is vague and lacks teeth. Court rulings interpreting this law have often tilted in favor of insurers. For instance, insurance companies have broad authority to decide what to cover and what to deny. And the law does not allow for punitive damages, which are designed to punish a company for abuse or fraud by eating into its profits.

Instead, patients who win ERISA cases get money to cover their treatment and the expense of hiring a lawyer. Nothing more.

Such cases do not, in other words, bring in the big dollars like those Salim had won in large personal injury lawsuits. Few attorneys in the country handle ERISA complaints. Salim said he talked with some of them. All told him his case was unwinnable.

But Salim had a secret weapon: his childhood buddy Ronald Corkern.

Salim grew up a few blocks away from Corkern in Natchitoches (pronounced “nack-a-tish”), a northwestern Louisiana town founded in 1714 and set high on the banks of Cane River Lake. Shops with wrought-iron balconies and columned galleries line the city’s red brick main road. Well-preserved slave plantations ring the outskirts.

The city is known for two things: “Steel Magnolias,” a 1989 movie about female friendships, was filmed there. And singer-songwriter Jim Croce and his entourage were killed when their plane struck a pecan tree near the end of the runway at the local airport.

Ronald Corkern at Salim’s office (Danielle Villasana for ProPublica)

Salim and Corkern left for different law schools, but both returned to practice in their hometown. They often found themselves on opposite sides of the courtroom, facing off in more than 100 trials, sometimes pulling pranks on one another.

Affable and deeply engaged in the civic issues of his hometown, Corkern had spent much of his life as a lawyer defending auto insurers. He had never before argued an ERISA case. But for his friend, he was willing to try.

“I got trapped into handling this case,” Corkern joked. At the end of February 2019, he sued Blue Cross. He started in state court, but Blue Cross quickly got it bumped to federal court in Alexandria, Louisiana, where ERISA law would apply.

Over the next several years, lawyers for Blue Cross argued that under the law, insurers had the ultimate authority to determine what to cover, and Blue Cross had decided that proton therapy wasn’t medically necessary in this case. Salim’s lawsuit, they contended, should be dismissed.

But prior court rulings had carved out an exception: If Corkern could prove that Blue Cross had committed an “abuse of discretion” — for instance, if it had blatantly ignored or twisted evidence supporting the therapy — the judge could force the insurer to pay Salim for his treatment.

A nine-page letter written by Fuller, Salim’s doctor, argued that very thing, criticizing the guidelines that AIM and Blue Cross had relied upon to deny payment.

AIM had cited 48 research studies to support its rejection of proton therapy. Fuller found only a few that pertained to head and neck cancer. One of those was out of date: It cited guidelines by a professional society of radiation oncologists that had subsequently been updated to support proton therapy for head and neck cancers.

And Fuller noted that AIM had “glaringly omitted” information from the National Comprehensive Cancer Network, an alliance of cancer treatment centers that included MD Anderson. In May 2017, the network issued guidelines that said the therapy was under investigation and noted that studies had indicated its potential in reducing radiation doses to critical nearby organs for some cancers. While proton therapy may have similar efficacy as other kinds of radiation treatment at eliminating cancer, studies have shown it generally has fewer side effects in treating sensitive regions of the body — a surgeon’s scalpel versus a steak knife.

Fuller’s touché: 17 academic studies (including some he co-authored) that supported the use of proton beam therapy. Several found significant decreases in radiation exposure and fewer side effects.

The therapy “minimizes toxicity for Mr. Salim, resulting in a more rapid recovery from the treatment of his cancer and less cost to him and you (as his insurer),” wrote Fuller, who declined to comment for this story.

Fuller’s letter played a big role in the case. A federal magistrate, Judge Joseph H.L. Perez-Montes, cited it 16 times in his 19-page opinion. Fuller showed that most of the evidence used by Blue Cross was “either outdated or did not pertain to the treatment of head and neck cancer,” Perez-Montes wrote. Blue Cross, he said, had “abused its discretion.”

A federal judge reviewed Perez-Montes decision and ordered Blue Cross to pay Salim for his proton therapy treatment.

Blue Cross appealed that ruling to the Fifth Circuit Court of Appeals in New Orleans. The company argued that the lower court had erred in accepting Fuller’s analysis over the insurer’s own experts. On May 3, 2023 — more than four years after Corkern filed the suit — a panel of judges ruled for Salim.

It is unclear why Blue Cross fought so hard to avoid paying Salim. In its appeal, the insurer told the court that the case involved an “important issue” regarding the interpretation of benefits under the ERISA law. It is unknown how much Blue Cross spent on the case. Corkern charged his friend the bargain price of $36,185.

Corkern, left, and Salim. The two friends are still fighting Blue Cross over payments for health care and attorney’s fees. (Danielle Villasana for ProPublica) An Unsettled Bill

The treatment worked. Salim has been cancer-free for almost five years, and he suffered few long-term side effects. His Creole accent now has a slight rasp to it. If his next checkup turns up no signs of a tumor, his doctors will consider him cured.

This year, he joined his friends for the U.S. Open again. And he’s found a new Goliath, joining other attorneys in a suit against the country’s largest pharmacy benefit managers — intermediaries in the buying and selling of medicines who have been accused of artificially inflating prices.

The Blue Cross lawsuit was the last one that Corkern ever filed. He spends most of his time these days conducting mediations between aggrieved parties.

The case itself remains open. The judges ruled that Blue Cross must pay for Salim’s treatment. But they did not say how much.

Salim is expecting the full $95,862.95 he paid. However, court records show that Blue Cross has said it only needs to pay Salim the discounted rate it had negotiated with MD Anderson at the time of his radiation treatment: $35,170.47. That’s what Blue Cross would have paid if its doctors had said yes in the first place.

A decision is expected later this year.

While not setting a precedent, the case may help persuade insurers and other courts that proton therapy is medically necessary in certain cases, legal experts said.

“They were wrong. Proton radiation is not experimental. It’s a wonderful tool,” Salim said. “If I played even a small part, it was a very successful lawsuit.”

Do You Have Insights Into Dental and Health Insurance Denials? Help Us Report on the System.

by Kitra Cahana, special to ProPublica, and Ed Williams, Searchlight New Mexico, photography by Kitra Cahana, special to ProPublica

This article was produced in partnership with Searchlight New Mexico, which was a member of ProPublica’s Local Reporting Network. Sign up for Dispatches and Searchlight’s free newsletter to get stories like this one as soon as they are published.

Last year, 63 kids in New Mexico turned 18 and aged out of foster care. It’s a fraught time; after spending their lives in a system that micromanages their every move, the teens are thrust into adulthood, left to fend for themselves while struggling with the aftereffects of a childhood often spent cycling among foster homes. Some thrive. Many do not.

Roughly 30% of foster youth end up homeless after aging out of foster care, national studies show. An estimated 1 in 4 end up incarcerated.

The New Mexico Children, Youth and Families Department has made efforts to reverse those grim statistics. Notably, CYFD launched its Fostering Connections program in 2020 for youth who age out of the foster system. It offers some assistance with housing, food and behavioral health care.

That’s often not enough, advocates say. Children in foster care experience high levels of trauma and high rates of post-traumatic stress disorder and other mental health conditions. Adding to their struggles, CYFD has been housing foster children in inappropriate and sometimes unsafe settings, where they can’t get the stability and psychiatric care they need. A 2022 investigation by Searchlight New Mexico and ProPublica found that some of CYFD’s highest-needs kids spent years going back and forth between psychiatric hospitals and youth homeless shelters. (CYFD leadership has previously acknowledged that kids should not be staying in shelters, but that sometimes they “have to make very difficult decisions under extraordinary circumstances.”)

Finding a place to live, getting work, buying a car and navigating the world can be overwhelming for any teen — but it’s even more so for teens who haven’t had supportive families and don’t have an adult in their life who can help.

Even teens who sign up for Fostering Connections can fall through the cracks. It can take months before they start receiving aid through the program, leaving them in limbo at one of the most vulnerable periods of their lives. According to their attorneys, teens can be so traumatized by their time in foster care that they refuse any offer of assistance from the agency after they’ve aged out. They’re determined to leave the state’s orbit completely.

Here are the stories of two young women who aged out last year. Although their stories are different in many ways, one difference in particular stands out: In the months after leaving foster care, one had the consistent support of a caring adult. The other didn’t.

Birdie

Roberta Gonzales, who goes by Birdie, was 10 years old when she and her younger brother were taken out of their aunt’s home in Albuquerque and placed in foster care. Her brother was adopted; Gonzales has not seen him since. But CYFD never found her a stable home.

Instead, she spent the rest of her childhood in residential treatment centers, first in San Marcos, Texas, and then at Desert Hills, one of several mental health facilities in New Mexico that have shut down in the last five years amid allegations of abuse, lawsuits and pressure from state regulators.

By 2019, with fewer residential treatment centers at its disposal, CYFD was increasingly relying on youth homeless shelters to house high-risk kids, including some who were suicidal. Once there, many teens routinely experienced mental health crises or ran away. When no shelters were available, CYFD would house some of them in its Albuquerque office building.

Gonzales was one of these teens. The cots and bean bag chairs at the CYFD office were too uncomfortable to sleep on, she recalled. “I usually just slept on the floor.”

Gonzales turned 18 last year and, after a stint in Las Cruces, moved back to Albuquerque.

One of her favorite things to do was attend services at places like Calvary Church, which hosts community events like an annual Fourth of July fireworks show, or Sagebrush Church, both in Albuquerque. She said she liked the pastors and the music.

Gonzales attends a service at Sagebrush Church in northwest Albuquerque.

As a former foster youth, Gonzales was entitled to housing assistance from CYFD. The agency helped her start the paperwork when she was 17, but as her 18th birthday came and went, she was unclear how the system worked and still had no idea what help she would get or when. Her former caseworker called to check on her periodically, she said. But she never seemed to get the help she needed.

“I got kicked out [of foster care] on my birthday and now I’m homeless,” she said. “CYFD just left me to do this on my own.”

When asked for comment, a CYFD spokesperson said that “Fostering Connections benefits are generally seamless.” It might take time for some youth to receive benefits after they turn 18, but “CYFD staff does assist with the paperwork and resources,” the spokesperson said.

After Gonzales aged out, an uncle gave her a little money to pay for food, clothes and shelter. The money went fast. Within weeks, she was broke. She lived briefly with a cousin before moving into a Christian adult homeless shelter.

But she found the shelter’s tight quarters and strict rules too stifling and soon decided to leave. She spent much of her time at the Alvarado Transportation Center bus stop downtown, sometimes riding the bus around town to pass the time.

While waiting to catch a bus, Gonzales notices a man lying on the sidewalk. Thinking he might have overdosed, she reaches out to touch him and realizes he is scarcely breathing. She calls 911 and then sees the man has resumed breathing more normally. Her bus arrives moments later, and she hops on with her new friend.

For a brief period, Gonzales’ uncle paid for a room in a motel so she could have a safe place to sleep for a few nights. The room — complete with a clean bed, pillows and private bathroom — was like heaven, she said.

Later that week, Gonzales went to Calvary Church, where a volunteer offered to pray with her and another woman joined in. Gonzales had told pastors at both Calvary and Sagebrush churches that she was homeless and living on the street. One pastor prayed with her and signed her up for a baptism.

A volunteer at Calvary Church leads a prayer.

Before going to Calvary Church, Gonzales had met a group of people who offered to take her to the Savers thrift shop so she could get some new things to wear. Someone had stolen her belongings, so she was ecstatic about the shopping trip. She eagerly tried on her new clothes in the Calvary Church parking lot and carried the Savers bag with her for days, with all her possessions inside.

After trying on clothes, she had no plan for where to sleep or what to do for food — that night or in the days ahead. She looked for somewhere to sleep after midnight. She found a ledge in front of her favorite bus stop.

But when a security guard spotted her and told her to leave, she walked across the street and settled on the sidewalk.

The following afternoon, Gonzales started to have difficulty breathing and began to feel very hot. After she called 911, paramedics met her under an overpass.

She was taken to the University of New Mexico Hospital and wheeled to a room. “It feels like I’m dying,” she told doctors.

Gonzales had previously been to the UNM Hospital, for various issues, and some of the nurses knew her by name.

Being at the hospital wasn’t so bad, she said — it was a comfortable place to sleep for the night, and she could charge her phone.

“Any changes to your address?” doctors asked her while preparing a nebulizer to stabilize her breathing. “I have no address,” she replied.

She stayed at the hospital for several days while the staff monitored her lungs. Doctors later diagnosed her with Castleman disease, a rare disorder that affects the lymph nodes.

More than a year has passed since then. When contacted this fall, Gonzales said she’d reconnected with her mother and talks to her regularly. She said a CYFD Fostering Connections worker has been in touch with her and checks in periodically over the phone. Although CYFD provides job assistance for youth who age out, it hadn’t helped her find a job, she said, so “I’ve been looking myself.” The agency hadn’t helped her find housing either, she added. She did find a place to live, briefly. But it didn’t last.

“I’m homeless again,” she said in September. Until she can find stable housing and a job, she’s living at a homeless shelter in Albuquerque.

It doesn’t always happen this way. With the right support, youth can thrive after foster care.

Nevaeh

Nevaeh Sanchez was 15 when CYFD investigators determined she needed to be taken into foster care. She and her younger brother had been living with their father in a run-down house in Española that didn’t have running water.

When a caseworker arrived to pick her up, she and her brother were driven not to a foster home, but to a youth homeless shelter in Taos, where they lived alongside other kids with nowhere to go.

CYFD told Sanchez and her brother they would be in the shelter for just a few days while the state found them a relative to stay with, or until the agency’s investigation was complete and they could return home. But the days turned to weeks, and the weeks to months. “We didn’t even know we were in the [foster] system until two months in,” Sanchez said.

Three months after her arrival in Taos, shelter staff kicked her out after finding marijuana in her room. CYFD moved her to a homeless shelter in Santa Fe. Then the agency moved her to another shelter in Albuquerque, then to another. And another. Between shelter stays, she would sleep in CYFD’s Albuquerque office building.

“It’s all just a waiting game” until they can find you a bed, which was inevitably at a shelter, Sanchez said. Kids say this “shelter shuffle,” as it’s known, makes them feel like the system has given up on them.

Last year, with the help of her mentor, Sanchez found a rental with a bedroom of her own.

Many of the teens Sanchez lived with in the shelters had nobody to support them and found themselves thrust into adulthood alone after aging out of foster care. But in this respect, Sanchez was lucky.

When she was taken into the system, a judge assigned Lori Woodcock to be her court-appointed special advocate, or CASA — a volunteer trained to support children in foster care.

CASAs have a critical role: They gather information about a child’s foster care case, recommend services and advocate for the child’s best interest in court proceedings. The help they’re allowed to provide, however, is mostly limited to issues related to the court case.

Sanchez needed help with real-world issues — finding a job, getting to work, finding a place to live.

“As a CASA I couldn’t drive her to appointments or job interviews, or any of the things she actually needed help with,” Woodcock said.

So Woodcock quit her role as a CASA volunteer, opting instead to work independently as a mentor to Sanchez. Working outside the foster care system, she was able to give Sanchez the help she needed to get on her feet.

Lori Woodcock helps Sanchez with paperwork to buy a car.

The Fostering Connections program offers some services for teens when they turn 18 to ease the transition out of foster care. But Sanchez said she didn’t get any help at the time of her birthday.

Sanchez had spent nearly all her time in foster care living in the shelter system, where the staff monitored the children 24/7. She always shared a room with other kids and needed permission to use her phone, go for a walk or even close a door.

But when she turned 18, with the help of Woodcock, she found a rental with a room of her own.

“I’ve never had a chance to live” before now, she said. “I’ve been surviving.”

“People don’t understand how lucky they are that they get to sleep in their own bed,” Sanchez says. “It’s crazy, I’m like, I can close my own door, I can be in my room all day, I can be on my own phone.”

In May 2021, Sanchez applied for a job as a cashier at the Frontier, a popular restaurant across the street from the University of New Mexico campus. She held the job for two and a half years — even earning three raises for good performance.

“She’s thriving,” Woodcock said.

Another huge step was getting her own cellphone.

During her time in foster care, Sanchez’s phone use had been regimented. Most shelters prohibit phones entirely because of liabilities and safety protocols.

Last summer, she bought a phone with her own money.

“You weren’t allowed anything near the internet, near a computer, near a phone or anything, unless it was completely authorized,” Sanchez says.

But there was an even bigger milestone to tackle: getting a car. With a vehicle of her own, she wouldn’t need to rely on others to get to work or to appointments in a city as sprawling as Albuquerque.

She had already gotten her driver’s license. But Sanchez had no savings. It was nearly impossible to find a used car that she could afford.

Then Woodcock saw a 2001 Dodge Neon for sale. She purchased the car outright for Sanchez, who reimbursed her over the following months.

It was a momentous step.

Woodcock works with Sanchez to navigate the paperwork for her car. “It still doesn’t feel real,” Sanchez said later that day. “I don’t have to be scared anymore. I don’t have to depend on other people.”

She’s now paid back the entire cost of the car — $3,000.

“She’s my role model,” Sanchez said of Woodcock. “I’m very glad that that woman found potential in me and helps me with my life. She sets me up for the right path.”

“Having even one single caring adult in a young person’s life can absolutely mean the difference between success and failure after leaving foster care,” said Annie Rasquin, executive director of CASA First, the office where Woodcock worked before leaving to help Sanchez.

The gaps in the CASA system have always been a problem, Rasquin said. Inspired in part by the success of Woodcock’s work with Sanchez, CASA First established a mentorship program this year. It trains volunteers to give extra support to foster teens who need it.

The small responsibilities adults have to manage — like changing a first flat tire — feel like big accomplishments, Sanchez says.

In October, Sanchez started focusing on her GED full time. In the coming years, she said she hopes to start a business as a cosmetologist or tattoo artist. Her Fostering Connections worker has helped her in making plans for the future, she said.

In the past, “I had nothing — 100% no control over my life,” she said. “I’m finally getting up for the first time.”

Sanchez in the yard of the home where she rented a room last year

How This Story Was Reported

Photojournalist Kitra Cahana set out in the summer of 2022 to document what happened when foster kids turned 18 and “aged out” of the child welfare system. The reporting was part of a project she did with Searchlight staff writer Ed Williams and ProPublica about New Mexico’s treatment of teenagers in foster care. Cahana spent five days shadowing and photographing Gonzales over the course of a week, including a stay at a motel until the early hours of the morning; she spent an additional five days with Sanchez over the course of several weeks. On other occasions, she met with the women to chat, grab some food, talk about their experiences and discuss the extent to which they felt comfortable sharing their stories with the public. Williams followed up with Gonzales and Sanchez this fall to find out how they’ve been faring. The women granted full access to both Cahana and Williams. They said they wanted the public to understand what foster teens go through.

by Agnel Philip

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As far as state and federal officials are concerned, the drinking water in Smithwick, Texas, is perfectly safe.

Over the past two decades, the utility that provides water to much of the community has had little trouble complying with the Safe Drinking Water Act, which is intended to assure Americans that their tap water is clean. Yet, at least once a year since 2019, the Smithwick Mills water system, which serves about 200 residents in the area, has reported high levels of the synthetic chemical 1,2,3-trichloropropane, according to data provided by the Environmental Working Group, an advocacy organization that collects water testing results from states.

The chemical, a cleaning and degreasing solvent that is also a byproduct from manufacturing pesticides, is commonly referred to as TCP. It has been labeled as a likely carcinogen by the Environmental Protection Agency for more than a decade. There have been few active sources of TCP since the 1990s, but its legacy lives on because it breaks down slowly in the environment.

How it got into the Smithwick Mills water supply is a bit of a mystery. There are some farms in the area, but it’s unclear whether they have used pesticides containing the chemical, and there are no known industrial sources nearby.

The TCP levels in the Smithwick Mills system are alarming to those who study water contamination. As with many chemicals, there’s limited information on TCP’s long-term effect on humans. But research involving animals shows evidence that it increases cancer risks at lower concentrations than many other known or likely carcinogens, including arsenic. Because of this, in 2017, California state regulators set a maximum allowable level for TCP in water of 5 parts per trillion. Water quality tests from the Smithwick Mills utility have revealed an average TCP level of 410 parts per trillion over the past four years — more than 80 times what would be allowed in California.

But the utility hasn’t taken any action. It doesn’t have to. The chemical isn’t regulated in drinking water by the EPA or the Texas Commission on Environmental Quality, which means neither agency has ever set a maximum allowable level of TCP. It’s not clear why Smithwick Mills was even monitoring for the chemical, though state officials said many utilities receive results for TCP as part of routine lab tests for a variety of chemicals that get reported to state regulators.

Residents said they received no notices about the high levels, which weren’t shared in the town’s annual consumer confidence reports from 2019 to 2021, the first three years TCP was recorded in its water. TCP test results appeared in the 2022 report, which the water utility sent to residents after a ProPublica reporter reached out to the company earlier this year.

Jerri Paul, who has lived in Smithwick for three years, said she’s disappointed in the lack of communication from the water system and regulators. She has little hope that Texas officials will act on their own, because the state government has generally been reluctant to expand environmental regulation.

“I just don’t see them doing something above and beyond what the feds do,” said Paul, who is a member of the Smithwick Mill Estates property owners association board. The community is made up mostly of working-class people and retirees, many of whom don’t have the resources to buy bottled water, she noted. “We’re really dependent on the federal government doing something and saying that this is a contaminant that is not acceptable.”

A representative from Corix Utilities, which operates the Smithwick Mills water system, said in a statement that the company’s review of the tests didn’t show a danger to the community’s residents and that the system is in compliance with drinking water standards.

TCP has been found in far more drinking water than just in this small Texas town. When the EPA last conducted nationwide testing about a decade ago, the chemical was detected in the water of 6 million people (though, at the time, not in Smithwick). Four million of those people were served by systems with average concentrations above California’s standard.

TCP is one of more than a dozen unregulated contaminants that have been found in the country’s drinking water. During the past decade, regulators have identified at least one of these substances at levels that could impact human health in the tap water of 61 million people, according to a ProPublica analysis of EPA data. Nearly 16 million of these people were exposed to potentially dangerous levels of possible or likely carcinogens, including TCP. And over the past 25 years, the agency has identified more than a hundred other water contaminants, including industrial and agricultural chemicals and microorganisms, that may present risks to humans. The potential health effects of these substances include developmental delays, reproductive issues and cancer.

During the Past Decade, the EPA Found Unregulated Contaminants at Potentially Unsafe Levels in the Tap Water of 61 Million People Note: Potentially unsafe levels refer to the systems where the average sample result was higher than the EPA’s health-based “reference concentrations.” The population figures represent those served by publicly regulated community water systems. The EPA does not regulate water quality for private well users. Source: ProPublica analysis of Environmental Protection Agency data (Jason Kao/ProPublica)

Experts and activists say this demonstrates fundamental shortcomings in the country’s approach to environmental threats. The Safe Drinking Water Act, designed to protect the nation’s water quality, requires an extensive, multistep process before adopting new standards. Critics say the EPA has struggled to move contaminants that have been on its radar for a decade or more through this process in a timely fashion.

The EPA’s inaction on these chemicals “just illustrates how broken the system is,” said Erik D. Olson, a lawyer who worked at the EPA during the Reagan administration and is now senior strategic director for health and food at the Natural Resources Defense Council, an environmental advocacy group. “The law really is incredibly cumbersome and difficult, and there’s just a lack of political will to regulate a lot of these things.”

An EPA spokesperson said in a statement that while the agency views TCP as a potential contaminant of concern, it hasn’t collected enough data on it. Before regulating a new contaminant, the agency must show that doing so will provide meaningful health benefits based on the law’s criteria.

“EPA must make regulatory determinations based on the best available data and peer reviewed science,” the spokesperson said in a written statement. The agency did not make officials available for interviews.

Action Is Rare

In 1974, soon after expanding regulations for surface water pollution through the Clean Water Act, Congress passed the Safe Drinking Water Act, directing the EPA to protect the nation’s tap water. But within a decade, many lawmakers felt the legislation hadn’t done enough. In 1986, Congress passed amendments to the law that directed the agency to regulate more than 80 additional contaminants, including bacteria, viruses and chemicals such as cyanide and PCBs, within five years; the EPA would have to add another 25 contaminants every three years after that.

The agency struggled to comply with the mandates and missed deadlines for setting standards. Many small water utilities and some states said that the EPA’s rulemaking process didn’t prioritize contaminants with the greatest health risks. So, in 1996, following this pushback, Congress amended the law again with the stated goal of basing the agency’s rulemaking process on “sound science.”

The amendments created a much more complex, multistep process for regulation proposals. The EPA would need to demonstrate not only that a contaminant was a danger to human health, but that it was found widely enough in drinking water to warrant regulation. The agency also had to show that the benefits of regulating the contaminant would outweigh the costs — a tricky calculation that requires the agency to weigh the known tangible price associated with treatment and cleanup versus often uncertain projections about the health impacts of newly studied substances.

“The activities of Federal agencies would not, as some have said, grind to a halt,” Republican Sens. Orrin Hatch of Utah and Jon Kyl of Arizona assured Americans in a New York Times op-ed in 1995 as the amendments were being debated.

Since then, the EPA has reviewed data on more than 35 unregulated contaminants, including sodium and the explosive RDX, through the primary process laid out in the 1996 amendments. None have yet been regulated.

In the vast majority of those cases, the agency decided there wasn’t enough evidence that the benefits of regulating a contaminant outweighed the costs. In one case — the chemical perchlorate — the agency initially decided in 2011 that it would set a maximum level, before reneging. (A federal appeals court recently ordered the agency to go through with its rulemaking process and set a standard for this chemical.)

The EPA has developed other regulations since 1996, including mandated treatment techniques and revisions to existing standards, the agency said in its statement to ProPublica. It also followed specific directives Congress made through the amendments to set limits for a handful of new contaminants using the law’s required cost-benefit analysis.

Steve Via, director of federal relations at the American Water Works Association, which represents utilities, said the agency is right to carefully consider costs before adopting new standards. Unnecessary regulations, he said, add a burden on systems that could lead to significant rate increases for customers.

“We need to protect public health, but we need to focus available resources,” he said, noting that the EPA was justified in not regulating some contaminants that weren’t widespread. “The best way to make that call is through a benefit-cost analysis.”

One family of chemicals has caused such an outcry that the streak could end soon. The EPA proposed this year to regulate a small group of perfluoroalkyl substances, or PFAS, also dubbed “forever chemicals.” The substances, which by some estimates number in the thousands and which got their nickname because they may may persist for centuries in the environment, were used in firefighting foam on military bases and nonstick materials like frying pans. They first garnered mainstream attention in the 2000s when residents in Parkersburg, West Virginia, sued DuPont, alleging the company knew that the chemicals it used at its Teflon plant there were toxic and had still exposed workers, livestock and locals to them. The company settled the lawsuit, which was portrayed in the 2019 film “Dark Waters.”

Studies have shown that prolonged exposure to PFAS in water may lead to cancer, decreased fertility, developmental delays in children, immune system suppression and other adverse health effects.

The agency first gathered data on the prevalence of six PFAS chemicals from 2013 to 2016, during the same time it was testing for TCP. It found at least one PFAS chemical in the water of 17 million people, according to an analysis of EPA data.

It turns out that was a vast underestimate, in large part because the tests used at the time weren’t sensitive enough to detect PFAS at very low concentrations. Follow-up testing has uncovered additional contamination: A 2020 study based on data from all 50 states estimated that the chemicals were likely present in the water of more than 200 million people.

Amid this heightened scrutiny, the Biden administration committed to take action, leading the EPA to announce in March that it would limit six chemicals from the PFAS family. For those who have been pushing for stricter drinking water standards, the proposal has provided some hope that the agency will act on other tap water threats, though this situation was unique because of the public scrutiny around the chemicals in recent years.

Waiting for Action

Of the more than 60 other “contaminants of concern” the EPA has identified, about 20, including TCP, are possible or likely carcinogens, and nearly 30 may have reproductive and developmental impacts.

For many of those contaminants, however, there is still uncertainty about the exact human health impacts. Scientists can’t do randomized controlled experiments on humans — the gold standard used to establish cause and effect — because it is unethical to expose people to substances that might cause serious health issues. Instead, human health data typically comes from observational studies, in which researchers recruit volunteers and follow their health outcomes over time. But these are expensive, difficult to conduct and come with their own uncertainties because they are not perfectly controlled experiments.

As an alternative, researchers often turn to controlled studies conducted on rodents or other animals to project what the effect might be in humans. In the case of TCP, researchers identified a link between the chemical and cancer in mice and rats in the 1990s, but to date no large-scale studies have investigated its effect in humans.

“A lot of times people who are not trained formally as scientists or researchers hear those uncertainties up front and say, ‘Oh well, this isn’t good enough, we need to wait,’” Sydney Evans, senior science analyst at EWG, said of findings on the health effects of TCP. “One of the issues with the way that contaminants and chemicals are regulated, especially drinking water contaminants, is that it takes entirely too long. And in the meantime, so many people are being exposed, just because we can’t be 100% certain.”

There is also limited information on the contaminants’ prevalence. The EPA has collected national drinking water data on less than half of its list of contaminants, and it can only monitor for 30 of them every five years. Some advocates for increased drinking water regulation say this limit, which was part of the 1996 amendments, makes it hard for the EPA to stay on top of emerging threats.

Not every small water system is required to participate in each testing round, and even among those that do, the data collected may not be useful to regulators. For example, during the monitoring period for TCP, the lab tests the EPA directed utilities to use couldn’t detect the chemical at low levels, similar to the testing sensitivity issue the agency faced in monitoring for PFAS. In 2022, the agency demurred on taking action on TCP, in part because it had no data on how widespread the chemical was at these lower levels. The agency declined to comment on why it didn’t use more sensitive tests that were available.

As with PFAS, follow-up testing by states and local utilities have found more people exposed to TCP than was initially documented, according to the Environmental Working Group data. ProPublica’s analysis of the data shows that since the EPA stopped its monitoring, TCP has been found in water systems serving an additional 6 million people, though many states recorded few or no tests during that time period. While many of these detections were in California, which requires testing, Texas documented TCP contamination in water from Smithwick Mills and dozens of other utilities.

Additional Testing Has Found More People Exposed to TCP Than Initially Documented Source: ProPublica analysis of Environmental Protection Agency and Environmental Working Group data (Jason Kao/ProPublica)

Alan Roberson, executive director at the Association of State Drinking Water Administrators, said the EPA should make a greater effort to provide final determinations on these contaminants of concern, including decisions to take them off its candidate list. There are three chemicals, for example, that have been on the list since 1996 without any final determination, according to the ProPublica review.

“They need a process for having a more manageable list and then doing the research to move it forward,” Roberson said. “Let’s make sure we have the stuff we need to make decisions, either up or down, on a regular basis.”

Leadership Void

In the absence of direction from the federal government, some states have acted on their own. In 2018, New Jersey joined Hawaii and California in regulating TCP. The limits vary widely, however. Hawaii’s TCP standard, which was enacted in the 1980s and revised 20 years ago, allows up to 600 parts per trillion in water.

Darrin Polhemus, deputy director of the division of drinking water with California’s State Water Resources Control Board, said the state’s laws allow it to be more aggressive in targeting health risks in drinking water. Unlike the EPA, which has to determine that the benefit of a drinking water standard outweighs the cost, California regulators are directed by state law to set a maximum level as low as possible, so long as most water systems can afford to implement the treatment.

“That is why I like our system better than the federal government’s,” he said. “It can be incredibly hard to calculate the benefit of the health outcome.”

If Smithwick Mills had been in California, the water utility would have had to drastically reduce the levels of TCP in its water to comply with the state’s standard, either by installing treatment technology to remove the chemical or changing its water supply. At minimum, residents would have been notified of the contamination levels. But since the system is in Texas, the chemical’s presence went largely unnoticed until now. State officials said they have no plans to regulate TCP.

Paul, the Smithwick resident, said what’s most unsettling is that no one seems to know how TCP entered the community’s water supply. For years, Paul drank only bottled water because she didn’t like the taste of what came from the tap. But after learning about her town’s TCP test results, she stopped giving her dog water from the tap, and now uses bottled water even to make bird feed and water her plants. She uses tap water only for cleaning and bathing.

“I don’t trust it for anything else,” she said.

How We Measured Drinking Water Contamination

To determine the scope of drinking water contamination from unregulated substances, ProPublica analyzed water quality test data compiled by the Environmental Protection Agency and Environmental Working Group.

The EPA data, which came from the agency’s two most recent Unregulated Contaminant Monitoring Rule periods, showed that during the past decade 61 million people were exposed to dozens of unregulated contaminants in their drinking water at potentially harmful levels. During the UCMR periods, which occur every five years, the EPA directs water systems to test for up to 30 contaminants. If a contaminant is detected at levels that exceed a certain threshold, known as the minimum reporting level, the utility must report the concentration found. The EPA also provides health-based “reference concentrations” for many contaminants. Using the results from the past two completed periods (2013-2016 and 2018-2021), we calculated average concentrations for each contaminant for every community water system in the dataset (treating nondetections as zeroes) and tallied the population served by systems with average concentrations higher than the reference concentration. For the majority the only contaminant found was chlorate, which is a disinfectant byproduct. Water from systems serving nearly 16 million people contained possible or likely carcinogens, though that figure doesn’t include PFAS chemicals since the EPA hadn’t yet determined that they were possibly carcinogenic at the time of testing.

The EPA data has some significant limitations. First, while every system serving more than 10,000 people must participate in UCMR testing, smaller systems are not required to. Instead, the Safe Drinking Water Act requires the agency to collect test results from a “representative sample” of small systems. Further, the tests cover a limited snapshot in time. Because the contaminants aren’t regulated, there is no requirement for systems or states to keep testing past the monitoring period.

To find the other communities affected by some of these contaminants, we used EWG’s Tap Water Database. Researchers with the environmental advocacy organization obtain the data from places that continue to test for unregulated contaminants beyond the end of monitoring periods. EWG checks the data against public sources to ensure that the samples in its database represent those taken after the water is treated.

The organization shared test results for some of the most widespread contaminants found during the EPA’s monitoring rounds, including 1,2,3-trichloropropane and PFAS. The data is complete for all states through 2019. The organization has released more recent data where available.

By comparing the water systems where additional testing has found 1,2,3-trichloropropane contamination to the EPA’s original monitoring results, we determined the chemical was found in the water of an additional 6 million people.

Clarification, Nov. 6, 2023: The figures in the second graphic have been expanded to include the tenths decimal place so it’s more clear why the two sides are different sizes.

Maya Miller and Max Blau contributed reporting.