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Big Insurance Met Its Match When It Turned Down a Top Trial Lawyer’s Request for Cancer Treatment

1 year ago

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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 T. Christian Miller

Here’s What Can Happen When Kids Age Out of Foster Care

1 year ago

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

The EPA Has Found More Than a Dozen Contaminants in Drinking Water but Hasn’t Set Safety Limits on Them

1 year ago

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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.

by Agnel Philip

Los Angeles Mayor Orders Residential Hotels to Be Used for Temporary Homeless Housing

1 year ago

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Los Angeles Mayor Karen Bass issued an order Wednesday that allows the city to use residential hotel rooms — which by law are intended to be used as permanent housing for some of the city’s poorest residents — to temporarily shelter homeless people.

The order goes against the goals of a 2008 city law, which sought to preserve nearly 19,000 mostly bare-bones residential hotel rooms as stable housing for low-income, disabled and elderly Angelenos, who were increasingly being displaced by the development of condos and tourist hotels. If residential hotel owners want to convert their buildings into other uses, they must either replace the housing units or pay an equivalent fee to the city.

The mayor’s order comes nearly four months after a Capital & Main and ProPublica investigation found that at least 21 hotels were renting rooms to tourists and advertising on travel booking websites in apparent violation of the law. In response, the mayor’s office ordered the city’s Housing Department to investigate and account for the lapse in enforcement. Housing officials have issued citations to the owners of 17 of the hotels, ordering them to restore their rooms to residential use. All but one of the owners have appealed the order.

The order is designed to open additional rooms for the mayor’s Inside Safe initiative and other programs until their participants can be placed in permanent housing. Since the mayor declared a homelessness emergency on her first day in office in December, Inside Safe has cleared some 29 street encampments and moved more than 1,600 people into temporary shelter in more than 40 hotels and motels.

The new directive, which is in effect until the emergency ends, would significantly expand the city’s short-term shelter options, as there are roughly 300 buildings designated as residential hotels across the city. Any vacant residential hotel unit could be used to provide temporary housing under an agreement with the city.

“This executive directive continues work to help bring unhoused Angelenos inside as quickly as possible so they don’t die on our streets,” Bass spokesperson Zach Seidl wrote in a statement.

But Barbara Schultz, the director of housing justice at the Legal Aid Foundation of Los Angeles, called the order “incredibly shortsighted” and “a huge step backwards.”

“Los Angeles is short tens of thousands of permanent units,” Schultz said. “As it is, we can’t move people from interim units into permanent units because of the shortfall. So how does removing permanent units help?”

Schultz said the mayor’s order could violate a 2006 lawsuit settlement that predates the residential hotel law and requires more than 65 downtown hotels to remain residential.

As of Oct. 13, Matt Szabo, the city’s chief administrative officer, reported that just 190 of 1,682 Inside Safe participants had found a permanent place to live.

Similar debates about who should get priority for limited housing and the best ways to address homelessness are playing out in large cities across the country.

Ray Patel, who heads the North East Los Angeles Hotel Owners Association, said the mayor’s order could be a “win-win” for the city and hotel owners, adding that housing Inside Safe participants would be a good option for hotels without amenities that would attract tourists. “We’ve always been a proponent of the market dictating how hotels rent,” he said.

Many residential hotel owners stand to earn more than they could from monthly rents as rates under Inside Safe have frequently exceeded $100 a night.

The city appears to be rethinking its enforcement of the residential hotel law. Under the order, the city would not deem residential hotels in violation if they rent out rooms to the city. This week, the Housing Department postponed at least two appeal hearings involving residential hotels that were offering rooms to tourists because the hotel had applied to participate in Inside Safe.

The mayor’s order also requires the Housing Department to “conduct a comprehensive review of all residential hotels” within 30 days, so that city officials can consider updates to the residential hotel ordinance.

Gabriel Sandoval of ProPublica contributed reporting.

by Robin Urevich, Capital & Main

The Scandal That Never Happened

1 year ago

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Prologue

Two years into his 25-year sentence for attempted aggravated rape, Nathan Brown could tell the man sitting across from him — a jailhouse lawyer improbably named Lawyer Winfield — was not going to help him get out of prison. It was astounding to Brown that he was pinning his hopes on a fellow inmate who had an eighth grade education and whose formal legal training amounted to a prison paralegal course. “But he knew more than I did,” Brown said.

Brown laid out for Winfield the details of his case. In the summer of 1997, a woman was assaulted in the courtyard of the apartment complex in Jefferson Parish, Louisiana, where Brown was living with his mother. The woman, who was white, fended off the attacker with her high-heeled shoe until he fled on a bicycle. When sheriff’s deputies arrived, a security guard suggested they question Brown — one of the few Black tenants in the complex.

Brown, 23 at the time, was in his pajamas, rocking his baby daughter to sleep. The deputies put him in handcuffs and brought him to the victim. When she couldn’t identify him, the officers allowed her to get close enough to smell him. She had told them her attacker had a foul body odor. Brown, she would later testify, smelled like soap; he must have showered immediately after, she speculated. In a trial that lasted one day, the jury found him guilty. After his appeal was rejected, he no longer had a right to an attorney provided by the state.

Winfield began translating Brown’s grievances into a legal petition. He argued that Brown’s lawyer had provided ineffective counsel: He had overlooked the most basic defense strategies, failing to challenge the discrepancies in the victim’s story and to insist on DNA testing. The two of them worked on the petition for months, so Brown was surprised when the Louisiana 5th Circuit Court of Appeal delivered a rejection just a week later. The denial — a single sentence that didn’t address any of Brown’s claims — bore the names of three judges. But something didn’t feel right. How could they return the ruling so quickly? Why was it so vague?

The answer to those questions would come years later, in the suicide note of a high-level court employee who disclosed that the judges of the 5th Circuit had decided, in secret, to ignore the petitions of prisoners who could not afford an attorney. It was a shocking revelation. In a state where police and prosecutorial misconduct frequently make national headlines and a stream of exonerations has revealed a criminal justice system still functioning in the shadow of slavery and Jim Crow, a group of white judges had decided that the claims of hundreds, perhaps thousands, of inmates — most of them Black — were not worth taking the time to read.

Among those petitions was Brown’s claim that a DNA test would have proven his innocence.

Part One A Death at the Courthouse

On a warm Monday morning in May 2007, as the secretaries and clerks began filing through the glass doors of the Louisiana 5th Circuit Court of Appeal, staff director Jerrold Peterson was inside his office with a 9 mm Beretta pistol. A letter he had written to the court’s eight judges was making its way to the chambers of Chief Judge Edward Dufresne Jr. Versions of that letter were en route to the Judiciary Commission, the panel responsible for investigating allegations of judicial misconduct, and to the Times-Picayune, the state’s most influential paper.

Peterson hoped the letter would unleash a massive scandal — one that he had helped perpetuate for more than a decade. Fifty-five years old, Peterson had long been a fixture at the courthouse, and he reminded the judges that he had kept their secrets, clearing contempt charges against their friends and fixing traffic tickets whenever they asked. But he focused his rage on one secret in particular: their handling of appeals sent to the court by prisoners who claimed they’d been unjustly convicted.

If you or someone you know needs help:

  • Call the National Suicide Prevention Lifeline: 988
  • Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741

Louisiana requires that a panel of three judges review all such petitions — known as pro se petitions, a Latin phrase that means “for oneself.” But Peterson wrote that the judges had instructed him to ignore the law and dispose of the appeals on his own. Dufresne, he explained, signed off on the documents “without so much as a glance.”

The implications were staggering. Over 12 years, the 5th Circuit, which is responsible for reviewing challenges from trial courts in four parishes, had disregarded at least 5,000 pro se petitions from Louisiana prisoners, according to the court’s records. The inmates ranged from people convicted of murder to nonviolent offenders sent away for life. Many had limited education and struggled to present their arguments in the language of the courts. If Peterson’s accusations were true, none of the judges had ever laid eyes on their claims.

Peterson, who was known to keep his door open, didn’t answer the business services manager when she came by to tell him that Dufresne wanted to see him. The chief judge instructed her to have the head of security unlock the door. As he slid in his passkey, the sound of a gunshot echoed through the building.

A police detective arrived at the courthouse and found Peterson at his desk, slumped to one side, the Beretta still clutched in his right hand. The rest of the office, the detective wrote in his incident report, “seemed to be void of any further evidence.” When the officer searched the room a second time “for a final attempt to locate a possible suicide note,” Dufresne joined him. The chief judge didn’t mention that he had already read Peterson’s suicide letter. The detective, though, sensed something was amiss. In his report, he noted that Dufresne “appeared to be evasive.”

The 5th Circuit courthouse sits on the edge of downtown Gretna, a sleepy New Orleans suburb of 17,000 that serves as the government seat for Jefferson Parish. A tight bend in the Mississippi River separates Gretna from New Orleans, but politically and socially, the two are much further apart. Connecting the cities are twin bridges that became notorious after Hurricane Katrina when thousands of New Orleans residents tried to evacuate over the span but were forced back by a line of Gretna police officers. For many Black people in Louisiana, the moment encapsulated the hostility of the suburb, an area shaped by white families who had fled school desegregation half a century earlier.

On the Gretna side of the bridge, the road becomes the Harry Lee Expressway, named for a sheriff of the parish who was elected in 1979 and returned to office six times on a platform of aggressive policing. Lee once proudly announced that he had ordered his deputies to stop any “young blacks” they might find driving at night in a white neighborhood. “There’s a pretty good chance they’re up to no good,” he explained. During Lee’s tenure, the voters of Jefferson Parish sent David Duke, the former grand wizard of the Ku Klux Klan, to the Louisiana House of Representatives for a term.

Dufresne’s ancestors were among the area’s early settlers. His father, a plantation owner known as Big Eddie, built a white-columned brick home at the edge of his sugarcane fields in the neighboring parish of St. Charles. Dufresne, known as “Little Eddie,” launched his first campaign — a successful run for clerk of court — while he was still in law school. After he won a seat on the court, a local publication called him “the Thomas Jefferson of St. Charles government” and asked, “Can Eddie Dufresne, Jr. go cold turkey on politics now that he’s a judge?” The answer was no. By the time he was elected to the newly formed 5th Circuit Court in 1982, he had become a power broker like his father, weighing in on disputes and promoting politicians he favored. Each spring, he hosted a lavish crawfish boil on the riverfront that drew sheriffs, businesspeople, judges and public officials.

Long before he became chief judge in 2001, Dufresne dominated the 5th Circuit. On most weekdays, he would arrive at the courthouse in the passenger seat of one of his Cadillacs, driven by his longtime secretary, who would pick him up at the plantation house. Yet he was perceived by many as a “real salt-of-the-earth kind of guy,” as one lawyer put it. He earned the loyalty of staff by keeping work hours short — he would often leave at 2 p.m. — and wages high. “Dufresne ran a court for the benefit of the judges,” another lawyer told me.

During a monthly meeting of the 5th Circuit’s judges in 1994, he proposed changing how the court handled criminal pro se petitions, also known as writs. The minutes note the proposal but only in passing; it’s sandwiched between a lengthy debate over plans to upgrade the court’s computer system and a discussion about renting a new office copier. Dufresne’s plan is described in two sentences: A three-judge panel would no longer rule on the petitions unless they were “special or unusual”; instead, Dufresne would oversee them himself.

“Administratively, it got somewhat cumbersome to have to select three-judge panels for every writ, because you’d get hundreds of them,” said Bryan Pedeaux, who was Dufresne’s longtime law clerk. “So Dufresne said, ‘Let’s see if we can somehow streamline the situation.’”

At the time, the 5th Circuit had the lowest caseload — and the lowest number of pro se petitions — of the state’s five appellate courts. In the year preceding the meeting, it reported 235 criminal pro se petitions, fewer than one-tenth of the statewide total. The 4th Circuit, which includes New Orleans, reported 1,031.

Dufresne’s proposal was in keeping with his judicial views, former staff members told me. He believed that people convicted of crimes were almost certainly guilty and that any issue they raised on appeal was an attempt to avoid paying for their actions. He almost never reversed a decision of the lower criminal courts. “There was a total prejudice against all people charged and convicted of crimes,” said a former law clerk. “They never planned to give any of these people any relief anyway, so what difference does it make?”

The minutes give no hint of why the judges believed they could circumvent the state’s law. Although Peterson attended the meeting, his future role in drafting rulings on the court’s behalf is not mentioned. Still, it was clear Dufresne was offering to substantially reduce the judges’ caseloads: At the time of that meeting, more than 75% of the court’s post-conviction petitions came from prisoners without an attorney. The change went into effect immediately.

ProPublica made multiple attempts to contact each of the three 5th Circuit judges who presided during the relevant years and are still alive. ProPublica also asked for comment from the 5th Circuit courthouse. None responded.

Entrusted with overseeing the new protocol, Peterson developed a system to dispense with the prisoners’ applications speedily. He drew up 15 rulings for his assistant to cut and paste; they were typically no longer than one or two sentences and ambiguous enough to fit a wide range of claims. A couple of the rulings were labeled “grants” but did little more than allow prisoners access to their trial transcripts.

Sixty years ago, the U.S. Supreme Court ruled in Gideon v. Wainwright that the Sixth Amendment guarantees all criminal defendants the right to an attorney. But in most states, including Louisiana, that right ends after an appeal of the initial conviction. Every subsequent appeal is part of the post-conviction process, an area of law that even experienced lawyers find challenging.

Judges often view pro se appeals skeptically because they are filed by people who are not only untrained in the law but sometimes barely literate. Even liberal courts struggle with the high volume of petitions that lack merit. They are frequently assigned to clerks, who tend to recommend that judges dismiss them on technical grounds to avoid having to unravel what they see as frivolous or poorly made arguments. Still, the post-conviction process is essentially the only avenue prisoners have to introduce new evidence of their innocence or to persuade the court a defense attorney didn’t do their job.

There is overwhelming evidence that state courts routinely send innocent men and women to prison. Researchers estimate that at least 1% of those serving time for violent offenses have been wrongfully convicted — roughly 7,000 inmates in state prisons alone — though they believe that number is much higher. Louisiana law says that people sentenced to death are entitled to court-appointed lawyers for all of their appeals. Subjected to such scrutiny, an astounding number of the state’s prosecutions have fallen apart. Since 1976, 82% of Louisiana’s death sentences have been overturned by appeals judges after defense attorneys exposed serious violations that occurred at trial. Most sentences were reduced to life; some prisoners were exonerated.

That statistic underscores a fundamental inequity. The people sentenced to lengthy or life sentences were arrested by the same police forces, prosecuted by the same district attorneys, represented by the same public defenders and convicted in the same courts as those on death row, but they are on their own. When they file a pro se petition asking Louisiana’s appellate courts to reconsider their cases, they are at a significant disadvantage. Those petitioning the 5th Circuit after that meeting in 1994 had no chance at all.

To create the appearance of a proper review, former staffers said Dufresne formed a “pro se committee,” which included three judges who agreed to lend their names to Peterson’s rulings. Whenever a judge on the committee retired, Dufresne appointed someone new. The nature of the pro se committee was an open secret at the courthouse. “I knew what they were doing, and I knew it was unconstitutional,” said one former clerk. “Everyone knew about it.”

In Louisiana, courts charge prisoners a fee for petitions — generally $50. Those costs are usually paid by parishes in which the defendants are convicted. By 1999, the 5th Circuit was charging $300. The money, paid by taxpayers, flowed into the 5th Circuit’s discretionary fund. In a period when the state’s criminal justice system was close to financial collapse, with some public defenders representing as many as 400 people at a time, records show that the 5th Circuit collected at least $1.7 million for the pro se petitions its judges did not read. Former 5th Circuit employees told me the judges spent the money on office furnishings, travel allowances — even for retired judges — and other perks the state didn’t cover. When asked about the fund’s expenditures, the 5th Circuit said it keeps financial records for only three years and could not provide an accounting.

The pro se petitions made up only a small part of Peterson’s responsibilities. His primary task was to oversee the court’s central staff, a group of lawyers who reviewed criminal petitions filed by attorneys and wrote recommendations for the judges. He also spearheaded the court’s lobbying of the state legislature and oversaw the construction of the new court building. “He loved that job more than anything in the world,” a former colleague told me.

Although Peterson often put in long days, he advised his staff to spend more time with their families. Those who knew him well said his devotion to his work seemed to rise and fall in proportion to what was occurring in his personal life, which was in a perpetual state of flux. Former colleagues said he was unhappy in his marriage and had several affairs with staff members. At times his home mail was delivered to the office, and some of his co-workers suspected he might sleep there on occasion. Putting his children through parochial school was a financial strain. One of his daughters had died in her teens, and a brother had killed himself. A devout Catholic, Peterson had a hard time reconciling his faith with his troubled marriage and bouts of depression.

Peterson was born into a family of river pilots responsible for guiding ships through the lower Mississippi. It’s one of the most lucrative jobs in the state, with pay frequently exceeding $700,000 a year. Peterson’s grandfather, father and brother all held the job, and two of his sons now do. Peterson took a different path. After he graduated from the U.S. Naval Academy, he attended law school at Tulane University and took a job at a firm in New Orleans. He joined the 5th Circuit at age 37; his time with the court was interrupted only by his military service — as a reserve Marine colonel, he served in both the Afghanistan and Iraq wars.

After years of overseeing the scheme, Peterson sought out Karla Baker, who had worked at the court years earlier and with whom he had been romantically involved. Baker was much younger than Peterson, and their relationship had continued after she left the 5th Circuit and took a job as a defense attorney at a prominent New Orleans firm. Peterson told her he wanted someone else to know what the judges had asked him to do, and he gave her a copy of his list of denials and the minutes from the 1994 meeting. He asked her not to do anything unless she heard from him.

On Saturday, May 19, 2007, two days before his suicide, Peterson received a call from Dufresne, summoning him to the courthouse. When he arrived, Dufresne and two judges were waiting in the conference room, and it quickly became clear they were there to fire him. They had evidence that Peterson had tried to improperly sway a case — that he had directed his staff to write a memo advising the judges to rule in favor of a defendant. Peterson rarely, if ever, recommended relief, even in cases filed by attorneys. But this happened to be a case Baker was defending, and Peterson had intervened.

Some law clerks had reported what they viewed as Peterson’s misconduct to the judges. Dufresne wanted to let it go, but a new judge on the court insisted they launch an investigation, which also revealed that Peterson was having a relationship with one of his subordinates. It had become too much to ignore. After more than a decade of denying the appeals of defendants, he was being fired for trying to aid one.

Peterson was blindsided. He had assumed he had a level of job security commensurate with the amount of dirty work he had done for the court. “Jerry thought he was one of them,” a former colleague told me. “He thought he was unfireable because he knew all the court’s secrets.” Now, some of the same judges who had asked him to break the law were dismissing him for what struck him as comparatively small-scale misconduct.

After the meeting, he sat down and began to write a letter to the judges. “Not one criminal writ application filed by an inmate pro se has been reviewed by a judge on the court,” he wrote. “Who’s integrity is really in question when you have conveniently ignored your duty to review pro se criminal writ applications so you can reduce your workload, present a false picture of the court’s work, and charge large sums for work you haven’t done?”

On the morning of his suicide, Baker said, she received an email from Peterson: “He said by the time he was finished it will be Gretnagate.” But he underestimated the determination of the state’s legal establishment to protect its own.

The Times-Picayune ran a short piece on the suicide a few days later. It described Peterson as a well-liked, reliable employee. A staff member told the paper that Peterson’s problems were personal ones: “As far as anyone knows it has nothing to do with anything here at the court.” The article made no mention of the letter Peterson had sent to the paper.

The Judiciary Commission initiated an investigation into the 5th Circuit. A person familiar with the inquiry told me it focused on Dufresne, but it never became public and never had any consequences. Its findings were sealed and sent to a storage facility that was already filled with the records of other misconduct investigations that are not subject to the state’s public records law.

None of the judges involved in the episode was disciplined. A few months after Peterson’s suicide, the 5th Circuit quietly adopted a new policy for handling pro se petitions: A panel of three randomly selected judges would now review them, as Louisiana law required. No one, however, alerted the men and women whose petitions the court had improperly rejected and who were in prisons across the state.

Part Two Hundreds of Petitions

Karla Baker wanted no part of the mess Peterson had left behind. But she had loved him, despite their complicated relationship, and felt partly responsible for his unraveling. She knew that Peterson had gotten into trouble because he had tried to influence the judges in her case. Although she never asked for him to intervene, she said, she worried her own legal career could be in jeopardy.

More than 16 years after Peterson’s suicide, Baker is still hesitant to talk about what happened, and unsure of how to cast herself in the story. Raised in Louisiana, she graduated from Loyola University New Orleans College of Law and began her career as a staff attorney for the state Supreme Court. When she joined the 5th Circuit as a law clerk in 2002, she was taken with Peterson’s intelligence and kindness. He never spoke down to her, she said, despite her lack of experience. He seemed to know everything about the courthouse, and he was always willing to help. As they became closer, she came to see a dark side. He was deeply unhappy, haunted. “He lived on the edge,” Baker said, but felt powerless to change his own circumstances.

Peterson could have taken his documents to the Innocence Project or another nonprofit dedicated to fighting the injustices of the Louisiana criminal justice system, but those were not his people. So, he had left it to Baker, who had never seen herself as an activist, to bring the scandal to light.

Baker anguished about the matter for months. She was engaged to someone by then and was embarrassed about having had a relationship with a married man. She wanted to put the episode behind her. She said she decided to send an anonymous complaint to the Judiciary Commission, laying out some details of the 5th Circuit’s pro se arrangement. She didn’t know about Peterson’s suicide letter or that he had sent the commission a copy. She waited for something to happen, but nothing did, even after she sent the commission a second letter, this time identifying herself as the one who sent the initial complaint.

Finally, Baker took the documents that Peterson had given her and drove to the Louisiana State Penitentiary at Angola. Roughly 130 miles north of New Orleans, the maximum-security prison sits on a former plantation that covered 18,000 acres and is named for the African country from which many of its enslaved people were taken. That year it housed some 5,200 inmates, most of whom were expected to die at the prison hospice.

Angola was once considered the most violent prison in the United States. Brutal assaults and murders among the inmates were common, and the guards were known for sanctioning a system of inmate rape and sexual slavery. After decades of federal intervention and grudging reforms, the prison has largely shed that reputation. Vocational programs, recreational clubs and a Southern Baptist Bible college that has ordained hundreds of inmates have been credited with reducing the violence. Angola also established one of the best prison law libraries in the United States, a sanctuary of sorts where jailhouse lawyers help other prisoners challenge their convictions and sentences.

After passing through security, Baker asked to see Ted Addison, a former client who could no longer afford her services but with whom she had kept in touch. Addison was halfway through a 20-year sentence for armed robbery. For years he had been petitioning the courts on his own, insisting he had been unfairly convicted.

Baker handed Addison a sheaf of documents, which included the list of canned denials Peterson had developed and the minutes to the 1994 meeting. Addison was stunned. Like many other prisoners, he had spent years trying to get the 5th Circuit to grant him a new hearing. He had filed six pro se petitions, and each had come back almost immediately with a brief rejection.

Addison took the documents to the prison law library. Here, amid the rows of concrete cubicles, they were both a revelation and a confirmation of what the jailhouse lawyers had long suspected. For years inmates had noticed an unusual pattern in denials coming from the 5th Circuit: They would arrive just days after the petitions were filed, a process that usually took months at the state’s other appellate courts, and the perfunctory language never varied, with only the names and dates changing from case to case. Now it all made sense.

The jailhouse lawyers set about alerting the prisoners who had petitioned the 5th Circuit during the relevant years. They believed Peterson’s accusations could revive their cases. Addison felt they were organizing “a movement.” He sent copies of Peterson’s documents to inmate lawyers at the state’s other prisons and introduced Baker to Kerry Myers, editor of Angola’s award-winning prison magazine, The Angolite. Myers had been convicted of killing his wife in 1984 and was serving a life sentence for second-degree murder. He had filed five unsuccessful pro se petitions with the 5th Circuit. “I actually had a lot of hope,” Myers told me. “I said, ‘This thing is going to blow up.’”

With Baker representing them, Addison and Myers filed a joint petition to the Louisiana Supreme Court, demanding an investigation into Peterson’s allegations and new hearings for all of the prisoners whose appeals had been ignored. Within three months, the court received 299 petitions from men and women across the Louisiana prison system, most of them drafted from a form that Baker had provided.

Baker also prodded the Times-Picayune to cover the story. The newspaper’s first article, which focused on the prisoners petitioning the state Supreme Court, quoted the suicide note Peterson had sent the paper more than a year earlier. Baker, who hadn’t known about the letter, filed a public records request to obtain a copy from the Gretna police. The Angolite ran a story as well, calling the 5th Circuit’s pro se system a “simple and lucrative process for disposing of the dispossessed.”

The independent review the inmates were asking for presented a threat to the 5th Circuit. If it showed that judgments were unjust, the appeals court could be exposed to civil lawsuits. If the reviews revealed a wrongful conviction, Dufresne and the other judges could face serious discipline, especially since the state’s laws against judicial misconduct take into account the harm the injustice has caused.

The probability that at least some of the 299 petitions had merit was high. More than 90% of the prisoners came from Jefferson Parish, where prosecutors were known for striking Black men and women from jury pools in felony trials at a rate more than three times as often as their white counterparts. Because the state had long allowed “split jury” convictions requiring only 10 of the 12 jurors to agree, many of the Black defendants whose petitions Peterson rejected were convicted by what amounted to an all-white jury.

The Jefferson Parish district attorney had also made aggressive use of the state’s “Habitual Offender” law, which can turn a two-year sentence into life without parole; almost all of the cases involved Black defendants. Many of the prisoners asking for a review had been sentenced under the law and were serving life sentences for nonviolent offenses like drug possession and “purse snatching.”

Some of the judges who had sent these men and women to prison had gained notoriety a few years before Peterson’s suicide, when an FBI corruption sting revealed they had accepted cash bribes and campaign contributions in exchange for allowing a bail bonds company to dictate the amounts defendants were required to post. The scandal sent two judges to prison and unseated a third.

More than 85% of defendants in the state are considered indigent, meaning they qualify for a public defender when they are prosecuted. Louisiana’s public defender system is widely considered one of the worst in the country. It relies primarily on traffic fines and court fees — an unpredictable source of revenue that has never come close to meeting the need. Offices across the state struggle with caseloads so large that they have no choice but to put defendants on long waitlists, leaving them in jail until an attorney becomes available. Some attorneys have so little time to prepare, they meet their clients for the first time on the day of trial.

The Louisiana Supreme Court did not grant the 299 petitioners an independent review of Peterson’s rulings. Instead, it adopted a plan proposed by Dufresne and the other 5th Circuit judges: Rather than saddle another court, the 5th Circuit offered to reconsider the cases itself. “We are guided in this request by a desire to avoid imposing financial or other burdens on other judges in this state,” the 5th Circuit judges wrote. In October 2008, the Louisiana Supreme Court remanded the 299 petitions to the 5th Circuit. (It did the same with another 155 that came later.) As part of the agreement, the 5th Circuit judges whose names had appeared on the Peterson rulings would not be involved in the “reconsideration” of the cases. New three-judge panels would decide whether the rulings, which their colleagues had never read, were nonetheless fair.

With new documents Baker had obtained through public records requests, including Peterson’s suicide letter and the Gretna police report raising questions about Dufresne’s behavior, Addison and Myers challenged the Supreme Court’s decision. The documents, they wrote, “show that all of the judges of the Fifth Circuit … have an apparent or actual conflict of interest in this matter.”

The Louisiana Supreme Court saw it otherwise, stating that it would not be appropriate to task the other appellate courts with the additional work or to spend $200,000 of the public’s money to pay for retired judges to review the cases. Justice Catherine “Kitty” Kimball wrote that the court could not base its decision on the allegations of a depressed court clerk and an “unsubstantiated” police report about his suicide. “While this may be the fodder of news reports and movies,” she wrote, “it is not, in my view, proper evidence for judicial action.”

While the Judiciary Commission inquiry was going nowhere, the state bar launched its own misconduct investigation — into Baker. The 5th Circuit judges had alerted the Louisiana Attorney Disciplinary Board that Peterson had intervened on her behalf. The following year, she left the defense firm and went into practice for herself, representing drug offenders and pursuing damages in personal injury cases. The bar association kept the case against Baker open for almost a decade before sending her a letter saying it found no evidence of wrongdoing and was dropping the investigation.

It took the 5th Circuit three years to review the pro se petitions of 454 prisoners. The Times-Picayune and other local news outlets had by then dropped the story, so no one was paying attention when the judges found that, aside from a dozen procedural mistakes, Peterson’s cut-and-paste denials had been correct. In one case after another, they wrote, “there was no error in the prior rulings of this court.” The court had investigated itself and found it had done nothing wrong.

Myers’ life sentence was commuted in 2013. Addison served out the remainder of his sentence and was released in 2016.

As for the 5th Circuit judges, they prospered in the years after Peterson’s suicide. Some were picked to serve on the state Supreme Court; others enjoyed successful political careers. Dufresne remained the court’s chief judge until he collapsed in the office of one of his businesses on December 7, 2010. His obituary in the Times-Picayune didn’t mention the pro se scheme. In St. Charles Parish, there’s a Judge Edward Dufresne Parkway, a Dufresne Loop and an Edward Dufresne Community Center, where a life-size bronze statue stands. He is wearing a suit with a lobster pin on his lapel and one of Lady Justice on his tie.

Part Three The Last Case

That might have been the end of the story but for an unusual confluence of events that landed a former federal law clerk with an extraordinary resumé in a prison bunk bed next to the last inmate still fighting the 5th Circuit’s sham denials.

On January 2, 2019, Haller Jackson IV walked into Angola to serve out the remainder of a sentence for soliciting sex from a minor. He was 37 years old, 6-foot-4 and weighed 200 pounds, but he carried himself like a man who was doing his best to appear smaller. His right eye was blood red, a reminder of a beating he’d received a few weeks earlier at another prison.

Jackson had begun his sentence in Angola four years earlier. When his legal advocacy on behalf of fellow inmates called attention to, among other things, the prison’s inadequate health care, he was transferred to Dixon Correctional Institute, some 35 miles away. After he was assaulted, Jackson said, his lawyer secured his return to Angola, as long as he promised to refrain from embarrassing the authorities.

Jackson was relieved to be able to resume his work as an inmate lawyer. He had a year and a half left on his sentence, and he wanted to make the most of it. As a registered sex offender, he likely would never be allowed to practice law. While he settled in that first day, a man in the adjacent bunk bed introduced himself. His name was Louie M. Schexnayder Jr., but in Angola everybody called him Schex.

Schexnayder was convicted of murder in 1995. He’d petitioned the 5th Circuit 11 times during the period of Peterson’s blanket denials, raising questions about the competency of his defense attorney and the testimony of a witness who later recanted. After the judges at the 5th Circuit affirmed Peterson’s rulings, Schexnayder hired a lawyer to help him petition the federal courts.

Standing in Schexnayder’s way — and in the way of all the 5th Circuit petitioners who tried to take their cases to federal court — was the Antiterrorism and Effective Death Penalty Act, a federal law signed by President Bill Clinton in 1996, at the height of his efforts to portray himself as a tough-on-crime Democrat. The law, known by its unwieldy initials as AEDPA, has made it all but impossible for federal judges to overturn criminal rulings by state courts.

AEDPA was supposed to help deter domestic terrorism and expedite delays in carrying out capital punishment, but it did neither. The time between sentencing and execution is almost twice as long today as it was 27 years ago, and by most measures domestic terrorism has increased. But the law has significantly undermined habeas corpus, the constitutional safeguard that gives prisoners the right to challenge their incarceration.

One of the act’s toughest restrictions, and the one keeping the Louisiana prisoners from taking their cases to federal court, requires federal judges to defer to state court rulings in all but the narrowest of circumstances. Federal judges can’t step in just because a state court proceeding or ruling violated a prisoner’s rights. They can reverse the state ruling only if it was so wrong that not a single “reasonable jurist” would agree with it. Before AEDPA, federal judges provided a critical safeguard. Unlike state judges, most of whom face reelection and can be loath to reverse convictions for fear of appearing “soft on crime,” they are appointed for life and are theoretically free from political pressure.

Since AEDPA was enacted, state convictions based on the fabricated testimony of jailhouse informants or obtained by prosecutors suppressing or falsifying evidence are routinely upheld. Even in cases in which trial judges adopted the prosecution’s brief as their ruling, typos and all, federal judges have declined to step in. Those who do have been repeatedly slapped down by the Supreme Court in opinions that further narrowed the grounds for federal review. If the better-known 1994 crime bill was intended to lock more people up, AEDPA effectively threw away the key.

While some federal judges have tried to push back against AEDPA’s restrictions, those in Louisiana have applied them with zeal. In case after case, Louisiana’s federal courts have signaled to state court judges that virtually no violation of a prisoner’s constitutional rights is so egregious as to warrant review. Dufresne’s pro se scheme was no exception. When Schexnayder asked a federal district court for a new hearing in light of Peterson’s revelations, the judge cited AEDPA in denying his request, and the federal appellate court affirmed. But on that day in January 2019, when Jackson climbed into the top bunk in the prison dormitory he shared with 85 other men, Schexnayder thought finally he might get the help he needed.

Angola has produced some formidable jailhouse lawyers, but Jackson was unlike any of them. The son of a prominent family in Shreveport, he had studied law at Tulane, graduating first in his class with the highest grade-point average in the school’s history. While also pursuing a doctorate in epidemiology, he served as editor-in-chief of the law review and shattered the school’s record for the number of awards and honors earned by an individual student. The lives of most Angola prisoners were marked by extreme poverty; Jackson had grown up in extraordinary privilege. If he hadn’t been gay, he believes he might have been a frat boy, practicing at the family law firm and going to the Shreveport Club for dinner, just as generations of Haller Jacksons before him had done. Instead, he distanced himself from that lineage. After graduating from law school, he landed several prestigious federal clerkships and focused his efforts on prisoner rights and habeas cases.

But it all came crashing down in 2014, when he was arrested in New Orleans after arranging online with an undercover agent to pay for sex with a 10-year-old boy. By his own account, he had become addicted to alcohol and dependent on methamphetamines. It was a spectacular downfall, and it made headlines in legal publications. Jackson pleaded guilty and asked to be sent to Angola. This was an unusual request. The prison still evokes fear and is generally reserved for people sentenced to more than 40 years. His lawyers were against it, but he insisted. “It’s my drag queen approach to life,” he said. “If you’re going to send me to prison, well, send me to Angola.”

It was also a way for Jackson to derive meaning from the wreckage. Angola is where Louisiana’s injustices intersect most dramatically, and Jackson knew his rare expertise in post-conviction law would be valuable. He had always understood that pro se petitioners got short shrift, but in Angola he was shocked to see how many of the prisoners’ claims had merit and how few managed to receive any attention from the courts.

Shortly after he arrived, Jackson met an inmate convicted of stealing a carpenter’s level. He had been sentenced to life without the possibility of parole under the state’s repeat offender law; his previous crimes included stealing a pack of cigarettes and a lighter and writing two bad checks to Home Depot. The man, Jackson wrote in a petition arguing the sentence was illegal, will die in prison over a “tool with a little bubble in it, worth less than $10.” It was denied. Jackson petitioned the court on behalf of a man who had found evidence of his innocence in a police report the prosecutor had withheld at trial. His request for a new hearing was rejected. As was a filing on behalf of a severely disabled man who was still in prison months after he should have been released, and another for a man who claimed he had lost his vision because of the prison’s neglect.

Almost all of Jackson’s filings speak not just to the particulars of a specific case but to the devastation wrought by the entire Louisiana criminal justice apparatus. The state has more people serving life without parole than Texas, Tennessee, Arkansas, Alabama and Mississippi combined. In a petition to the U.S. Supreme Court for a man serving a life sentence for possession of cocaine, Jackson protested “this destruction of another black family — perhaps a tiny tragedy in the civil rights Chernobyl that has been Louisiana’s war on drugs.” There was no evidence linking the man to the ounce of cocaine found at a relative’s home, he wrote. “And yet here he sits still, sentenced to life without parole on the banks of the Mississippi,” he continued. “As seen from the heavens, the scene on these banks has changed little since 1820.” The petition was denied.

By the time Jackson met Schexnayder, his writing had progressed “from disappointed but fundamentally-confident-in-justice liberal to just this side of burn-the-house-down nutter,” he told me. The indignation he felt over the 5th Circuit’s pro se cases was not because of the court’s obvious indifference to the inmates; this he had come to expect. “It’s that the judges got caught saying they don’t care,” he said. “The poor already knew this and have known it viscerally all their lives — from the way every arm of the state has ever treated them.” But here was a case in which they had irrefutable proof, and still there was no outrage on their behalf. “It was crickets,” he said. “They got caught so, so red-handed, and the response of all the other courts has been a collective shrug.”

Schexnayder, who had a criminal record so long that he would almost certainly have landed in prison for life much sooner had he been Black, could hardly be seen as the face of Louisiana’s criminal justice failures. But of all the 5th Circuit petitioners, Schexnayder was the one who had somehow managed to keep his case alive. Jackson knew that a victory for him could open the door for the others. He began working on a petition to the U.S. Supreme Court, arguing the 5th Circuit’s reconsideration of Peterson’s denials did little more than allow the judges to “whitewash the scandal.”

“Why would the Louisiana 5th Circuit think it could get away with such appalling misconduct?” Jackson wrote. “To this there is an easy, if disturbing, answer: Because it has. And now, the lower federal courts are deferring to that court’s decisions in the affected cases, many involving a sentence to life without parole.”

Jackson realized the case was unlikely to get any attention unless he could line up some outside help. AEDPA had been a particular target of one of his mentors, Alex Kozinski, a federal judge on the 9th U.S. Circuit Court of Appeals for whom Jackson had clerked. Frequently mentioned as a candidate for the U.S. Supreme Court, Kozinski had been one of the country’s most prominent judges, a Reagan appointee known for his cutting and iconoclastic opinions. In a 2015 law review article, he wrote that AEDPA was “a cruel, unjust and unnecessary law that effectively removes federal judges as safeguards against miscarriages of justice.” He called for its repeal.

But like Jackson’s, Kozinski’s career had come to an abrupt end. In 2017, amid multiple accusations of sexual harassment, he left the bench. Within the legal world, especially around issues of criminal justice, however, his opinion still commanded respect, even among some of his accusers. Jackson knew that his involvement could draw attention to Schexnayder’s petition. He called the former judge at his home in California. Kozinski thought the 5th Circuit’s conduct — and the federal courts’ unwillingness to wade into it — might provide a valuable test for AEDPA. The law requires deference to the work of state court judges, but what if those judges hadn’t done the work? Kozinski asked the National Association of Criminal Defense Lawyers to submit a brief in support of Schexnayder’s petition and recruited another former clerk to write it.

In April 2019, the U.S. Supreme Court asked the state of Louisiana to submit a response to Schexnayder’s claims, signaling that someone on the court was interested in considering the case. The justices were initially scheduled to vote in April on whether to grant a full hearing, but they postponed that decision nine times over the next eight months. The delays gave Jackson hope. Maybe one of the justices was working to drum up enough votes to give the case a chance or preparing a powerful dissent from the court’s refusal to hear it.

Instead, on Dec. 9, 2019, the court unanimously rejected the case. Justice Sonia Sotomayor wrote a short opinion, citing technical issues with Schexnayder’s original petition to the Louisiana federal court as her reason for agreeing with her colleagues’ decision. She ended with what seemed like an encouraging note to the prisoners, saying the 5th Circuit’s reconsideration of Peterson’s rulings brings up “serious due process concerns.”

“I expect that lower federal courts will examine the issue of what deference is due to these decisions when it is properly raised,” she wrote.

But the federal courts will not get that chance. The 454 prisoners whose denials the 5th Circuit “reconsidered” have exhausted their appeals and can no longer ask federal judges to weigh in on the 5th Circuit’s conduct. In refusing to hear Schexnayder’s case, the Supreme Court has prevented the episode from being raised in federal court again.

When Jackson found out that Schexnayder’s petition had been rejected, he struggled to articulate his reaction. After a long silence, he said, “Well, they got away with it.”

Since they petitioned the Louisiana Supreme Court, some of the 454 inmates have died in prison. Others have been released after serving their time or have had their sentences reduced as a result of recent criminal justice reforms. But at least 170, including Schexnayder, are still incarcerated. They continue to petition the appellate courts, trying to show new evidence of their innocence or to argue that their sentences should be reduced.

After the Schexnayder episode, Jackson set his sights on the modest goal of filing as many petitions as he could before his release. “I’m going to make them tell me they’re OK with all these crazy cases,” he said. When he walked out the prison gates in June 2020, he smuggled several office boxes containing case files he had secretly copied — documents he would use to help the men he was leaving behind. In the months that followed, Jackson found lawyers to represent dozens of prisoners and worked with legal nonprofits to reduce the sentences of more than 100 people. Among them are several men whose pro se petitions the 5th Circuit had ignored.

Epilogue

In the years that Peterson was rejecting pro se petitions, the 5th Circuit denied claims that ended in at least five exonerations. Four of these men were freed only after the New Orleans Innocence Project agreed to represent them. Nathan Brown was one of them. He had appealed to the organization early in his incarceration, and lawyers there had discovered that the victim’s dress had been preserved as evidence and could be tested for DNA.

Hurricane Katrina put a stop to everything, though, and for a long time Brown heard nothing. While he waited, the 5th Circuit reviewed Peterson’s denial and concluded that the failure of Brown’s attorney to introduce DNA evidence was “within the scope of trial strategy” and did not constitute inadequate counsel.

Then, on his 39th birthday, Brown received a letter from the national Innocence Project, saying it would take his case. Brown’s new lawyers compelled the Jefferson Parish district attorney to send the dress for DNA testing, and the analysis identified another man — a convicted felon — as the attacker. In 2014, after 16 years, 10 months and 18 days, Brown was exonerated.

It’s been nine years since Brown was released, and he’s still trying to find stable ground. He has struggled with addiction and depression. He cycles through phones. He has lost his Social Security card so many times the federal government will no longer replace it. The dreams he had for himself when he was in prison — that he would go to college, that he would help his daughter to rise above the poverty that had plagued his own childhood — have slipped so far out of his reach he can hardly allow himself to believe in them. Still, he knows how exceptional his case is.

“They have a lot of guys in prison that are filing claims,” he told me. “They’re not all saying, ‘I didn’t do this.’ They’re just saying, ‘The way you sentenced me is wrong. The crime doesn’t warrant all this time you gave me.’ But they can’t come home, because once they get you, they got you, and the courts — they’re not listening. They don’t see you.”

How We Reported This Story

For this story, ProPublica reviewed thousands of pages of documents, examined the cases of more than 450 prisoners, and interviewed several dozen people, many of whom had never before spoken publicly about these events.

Richard A. Webster contributed reporting. Art direction by Alex Bandoni and Lisa Larson-Walker. Development by Jason Kao.

by Anat Rubin, Illustrations by James Lee Chiahan, special to ProPublica

The Supreme Court Will Decide if Domestic Abuse Orders Can Bar People From Having Guns. Lives Could Be at Stake.

1 year ago

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

This story contains some graphic descriptions of gun violence.

The U.S. Supreme Court will hear arguments next week in a pivotal firearms case that could have profound implications for how police and courts deal with domestic violence.

The question: Should people who are placed under domestic violence protection orders also lose access to their guns?

For many victim advocates, the answer is obvious. Women are five times more likely to be killed in a domestic violence incident when the abuser has access to a gun. Advocates argue that the gun restrictions tied to such orders are among the most powerful tools for domestic violence victims and that without them, more people will die.

For gun rights groups and their most ardent supporters, that is beside the point. They contend that people subject to protection orders haven’t been convicted of a crime and that taking their firearms away violates the Second Amendment. If the government can disarm them, they ask, who could the government disarm next?

Earlier this year, the U.S. Court of Appeals for the 5th Circuit sided with gun rights supporters, invalidating a federal law passed by Congress in 1994 that bars people under domestic violence orders from having firearms.

If the Supreme Court upholds that decision and rules that gun restrictions tied to restraining orders are unconstitutional, states would have fewer options to stop domestic abusers from possessing, and using, guns. And in conservative states, the aggressive rollback of gun control laws means that it is already easier for people to get guns to begin with.

This year, WPLN and ProPublica have been reporting on the issue at the heart of the Supreme Court case: the difficulty of separating domestic abusers from their guns. The court’s ruling could have immense ramifications in Tennessee, where weak enforcement of gun laws has allowed firearms to slip through the cracks with deadly consequences. According to our reporting, nearly 40% of the victims shot in domestic violence homicides in Nashville since 2007 were killed by people legally barred from having guns.

Over the past decade, the state has also made it easier for more people to get guns and carry them in more places. And a special legislative session in August — called in the wake of the March shooting at the Covenant School, where three children and three staff members were killed — failed to yield any gun reform.

The Supreme Court’s decision could also inform rulings on other laws barring people with felonies and drug addictions from having guns as well as red flag laws designed to prevent shootings by temporarily removing guns from people who’ve shown signs they might hurt themselves or others.

Such laws were central to this summer’s legislative session in Tennessee and have gained renewed attention following last week’s shooting rampage in Maine. Those laws are designed similarly to the gun dispossession requirements under domestic violence orders, using a civil court process to prevent threatened violence from escalating.

The Supreme Court case involves a Texas man named Zackey Rahimi, who was issued a restraining order after his ex-girlfriend reported that he assaulted her and threatened to shoot her if she told anyone. According to police, he was then involved in five separate shooting incidents over a two-month period. Police found two guns during a search of his home, and he was indicted for violating the federal prohibition on gun possession for those under protection orders.

Rahimi moved to dismiss the indictment, but the district judge ruled against him. Rahimi then pleaded guilty. The 5th Circuit originally affirmed the district court decision. But after the Supreme Court ruling last year that gun laws should be reviewed against the nation’s “historical tradition of firearm regulation,” the 5th Circuit issued a new opinion, this time agreeing with Rahimi that the firearms ban violated the Second Amendment and that domestic abusers couldn’t be singled out as a group.

“Could speeders be stripped of their right to keep and bear arms?” 5th Circuit Judge Cory Wilson wrote for the court. “Political nonconformists? People who do not recycle or drive an electric vehicle?”

But research has shown that domestic abusers are a particularly dangerous group of people, and they are even more so with guns. One study by the National Law Enforcement Officers Memorial Fund found that domestic dispute calls are “the most dangerous circumstance” for police to respond to, leading to more officer deaths than any other type of call. In addition, more than two-thirds of mass shootings involve domestic violence or are committed by someone with a history of it.

“Domestic violence homicides that involve guns are more likely to have additional victims than other types of homicide that involve guns,” said April Zeoli, a professor who researches gun policy and public health at the University of Michigan.

The consequences can be devastating.

In one case in northeastern Tennessee in 2013, a 12-year-old girl called 911 and told dispatchers that her father had shot her. According to the police report, when officers arrived, they found her lying dead in a pool of blood on the living room floor. Her 11-year-old brother was lying in his bed. Officers peeled back the blankets and found two bullet wounds to his stomach. Their mother, Bridget Hughes, was found dead in the bedroom down the hall, her body pressed against the door as if to keep the shooter out.

And finally, the police found her husband, Herbert Clyde Hughes. According to police reports, he had killed his whole family, gotten into bed and then turned the gun on himself.

Weak Interventions for Domestic Abusers

One reason that victim advocates have pushed hard for gun dispossession to be included in protection orders is that alternatives for controlling domestic abuse are not always successful. Criminal prosecution can take a long time and require a high burden of proof for victims to overcome the sentiment that domestic violence is a proverbial “he said, she said.”

Domestic violence protection orders can also be difficult and sometimes even dangerous to get.

States have different policies and procedures for getting orders of protection, but in Tennessee the process goes something like this: If someone is being threatened or abused, they can fill out paperwork describing the abuse and request a protection order from the court. If facing immediate danger, they can also ask for a temporary protection order that lasts a few weeks until a hearing can be called.

A full protection order is issued only after a court hearing, where both the accuser and accused go in front of a judge. The statute dictates those hearings should be held within 15 days of notification, but they can sometimes be delayed. In the meantime, the decision to seek legal help can ratchet up tensions, leaving victims vulnerable.

The delays, paperwork and fear of facing their abusers in court can all be deterrents for victims trying to secure protection orders. If they do go through the process, their requests are not always granted. In Nashville, more than 1,900 petitions for protection orders were filed in the first half of 2023, according to Davidson County court records. Only about 550 were granted during that period.

Caption: An excerpt of Temptress Peebles’ July 2019 temporary order of protection against her ex-boyfriend. (Obtained by WPLN)

Temptress Peebles tried to get a protection order in Nashville three times in the months before her death in 2019. She told a court that her ex-boyfriend had pointed a gun at her and threatened to kill her. But Davidson County court records show that she was never able to secure a protection order after she missed a court date and became difficult to reach. In her final petition for an order, she wrote that she was terrified that her ex-boyfriend was going to kill her.

A week later, police say, he did, in front of her 8-year-old daughter.

Peebles’ ex-boyfriend has not yet entered a plea, and his lawyer didn’t respond to a request for comment.

“There is a myth out there that it is very easy to get a protective order, that judges are just handing out protective orders like candy to trick-or-treaters,” said Natalie Nanasi, director of the Judge Elmo B. Hunter Legal Center for Victims of Crimes Against Women at Southern Methodist University in Dallas. “And that's absolutely not the case.”

Even when women do get protection orders, they aren’t always enforced. Michaela Carter, also from Nashville, got one in 2021 after reporting that her husband had repeatedly hit her in the face with a whiskey bottle. When he got out of jail months later, called her repeatedly and was seen near a relative’s apartment with a gun, she called 911. But the police told her there was little they could do and left.

KiAndrea Jones holds a photo of her sister, Michaela Carter, outside her home in Antioch, Tennessee. Carter, 24, was killed by her estranged husband despite having a protection order against him following a history of domestic abuse. (William DeShazer for ProPublica)

Ten minutes later, according to police and 911 records, she was shot to death by her estranged husband.

He hasn’t entered a plea in the case, and his lawyer didn’t respond to emails seeking comment.

In light of such cases, criminal prosecutors and victim advocates say people subject to restraining orders not only need to be barred from having guns, but that more needs to be done to ensure they relinquish them and can’t get new firearms.

Medical and public health experts found that state laws requiring people subject to domestic violence restraining orders to turn over their firearms were associated with a 14% lower rate of intimate partner gun homicides than states without such laws.

The civil orders, they say, can protect victims while the criminal trial process unfolds. Many victims and witnesses fear retaliation, and gun restrictions can help them feel safe enough to testify against abusers.

From 2007 to 2021, more than 20,000 orders of protection were signed in Nashville’s civil courts. Yet WPLN and ProPublica’s analysis found only three cases where there was a protection order in effect and the violence escalated to a fatal shooting.

Julia Weber, who has worked for decades on domestic violence and firearms policy, including at the Giffords Law Center to Prevent Gun Violence, likens gun dispossession to seatbelts — it’s widely accepted that seatbelts save lives, even though requiring them may limit individual freedom.

“Similarly, we need to limit some people’s freedom because other people’s freedom is impacted,” she said. “If we care more about someone’s ability to have access to firearms than we care about my ability to be free from firearm violence, we have a problem.”

In a state like Tennessee, the impact of the Supreme Court’s decision depends on how sweeping it turns out to be. The justices could rule against Rahimi, and the system would continue functioning as it does now. Or the court could rule similarly to the 5th Circuit, which deemed the federal ban unconstitutional but did not address state order-of-protection laws like those that exist in nearly all 50 states, including Texas and Tennessee. That could leave those laws intact for now.

Weber said the most dangerous outcome would be if the Supreme Court rules that gun restrictions tied to protection orders more broadly violate the Second Amendment.

“It could upend all of the 50 states’ laws around what restraining orders can provide,” she said. "Not every state has state-level prohibitions, but it could tie the hands of the legislatures in the future if they were to consider any kind of prohibition."

If Rahimi wins, it could bolster the efforts of gun lobbying groups to further weaken gun laws in states like Tennessee, pushing for what they call “real constitutional carry” — with no restrictions on who can carry firearms and where they can carry them.

And the state will have few interventions that will work better than taking away alleged abusers’ guns. The most likely outcome, Weber said: “Lives will be lost.”

by Paige Pfleger, WPLN/Nashville Public Radio

The Night Doctrine: ProPublica’s First Animated Documentary Traces Reporting on Afghanistan’s Zero Units

1 year ago

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The Night Doctrine,” ProPublica’s first animated documentary, traces the story of Lynzy Billing, a young British journalist of Afghan-Pakistani origins, who returns to Afghanistan to find out who killed her family 30 years earlier, only to stumble upon a secretive U.S.-backed program killing hundreds of civilians.

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Amid the chaos of war, Billing undertakes a dangerous quest to uncover the truth about the Zero Units, squads of Afghan commandos funded, trained and directed by the CIA to go after threats to the United States. As Billing tracks the deadly night raids conducted by one of the units, she learns the stunning hidden cost of the program: The raids were often getting it wrong, killing scores of people with no connection to the Taliban or any other terrorist group.

Driven to compile an accounting of the dead, Billing crisscrosses the country to meet with the survivors of the raids, some of whom were wrongly targeted and suffered life-altering losses, and others who’d lost family members and had nowhere to turn for answers. She persuades Afghan commandos to speak candidly about their role in killing their countrymen. Interweaving the stories of survivors and soldiers with her own, “The Night Doctrine” is a powerful and thought-provoking short that sheds light on the impact of the CIA’s failed tactic of war and the need for accountability and justice.

The 16-minute film, directed by ProPublica’s Mauricio Rodríguez Pons and Almudena Toral and animated by Rodríguez Pons, premiered at the Tribeca Film Festival in June. It has since been featured at a dozen film festivals around the world.

The documentary, presented in partnership with The New Yorker, is a companion piece to Billing’s reporting in “The Night Raids,” a gripping and powerful investigation published in 2022. Billing is a producer of the film, which is scored by Afghan composer Milad Yousufi.

by ProPublica

A Texas Billionaire’s Associates Are Trying to Sink a School Tax Election via Their Dark Money Nonprofit

1 year ago

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This article is co-published with The Texas Tribune, a nonprofit, nonpartisan local newsroom that informs and engages with Texans. Sign up for The Brief Weekly to get up to speed on their essential coverage of Texas issues.

Update, Nov. 8, 2023: On Nov. 7, Midland school district voters approved a $1.4 billion bond proposal by a 56% to 44% vote, rejecting arguments against the measure from a nonprofit led by associates of billionaire oilman Tim Dunn.

Allies of influential Texas billionaire Tim Dunn are pushing ahead in Austin with efforts to create a private-school voucher system that could weaken public schools across the state. Meanwhile, Dunn’s associates in his hometown of Midland are working to defeat a local school bond proposal that his district says it desperately needs.

Dunn, an evangelical Christian, is best known for a mostly successful two-decade effort to push the Texas GOP ever further to the right. His political action committees have spent millions to elect pro-voucher candidates and derail Republicans who oppose them. Defend Texas Liberty, the influential PAC he funds with other West Texas oil barons, has come under fire after The Texas Tribune revealed that the PAC’s president had hosted infamous white supremacist Nick Fuentes for an October meeting and that the organization has connections to other white nationalists.

Less known are Dunn’s efforts to shape politics in his hometown of Midland, which will come to a head next week. On Tuesday, residents in the Midland Independent School District will vote on a $1.4 billion bond, the largest in its history, after rejecting a smaller measure four years ago. A dark-money organization whose leaders have ties to Dunn’s Midland oil and gas company, as well as to a prominent conservative public policy organization where Dunn serves as vice chairman, have become among the loudest voices against the bond.

On Sept. 21, less than two months before the Midland bond election, three Midland residents with deep connections to Dunn and his associated public policy organization registered a “social welfare” nonprofit called Move Midland.

The nonprofit is headed by Rachel Walker, a public affairs manager for Dunn’s oil and gas company, CrownQuest Operating LLC, according to public records. A second member, Ernest Angelo, is a former Midland mayor and board member of the Texas Public Policy Foundation, a conservative think tank that Dunn has helped lead for more than two decades. The third member of the nonprofit’s board is Elizabeth Moore, a former West Texas development officer for the Texas Public Policy Foundation.

Within weeks, the nascent nonprofit had a website, campaign signs and a social media presence as its directors appeared on local radio shows and in community debates to oppose the bond. In the local newspaper, another former mayor urged residents to visit Move Midland’s website for insights about the election. That former mayor, Mike Canon, had run for the Texas Senate in 2018 to unseat Kel Seliger, a prominent Republican who opposed vouchers. Another PAC funded by Dunn, Empower Texans, provided the bulk of his war chest, nearly $350,000, in a losing effort.

Move Midland and its directors have not called attention to their relationship to Dunn and his entities in public appearances. Biographies of the three directors on the nonprofit’s website make no mention of Dunn, CrownQuest or the Texas Public Policy Foundation, where Dunn serves as vice chair of the board.

Walker and other members of the group did not respond to voice messages, emails, Facebook messages or requests made through the Move Midland website.

Dunn likewise did not respond to specific questions regarding the Midland bond and the role of his various entities. Defend Texas Liberty has condemned Fuentes’ “incendiary” views and replaced its president, but has not provided any details about its association with the white nationalist. Dunn has reportedly called the PAC’s meeting with Fuentes a “serious blunder.”

During a debate hosted by the Midland Reporter-Telegram, Walker said that the group is “more than just me. There is a group of informed and involved Midlanders involved in this organization. And we have every right to speak on this issue, because we are taxpaying citizens, just as the rest of the involved and informed community does.”

Walker has said that the group would be open to a scaled-down version of the bond in the future, but that should come when “our taxpayers feel like they have trust in the system, and right now, they just have an overwhelming distrust of how MISD is spending their tax dollars,” she told Marfa Public Radio.

Because Move Midland was formed as a nonprofit and not a political action committee, it is not required to disclose the sources of its funding. Organizations that engage in campaign activity but don’t disclose where their money comes from are typically considered “dark money” entities. A small number of states, including New York and Connecticut, require disclosure of donors who contribute to 501(c)(4) nonprofits that engage in lobbying or make political contributions.

The IRS allows such nonprofits to shield the identities of donors as long as political activity doesn’t constitute the group’s primary activity, though it rarely takes action against nonprofits that violate its rules.

According to its website, Move Midland is “dedicated to making Midland better” and plans to tackle various community issues. The bond election represents the group’s “current area of focus.”

Bond supporters, including a large chunk of the Midland energy sector, say it is crucial to relieving overcrowding and modernizing outdated facilities.

Supporters also have raised questions about the timing of Move Midland’s creation and expressed frustration that its donors are shielded from public view, unlike funders of traditional PACs.

“It seems disingenuous and also unfair and very odd that you would not disclose who’s behind it when as a PAC, they would have to,” said Josh Ham, a volunteer with the pro-bond PAC Energize Midland Schools.

Texas Ethics Commission records show the Energize Midland PAC has received more than $530,000 in contributions, most of it coming from Midland energy companies, which hail the election as an opportunity to cultivate a more robust labor force.

That far outstrips the $10,252 raised by Midlanders for Excellence in Education, a local PAC that opposes the bond. According to campaign finance reports, Midlanders for Excellence in Education has used much of that money to pay for signs and radio advertising.

Walker, the Move Midland leader, reported spending $33,432 to oppose the bond, including payments for direct mailings, text messages and yard signs. Texas law requires nonprofits that engage in independent campaign activity to disclose campaign-related expenditures to the state, but like the federal government, it does not require such groups to disclose the source of their funding. It is unclear if Dunn has given money directly to the group.

Ham said that he does not know who is funding Move Midland, but that its sudden appearance after two years of bond planning makes him question the motivation behind the effort. “To have someone just come along overnight and pop up with just a couple of talking points and with no real support is disappointing,” he said.

Dunn has not been quiet about his concerns over the bond. In an Oct. 15 commentary in the Midland Reporter-Telegram, Dunn accused bond supporters of not being forthcoming with voters about the bond’s tax impact. The district says the bond won’t raise tax rates because the new rates adopted in September were set lower than the previous year’s and included the bond’s impact. Dunn argued that the bond will soak up the $18 million in statewide property tax relief recently approved by the Legislature and that tax rates would be even lower if not for the bond.

While Dunn’s oil companies operate in multiple states, they control mineral properties that, combined, owed more than $1.3 million in estimated property taxes to the school district for 2023.

Dunn called claims that the bond won’t result in a tax rate increase “somewhere between materially misleading and factually false.”

In fact, Dunn noted, the actual ballot language Midlanders will find when they go to the polls will include the clause, “This is a property tax increase.”

Public policy organizations connected with Dunn played a central role in ensuring that the phrase is attached to every single school bond ballot measure in the state, regardless of the bond measure’s actual impact on local taxes.

The phrase, tucked into a 308-page bill in 2019, didn’t make headlines at the time, but those six words have since had an outsize impact on school bond passage rates. According to Dax Gonzalez, director of governmental relations at the Texas Association of School Boards, the phrase is at least partly responsible for the decline in school bond passage rates in subsequent years.

From 2000 to May 2019, about 75% of all school bond proposals passed, according to data from the state’s Bond Review Board. That passage rate has dipped to 64% since November 2019, which bond supporters have attributed to the new ballot language and pandemic-related worries. In elections this past May, that number rebounded to 78%.

“I really do believe that the sole purpose of that language is to decrease the amount of bonds that pass,” said Gonzalez.

Earlier this year, Dunn-backed entities marshaled opposition to attempts favored by public education supporters to give districts more flexibility in the required ballot language in cases where bonds don’t result in tax rate increases. None of the bills made it out of committee.

Dunn has weighed in on local Midland politics before. In 2019, Dunn cast doubts on the Midland school district’s $569 million bond proposal in an op-ed in the local newspaper in which he wondered whether school district officials were “sufficiently committed” to improving the quality of students’ education.

Although officials initially announced the bond had passed on election night, the bond proposal ultimately lost by 26 votes after Midland County election workers discovered a box of unopened ballots weeks after the election.

A few months later, Dunn threw his support behind a sales tax increase for the Midland County Hospital District, explaining in a newspaper column that “high property taxes violate a founding principle of America: private property ownership.”

Sales taxes, Dunn argued, “are the only broad-based, transparent and optional forms of taxation.”

The sales tax increase passed handily in July 2020.

A shift from property taxes to sales taxes at the state level has long been a goal of the various public policy organizations associated with Dunn. According to Texas Comptroller estimates analyzed by the Tribune, sales tax increases cost poor Texans more than wealthier ones, making it a regressive tax.

For some bond supporters, Dunn’s opposition to the current bond proposal is a reflection of his embrace of vouchers for private schools.

“Having a vested interest in a private school, while politically funding an agenda that includes private school vouchers, appears to present a pretty clear conflict of interest for Tim Dunn,” said Reagan Hignojos, a former Midland school board candidate and bond supporter. “These private schools would not be held accountable or be transparent by the same standards of public schools.”

Dunn is the founder of Midland Classical Academy, a private school that offers its approximately 600 K-12 students a “Classical Education from a Biblical Worldview,” according to its website. The school explains that through this lens, “human civilization is rightly understood to have begun in the garden with Adam and Eve.” The school believes in interpreting the Bible in its literal sense, which it takes to mean that marriage can only be between a man and woman and that there are only two genders.

Dunn’s school is currently unaccredited, however, according to data provided by the Texas Private School Accreditation Commission. Under legislation proposed by Texas lawmakers, including several state senators who have received campaign funding from Dunn and his associated PACs, private schools would need accreditation to be eligible for taxpayer dollars.

Dunn has not weighed in on whether his school would pursue voucher payments, and in 2014 he explained the lack of accreditation, writing that the requirements “deal mainly with processes and credentials rather than focusing on an excellent academic and student life opportunity.”

The school did not respond to questions about any potential accreditation or voucher plans.

According to its 2021 IRS filing, the most recent available, the school had $10.4 million in total assets and revenue of $6.3 million, a 66% percent increase compared to what it earned in 2020.

Dunn and his family own five million-dollar homes on land adjacent to Midland Classical Academy, where property taxes go to Midland ISD.

by Jeremy Schwartz and Dan Keemahill

UC Berkeley Takes Significant Step to Repatriate 4,400 Native American Human Remains

1 year ago

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The University of California, Berkeley, took a significant step this week toward repatriating nearly half of the 9,000 Native American remains it holds in its anthropology museum, saying they do not belong on its campus and should be returned to Indigenous people.

A notice filed Tuesday in the Federal Register indicates UC Berkeley is committed to repatriating 4,440 ancestral remains and nearly 25,000 items — including jewelry, shells, beads and baskets — that were excavated from burial sites across the San Francisco Bay Area. The notice follows extensive consultations between the university and tribes, including those that claim the Bay Area as their ancestral lands but are not recognized by the federal government, the university said.

One of the tribes, the Muwekma Ohlone, had for decades asked the school to relinquish ancestral remains, according to records reviewed by ProPublica. But Chairwoman Charlene Nijmeh said the tribe’s requests were repeatedly dismissed by UC Berkeley. A turnover in university staff and leadership in recent years has led to a commitment to supporting the Muwekma Ohlone’s repatriation efforts, she said.

“Our people have always been involved in the protection of our ancestors and returning our ancestors from these different institutions,” Nijmeh told ProPublica. “Berkeley was very unique because they always shut the door on our people.”

Repatriating the ancestral remains and items to tribes would mark a significant moment for UC Berkeley, which has lagged far behind other institutions in returning its massive holdings under the federal Native American Graves Protection and Repatriation Act. The 1990 law requires federally funded museums, universities and government agencies to report the human remains and items in their holdings that came from Indigenous burials in the United States so that they can be claimed by tribes and returned to them.

But as ProPublica has reported this year, more than three decades after the law’s passage, scores of institutions have been slow to complete repatriations. U.S. institutions continue to hold an estimated 100,000 ancestral remains, according to data maintained by the National Park Service. UC Berkeley holds the most, having repatriated just 22% of the 11,000 ancestors it initially reported holding.

Many of these institutions say that they do not know where their holdings are from because of poor record-keeping in the past, or that they do not know which tribe they should repatriate to. ProPublica has also found that some institutions used the remains to pursue scientific research, over the objection of Indigenous people.

“Our campus community is motivated to ensure these people are returned to their community and intended resting places,” the university said in a written statement to ProPublica. “We realize that so long as the remains of ancestors, sacred objects, and cultural items remain in the University’s possession, contrary to Tribal wishes, justice will not be served, and the healing we seek will not be complete.”

The release of 4,440 remains and many more items to tribes would mark UC Berkeley’s largest repatriation by far and come as many institutions have signaled changes in their handling of repatriation requests from tribes. It also would follow a wave of pledges from institutions to prioritize repatriation work following ProPublica’s reporting.

UC Berkeley stressed that this week’s notice in the Federal Register is just one step in the lengthy NAGPRA process. Citing federal repatriation law, the notice says tribes — namely those with historical or present-day ties to the Bay Area — have 30 days to file claims for the human remains.

If the repatriation is ultimately completed, the school would no longer have the unwelcome distinction of holding more Native American remains than any other institution in the country, according to the National NAGPRA Program within the National Park Service. Based on federal data from Sept. 30, the Ohio History Connection, a museum and research center in Columbus, would have the most.

Tribes, especially in California, have for decades expressed frustrations with UC Berkeley’s handling of their repatriation requests. In the past, the university stalled or challenged tribal groups’ efforts to make claims to the remains of their ancestors.

In 2018, for example, a UC Berkeley repatriation of 1,400 ancestral remains to the Santa Ynez Band of Chumash Indians, situated near the California coast, resulted in a series of missteps and delays, as ProPublica reported this year. A decade passed between the school publishing in the Federal Register its intent to repatriate the remains to the Santa Ynez Chumash and the tribe finally retrieving them in the summer of 2018.

Then, two years later, the university notified the tribe that the remains of six ancestors that should have been repatriated to them hadn’t been because they were stored in a teaching laboratory. The professor who had oversight of the laboratory said movers may have mistakenly placed the remains there years earlier when the laboratory was relocated from one campus building to another.

UC Berkeley has since pledged to change its ways in response to persistent pressure from California tribes, which led to a 2020 state audit. This spring, a letter from a group of U.S. senators that cited ProPublica’s reporting on repatriation called on the university — and four other U.S. institutions — to explain why they had been slow to complete repatriations in the 33 years since NAGPRA’s passage.

In response, Chancellor Carol Christ told lawmakers in June that the school had reformed policies and practices that had been blamed for stalling repatriations. “We are not proud of the fact that the NAGPRA eligible collection at the museum is one of the largest collections in the country and are working to address this injustice,” Christ’s letter said.

For Nijmeh, the Muwekma Ohlone chairwoman, the fact that UC Berkeley is moving closer toward repatriating the 4,440 ancestral remains and tens of thousands of items from the Bay Area is bittersweet. On the one hand, the school is showing in official documents, like the notice in the Federal Register, that it recognizes the human remains and items it collected from the Bay Area come from the aboriginal lands of the Ohlone people, she said.

On the other, however, the United States does not recognize the tribe, which could result in a repatriation process that is far more complicated than it would be if the tribe had federal recognition, she added. She also said that the Muwekma Ohlone Tribe does not have land as a result of lacking federal recognition. So if the day does eventually come for the tribe to reclaim the ancestral remains, she hopes that UC Berkeley will arrange to set aside land for them.

“We don’t have land to rebury,” she said. “It’s not going to be easy.”

Ash Ngu contributed reporting.

by Mary Hudetz

People Who Used Recalled Philips Breathing Machines Face Painful Choices

1 year ago

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They thought they were getting clean air from the lifelines at their bedsides, coveted nights of healthy sleep that for too long did not come easy.

Near Portland, Oregon, Kim Binford’s sleep apnea machine helped him manage chronic pain. Outside Indianapolis, Connie Thompson was able to stay awake in class during her senior year of high school. In the suburbs of Atlanta, Debra Miller could put her grandchildren in the car and drive without fear.

But in June 2021, Binford, Thompson, Miller and millions of others learned that a defect in the breathing machines they relied on for years had the potential to inflict serious harm, including cancer, kidney and lung problems, and severe respiratory infections.

In announcing a massive recall of ventilators and sleep apnea machines, Philips Respironics acknowledged that an industrial foam placed inside the devices to reduce noise could break apart and send tiny particles and fumes into the noses, mouths and lungs of patients.

As many as 15 million devices from two Pittsburgh-area plants were made with the crumbling material, including the company’s popular DreamStation continuous positive airway pressure, or CPAP, machine used by those with sleep apnea. The disorder causes breathing to stop and start through the night.

Since the recall, thousands of consumers have described unexplained illnesses while the reported death count linked to the recalled machines rose to more than 370. Some stopped using their devices altogether. Others bought secondhand machines, waited on a replacement from Philips or simply gambled, continuing to use their defective devices long after the recall.

Losses mounted quickly: lost sleep, lost money, lost nights spent worrying about a health threat that the U.S. government determined could cause severe illness or death.

Though it’s impossible to know what caused individual illnesses, or whether the machines were capable of advancing cancers that may have developed prior to use by patients, some medical experts say they fear long-term harm. The Food and Drug Administration has said the degrading foam, when inhaled or ingested, can lead to headaches, asthma, inflammatory conditions, respiratory tract problems and “toxic or cancer-causing effects to organs,” among other health complications.

Lawsuits against the company are ongoing in federal court in Pittsburgh, waged by families who say Philips should be held accountable for failing to warn customers about the risks years earlier.

In a statement, Philips said that patient health and well-being is a top priority and that the company increased production amid supply chain challenges to send replacement devices to customers. The company added that some received entirely new machines while others received a CPAP motor that would work with existing components.

Since the recall, Philips has walked back its initial assessment that the machines were potentially unsafe, saying new testing on the DreamStation and similar devices has shown that chemicals released by the foam are not at levels that can cause “appreciable harm.”

Medical experts and engineers familiar with the testing dispute that claim. Last month, the FDA announced that the company’s testing was inadequate and said that Philips had agreed to conduct additional assessments.

In the United States and beyond, families are still struggling.

“I worked my whole life to be pretty healthy,” said Miller, a retired elementary school teacher. “I didn’t want any debris in my lungs.”

CHURCH POINT, LA. Sleeping Alone After 32 Years Shawne Thomas’ husband, Rodney, died in hospice, holding her hand. She said the company should have warned them earlier about potential health risks.

In the middle of the night in June 2021, in a bedroom that overlooks landscaping projects that her husband never got to finish, Shawne Thomas scrolled through YouTube videos.

Rodney Thomas, a former Marine, had died a few days earlier from a rare form of nose and throat cancer after punishing rounds of chemotherapy and radiation. He was 51 and had recently retired, with plans to spend more time with their grandchildren.

An online post made Shawne Thomas stop cold: Philips had recalled millions of CPAPs and ventilators, saying the machines could send potentially “toxic and carcinogenic” material into the masks of users.

Thomas rummaged through her bedroom closet and found the machine that her husband had used for about 20 months. It was one of the recalled CPAPs, the widely used Philips DreamStation.

“I was amazed, hurt and angry all in one — and then I was furious,” she said.

Thomas, 53, met her husband in the late 1980s when they were both Marines and stationed in California as radio operators. He proposed on Valentine’s Day, and the couple wed a few months later.

Rodney Thomas

Married for 32 years, they lived on 20 acres in rural Louisiana across from a field of pecan trees. Rodney Thomas took care of the yard, the chores and his wife, who is disabled from a spinal cord injury sustained during military service.

Diagnosed with stage 4 cancer in early 2021, he underwent two surgeries, seven-hour chemotherapy sessions and radiation treatments.

He died in hospice, holding his wife’s hand, one week after the Philips recall was announced. Shawne Thomas threw a celebration to honor her husband’s life and then, like thousands of others, decided to join litigation against the company.

Thomas said that she and so many others should have been warned far earlier about the potential health hazards.

“I start to feel those thoughts and get angry and get into that dark place, and I have to remind myself I had 32 wonderful years with this man, and I am very lucky to have had that,” she said.

More than two years after her husband’s death, she said, she still has trouble sleeping. On cold nights, she lies under a quilt made of his T-shirts, next to a stuffed panda he gave her when he proposed years ago.

LAFAYETTE, LA. “Fearful” Veteran Stopped Using a CPAP Lee worries about his health, but he can’t bring himself to go back on a CPAP.

Jules Lee Jr. isn’t scared of much.

The 56-year-old Army veteran watched tanks explode, dodged bullets and swept through enemy bunkers during the Gulf War in the early 1990s. But when he learned in 2021 that the DreamStation that he had been using for three years to help him breathe at night had been recalled, Lee got scared.

His best friend, Rodney Thomas, who had also used a DreamStation, died from nose and throat cancer only days after the recall was announced. Like Thomas’ wife, Shawne, Lee said he fears the recalled CPAP was to blame.

Lee decided to stop using a breathing machine altogether.

“That really solidified me not using the machine — and not wanting to use any machine,” said Lee, who lives outside Baton Rouge.

He is not alone: Doctors surveyed for a study published in the Journal of Clinical Sleep Medicine said that 1 in 4 patients with sleep apnea stopped using their CPAP machines after the Philips recall. A majority of the doctors also reported that patients had lost trust in medicine.

Lee said he knows a CPAP machine will help control his sleep apnea, which, left untreated, can lead to strokes and heart problems. But he decided that he would rather die in his sleep than risk experiencing what his friend felt during months of cancer treatment.

Struggling with post-traumatic stress disorder, Lee said his depression worsened after Thomas died. On good days, Lee takes deer-hunting trips to Alabama and keeps up with a group of men who served together through basic training in Oklahoma and operations in the Middle East.

He said he worries about his health, his choice and what might come next, but he can’t bring himself to go back on a CPAP.

“I’m fearful and untrusting,” Lee said. “This is too fresh for me to want to start using a new machine.”

HILLSBORO, ORE. Ex-Marathoner Waited Over 2 Years for a Replacement Machine Binford said he used his recalled machine for about two years until he received a new one.

Kim Binford can’t remember the last time he felt like himself.

In the middle of the night, he wakes up in pain, with excruciating spasms near his heart or in his legs, arms and torso. He paces for long stretches and tries to go back to sleep.

Most nights, he just waits for morning.

The retired engineering manager who once ran marathons has sleep apnea as well as a rare condition known as benign cramp-fasciculation syndrome, which triggers severe muscle spasms.

He used a specialized Philips bi-level positive airway pressure, or BiPAP, machine for more than a decade to treat the conditions, but he stopped after learning in 2021 that his device and millions of others were recalled. Binford said he immediately called the company and registered for a new BiPAP.

Then he waited.

For several weeks after the recall, he said he managed to stay off his recalled machine altogether. But he stopped breathing one night and didn’t rouse quickly when his wife tried to jostle him awake at their home in the suburbs of Portland, where they live with two rescued Chihuahuas.

The father of two, who lives on a fixed income and could not afford to pay thousands of dollars for a new machine, started using his old one again.

“I’m kind of damned if I do, damned if I don’t,” he said. “Anything’s better than nothing. I’m just gonna roll the dice with my life.”

In September, more than two years after the recall, Binford said his insurance company finally sent him a refurbished machine.

“My condition was getting worse and worse and worse,” he said.

ATLANTA She Finally Got a New Machine — With Missing Parts After waiting a year for a replacement machine, Miller said she received a CPAP motor without an electrical cord or instructions for use.

One year after Philips recalled millions of breathing machines, retired elementary school teacher Debra Miller decided she was tired of waiting for the company to send a replacement.

So she took matters into her own hands.

In June 2022, she emailed Philips, writing: “I’ve had a difficult year. I would like my machine as soon as possible.”

Three days later, Miller said, a box from Philips arrived at her two-bedroom home in the suburbs of Atlanta. It had a refurbished CPAP machine motor, she said, but no electrical cord or instructions for use.

“The components of the machine came, and they’re just dumped in a box,” said Miller, 70, who taught in public schools for 30 years.

Miller started using a CPAP machine in 2019 after she passed out driving her Ford Escape and crashed into three other cars, puncturing her liver. The other cars were totaled in the wreck; the drivers had minor injuries.

Miller was diagnosed with sleep apnea and daytime narcolepsy. The grandmother of three was not charged in the accident.

She got her first Philips machine soon after the diagnosis and used it every night.

After the recall, as she waited on a replacement from the company, she withdrew $1,000 from her retirement account to buy a new machine from a Philips competitor. Eleven months later, she received the refurbished CPAP from Philips — and stashed it in her bedroom closet.

“I literally got … half of an old machine,” she said.

IBERVILLE PARISH, LA. Local Sheriff Still Thinks About Mysterious Material in His CPAP Brett Stassi, who was diagnosed with kidney cancer, is hoping to complete his fourth term as sheriff.

Sheriff Brett Stassi figured the black particles that turned up in the CPAP machine he used every night for four years were harmless.

That changed in 2021 after the Philips recall, when Stassi learned that an industrial foam embedded inside the devices could crumble and send debris and fumes into his lungs.

“You’re worried about dying in your sleep, and you come to find out that the machine might be doing more damage than the apnea,” he said.

Stassi said he has good reason to worry.

One month before the recall, he was rushed into surgery after a routine visit to the doctor yielded an unexpected diagnosis: kidney cancer. His right kidney was removed, and he was treated with an immunotherapy drug.

Now in remission, the grandfather of five said he’ll never know if those black particles made him sick. But he’s suing Philips, he said, because the company should have alerted its customers to the health risks years before the recall.

In Iberville Parish outside of Baton Rouge, Stassi tries not to dwell on the diagnosis. He keeps busy supervising 148 deputies and a jail filled with inmates.

His doctors have warned Stassi that the cancer could return, possibly in his lungs or brain. For now, the scans are clear, and he’s hoping to finish a fourth term as sheriff. On a spring morning in an office filled with thank-you notes and photos of his children on their wedding days, Stassi flipped through pictures of his infant grandson.

“See why I’m trying to stay alive?” he said.

MARTINSVILLE, IND. At 24, She’s Bracing for a Lifetime of Worry After using a recalled CPAP for four years, Thompson said she’ll always worry about her health.

Connie Thompson spends her days studying public safety, advocating for social and economic justice, and caring for her disabled mother.

At night, the 24-year-old races to the theater. She auditioned at an Indianapolis community theater for the first time last year and was cast in a production of “Little Women.” She has since moved on to the musical “Into the Woods.”

“It’s like, ‘Oh my God, I belong here,’” she said.

Thompson is busy mapping out plans for a future on stage but worries about the years ahead.

Diagnosed with sleep apnea as a teenager, she used a DreamStation for four years before learning about the recall and safety risks. Thompson said she fears that the prolonged use will one day impact her health.

“There’s so much that I want to do,” she said. “All of the opportunities that I’ve earned, I want to take them to their absolute fullest. The idea [that] I might not have a choice in that just shattered my world.”

Thompson first started using her CPAP machine in high school after excessive fatigue often kept her out of school. When her doctor told her in 2021 that her device had been recalled, Thompson said she had no choice but to continue to use her old one even though she often found black particles in her mask.

Unable to afford a new machine, she waited a year for Philips to send a replacement, cutting up surgical masks and wedging them into the tube that connects to her face mask to try to filter the debris. Lost sleep, she said, wasn’t an option. Her mother has rheumatoid arthritis and needs support around the house.

Thompson also takes classes at Ivy Tech Community College and has long considered herself a political activist, with views shaped in part by her experiences as a transgender woman.

She was recently cast in her first paid acting role and is preparing to audition for four-year conservatory programs to study musical theater. But she said insecurity about her health lingers.

“To know that I could get cancer or some other health effect from using a defective machine for so long brings me right back to square zero — the powerlessness of being completely incapacitated by health problems not under my control,” she said.

BATON ROUGE, LA. For Former Federal Marshal, Every Breath Is a Struggle Carey Jenkins continues to serve as a constable despite a lung cancer diagnosis.

Just months before he was diagnosed with lung cancer, Carey Jenkins walked 60 miles over eight days in the mountains of Alaska on a bear-hunting trip.

Jenkins had always followed a strict exercise regimen. He had served as a deputy federal marshal for 16 years and was later appointed by former President George W. Bush as head marshal for the Middle District of Louisiana. Fitness was required for promotions: running a timed mile and a half, completing situps and pushups, and maintaining a low body fat ratio.

Jenkins went on to serve as an elected constable in his East Baton Rouge parish.

Everything changed, however, when his doctors found a spot on his lower right lung in the fall of 2019. Two years later, it had grown bigger.

The day he went to schedule surgery in 2021, he said he found a notice at the Louisiana home where he and his wife have lived for 30 years. It detailed the sweeping recall of breathing machines, including the DreamStation, which Jenkins used for several years to treat sleep apnea.

Like so many others, the 68-year-old grandfather of four said he worries the machine that helped him breathe at night instead imperiled his health.

With a malignant tumor on his lung removed, Jenkins is still working as a constable. But he said that even walking down his driveway to the mailbox is difficult, and he can no longer help his wife carry the furniture and crystal that she sells through her antique company. He sometimes takes supplemental oxygen with him to catch his breath.

“Before I do something, I know that there’s a limit that I have to stop at,” he said. “I’m just doing everything I can do to get a deep breath. … You have to work on it.”

In recent months, he’s been able to return to the gym with a trainer. Now, instead of exercising for his job in law enforcement, he’s keeping fit to try to live longer.

His goal: a hunting trip with his son next year.

ST. LOUIS A Father of Four Is Laid to Rest Terry Flynn, a father of four, died in 2021. From left: his daughter Colleen Flynn, widow Mary Ann Flynn and son Sean Flynn.

In a church in St. Louis, hundreds of people gathered to honor Terry Flynn with a song: “When Irish Eyes Are Smiling.”

The father of four died in 2021, two weeks after he was diagnosed with esophageal cancer. He was 63 and had never made it to Ireland. A family friend planted a tree there in his memory.

“Before I even got engaged to Terry, one of the first things we did was attend a St. Patrick’s parade,” said Mary Ann Flynn, his wife of 35 years.

Terry Flynn used a recalled Philips machine for nine years to treat sleep apnea. His wife and children say they’ll never know if the device caused his illness, but they blame the company for not alerting patients to the potential health risks sooner.

Mary Ann Flynn said her husband, who went to the gym every morning before work at a law firm, would have immediately stopped using the machine.

“Had someone come to us … we would have been like, ‘Toss it out the window,’” she said. “It would have changed the scope of so many things.”

Terry Flynn was born and raised in St. Louis, where he coached soccer and baseball and liked to go fishing in local lakes. He met his wife in college, and they married shortly after graduation.

In 2021, the couple were planning a family vacation to Florida to celebrate the birthday of their twins, who were turning 21, and their older son, Sean, who had just been certified as a public accountant.

The trip never happened. Flynn was diagnosed with cancer that had spread from his esophagus to his liver and kidneys and died days later. Mary Ann Flynn said she and her family decided to sue Philips for failing to alert customers about the defective devices.

“It’s a machine to help you breathe by a reputable company,” she said, adding, “You kind of just trust.”

TORONTO Around the World, Outrage Over Philips Recall A family photo of Pedram Ghaitani with his wife, Ganna Kron

Pedram “Pedy” Ghaitani needed his sleep.

On most days, the driver for a medical company left his wife and young son in their apartment before sunrise to shuttle patients to appointments across the city. Ghaitani drove a limousine in his spare time, racing to airports, weddings and business meetings.

When he was diagnosed with sleep apnea in 2016, he became a faithful user of the DreamStation. He continued to use the machine even after doctors discovered in 2019 that he had a rare form of lymphoma. The 51-year-old Iranian immigrant died later that year.

“I always thought whenever he used to come home late, sometimes 2, 3 o’clock in the morning, ‘Thank God,’” said his wife, Ganna Kron. “He always came home. And then he didn’t.”

Kron is among thousands of people involved in litigation against the company in Canada. Anger has swept the world, with lawsuits similar to those in the United States unfolding in several countries.

Kron said she’ll never know exactly what caused her husband’s illness but fears his recalled CPAP played a critical role. “Carcinogenic particles — it just baffles my mind,” she said.

Ghaitani fled Iran as a teenager and settled in New York. After he met Kron, he moved to Toronto. The couple married and had a son, Nash.

“He missed the chance to grow up with such a great man,” Kron said. “That is my heartbreak.”

Kron and her son, Nash

Reporting was contributed by Debbie Cenziper of ProPublica; Michael D. Sallah and Michael Korsh of the Pittsburgh Post-Gazette; and Molly Burke, Aidan Johnstone and Bridgette Adu-Wadier of the Medill Investigative Lab.

by Margaret Fleming, Monica Sager, Nicole Tan, Susanti Sarkar, Evan Robinson-Johnson and Claire Gardner, Medill Investigative Lab; Photography by Liz Moughon, ProPublica

A Sweeping Report on a Michigan School Shooting Finds Multiple Failures and a Troubled Aftermath

1 year ago

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.

In the end, it took 699 days to account for what went wrong before, during and after a deadly shooting at Oxford High School in Michigan.

Nearly two years after the shooting, which killed four students and injured seven others, an outside consulting firm that conducted an independent investigation issued a sweeping report that faulted top administrators and other school officials for “failure and responsibility by omission.”

The 572-page report from Guidepost Solutions, a New York-based firm that specializes in investigations, compliance and security, said that had threat assessment and suicide intervention been carried out appropriately, the November 2021 shooting could have been prevented.

Guidepost also found missed opportunities in the aftermath of the shooting. The report describes efforts by the lawyers for Oxford Community Schools and the teachers union to discourage people from cooperating in the investigation, showing why it can be so difficult for communities to find transparency and accountability following a mass shooting.

Some school leaders encouraged staff to participate in interviews with the consultant, the report said, but the school board made it voluntary, rather than a condition of employment. The board didn’t even say it “expected” district employees to participate.

This “hindered our ability to conduct the investigation effectively,” the report said.

Of the 161 people Guidepost investigators asked to interview, 70 refused or did not respond, including most of the shooter’s former teachers and several critical witnesses to the shooting. Both employees who met with the shooter hours before the incident did not cooperate. Of those who were interviewed, some would not speak about threat assessment practices preceding the violence.

For the report, investigators also turned to police reports, surveillance video, social media posts, deposition transcripts and other records, including files from the county prosecutor’s ongoing criminal investigations.

In May, a ProPublica story described how comprehensive third-party reviews of school shootings are very rare — typically happening only after the highest-profile tragedies. Even then, haphazard approaches can breed mistrust and waste the chance to learn lessons on prevention.

Oxford Community Schools declined multiple offers from Michigan’s attorney general to investigate, the story said. For six months, Oxford’s board followed guidance from a lawyer retained by the school’s insurance company, SET SEG, as it insisted that it couldn’t launch a review until criminal and civil cases were resolved. But there was no such prohibition from prosecutors.

ProPublica’s story described how the delay in approving an independent review contributed to an atmosphere of mistrust among parents and community members.

The morning after the report’s release, Renee Upham, an Oxford mom who used to teach at the district’s middle school, wrote an email to school officials that she shared with ProPublica, calling on them to apologize to students, staff members and families. It also asked when key figures will be put on leave or terminated.

“The report is damning,” Upham wrote. “At its core, it shows failures going back years that could have prevented the murder of four children and the injuries, both physical and emotional, of others.”

After allowing “two years to pass before the truth came out,” she wrote, the district now has a chance to own it. “Please do so, she wrote. “That is what authentic leadership is.”

The report released Monday was the second from Guidepost. In May, the firm released a 179-page report that assessed Oxford’s current security, suicide intervention and threat assessment strategy. But the accountability report released Monday is the one many community members wanted most.

On Thursday, Guidepost will host three town hall meetings to answer questions from the community about the report.

“I cannot believe it has taken almost two years to get to this point,” wrote Danielle Krozek, an Oxford mom, in an email to two Guidepost leaders this month that she shared with ProPublica. She thanked them for their time and effort, but also said she felt “on edge and skeptical.”

“This community and administration have missed the opportunity to acknowledge devastating failures and set the example for our state and nation,” she wrote.

In an interview with ProPublica earlier this year, Dan D’Alessandro, then-president of the school board, acknowledged the community’s anxiety and mistrust over the long wait. “Sometimes the messaging that comes out from the legal system and the legal teams isn’t necessarily reflective of that of what the school district is trying to do,” he said.

During the Nov. 30, 2021, rampage, an Oxford sophomore killed Tate Myre, 16; Hana St. Juliana, 14; Madisyn Baldwin, 17; and Justin Shilling, 17. The shooter pleaded guilty to charges including murder and terrorism and faces the possibility of a life sentence without parole.

In an unprecedented case, prosecutors also charged the shooter’s parents with involuntary manslaughter, alleging they failed to respond to multiple red flags about their son. Four days before the shooting, his father bought a gun for him. The parents have pleaded not guilty.

At school, there were also a number of warning signs, including a disturbing drawing that pictured a gun and a bleeding body made in math class the morning of the shooting. It prompted a meeting with a school counselor, the dean of students, the teenager and his parents. Nobody in the family mentioned the gun, according to court records, and school officials didn’t ask about access to weapons.

Officials also didn’t insist the student leave school, alert senior administrators or call outside authorities, and they didn’t check the student’s backpack before returning it to him and writing him a pass back to class. The gun was in the backpack, along with ammunition and a journal where every page described shooting the school. Less than two hours after the meeting, he began firing at teachers and classmates.

“Missteps at each level throughout the District — from the Board, to the Superintendent, to the OHS administration, to staff — snowballed to create a situation where a student’s communications and conduct should have triggered a threat assessment and suicide intervention on November 30, but did not,” the report said. “None of these mistakes were intentional. But costly mistakes they were.”

The Oxford school district failed to put its written threat assessment policy into practice with instructions and guidelines, according to the Guidepost report. No senior administrators acknowledged having responsibility for implementing the policy.

Moreover, the district’s suicide intervention guidelines were out of date. Even so, existing school protocols should have led educators to send the troubled boy home, rather than let him return to class, according to the report.

The report also described “extraordinary acts of bravery and kindness” by district personnel, including administrators who tried desperately to save student lives during the shooting.

In the aftermath of the shooting, parents filed civil suits, alleging gross negligence against several school employees and arguing the district was liable for what happened. But strong governmental immunity protections are difficult to surmount. In May, a state circuit court judge dismissed public employees and institutions from all suits.

Federal suits alleging a “state-created danger” and naming the district and the two officials at the meeting with the teenager on the morning of the shooting are still being litigated.

In an earlier motion to dismiss, a lawyer, on behalf of the district, wrote that no one “can claim with a scintilla of support that the employees were not attempting to help this student.” The motion also argued: “With the benefit of hindsight, it is easy to suggest that more could have been done. However, that is not the legal standard.”

Shortly after the shooting, the Oxford school board voted for a third-party review to begin “immediately.” According to the board’s resolution, it should “look far beyond the criminal investigation and into all the systemic factors that were at play.”

When a review didn’t happen, community members challenged the explanation from the school board that such an investigation had to wait for legal reasons. Those parents eventually learned directly from the county prosecutor’s office that, in fact, an investigation would not interfere with criminal cases. The prosecutor’s office further indicated that it had made this clear to the school’s lawyers, and at least one parent forwarded the message directly to the school board.

Finally, in May 2022, Oxford hired Guidepost for the investigation. It was led by Bradley Dizik, an executive vice president who heads the company’s emerging issues and technology practice group, and Andrew O’Connell, president of investigations and private client protection.

But even then, Timothy Mullins, the lawyer retained for the school by the insurance company, and union officials cautioned against talking. The union has pointed out that some members did cooperate with the investigation.

Mullins, in an email to ProPublica earlier this year, said that “critical witnesses have all been interviewed by law enforcement officials. They have also been deposed — under oath — by victims’ attorneys. Their sworn testimony has been set forth in voluminous transcripts, which are available to all parties and were provided to Guidepost by my firm.”

Deposition transcripts were useful but insufficient for the investigation, according to the report. Investigators noted that lawyers had different goals than they did and asked different questions than they would. (The report said that anyone interviewed by Guidepost was welcome to have an attorney present.)

Former board members told ProPublica that they worried that if they didn’t heed the advice of the lawyer retained by SET SEG, the school’s insurer could rescind coverage. Given the concerns of the district and certain employees, the report suggested legislation that explicitly prevents insurers from denying coverage to public schools and their employees if they participate in independent investigations into school shootings.

Anticipating the report, Oxford’s superintendent and the current board president informed families this month that the district would increase mental health support on campuses following its release and noted that the publicly funded All for Oxford Resiliency Center, established for those affected by the shooting, would expand its hours. They also pointed families to Oxford’s recovery plan and support services from county partners.

by Anna Clark

This Billion-Dollar Plan to Save Salmon Depends on a Giant Fish Vacuum

1 year ago

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

To free salmon stuck behind dams in Oregon’s Willamette River Valley, here’s what the U.S. Army Corps of Engineers has in mind:

Build a floating vacuum the size of a football field with enough pumps to suck up a small river. Capture tiny young salmon in the vacuum’s mouth and flush them into massive storage tanks. Then load the fish onto trucks, drive them downstream and dump them back into the water. An enormous fish collector like this costs up to $450 million, and nothing of its scale has ever been tested.

The fish collectors are the biggest element of the Army Corps’ $1.9 billion plan to keep the salmon from going extinct.

The Corps says its devices will work. A cheaper alternative — halting dam operations so fish can pass — would create widespread harm to hydroelectric customers, boaters and farmers, the agency contends.

“Bottom line, we think what we have proposed will support sustainable, healthy fish populations over time,” Liza Wells, the deputy engineer for the Corps’ Portland district, said in a statement.

A rendering of the Corps of Engineers’ proposed floating fish collector as envisioned by a design firm hired by the agency. (U.S. Army Corps of Engineers)

But reporting by Oregon Public Broadcasting and ProPublica casts doubt on the Corps’ assertions.

First, some leading scientists have said the project won’t save as many salmon as the agency claims.

A comprehensive scientific review in 2017 concluded that the use of elaborate fish traps and tanker trucks to haul salmon, as the Corps proposes, will “only prolong their decline to extinction.”

Moreover, many of the interests the Corps says it’s protecting maintain they don’t need the help — not power companies, not farmers and not businesses reliant on recreational boating.

The Corps’ effort to keep its dams running full-bore is a story of how the taxpayer-funded federal agency, despite decades of criticism, continues to double down on costly feats of engineering to reverse environmental catastrophes its own engineers created.

The 276-foot Lookout Point Dam on the Middle Fork of the Willamette River poses a major obstacle for tiny juvenile salmon as they attempt to migrate downstream (U.S. Army Corps of Engineers)

The only peer-reviewed cost-benefit analysis of the Willamette dams, published in 2021, found that the collective environmental harms, upkeep costs and risks of collapse at the dams outweigh the economic benefits.

Congress has weighed in, twice calling on the Corps to study shutting down hydropower, which would free up more water for salmon. The agency blew its first deadline last year and now says it will perform an “initial assessment” to help decide whether to do the study required by law.

Emails obtained by ProPublica and OPB show that as Corps officials hashed out how to handle the mandate from Congress, they proposed actions that could increase public support for preserving hydropower. The Corps is now finalizing a plan that would continue electricity generation for the next 30 years.

“How can you finalize a long-term plan if you don’t know whether or not you’re going to continue hydro?” said former U.S. Rep. Peter DeFazio, D-Ore., who pushed for legislation ordering the Corps to study ending hydropower.

“They’re doing that without the study and the information they need,” he added.

Democrat Val Hoyle and Republican Lori Chavez-DeRemer, who now represent portions of DeFazio’s former district, said in separate written statements that it was urgent for the Corps to finish its study and no decisions on the Willamette should be made until that happens.

There is a simpler way to protect fish: opening dam gates and letting salmon ride the current as they would a wild river. It costs next to nothing, would keep the Willamette Valley dams available for their original purpose of flood control and has succeeded on the river system before. This approach is supported by Native American tribes and other critics.

The Corps ruled it out as a long-term solution for most of its 13 Willamette River dams, saying further reservoir drawdowns would conflict with other interests.

The debate and the consequences of the decision are real for the Confederated Tribes of the Grand Ronde, who have fished the Willamette for thousands of years. Grand Ronde leaders said they’ve met with the Corps seven times to spell out potential alternatives to building giant fish collectors and maintaining hydropower.

“They always feel like they can just build themselves out of problems. And this is really something that we don’t need to build,” said Michael Langley, a former tribal council member for the Grand Ronde.

First image: Grand Ronde tribal member Michael Langley stands in front of the tribe’s plankhouse, used for cultural ceremonies, weddings and funerals. Second image: Langley has an outline of a 53-pound Chinook salmon his father, Leonard Langley, caught in 1975. In Michael Langley’s former role as a tribal council member, he said he met with the U.S. Army Corps of Engineers about taking more measures to restore healthy salmon populations, because “the way we’re doing it right now, it’s more likely to lead to extinction.” (Kristyna Wentz-Graff/Oregon Public Broadcasting)

The tribes have also said generating electricity at the dams doesn’t pencil out for anyone. By the Corps’ own estimates, the cost of hydropower over the next 30 years will outstrip revenues from electricity customers by more than $700 million.

The tribes filed a letter with the Corps in February that included a pointed summation: “Killing salmon to lose money deserves a deeper analysis.”

Confederated Tribes of the Grand Ronde tribal members Sara Thompson, left, and Matt Zimbrick, center, along with the tribe’s fish and wildlife program director Kelly Dirksen, navigate the rocks at Willamette Falls, a waterfall just south of Portland that has long been an important fishing site for the region’s tribes. In recent years, salmon counts at Willamette Falls have reached historic lows. (Kristyna Wentz-Graff/Oregon Public Broadcasting) “Tooth and Nail”

Many of Oregon’s most populous and valuable places, like downtown Portland, would spend parts of the year underwater if not for dams.

Housed at the bottom of Lookout Dam, these three generator turbines contribute 143 megawatts of energy to Oregon communities when fully operational. (Caden Perry/Oregon Public Broadcasting)

Congress ordered the Army Corps to build the system during the 1940s, ’50s and ’60s to hold back floodwaters in Oregon’s fertile Willamette Valley. Towns sprouted up in the security of 300-foot walls. Lawmakers approved additional uses for the dams. The rivers they impounded provided places for people to drive power boats as well as deep pools of water to spin hydroelectric turbines. Today, eight of the 13 dams generate power.

But the monumental structures caused harm, too. Salmon evolved to swim and spawn in cold, free-flowing rivers that the dams choked into warm, stagnant lakes, full of bass and other invasive predators. Salmon need to get to the ocean and back, but the dam walls blocked their path. Whirring turbines bashed fish that attempted to scoot past.

In 2021, after salmon numbers on the Willamette reached historic lows, a federal judge said the fish’s recovery had been stymied far too long.

U.S. District Judge Marco A. Hernandez admonished the Corps for having “fought tooth and nail” against better measures for fish ever since it was first sued over the issue in 2000, foot-dragging that the judge said had pushed the fish closer to the edge of extinction.

Lookout Point Dam blocks nearly 100% of historic spawning habitat for salmon on the Middle Fork Willamette River, which once had one of the most abundant salmon populations in the Willamette Valley. The Corps is currently drawing down the Lookout Point reservoir to aid salmon migration but proposes replacing that measure with a giant floating structure to collect fish. (Caden Perry/Oregon Public Broadcasting)

Gates in the dam walls can provide a passage for young salmon to pass downstream, but they’re usually too deep underwater for the little fish to find because they stay near the surface. Those that do dive down to the deep gates can get the bends and die. The judge ordered the Corps to drain several reservoirs to levels lower than any since the dams were built.

Scientists had observed that whenever reservoir levels dipped seasonally, more fish passed through dams. Knowing this, Corps biologists had been experimenting with draining a reservoir known as Fall Creek until it nearly replicated the original river channel.

The drawdown worked. It moved salmon quickly and safely past the dam and eliminated many of the invasive predators dwelling in the reservoir. At virtually no cost, the Corps increased the number of adult fish that returned tenfold, surpassing what biologists thought possible.

A fish ladder at Fall Creek Dam offers adult salmon a swimming route. At many dams, fish ladders offer salmon a way up and over dams blocking their path. At the tall dams on the Willamette, these ladders lead to pens that hold fish until they can be transported by truck. (Kristyna Wentz-Graff/Oregon Public Broadcasting)

The Corps has argued that there are limits to this approach. Fall Creek’s openings are more fish-friendly than those at other dams. And Corps officials worried draining many dams all at once might trade one hazard for another, such as by leaving too little streamflow for fish.

But Hernandez ruled that the weight of the evidence showed drawing down reservoirs was “the most effective means for providing safe fish passage” and “necessary to avoid irreparable harm” to salmon. He ordered the Corps to try partial drawdowns at three other dams. Then he set a 2024 deadline for the Corps to have a new long-term plan to save salmon, which he expected to go even further than his order.

Tribes and environmentalists cheered the judge’s ruling as a long-overdue remedy.

But the Corps had its own ideas.

Building a Better Fish Trap

In 2022, the Corps released a draft of the document the judge had ordered: a 5,782-page environmental impact statement for Willamette dam operations.

At the two dams that threaten salmon the most, the Corps would build complex structures called floating fish collectors.

Versions built elsewhere resemble industrial buildings atop the water, loaded with fish pens, electrical equipment and water pumps. The idea is for fish to mistake the whooshing current created by the pumps for the river’s flow and get lured into the trap.

Collectors that Corps envisions for Detroit and Lookout Point dams would cost a combined $622 million. In addition, the Corps would spend $432 million on an enormous water-cooling device at Detroit. Other money would buy smaller fish traps and habitat restoration.

Hydropower Dams Block Salmon Migration in the Willamette River Valley

At two of the most crucial dams for salmon restoration in the Willamette Valley, the Army Corps of Engineers has proposed building massive fish collectors that suck in and trap young salmon, which would then be placed in trucks and driven downstream.

(Lucas Waldron/ProPublica)

The Corps first tried a kind of floating fish collector on the Willamette in the 1950s but declared it a failure.

As salmon populations dwindled into the 21st century, the Corps decided to try again, building a small collector on an offshoot of the Willamette. To track the baby fish they were trying to entice, biologists implanted nearly 1,500 with microchips and released them behind Cougar Dam.

Eight found their way into the collector.

The agency ended the experiment ahead of schedule.

Floating collectors at other dams in the Northwest have shown better results. But at the location biologists consider most comparable to the Corps’ Willamette dams, it’s been a struggle. The fish collector on southwest Washington’s Lewis River captured just 3% of the Chinook salmon it was targeting, a peer-reviewed study found. The dam’s owner reported success rates as high as 33% in later years.

“You don’t have to be a rocket scientist to go back and look at how these structures performed in other locations to see that there’s been some challenges,” said Greg Taylor, the Corps’ supervisory fish biologist.

For this reason, the Corps did propose deep and sustained drawdowns at Cougar and Fall Creek dams.

But the number of fish helped would be relatively small because of these dams’ locations. By contrast, the dams where the Corps wants to try fish collectors wall off about 70% to 100% of the area where fish hatch. The Detroit and Lookout Point dams block rivers that once supported some of the valley’s most abundant fish runs.

The Corps didn’t consider these dams good candidates for a drawdown because of the way they were built and because Corps officials viewed their operations as too crucial to justify it.

So agency leaders commissioned a study of previous fish collector builds to devise improvements. They arrived at a plan for collectors five times as wide and five times as powerful as any ever evaluated. The structures at Detroit and Lookout Point would take a decade to complete.

The National Oceanic and Atmospheric Administration, which must approve the Corps’ actions before it can proceed, said in a statement its scientists “are confident that collectors can be effectively applied” as the Corps optimizes their design.

Big uncertainties remain, though.

Supersizing the collectors for better performance makes sense in theory, according to U.S. Geological Survey biologist Tobias Kock, who led the 2019 study. But because what the Corps is proposing is so much bigger than anything Kock and his colleagues looked at, he told OPB and ProPublica, “we don’t know how well that performance prediction’s going to work.”

The most successful floating collector in Kock’s study captured roughly 60% of Chinook salmon, on a reservoir with far more favorable conditions than on those the Corps owns. The Corps, meanwhile, estimates its supersized fish collectors will capture between 80% and 95%.

The Corps’ environmental impact statement acknowledges its numbers are a guess. It says the collectors the agency contemplates “have yet to be successfully implemented and there is considerable risk and uncertainty about the realized effectiveness of these structures.” In a September statement to ProPublica and OPB, Corps officials went further, calling their projected success rates “overestimates.”

University of California, Davis researchers Robert Lusardi and Peter Moyle published a 2017 study in the journal Fisheries warning that the kind of trap-and-haul programs the Corps has proposed “should proceed with extreme caution.”

Lusardi said in an interview that their success rates are artificially inflated and that removing young salmon from the river stresses them, increasing their risk of dying before they find their way home to spawn as adults.

“Transportation of fish, whether it’s juveniles or adults, has a really seismic effect on the fish themselves,” Lusardi said.

First image: Corps biologists Greg Taylor, left, and Chad Helms move a pair of salmon from a collection area at the base of Cougar Dam. The structure traps adult fish that are migrating upriver and holds them in pens until they can be transported past the dam. Second image: Two male salmon are drained from a holding tank into a tanker truck below. (Kristyna Wentz-Graff/Oregon Public Broadcasting) A tanker truck hauls the salmon upriver past dams on the Willamette River system. The Corps has been trucking adult fish upriver past dams for many years. It now proposes hauling juvenile fish downstream as well. (Kristyna Wentz-Graff/Oregon Public Broadcasting)

Rich Domingue, a former NOAA hydrologist who provided expert testimony for environmental groups that sued the Corps, said these flaws and others biased the Corps’ analysis in favor of preserving hydropower.

Instead, Domingue said, the Corps should be drawing down more reservoirs and closely monitoring the results, “rather than spending billions over decades in a high-risk gamble.”

“Human Error Fixing Human Error”

At the heart of the Corps’ push to find a technological fix for dams is its claim that people throughout the Willamette Valley cannot live without the hydropower, recreational boating and irrigation that the dams make possible. The trouble is, it’s hard to find people in the Willamette Valley who feel the same way.

Even the hydropower industry opposes the Corps’ plan to continue with hydropower.

Ending power generation on the Willamette would be “the best for consumers, the best for fish, and the best for taxpayers,” wrote Scott Simms, executive director of the Public Power Council, and Mark Sherwood, head of the Native Fish Society, in a joint 2021 letter published in the Eugene Register-Guard.

Records newly obtained by OPB and ProPublica via the Freedom of Information Act show the federal government’s hydropower agency for the region, the Bonneville Power Administration, also wants the Corps to do away with hydropower on the Willamette.

Bonneville, which pays roughly half the costs of operating Willamette dams, urged the Corps last year not to spend hundreds of millions of dollars to keep turbines running when cheaper solutions exist. The streams feeding the Willamette are wildly inefficient at producing electricity compared with dams on larger rivers, costing up to five times as much to light a home.

Similarly, farmers in the lush Willamette Valley are far less dependent on water stored in reservoirs than their counterparts in the high desert of eastern Washington, Oregon and Idaho, where current farming practices would be impossible without the irrigation that dams and reservoirs supply. The valley gets drenched with 50 inches of rain a year. Draining reservoirs each fall would have a marginal impact on water supplies downstream, according to the Corps’ own analysis.

The Oregon Water Resources Department said the drawdowns already happening under the court injunction have not undermined anyone’s ability to irrigate with water from the Willamette and its tributaries.

“It has no negative impact on me,” said Bob Schutte, owner of Northern Lights Christmas Tree Farm just downstream of two reservoirs that are already being drained each fall.

Lagea Mull runs the chamber of commerce for Sweet Home, a town that sits on a major route to Foster and Green Peter reservoirs. Mull said residents there want salmon to thrive and have adapted to the temporary drawdowns the judge ordered in 2021.

“When the dams came in, that was a massive change to the area,” said Mull, who knows people whose homes are now at the bottom of the reservoirs. “So now this is just another change.”

Linn County Commissioner Will Tucker is among the most vocal with concerns about draining reservoirs. But as a lifelong Willamette Valley resident, he also cares about the salmon.

“If it recovers the salmon,” he said of drawdowns, “it's the right thing to do.”

Tucker wants the Corps to help offset what he worries would be the biggest impact, to the river’s recreation economy. More than 2.5 million people take their power boats or kayaks or inner tubes out on the Willamette River system annually. Visitors inject enough money into marinas, restaurants and shops to keep some towns afloat all year.

But the Corps estimates the kind of limited drawdowns it studied and ruled out would leave boat launches high and dry only at the tail end of the boating season, reducing visits by about 7% and spending by $1.3 million.

One business owner, Dawn O’Donnell, has already adapted her boat rental shop to the shorter season brought by court-ordered drawdowns. She delivers kayak and paddle boards to lakes that haven’t been affected.

Still, she is skeptical that anything the Corps does can actually help salmon to recover.

“It’s kind of like human error fixing human error, after human error, after human error,” O’Donnell said. “How can we make it right now that we’ve ruined it?”

Cougar Dam, on the north fork of Oregon’s McKenzie River, is one of two dams where the Army Corps has proposed draining the reservoir behind the dam down to the original river bed to aid salmon passage. (Kristyna Wentz-Graff/Oregon Public Broadcasting) A View of the River

For the past two years, the Corps has been developing a response to the court order, in which Hernandez stated it was “abundantly clear” the agency needed to change its operation of Willamette Valley dams.

Yet top Corps officials openly acknowledge that they never intended to veer very far from the status quo. Preserving dam uses like hydropower generation and water storage was the goal of its court-ordered environmental impact statement.

Wells, the deputy district engineer for the Corps in Portland, said in an interview that the work that went into the document “isn’t really a planning process for us to change the way we operate.”

As long as the law authorizes uses like hydropower and boating, the Corps has to find ways to preserve them, she said, adding that future needs for the water storage that reservoirs offer will only grow as the climate warms.

“The people that work here are really trying hard to think of what the best ways are to tackle this really tough problem in the space we have,” Wells said.

One internal email obtained by OPB and ProPublica under the Freedom of Information Act reveals how the Corps hoped to build support for staying the course.

Kelly Janes, a Corps planner assigned to the congressional request for a study into ending hydropower, suggested to colleagues that the Corps produce a series of videos and perhaps a podcast showing that hydropower has many benefits. These might generate public comments in support for hydropower that the Corps could forward to Congress.

“The public and Congress are only hearing one side of the story from the Public Power agencies who think hydropower in the Willamette is no longer profitable and Environmental groups who believe that hydropower deauthorization could be a silver bullet for the endangered species issues at our dams,” Janes wrote colleagues in April.

Asked to explain the Janes email, Corps officials denied they were trying to shape public opinion about hydropower. They said they wanted to make sure the public understood the complexities of hydropower and how integrated it is into their dams.

As for why the Corps is locking in a 30-year plan that preserves hydropower before studying an end to it as Congress ordered, the agency cited a looming deadline from Hernandez, the federal judge, and said the Corps has done the best it could in the time allotted.

Former employees and scientists who’ve worked closely with the Corps say its officials are afraid to change because drawing down reservoirs and eliminating hydropower would call into question the agency’s usefulness in the Willamette Valley.

“They don’t like to be seen as an agency that can’t execute,” said Judith Marshall, who spent six years as an environmental compliance manager for the Corps.

Marshall, whose work included projects in the Willamette Valley, filed a complaint with the federal Office of Special Counsel in 2017 alleging the Corps ignored obligations under federal environmental laws.

“They’re some of the smartest people I’ve ever encountered,” Marshall said, but “they’re so wound up in their models and what they’re doing, like they can’t see the forest through the trees.”

From her office in downtown Portland — with a sweeping view of the Willamette and the mountains beyond it — Wells mused on the possibility the Corps might someday take a broader look at what the region really needs from its dams and whether it should allow the river to run more naturally.

“Maybe that’s where this is all going in the future,” Wells said.

For now, the Corps has a $1.9 billion fish plan to finish.

by Tony Schick, Oregon Public Broadcasting

In 2018, We Reported on an Abusive Cop. He Was Just Sentenced to a Year in Prison.

1 year ago

ProPublica is a nonprofit newsroom that investigates abuses of power. This story was originally published in Dispatches, a weekly newsletter that spotlights wrongdoing around the country and journalism from our newsroom.

Having come to journalism after dropping out of law school (where I discovered I didn’t want to be a lawyer) and dropping out of the Peace Corps (where I discovered I can’t grow vegetables in the Sahara), I started small, working at newspapers with names you probably would not recognize.

My first job was at the Valley Courier in Alamosa, Colorado, where my beat was sports and courts. I’d drop into a trial in the afternoon, perhaps a stabbing, then cover high school basketball games at night. My second job was at the Times-News in Twin Falls, Idaho. It was there, on the night cops beat, that I had a police department source who would call the newsroom and leave, anonymously, a message saying, “The little birdy has flown,” which was his signal for me to call him. From there I went to the Times-Advocate in Escondido, California.

I came to appreciate, and love, local news. I learned how much people care about school bonds and that you spell their street name right. I learned, from interviewing 13-year-old Jimmy Dodds at the Twin Falls County Fair, about the joys of riding the Gravitron. (“If you throw up, it flies back in your face,” he told me.) And I learned that our work can live on long after we leave — that a story’s impact can endure for years.

I was reminded of that earlier this month, because of a court hearing in northern Indiana.

When I began working at ProPublica in the fall of 2017, the Valley Courier was 30 years behind me. But I still loved local news. And, as luck would have it, ProPublica was just then launching an initiative called the Local Reporting Network.

The mission of the Local Reporting Network, or the LRN as we call it, is both simple and righteous. Mindful of the many local news organizations that are shrinking or disappearing, ProPublica partners with local newsrooms strapped for resources, to help them execute bold investigative projects. The first group of LRN partners published stories in 2018. And one of that first group’s members was Christian Sheckler, then a reporter at the South Bend Tribune in Indiana.

Sheckler was not the kind of reporter you see in moviedom. He does not swear. He is unerringly polite, and I do mean unerringly: I’ve never seen him say a mean thing to anyone. He is earnest and humble. But don’t underestimate him; he is also dogged — and a true believer in journalism as a force for good.

When Sheckler applied to the LRN, he was 29. He’d been a reporter for six years, four in South Bend and two in Fort Wayne. He wanted to dig into the criminal justice system in nearby Elkhart, where, according to his application letter, there was a “decades-old pattern of misconduct.” He believed reporting could produce answers about why some people had been wrongfully convicted and “an accounting” from public officials.

To do what he wanted, he needed time. In words that will resonate with every reporter who’s ever churned out five, 10 or 15 stories a week at a small or midsize daily, Sheckler wrote that he needed “a sabbatical from the press conferences and school board meetings that, in today's understaffed newsroom, can stand in the way of the most ambitious investigative journalism.”

In Escondido, I once had six stories in one day’s paper. Reading Sheckler’s application, I knew where he was coming from. And I wanted to go back there, if he was willing. I asked Sheckler if he’d be up for me partnering with him on this project, and he graciously agreed.

We set to gathering up records, which proved surprisingly difficult as a judge barred us from getting an array of documents that are routinely available to the public. She barred us from seeing police reports included in court files. She barred us from seeing trial exhibits that had been shown to jurors. Only after we filed a complaint with Indiana’s public access counselor were we able to get some, but not all, of the records we wanted. Meanwhile, when we asked the city of Elkhart for certain other records, we were told the documents were in storage, in a box, and that other boxes were in front of that box, and the city didn’t have anyone available to move the boxes blocking the path to the box with the records.

Sheckler and I wrote a dozen stories in 2018 and then more in years after. We investigated how poor policing led to wrongful and questionable convictions. We exposed dubious investigative practices and a lack of police accountability. We found that of the Elkhart Police Department’s 34 supervisors, 28 had disciplinary records and seven had opened fire in at least one fatal shooting. One officer was promoted to sergeant after receiving 11 suspensions, 15 reprimands and one verbal warning. (“He was promoted in the wake of all this?” one criminal justice expert said to us. “That’s very strange. ... I have no explanation for this. ... This is bizarre.”)

In the wake of our joint investigation, the city’s police chief was suspended for 30 days. Then he resigned. The city’s mayor abandoned his reelection campaign. The city commissioned an outside study of its police force, which found that officers were viewed in the community as “cowboys” who engage in “rough treatment of civilians.” The 97-page study criticized the department’s lack of accountability and its “vague and non-descriptive” use-of-force reports. In 2022, Keith Cooper, a man whose wrongful conviction we’d written about in 2018, received $7.5 million in a record settlement with the city, which apologized for its handling of his case.

This year, the fallout has continued. In 2018, Sheckler obtained a video showing two Elkhart police officers repeatedly punching a handcuffed man inside the police station’s detention area. We wrote up what the video revealed, and ProPublica’s Lucas Waldron analyzed and edited the footage. In 2019, a federal grand jury indicted the two officers on civil rights charges. Both officers eventually pleaded guilty to one count each. Last year, one of the officers, Cory Newland, was sentenced to 15 months. (His lawyers, in an email to ProPublica, wrote that Newland “long ago accepted full responsibility,” adding, “It is clear to us and to all who know Cory, that his conduct was not representative of his true heart and character as a person.”) Joshua Titus, the second officer, appeared for sentencing just this month — and received a year in prison.

At the sentencing hearing, in federal court in Hammond, Indiana, Titus expressed gratitude for the video being made public by the Tribune and ProPublica. He’d been dealing with severe post-traumatic stress disorder from his service in the Air Force, Titus said. “I was in denial of my psychological issues,” he said, adding that the video’s release “opened my eyes and gave me a renewing of my soul.” Publication of the videotaped beating also “helped change the culture at the Elkhart Police Department,” he said.

Titus’ attorney, Mike Allen, of Cincinnati, is a former police officer himself. Allen told me of Titus, “He’s a good man that served his country, and served his country well and honorably, who made a mistake and is now paying for it.” Titus is already getting counseling, Allen said, and is likely to get more help in the federal prison system. As for what Titus said in court about being thankful for the video’s release, Allen told me, “The thing about him is, if he says it, he means it.”

Elkhart, Indiana, police officer Joshua Titus (Obtained from Elkhart Police Department)

In journalism, we sometimes indulge in the fantasy that our work will always have immediate impact, with every flaw we’ve exposed getting addressed and resolved within days, weeks or months. Readers want that too. But the reality is sometimes slow, incremental change over years. The criminal prosecution launched against these two officers didn’t conclude until five years after we first reported on the videotaped beating.

In 2021, I did a second tour with the LRN, partnering with Nashville Public Radio’s Meribah Knight to write about children being illegally arrested and jailed in Rutherford County, Tennessee. Knight has stayed with this story for more than three years, doing work that has resonated in and beyond Tennessee. After we published our first story, 11 members of Congress sent a letter asking the Department of Justice to open an investigation into Rutherford County’s juvenile justice system. Subsequently, the judge who had been in charge of that system announced she would not run for reelection.

Now the story is the subject of a podcast series hosted by Knight and produced by Serial, ProPublica, Nashville Public Radio and The New York Times. The first two episodes just dropped. I hope you’ll listen.

In South Bend, the Tribune’s top editor when the Elkhart project was published was Alan Achkar. (He’s now the executive editor at the St. Louis Post-Dispatch.) Newsrooms are accustomed to fielding a lot of complaints, Achkar said. But with the Elkhart stories, readers wrote and called to say thank you. “I stopped counting the emails,” Achkar said. “It was encouraging, it was heartening, it was validating.”

As for Sheckler, he’s now 34. In the years since he began digging into Elkhart, he and his wife have had two children. Last year, Sheckler left the Sound Bend Tribune — and journalism. In journalism, “the pay’s not great,” Sheckler said. He wanted more stability for himself and his family. But he also wanted to keep doing work that he believed in, that was important and rewarding, so he took a job at the Notre Dame Exoneration Justice Clinic. He’s the clinic’s staff investigator. “I wanted to still be in a fight, on the right side of a fight. And this was a great opportunity to do that,” he said.

Sheckler is grateful for his time at the Tribune. And he’s grateful his work in Elkhart made a difference: “People took the reporting seriously. There was accountability.”

In the five years since Sheckler and I worked together to investigate Elkhart, the LRN has expanded and created change in communities across the country. To date, ProPublica, through the LRN, has partnered with 71 newsrooms on 90 projects. Exceptional reporters have done extraordinary work in Alaska; Memphis; Palm Beach, Florida; Rhode Island; Vallejo, California; and points beyond.

At the Tribune, another reporter took over the public safety beat that Sheckler had covered for years. That reporter has since left, and now the Tribune is looking to hire a replacement. The Tribune has put up a job posting for a public safety reporter, looking for someone who will “write about serious crime, scrutinize police tactics and spotlight social issues,” and chase challenging stories “with passion.”

by Ken Armstrong

Top Philips Executive Approved Sale of Defective Breathing Machines by Distributors, Despite Tests Showing Health Risks

1 year ago

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After tests showed that breathing machines made by Philips Respironics could spew dangerous particles and fumes into the lungs of patients, the company in April 2021 decided to stop shipping the devices from its factories near Pittsburgh.

Philips notified the Food and Drug Administration and said it was considering a recall.

But for the distributors of the devices, the company had another message: Keep selling them.

Despite the findings of its own scientists that showed the machines posed critical risks to patients, Roy Jakobs, now the CEO of parent company Royal Philips, told his employees that the distributors could continue to sell the devices in their inventory, according to testimony in federal court.

The revelations that unfolded during a hearing in Pittsburgh last week over the parent company’s potential liability for damages casts new light on the inner workings of a global corporation accused of risking the health of patients who used its sleep apnea machines and ventilators, in some cases to stay alive.

“They’re still telling customers who have these devices that they can keep using them,” Caleb Seeley, a lawyer whose firm represents thousands of plaintiffs in claims against the company, told U.S. District Judge Joy Flowers Conti.

An investigation by the Pittsburgh Post-Gazette and ProPublica published last month showed that Philips kept secret more than 3,700 complaints about the faulty devices over the course of 11 years before eventually initiating one of the largest recalls of its kind.

While lawyers for Royal Philips argued in court that the parent company should be shielded from claims and that the responsibility lies with the U.S. subsidiary, Philips Respironics, attorneys representing thousands of patients countered that decisions over the safety of the company’s operations were made at the highest levels of the Dutch corporation.

Philips said in response to questions from the Post-Gazette that Jakobs approved the sale of the machines held by distributors because Philips was still assessing the risks of the devices and its “understanding of the issue was still evolving.”

The company launched a recall to pull the machines from the shelves in June 2021 — two months after the halt on shipping — when additional data became available, Philips said in a statement.

The decision was made “after careful consideration of a reasonable worst-case scenario and in an abundance of caution,” the company said.

But for the two months leading to the recall, Philips did not warn the public that the company had found the risks to patients to be “unacceptable” and that foam breaking down in the devices was emitting chemicals that could cause “life-threatening” injuries or “permanent impairment,” records show.

The move by the company to allow the sale of the defective devices while its own experts were warning about the dangers drew sharp criticism from public health experts interviewed by the Post-Gazette and ProPublica.

“It’s disturbing to hear that they put a hold on the machines at the factory and then it’s being distributed” by the suppliers, said Dr. Robert Steinbrook, director of Public Citizen’s Health Research Group in Washington, which lobbies on behalf of patient safety. “It doesn’t make a lot of sense.”

The evidence disclosing Philips’ directive, which was presented in a slideshow at the Oct. 17 hearing, is the latest in a series of efforts by plaintiffs in court to show how decisions by the company delayed safety measures in what would grow into a worldwide health crisis.

Since the recall two years ago, Philips has changed course and said further tests have shown there is no long-term health impact from the foam — prompting the FDA to issue its own statement on Oct. 5 to say the company’s tests have not been adequate to “fully evaluate the risks” posed to users.

Though medical experts say it can take years to establish any links between the machines and illnesses, FDA records show at least 2,000 cases of cancer have been reported by health care providers and users of the devices, along with 600 kidney and liver ailments and 17,000 cases of respiratory infections.

During the court hearing last week, lawyers for the plaintiffs argued that top executives in Amsterdam for years were aware of the problems taking place in the U.S. involving the machines.

Jakobs had been chief business leader since 2020 of the company’s Connected Care unit, which oversaw the breathing devices. He was named to the CEO position in 2022.

Lawyers for the plaintiffs, who are suing Philips in hundreds of injury claims and a class-action suit to force the company to pay for medical monitoring, told Conti that former CEO Frans van Houten also took on a key role in the U.S. operation.

While leading the company in 2015, van Houten flew to Washington to meet with the FDA to discuss safety issues that had emerged at the Philips plant in Cleveland, Seeley told the court.

In a case that was unrelated to the breathing machines, the company had received warning letters from the FDA over a failure to file reports to the government about problems involving medical imaging devices made at the facility, records show.

During the visit, van Houten met with Jeff Shuren, the head of the FDA division that oversees medical device safety, and Robert Califf, now the agency’s commissioner, FDA records show.

Seeley said van Houten reportedly assured the agency’s top administrators that Philips would be making greater strides to meet safety thresholds.

The previous year, Philips temporarily shut down the Ohio facility after the FDA inspected the plant and found “manufacturing control” problems that had not been properly addressed, the company said.

Philips said in a statement that “we regularly engage with the FDA, and we are committed to continuing to do so.”

Since the June 2021 recall of the breathing devices, Jakobs has attempted to distance the parent company from the crisis, saying during an earnings call in May that the complaints about the machines were handled by the U.S. subsidiary.

“They did some action and they closed it and carried on,” he said to shareholders.

Jakobs and van Houten have previously declined to comment to ProPublica and the Post-Gazette on the company’s handling of the tainted machines. After the recall, then-CEO van Houten said, “I very much regret the impact of the … recall on patients, care providers and shareholders.”

The fight by the parent company to separate itself from the myriad lawsuits comes as more plaintiffs step forward to join the legal cases against Philips and as government scrutiny of the company’s actions deepens.

Just days after the Post-Gazette and ProPublica published the initial investigative story in September, top members of Congress called for immediate action, with Sen. Richard Blumenthal, D-Conn., demanding an investigation and a crackdown on the company by the Justice Department.

Conti said during the hearing last week that the motion by Philips to dismiss the parent company from the proceedings could have sweeping implications for some of the world’s largest corporations. One of the reasons: Multinational companies are made up of many different subsidiaries that operate in different countries with various levels of liability.

Royal Philips controls a global empire with subsidiaries operating across more than 100 countries, and it reported more than $18 billion in revenue last year. Top executives of an operation that large can’t micromanage every plant in their domain, Michael H. Steinberg, a lawyer for Royal Philips, argued at the hearing.

“Philips has [quality] controls,” Steinberg said. “Whether people follow those controls, that’s a separate issue.” Its lawyers argue the company should only have to fight one of the allegations against it: negligence in how it handled the recall — and even then, only for complaints filed in Pennsylvania, the jurisdiction of the federal court hearing the case.

In several high-profile cases, courts have shielded major parent companies from the liability of their subsidiaries, setting legal precedents that entire corporations have organized themselves around, the lawyer for Philips told the judge. “Corporations are trying to be efficient, trying to mitigate risk,” Steinberg said.

Lawyers for the plaintiffs countered that the legal protections normally given to parent corporations don’t apply in the Philips case. Seeley painted a picture of an organization with few boundaries, where top executives like Jakobs weighed in on decisions as minute as what Philips Respironics’ employees should tell their customers.

“Philips is unusual. It’s not the norm,” Seeley said.

One legal expert reached by the Post-Gazette said the evidence in the case, including the actions taken by the top corporate leaders, may ultimately be used in legal matters beyond the liability battle.

“The information that comes out is about who knew what and when did they [know] it,” said Michael Gonzalez, an Ohio lawyer who advises companies on health care compliance. “It’s not only about liability, but the culpability for [violating] the rules.”

Madris Kinard, a former FDA analyst who has examined many of the complaints filed with Philips about the defective machines, said the company was aware of the breakdowns in the devices years before the recall. “They could have acted earlier, and they could have acted with integrity when learning of the risks posed by the foam,” said Kinard, founder and CEO of the York, Pennsylvania-based health data group, Device Events. “This Philips recall is going to be held up as an example of what not to do.”

by Michael D. Sallah and Mike Wereschagin, Pittsburgh Post-Gazette

Secrecy Shields Powerful Adults in Our Juvenile Justice Systems. Kids Showed Me What’s Really Happening.

1 year ago

This article was produced in partnership with WPLN Nashville Public Radio, a former member of ProPublica’s Local Reporting Network. Sign up for Dispatches to get stories like this one as soon as they are published.

It has been a little over three years since I began my reporting on juvenile justice in Tennessee. Until then, I hadn’t paid much attention to juvenile courts. For a reporter, they’re difficult to cover with any kind of intimacy. They are shrouded in secrecy in a way adult courts are not. The records are sealed. The proceedings are mostly private. And it’s for good reason: The dumb stuff you do as a kid shouldn’t follow you into adulthood.

But this privacy has its downside, because it can shield the adults in charge from accountability. And as I soon found out, juvenile justice in the state does need someone — maybe a reporter — to pay attention.

Tennessee has 98 juvenile courts and even more juvenile judges. Those judges have a lot of discretion, making decisions on everything from whether to take a case to whether a kid should get locked up and for how long. What’s more, in Tennessee, kids have no right to a jury trial. So, there’s really no check to a judge’s authority in a case — they decide how to interpret the facts and the law.

“It’s like the Wild West out here,” one juvenile defense lawyer told me. “Each judge is its own county, some are hard on crime, some are progressive.”

I can tell you from my reporting, he’s not wrong. Along with my colleague Ken Armstrong, I embarked on this story, now a podcast, to try to see inside one county’s juvenile court system, where an all-powerful judge and the jailer she appointed were playing by their own rules and the children were caught in the middle. But I learned about other juvenile justice systems along the way.

In a county about 20 miles northeast of Nashville, I observed a hearing on a case involving a group of kids, one armed with a BB gun, who had stolen a phone and car keys from a teen couple. The hearing was for a 16-year-old girl who had held onto the stolen phone during the robbery. The assistant district attorney, known for his tough-on-crime approach, had charged her with aggravated robbery and filed a motion to have her case transferred to adult court. Despite pleadings by her attorney — this was the girl’s first offense, she’d been questioned by police without a parent or guardian present and was never read her Miranda rights — the judge granted the transfer. That means that this case, and any subsequent infraction, no matter how minor, would go straight to adult court, where the girl would face the same penalty as a grown-up. When the hearing ended, the girl, who stood less than 5 feet tall, was handcuffed and taken away with a bond set at $10,000. “I about died,” her lawyer told me afterwards.

The woman who conceived of juvenile court at the turn of the 20th century, a Chicago social worker named Jane Addams, believed that children could be corrected and rehabilitated because of their young age. And she believed that juvenile courts could step in to help make rehabilitation happen, acting in loco parentis — in place of the parent. Which meant making decisions in the best interest of the child.

That was the hope for Sharieka Frazier, the mother of a boy named Quinterrius Frazier, who was featured in our original investigation. They lived in Rutherford County, Tennessee, and when Quinterrius was in his early teens, he started running away, disappearing for a day or longer and hanging out with older kids. It worried Sharieka no end, so she started to track his phone. She’d go knock on doors looking for him.

Sharieka Frazier hoped the juvenile justice system would help her son. Instead, he wound up in prison. (Stacy Kranitz, special to ProPublica)

But as Quinterrius got older, his mother began to lose her grip on him. He stopped playing basketball, a sport that had kept him focused and engaged. And he started hanging out with older kids who spent their free time on less wholesome activities. So Sharieka turned to the juvenile justice system for help. She called the police and took out a runaway petition (treated as a warrant) on Quinterrius to get him back home. “I just figured anything’s worth trying at this point,” Sharieka told me. “I was desperate. I didn’t have any help. I didn’t know what else to do. So that was where I turned.” Sharieka isn’t an outlier. I came across a number of cases where it was parents or relatives who made that first call to police, hoping law enforcement would step in to help.

As years passed, Quinterrius got sucked deeper and deeper into the juvenile justice system. Rehabilitation didn’t materialize. But a life of incarceration did.

When you spend time in juvenile court, you can still see the remnants of this rehabilitative mission. It’s there in the lingo of the court: There are “petitions” or “summons” instead of “warrants,” “juvenile delinquents” instead of “criminal defendants.” Courts make “determinations” on cases rather than handing down “convictions.” There are juvenile “detention centers” instead of juvenile “jails,” youth “development centers” instead of youth “prisons.”

But after years of covering the juvenile court system, I’ve come to realize that this belief in treating kids differently isn’t much more than semantics. During my reporting, I saw what amounted to a carbon copy of the adult system.

Rutherford County Juvenile Detention Center, where for years children were jailed illegally (Stacy Kranitz, special to ProPublica)

In Rutherford County, where our new podcast takes place, children were wrongfully arrested and jailed illegally for years. At least hundreds, likely thousands of kids, were stripped of their civil rights, arrested and held in jail when their alleged offenses didn’t meet the state’s legal criteria for incarcerating children. Some were then placed in solitary confinement. (You can read our 2021 investigation.) But just how much this juvenile justice system has strayed from Addams’ ideals, and the ways that the officials and court staff are complicit in that, is what kept me reporting on this story for years after the ProPublica articles were published.

I needed to clearly understand exactly how this had happened and to let you, the listener, hear directly from the people responsible, the people impacted and the people who tried to fight back. Because this wasn’t some state secret. Some of what was happening to kids in Rutherford County was known to officials. Years before its juvenile court was mired in lawsuits, the federal government had cited it for keeping kids locked up for too long. The county’s juvenile judge, Donna Scott Davenport, typically sentenced kids to two to 10 days in jail for cursing in the courtroom, which was common. Davenport was reprimanded for it, which led to a loss of grant money and some bad PR, but she didn’t seem bothered. “Was I in violation?” she told the local paper. “Heck yes. But am I going to allow a child to cuss anyone out? Heck no.”

A 2020 report by Human Rights for Kids, a nonprofit that investigates and reports on the human rights of children, ranked Tennessee one of the worst states in the country for its inability to protect the rights of children in the justice system. When our reporting on Davenport’s behavior came out, the local university where she was an adjunct lecturer cut ties with her. Later she announced she would not seek reelection and retired at the end of her term.

“Despite what you may hear about in the media, there is no such thing as ‘scaring a child straight,’” said Kathy Sinback, the longtime administrator in Davidson County’s juvenile court. “The evidence shows that children struggling with behavioral issues have the best outcomes when they are provided with support, encouragement, and positive opportunities — not isolation, fear and shame.”

I heard this same sentiment from the young people I spoke to. I met with one young man who was first arrested for truancy at 12. It was right after his mother died of a drug overdose and he was sent to live with a grandmother he barely knew. He wound up spending a decade in prison. “I wasn’t really a bad kid,” he told me, “ I was just a hurt kid.”

When I asked a few longtime juvenile court lawyers and administrators what they’d tell families who found themselves in the crosshairs of this system, their advice was to pay attention, ask for representation and don’t expect harsh punishments to fix a kid’s bad behavior. Chris Kleiser, a public defender of kids in Knox County, recommended asking for a lawyer for your child “at the earliest possible stage. And that includes if law enforcement wants to speak to your child before charges are ever brought.”

But even access to a lawyer isn’t guaranteed. Recently, the dearth of lawyers available to judges has hit a crisis point in Tennessee. According to the state’s administrative office of the courts, nearly half of all cases with a court-appointed lawyer are in juvenile court, and finding lawyers willing to take these cases is harder than ever. The juvenile judge in Henry County said her list of available lawyers is the shortest it has been in her 17 years on the bench. What’s more, Tennessee’s reimbursement rate for these lawyers — $50 an hour — is the lowest in the country and it hasn’t changed since 1994.

Addams conceived of juvenile court with a clear-eyed mission to rehabilitate the child. In Tennessee the juvenile delinquency statute is explicit: Decisions must be “in the best interest of the child.” But, as one lawyer put it to me, “that means whatever the judge thinks.”

Some places have explored newer and more child-focused approaches. In Nashville, for example, juvenile Judge Sheila Calloway launched Tennessee’s first restorative justice program for youth offenders, through which children accused of crimes as serious as aggravated burglary, felony theft or even homicide can be diverted away from the court system completely. Instead of meting out justice in a courtroom, a community-based organization guides conversations between victims and offenders, working toward truth and reconciliation and making meaningful amends.

“The less we use draconian measures, the more successful we are,” Calloway said when the program launched in 2018.

Davenport, who was featured in the podcast, did not subscribe to that point of view. Over and over she said, “​​We don’t punish our children at all. It’s all about treatment.” “I want the children that come in front of me to leave better than they came in,” she said. But Davenport’s actions belied her words.

Watch video ➜

In Rutherford County, kids as young as 7 were being jailed, in violation of the law. And Tennessee is moving further in Davenport’s direction: Today, state lawmakers are working to make harsher sentences for children more accessible to judges. Waiting in the wings for the next legislative session are a flurry of bills that would make it easier to transfer a child to adult court and increase juvenile punishments.

The bills have been criticized by juvenile attorneys, the ACLU and national experts. And the concerns raised about the bills also showed up in my conversations with lawyers, judges and experts, not to mention dozens of people jailed as kids: increases in recidivism, educational disruptions, mental health issues, trauma and a boatload of other negative outcomes.

“You want to believe that you can trust your justice system and your judges and with your children,” said Karerra Brewington, who was arrested as a child and whose brother was jailed repeatedly for much of his youth. “But you know, it ruined my life, it ruined my brother’s life.”

Another young man, Dylan Geerts, was 15 when he was illegally jailed by Rutherford County for breaking into unlocked cars and stealing a small radio, some loose change, a hat, a phone case and cologne. Dylan had never been arrested before, let alone jailed. But when police took him to the Rutherford County Juvenile Detention Center, staff there locked him up for four days. He proceeded to unravel emotionally and mentally.

I spoke with Dylan eight years after his incarceration. He’d become the named plaintiff in a class-action lawsuit against Rutherford County over its illegal policy that jailed so many kids, including himself. (Eventually that suit was settled and Dylan got $25,000 from it.) I asked him what he thought of Davenport’s statement that children should leave the system better than when they arrived. He looked right at me, shook his head and said, “They’re not coming out better than they went in.”

Dylan Geerts was illegally jailed in Rutherford County when he was 15. (Stacy Kranitz, special to ProPublica) Listen to and Follow “The Kids of Rutherford County”
by Meribah Knight, WPLN/Nashville Public Radio

Dairy Workers on Wisconsin’s Small Farms Are Dying. Many of Those Deaths Are Never Investigated.

1 year ago

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On a below-freezing morning in March 2013, Israel Lepe Quezada was crushed to death while working on a dairy farm in northeast Wisconsin. The farm’s owner had found Lepe pinned between the engine compartment and hydraulic arms of a forklift-like machine.

Almost six years later, Blas Espinoza Cuahutzihua was killed when the arms of a skid-steer loader, another kind of farming vehicle, fell on him at the dairy farm where he worked near the Minnesota border. His last words, according to court documents, were to say goodbye to his family.

And one night in March of this year, Florencio Gómez Rodríguez drowned after he drove a skid steer into a 14-foot-deep pond filled with cow manure on a dairy farm where he worked.

When the daughter of the farm owner called 911, she told the dispatcher it was unlikely Gómez had survived. “Usually when you go down, you don’t normally come back up,” she said. “It’s thick.”

An autopsy found traces of manure in Gómez’s airway.

In all three cases, inspectors from the Occupational Safety and Health Administration, the federal agency responsible for workplace safety, went to the farms. And in all three cases, they left within an hour — without conducting investigations into the deaths.

The inspectors concluded they couldn’t investigate because OSHA is banned from enforcing safety laws on farms with fewer than 11 workers unless they have employer-provided housing known as a “temporary labor camp.”

Since 2009, at least 17 workers, most of them immigrants, have died on Wisconsin dairy farms. Twelve of the deaths happened on farms with fewer than 11 workers. OSHA did not inspect eight of those 12, each time citing the small farms exemption.

Records reviewed by ProPublica and interviews show that the agency may have more power to open an investigation into these farms than even its own leaders seem to be aware of.

When Lepe, Espinoza and Gómez died, it’s unclear whether OSHA inspectors tried to determine if the farmers who employed them provided housing for their workers before deciding there wasn’t a temporary labor camp and leaving. Had the inspectors taken a slightly closer look, they might have learned that the farmers had readily talked with law enforcement officials about providing housing for their immigrant workers.

And if the inspectors had read OSHA’s own files, they would have known that the agency has repeatedly, though inconsistently, inspected small farms after concluding a housing arrangement was a temporary labor camp.

How OSHA interprets and applies its definition of a temporary labor camp — and whether it should consider dairy workers temporary when farms produce milk year-round — has significant implications for the safety of thousands of workers in one of America’s most dangerous industries.

It is the difference between workers’ deaths, injuries or safety complaints being investigated or ignored. Without OSHA inspections, no one ever determined whether the deaths of Lepe, Espinoza or Gómez could have been prevented.

“Nothing was investigated at all,” said Lepe’s sister, Enedina Lepe Quezada. “He died. His body was sent home. We buried him. And then there was silence.”

Israel Lepe Quezada (Courtesy of Enedina Lepe Quezada)

The three men — all undocumented immigrants from Mexico — died from well-known hazards in agriculture. In two of the deaths, workers were performing dangerous tasks that OSHA includes on its “Dairy Dozen,” a list that is supposed to help inspectors and farmers ensure that farms are safe workplaces.

“We need to do everything to prevent worker deaths,” said Amy Liebman, a chief program officer with the nonprofit Migrant Clinicians Network who focuses on worker health and safety. “Whether they are on a smaller farm or a bigger farm, the idea behind OSHA going out is to understand what happened and stop it from happening again.”

ProPublica asked OSHA to explain why the agency didn’t open an inspection after the most recent death, that of Gómez in the manure lagoon. Reporters also asked OSHA to clarify whether it continues to view employer-provided housing for immigrant workers as a basis for opening inspections on small farms.

OSHA officials declined interview requests but responded to some written questions. The agency first said that Gómez lived “in a different town and paid for his own housing” and that the farm he worked for did not provide housing for its workers. Reporters told the agency that interviews and law enforcement records showed that Gómez and other workers lived in a house down the road provided by the farm owner and that another worker lived in a trailer on the farm. In response, OSHA officials said that an inspector hadn’t found evidence of a temporary labor camp.

What OSHA calls a temporary labor camp has varied from case to case. The agency has said it wouldn’t consider employer-provided housing a temporary labor camp if the workers’ jobs were permanent. Yet OSHA case records from 2009 to as recently as spring 2022 show that the agency has repeatedly described immigrant or Hispanic dairy workers who lived in employer-provided housing as temporary workers.

ProPublica identified five cases — four deaths and one complaint — on small Wisconsin farms where OSHA said housing for immigrant workers constituted a temporary labor camp, giving it jurisdiction to open investigations.

Former OSHA officials said the agency’s scattered approach might be a byproduct of disorganization or shifting priorities in a large bureaucracy that’s responsible for inspecting hundreds of deaths in all kinds of workplaces each year. Jordan Barab, a former deputy assistant secretary at OSHA during the Obama administration, said he was “mystified” that the agency would inspect some small farms that housed immigrant workers but not others. “It is essential for OSHA to have a consistent and consistently applied policy especially when it comes to controversial issues like this,” he said.

This uncertainty creates challenges for dairy farm owners and their workers. Farmers are often unaware that OSHA can set foot on their farms, much less conduct multiday investigations of deaths or injuries. Lawyers and advocates for dairy workers say they don’t even bother calling OSHA when workers are killed or injured on smaller farms because they’re so used to the agency citing the small farms exemption.

Lola Loustaunau, an assistant professor at the University of Wisconsin-Madison School for Workers, said that “it would really open the door for a lot of protections for workers” if OSHA consistently inspected small dairy farms that provide housing to immigrant workers.

“If they are politically interested in doing something,” she added, “it looks like they have all the basis to do it.”

The small farms exemption — a limitation Congress has written into OSHA’s budget each year since 1976 — was intended to protect small family farms from government overreach. It’s so ingrained in American agriculture that many dairy farmers assume that OSHA won’t even try to go onto their property.

So when OSHA officials were notified in October 2009 that a worker had drowned in a manure lagoon on a dairy farm in western Wisconsin, they first had to determine whether the small farms exemption would apply.

OSHA inspectors quickly learned that Val-O-Mo Farm, the dairy farm where José Candelario Zacarías Rayón died, had just five workers apart from the farmer’s family members. Zacarías and three other immigrant workers lived in a trailer on the property. In their report, the inspectors dedicated more than a full page to explaining why that trailer counted as a temporary labor camp that would put the farm under the agency’s jurisdiction.

Though dairy work is year-round, Zacarías and the other workers’ status as immigrants made the employer-employee relationship a temporary one, the inspectors wrote. There is “no defined milking season,” they wrote, but workers are hired “with the understanding that they were offered employment” for the “duration of their own choosing and that they were able to come and go from the farm to return to Mexico to visit their families.”

OSHA inspectors wrote that the on-site housing helped ensure the farm always had workers on hand. The workers didn’t own cars and relied on family and friends to help them get food and other essentials. (Wisconsin bans undocumented immigrants from getting driver’s licenses, as ProPublica has previously reported.) There weren’t any nearby alternatives for housing, and workers weren’t charged rent, creating incentives to live on the farm. Inspectors also found that “Hispanic employees were provided little time to rest in between shifts and therefore living offsite, although technically allowed, was impractical to the Hispanic workforce.”

The housing arrangement at Val-O-Mo remains standard at dairy farms of all sizes in Wisconsin and other parts of the country. Nationally in 2019 about three-quarters of dairy farms provided housing or a housing allowance to their workers, according to a survey commissioned by a dairy industry association.

OSHA’s investigation found that a guardrail at the push-off platform to the approximately 7-foot-deep manure lagoon had fallen off or been removed several years earlier and had never been replaced.

The farm owners told OSHA they had often warned employees to be careful near the edge of the lagoon’s platform. According to OSHA’s inspection report, Steven Weinzirl, one of the owners, “stated that although he was not denying he personally was at fault,” he believed Zacarías knew what he was doing “since he had been performing the task for nearly two years.”

Weinzirl installed a new guardrail on the manure lagoon after Zacarías’ death, records show.

OSHA also found that Zacarías had worked about 40 hours in the three days leading up to his death, and that he “was in a state of fatigue.” What’s more, inspectors noted, it “was not uncommon for the Hispanic farmhands to perform off the clock work beyond the normal set schedule.”

Workers had also complained about the long hours to the local sheriff’s department when it investigated Zacarías’ death. (The drowning was ruled an accident.) One worker said Zacarías sometimes slept in the cattle stalls in the barn, “saving him the time from walking from the cattle barns back to the trailer house to be able to go to bed so he would be able to get more sleep,” according to the Dunn County sheriff’s report.

One of Zacarías’ nephews, who worked on a nearby dairy farm at the time, said he rarely saw his uncle because they both worked so much. “You work and you sleep,” he said in an interview.

OSHA issued citations to Val-O-Mo for nine safety violations. The agency has few rules that pertain specifically to agriculture, and none about manure lagoons. But OSHA used its catchall “general duty clause” to cite the farm for failing to protect its employees from a recognized danger likely to cause death or serious harm.

Months after OSHA opened its inspection, Weinzirl questioned why the agency considered the trailer a ”temporary labor camp,” records show. But he agreed to correct the safety violations on the farm and paid $4,320 in fines. He declined to comment for this story.

Zacarías was 31 when he died. He left behind a wife in Mexico, according to relatives.

People who study agricultural safety say OSHA inspections are important because they prompt farms to become safer for workers, farmers and their families. Inspectors interview workers about hazards and safety measures, such as whether they received training to operate machinery in a language they understand or if they were taught how to deal with dangerous chemicals. The inspections also show workers that there’s a government agency they can call with confidential safety complaints, though many are unlikely to do so for fear of getting fired or deported. There can also be ripple effects, as other farmers might take corrective actions on their own farms.

After Zacarías’ death at Val-O-Mo, OSHA began to pay more attention to Wisconsin’s dairy industry, which had undergone a dramatic transformation from mostly small, family-run farms to larger operations that required hired labor. Many of those workers were undocumented immigrants.

The agency launched a program dedicated to improving safety on dairy farms across the state. And OSHA continued to use the temporary labor camp provision, even if inconsistently, to investigate deaths from known hazards on small farms. In one case, a 17-year-old boy from Mexico was crushed to death while herding cows into an indoor corral on just his 10th day of work.

Dexter Covey, a former OSHA inspector who conducted some of those investigations, said he understood that many dairy workers were immigrants who traveled back and forth from Wisconsin to visit their families in Mexico. He said inspectors used a clear set of criteria to determine whether housing provided to immigrant workers would allow OSHA to open an inspection. They also interviewed farmers and workers about the housing.

“I don’t think they were trying to hide anything,” Covey told ProPublica.

But the work Covey and his colleagues did to investigate deaths on small farms with housing doesn’t appear to have been well-known to top OSHA officials, both in the Midwest and nationally.

John Newquist, a former assistant administrator for the Midwest region, said he wasn’t aware of those investigations until ProPublica shared a copy of one of the reports with him. Had he known about the investigations, Newquist said, he would have encouraged inspectors to look for worker housing so they could investigate deaths on small farms. He said the small farms exemption was a source of frustration for OSHA inspectors “because you get out there and you can’t do anything because it’s a family farm.”

Years after Newquist retired, one family challenged OSHA’s right to inspect their farm, and the dispute made it to top agency officials in the Midwest. Those officials were resolute about OSHA’s jurisdiction.

In 2017, OSHA received a complaint about an employee who had been injured by a cow on a small farm in northwest Wisconsin. When OSHA inspectors arrived, and in the months that followed, the Byl family said they thought their farm was exempt from inspections because it only had five workers, records show. They questioned whether the trailer they provided should be considered a temporary labor camp when workers weren’t required to live there. Plus, they said their employees weren’t temporary.

“My farm is a family affair and we are taking this to heart,” the Byls wrote to OSHA. “We had no idea we qualified under OSHA standards and we are working diligently to comply.”

The Byls asked the Wisconsin Farm Bureau Federation and their congressional representative, Sean Duffy, to help them verify whether OSHA had jurisdiction over their farm. Both Duffy and the Farm Bureau wrote to OSHA on the Byls’ behalf. A Farm Bureau official even attended a meeting with OSHA and questioned its jurisdiction.

During that meeting, OSHA’s Eau Claire area director acknowledged the “grey or borderline issue surrounding the temporary labor camp definition” but maintained the agency had jurisdiction, records show. OSHA never determined whether a worker was actually injured and, in fact, identified a number of safety features on the farm, including 2-foot-high concrete barriers around the manure lagoon. Still, OSHA fined the farm $650 for its failure to provide workers with safety training or manuals for handling chemicals used on the job.

The Byls declined to comment. Duffy, a Republican who is no longer in office, did not respond to an interview request. A spokesperson for the Wisconsin Farm Bureau Federation referred reporters to OSHA.

Even as OSHA investigated some deaths on small farms in Wisconsin that provided housing to immigrant workers, the agency didn’t investigate other farms with the same sort of housing. In some of these cases, records show, the farmers had spoken openly to law enforcement and medical examiner officials about the housing they provided their workers.

That’s what happened when Lepe died on a farm just outside of Green Bay on March 3, 2013. Records show the owner of the farm told Brown County sheriff’s deputies that Lepe lived in a bunk room above the milk house. A medical examiner’s report notes that Lepe lived on the farm, Ranovael Dairy. OSHA records are limited due to the age of the case, so it’s unclear whether the inspector who went to the farm the following day ever learned this information.

Lepe began his shift at Ranovael Dairy around 6 a.m. on the day he died. The temperature was in the single digits, and he wore pants and a thermal undershirt under his camouflage insulated coveralls and boots.

Less than two hours later, Ray Vanden Elzen, the farm owner, found Lepe crushed by a telehandler, a rough terrain forklift that can be used to move or lift heavy materials and is known to pose significant safety risks. Lepe had gotten pinned between the machine’s engine compartment and its hydraulic arm, according to the sheriff’s report.

“The loader malfunctioned and the hydraulics released, causing the weight of the loaded scoop to fall to the ground,” a sheriff’s sergeant wrote. “This caused the cross arms to crush the mid section of the deceased victim’s body.”

Vanden Elzen could not be reached for comment.

Lepe had worked at Ranovael for about eight years and did “everything” on the farm, Vanden Elzen told Brown County medical examiners. He also told sheriff’s deputies that he knew that Lepe was undocumented and had used an alias “to avoid deportation for several years,” records show.

Lepe had grown up working with cattle on a small farm in the Mexican state of Jalisco, and he enjoyed his job in Wisconsin, his sister told ProPublica.

But it was dangerous. A few weeks before he died, Lepe told his sister that he had lost the tips of two fingers in a farm accident.

Lepe was 29 and a widower. He left behind a young daughter.

Almost six years later, another worker was crushed by similar machinery on a farm on the other side of the state.

Crawford County sheriff’s deputies investigating the Jan. 12, 2019, death of Espinoza on a farm in Steuben, in western Wisconsin, noted that he lived on-site. The farm owner, Eugene Fritsche, even told deputies that Espinoza and another worker left the farm “only one time a week to go shopping for food,” and that they “always stayed on the farm and sent all of their money back to their family in Mexico,” according to a sheriff’s report. The county coroner also said that Espinoza lived on the farm.

Despite this, an OSHA inspector who spoke with Fritsche noted that “the farm did not supply housing” for the two workers. It’s unclear how OSHA reached that conclusion.

Espinoza had been standing next to a skid steer, removing manure and mud from the machine, according to a report from the sheriff’s department and an ongoing wrongful death lawsuit filed against the farm by Espinoza’s family.

At some point, Espinoza became pinned between the machine’s cab and hydraulic arms, which crushed his thighs and abdomen. A co-worker in the milk house heard him scream and ran over.

Fritsche told deputies that he thought Espinoza had accidentally activated the skid steer’s arms to move them downward. He said the machine had safety mechanisms, “but Blas did not have those engaged to lock the arms in place.”

The lawsuit alleges that Fritsche knew that the skid steer had mechanical problems but failed to provide the “necessary protection, training, or concern for Mr. Espinoza’s safety.”

In court records, the farm and its insurance company have denied the allegations. Their attorney declined to comment. A woman who answered the door at Fritsche’s home also declined to comment, as did a lawyer for Espinoza’s family.

Espinoza was undocumented, according to relatives. A sheriff’s deputy who asked Fritsche about his workers’ immigration status wrote that he simply “took what paperwork he was given” by them and “used that information on their employee paperwork.”

Espinoza was 45. He left behind a wife and two children back in the eastern Mexican state of Veracruz.

Local authorities ruled both deaths as accidents.

Since Espinoza’s death in January 2019, at least seven other workers have died on Wisconsin dairy farms. One was crushed against a wall by a cow. Another was disemboweled by machinery in a grain silo. Another was pinned under a tractor that had tipped over.

In the most recent death, that of Gómez, who drowned in a manure lagoon on March 28, the OSHA inspector asked about Gómez’s housing but failed to find out where he and other workers lived.

An OSHA inspector showed up to the farm in Melrose, in western Wisconsin, the morning after Gómez’s death and spoke to the owner, Donald Antal Jr. The inspector’s interview notes indicate that the Antal Dairy Farm employed six workers and that Antal said Gómez “did not live on our property.”

But Gómez and a few other men who worked on the farm lived together in a house provided by the Antals for their workers about a half-mile down the road from the farm, ProPublica learned through interviews and law enforcement records. Another worker lived with his family in a trailer on the farm. It’s unclear whether the inspector ever learned about any of this housing for workers or took it into account when deciding that the small farms exemption applied.

On the night he died, Gómez was supposed to be operating a skid steer to scrape cow manure off a barn floor and into the nearby manure lagoon. But nobody could find him.

His coworkers looked out to the black surface of the 150-by-50-foot lagoon. Manure lagoons pose well-known drowning risks; due to their steep walls and manure’s slippery texture, they are nearly impossible to get out of.

Through the dim light from the barn, workers could see several inches of white metal sticking out above the manure. It was a part of the skid steer.

Workers alerted Antal, who rushed to the manure lagoon. Antal’s adult daughter called 911: “A worker fell in the shit pit and sunk and they think he’s dead.”

The skid steer was submerged 15 feet from the edge of the manure lagoon. Firefighters used a boat to reach it so they themselves wouldn’t drown and linked a chain to the skid steer. Then Antal hauled it out with a tractor.

A window at the front of the vehicle was shattered, and manure had filled the cabin. Gómez was inside, slumped over in his seat. He died of asphyxiation, according to the medical examiner’s report.

Gómez had a blood alcohol concentration of 0.18%, more than twice the legal limit for driving. Bonnie Kindschy, the Jackson County medical examiner, said she has no way of knowing whether Gómez would have fallen into the manure lagoon if he hadn’t been drinking. His death was ruled an accident.

Kindschy called OSHA because she believed Gómez’s death was clearly work-related and she thought it needed to be investigated. And OSHA does investigate workplace injuries and deaths regardless of whether workers were intoxicated or using drugs.

But OSHA didn’t investigate Gómez’s death. No other agency that responded to the emergency that night asked whether the lagoon had a barrier in place to prevent people and machines from falling in or, if there was a barrier, whether it was strong enough to hold back a 6,700-pound skid steer.

A collection box for Florencio Gomez’s family at a Mexican grocery store where he used to shop in Eau Claire, Wisconsin (Maryam Jameel/ProPublica)

Jackson County Sheriff Duane Waldera said his department had looked into whether a crime was committed, not farm safety. “We didn’t look into barricades and how farms should be,” he said in an interview.

Antal declined to comment.

Gómez was 32. He was also undocumented, a family member told ProPublica, though the Antals found some type of U.S. identification card with Gómez’s name on it in the “farmhand living quarters,” according to the sheriff’s report.

A Veracruz native, Gómez had worked on Wisconsin dairy farms for about half his life and had worked at Antal Dairy for about 30 days before he died. He left behind a wife and a daughter. He had been saving up to bring them to the U.S.

Outside of their immigrant communities, the deaths of Israel Lepe Quezada, Blas Espinoza Cuahutzihua and Florencio Gómez Rodríguez received little attention.

After Gómez died, the owner of a Mexican grocery store and restaurant more than an hour north of Antal Dairy put a small donation box near the register. A photo of a smiling Gómez in a Green Bay Packers winter hat was taped alongside a handwritten note in Spanish. “We are asking for donations for our friend Florencio who suffered an accident at work,” the note read. “The help is for his family.”

In April, a small caravan of immigrant workers traveled across the Minnesota border to the town of Saint Michael to attend a visitation at the funeral home that handled the arrangements to send Gómez’s body home.

Many of the people who were at the farm the night Gómez drowned, including the medical examiner and the local fire chief, said they wonder if his death could have been prevented.

Tim Kunes, the chief of the Melrose Fire Department, said he learned OSHA had decided not to investigate when he returned to the farm a few days later and spoke with the owner of the farm. He said he was surprised to learn OSHA hadn’t opened an investigation.

Kunes runs a small farm himself, though he doesn’t have any employees. But he said most of his neighbors with dairy farms do have workers, and they’re often immigrants. All of the farms, he said, have fewer than 11 employees.

“So their magic number is 11 and above?” he said.

In general, Kunes said, he doesn’t like the idea of more government regulation or fining small farms. But he knows how dangerous farming can be.

“Could it have been stopped with a couple of simple measures?” Kunes asked of Gómez’s death. “Maybe. We’ll never know.”

Recently Kunes noticed something new when he drove past the Antal Dairy Farm: a fence around the manure lagoon.

Help ProPublica Journalists Investigate the Dairy Industry

Illustrations by Cuauhtémoc Wetzka for ProPublica

Mariam Elba contributed research. Jeff Frankl and Jeff Ernsthausen contributed data reporting.

by Maryam Jameel and Melissa Sanchez

Voters in at Least 10 States Are Trying to Protect Abortion Rights. GOP Officials Are Throwing Up Roadblocks.

1 year ago

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In Ohio, a GOP-controlled agency rewrote language for a ballot measure that would guarantee access to abortion in the state constitution, swapping in new wording that opponents said was designed to confuse voters. In Missouri, a Republican official launched legal challenges that have stalled a citizen-led effort to pass a law guaranteeing reproductive health care. And in Michigan, a Republican lawmaker went one step further, introducing a bill that would undo a popular new access law.

In the year since Roe v. Wade was overturned, Gallup polling shows that a majority of Americans believe abortion should be legal, with two-thirds of those polled saying it should be permitted in the first trimester.

To protect access to reproductive care, coalitions across the country are organizing ballot initiatives — a democratic tool that enables proposed amendments to become state law with enough petition signatures.

But abortion-rights advocates say their opponents are increasingly matching their efforts with an assortment of legal and political challenges that have stalled or even blocked their ability to introduce initiatives.

To do so, anti-abortion lawmakers and others are using strategies from the playbook of conservatives who sought to restrict access to voting, even trying to change the rules for citizen-led initiatives. ProPublica found legislation or proposals introduced in at least four states in the last year that would undermine ballot initiatives adding abortion protections to state law.

Sarah Walker, policy and legal advocacy director at the Ballot Initiative Strategy Center, said that efforts to make ballot initiatives harder to pass are not new, but they’ve intensified after several wins for abortion advocates. Last year, voters in red states such as Kentucky and Kansas rejected amendments that were intended to restrict the procedure.

“Voters are smart, and they see through politicians who are trying to tilt the scales and the levers of power of democracy, and take away freedoms to make decisions about their lives,” Walker said.

Currently, efforts to bring the issue of abortion rights — both for and against — directly to voters are underway in at least 10 states, according to the Ballot Initiative Strategy Center, an organization that implements a national progressive strategy to support ballot measures across the country.

In at least one state, Missouri, voters in 2024 may face dueling ballot initiatives: one in favor of abortion access and another restricting the procedure.

In Ohio, abortion-rights advocates said their opponents, including the secretary of state, were willing to upend the entire ballot initiative process to keep a reproductive freedom amendment off the ballot. Voters didn’t back the proposed changes, and the amendment, which would make abortion legal in some cases, is on the November ballot.

Anti-abortion groups see such ballot measures as a threat — and an end-run — to their work with state legislatures to ban the procedure.

Carol Tobias, president of National Right to Life, said that countering direct-to-voters ballot initiatives has been an uphill battle for her group. She warned that the rise of such initiatives risks making state legislatures obsolete.

“Well, now if we’re going to start making our laws based on amending the constitution, I think constitutions become meaningless,” Tobias said.

Similar Strategies

Abortion-rights advocates say the fight to stop voters from protecting access to the procedure looks a lot like the fight to restrict voting rights in general. Many of the same Republican lawmakers who supported laws limiting access to the ballot box also seek to prevent citizen-led drives to enshrine reproductive health care into state constitutions, advocates say.

Walker said efforts to undermine ballot initiatives have played out in three ways: Officials have proposed laws changing the process, made legal challenges at each step of an initiative’s process or tried to make enacting the initiative more burdensome once it’s passed.

Officials in at least four states, Ohio, Michigan, Florida and Missouri, have used such tactics.

Last November, Michigan voters approved codifying abortion rights in the state with its reproductive freedom ballot initiative. Then roughly seven months later, state Republican lawmaker Neil Friske proposed bills that would amend the state constitution to remove the reproductive amendment as well as bring back a 1931 abortion ban.

“While unlikely to pass, this package should serve as a guideline for Republican pro-life legislators. This pro-life model should be the official Republican platform for life,” Friske said in a statement at the time.

In Ohio, abortion-rights advocates have faced a few hurdles to get their proposed amendment on the November ballot.

In May, Republican state lawmakers passed a controversial resolution to hold a special election to raise the threshold needed for a citizen-led amendment to pass. At a June event, Secretary of State Frank LaRose said he supported the proposal to make it harder to change the constitution in response to an effort to enact abortion protection.

“This is 100% about keeping a radical, pro-abortion amendment out of our constitution,” he said, according to audio obtained by a local Cleveland TV station. The proposal, known as Issue 1, which would have made ballot initiatives harder to pass, was defeated in an August special election.

Next, the Republican-led state ballot board in Ohio changed the language for the reproductive rights amendment. Instead of “fetus,” the board substituted “unborn child.” Ultimately, a ruling from the Ohio Supreme Court has allowed the language to stay for the upcoming ballot measure.

Catherine Turcer, executive director for Common Cause Ohio, an organization dedicated to pro-democracy efforts, said that the organization supports the reproductive freedom amendment and that the board’s summary is too partisan.

“It’s not fair to the voters of Ohio who go to the polls expecting accurate, neutral information,” Turcer said.

In Florida, the Republican attorney general, Ashley Moody, filed a legal challenge to the state Supreme Court in response to a ballot measure that would protect abortion access. In an op-ed, Moody said: “I am pro-life, unabashedly so. … But my decision to oppose the placement of Floridians Protecting Freedom, Inc.’s initiative on the ballot has nothing to do with my personal views on abortion.” Moody argued the amendment was “misleading.”

The Dobbs v. Jackson Women’s Health Organization decision, which overturned federal abortion protections in Roe v. Wade, was a victory for the National Right to Life, one of the oldest anti-abortion organizations in the U.S. Tobias, the group’s president, said the organization worked on a strategy to counter ballot initiatives seeking to add abortion rights into state law.

Tobias said the group’s members learned from their experience in Kansas, where voters decided to keep abortion legal in a state that voted for former President Donald Trump in 2020. “They were overwhelmed. It was hard for them to counter the message,” Tobias said. “They weren’t told that this was going to prevent the state from allowing any limits on abortion whatsoever.”

Abortion is legal in Kansas until the 22nd week of pregnancy.

Citizen Drives Followed Dobbs

The momentum with abortion-related ballot initiatives began before the Supreme Court overturned Roe last year.

In the 2022 midterm, abortion showed up on the ballot in at least six states, and in every state voters preserved access to abortion — including red states such as Montana, Kansas and Kentucky, where the ballot measures were intended to restrict the procedure.

Ryan Stitzlein, vice president of political and government relations for Reproductive Freedom for All, said that one change since the midterms is that there are fewer initiatives in the works for next year that would restrict abortion access.

“I think it’s an acknowledgment on that side that the momentum is not with them and it’s an uphill battle,” Stitzlein said.

Missouri, Florida, Colorado, Arizona, Maryland, Nebraska, Nevada and New York are all in various stages of the ballot initiative process, but they’re expected to get abortion protections on the ballot for 2024. College students in South Dakota have started gathering signatures to petition for a ballot measure in 2024, a local television station reported.

In Missouri, the secretary of state, Jay Ashcroft, oversees the citizen-led initiatives that end up on the ballot.

Ashcroft included ballot summary language that asks voters if they want to allow for “dangerous, unregulated” abortions from conception to live birth. Abortion rights proponents sued in response. A judge ruled against Ashscroft’s language.

“The court finds that certain phrases included in the Secretary’s summary are problematic in that they are either argumentative or do not fairly describe the purposes or probable effect of the initiative,” the judge’s order said. Ashcroft said he intends to appeal the decision.

If organizers can meet the signature threshold by May, the proposed amendment will be before Missouri voters in 2024.

Update, Oct. 24, 2023: This story was updated to note that abortion is legal in Kansas until the 22nd week of pregnancy.

by Cassandra Jaramillo

Trump’s Court Whisperer Had a State Judicial Strategy. Its Full Extent Only Became Clear Years Later.

1 year 1 month ago

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In July 2015, Wisconsin’s Supreme Court shielded Gov. Scott Walker, then a rising Republican star with aspirations to the presidency, from a criminal investigation.

The court’s conservative majority halted the probe into what prosecutors suspected were campaign finance violations. One of the deciding votes was cast by Justice David Prosser, a conservative who had won reelection a few years earlier in a heavily contested race. During the race, a state GOP operative said if their party lost Prosser, “The Walker agenda is toast,” according to an email included in a trove of documents the Guardian surfaced. Another vote for Walker came from Michael Gableman, a justice who had also waged a contentious campaign for his Wisconsin Supreme Court seat.

The high court, determining the prosecutors had overreached, ordered the investigation’s documents destroyed. But not before the Guardian got its hands on a copy. And buried in the 1,500 pages was a reference to a key figure in propelling both Prosser and Gableman to victory: the co-chair of the right-leaning legal group the Federalist Society, organizer of dark money groups and conservative strategist Leonard Leo.

The Prosser and Gableman races were crucial skirmishes in Leo’s decadeslong, ambitious effort to shape American law from the ground up. It’s a project whose full dimensions are only now becoming clear. ProPublica detailed the arc of Leo’s activism in a recent story and podcast with “On The Media.”

If Leo’s name sparks a note of recognition, it’s usually because he was Donald Trump’s judge whisperer and a leading figure in helping create the 6-3 conservative supermajority on the U.S. Supreme Court. Leo realized decades ago it was not enough to have a majority of Supreme Court justices; he would have to approach the legal system holistically if he wanted to bring lasting change. To undo landmark rulings like Roe v. Wade, Leo understood that he needed to make sure the court heard the right cases brought by the right people and heard by the right lower court judges.

Leo at a dinner hosted by President Donald J. Trump at the White House in 2017. (Official White House Photos by Shealah Craighead)

Leo built a machine to achieve that goal. He helped ensure the nominations of justices from Clarence Thomas to Amy Coney Barrett. He used his closeness to the justices to attract donors to support his larger effort. He then used those donations to build a network of dark money groups supporting his candidates and causes across the U.S. And he helped elect or appoint state Supreme Court justices who were predisposed to push American jurisprudence to the right.

Wisconsin was where Leo honed his strategy. In 2008, in a racially charged challenge to the state’s first Black Supreme Court justice, Leo himself raised money for Gableman, according to a person familiar with the campaign. Leo passed along a list of wealthy donors with the instructions to “tell them Leonard told you to call,” this person said. All those people gave the maximum. Gableman won, the first time an incumbent was unseated in Wisconsin in 40 years. (Leo declined to comment to us on his role in that race.)

Then in 2011, state GOP operatives turned to Leo to boost Prosser. They hoped he would help them raise $200,000 for “a coalition to maintain the Court,” the emails show. Prosser won, by half a percentage point. (When the emails mentioning his race surfaced, Prosser defended his independence.)

In 2016, Leo got involved again. Walker had a vacancy to fill and had three people on his shortlist: two Court of Appeals justices and the former attorney for an anti-abortion group and Federalist Society chapter head, Dan Kelly. “Leo stepped in and said it’s going to be Dan Kelly,” a person familiar with the selection told us. Walker denied speaking to Leo, who said he didn’t remember. From 2016 until the present, a group called the Judicial Crisis Network (which is now known as the Concord Fund), was a regular donor to state judicial races. Leo has no official role at the JCN, which as a dark money group does not have to disclose its donors. But he helped create and raise money for it, and JCN often works toward the same goals as the Federalist Society.

JCN was a crucial financial supporter of the public campaigns to win support for Supreme Court nominees backed by Leo, from Chief Justice John Roberts to Samuel Alito, Neil Gorsuch, Brett Kavanaugh, and Coney Barrett. In Wisconsin, JCN sent increasing amounts of money to judicial races through circuitous routes. Sometimes the contribution flowed through a national political organization like the Republican State Leadership Committee. Other times, the money was sent to Wisconsin-based outfits.

Wisconsin is not the only state that Leo focused on. North Carolina shows the effects of more than a decade’s worth of big-dollar funding from his network and a torrent of negative ads questioning the integrity of the judiciary.

In 2022, after years of sustained campaign spending by the Judicial Crisis Network and allied groups, North Carolina’s high court flipped from a 4-3 Democratic majority to a 5-2 Republican majority. Months later, the court did something extraordinary: It reinstated a voter ID law that the same court, in its Democratic-led iteration, had found discriminated against Black voters. It also overturned a newly court-approved elections map that had produced an electoral outcome reflecting the state’s partisan split.

In Wisconsin, the battles over the high court continue to be fierce. In April, Kelly, Leo’s chosen candidate, ran to maintain a conservative majority on the Supreme Court. It was the most expensive judicial race in U.S. history, with both sides spending at least $51 million. But Democrats were activated by the U.S. Supreme Court’s ruling to overturn Roe and by election maps that had maintained Republican dominance in the Legislature in a state evenly divided along partisan lines. Their candidate, Janet Protasiewicz, won resoundingly.

But that hasn’t stopped Republicans from trying to regain control. In September, there was talk of impeaching Protasiewicz because of comments she made during the campaign about “rigged” election maps. That effort has subsided — for now.

Leo’s candidate lost in Wisconsin — but his efforts over the years have succeeded in something else: transforming seats on state Supreme Courts into political prizes. In many states, such judges are no longer viewed as independent arbiters from a branch of government that operates outside partisanship but as a kind of super-legislator. “That’s bad for the system,” Robert Orr, a former Republican North Carolina justice, told us. “It’s bad for democracy. It’s a very dangerous path to tread down.”

In a written statement, Leo said state courts “are more independent and impartial today than they were when trial lawyers and unions dominated state judicial races without any counter.”

The stakes for democracy are stark. Already, a University of Washington study ranking the health of democracies in states found North Carolina and Wisconsin have plummeted from two of the highest-scoring states to scraping the bottom.

One result of this project is clear. Today, the practice of deploying every weapon in the American political arsenal, from nasty campaign ads to spending by groups whose donors are hidden, is now a routine aspect of campaigns for the judges who rule on state laws and, in 2024, might well decide the outcome of elections in battleground states.

by Andrea Bernstein and Andy Kroll

Minnesota Attorney General Opens Investigation Into Controversial Contract-for-Deed Real Estate Practices

1 year 1 month ago

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The Minnesota attorney general’s office is investigating potentially exploitative real estate transactions that have targeted Somali and Hispanic immigrant homebuyers in the state.

The attorney general’s action follows a report by ProPublica and Sahan Journal last year that revealed how contracts for deed — an alternative home sale agreement made directly between a seller and a buyer — can lock purchasers into inflated prices and unfavorable terms, and sometimes lead to eviction and the loss of their life savings.

“We have received a high number of complaints about predatory lending practices,” Mark Iris, an assistant attorney general in the office’s civil rights division, said in a statement. “Our office is concerned with the potential for abusive lending tactics that extract wealth from already impoverished communities.”

The Sahan Journal-ProPublica investigation identified a rising market in and around the Twin Cities for contract-for-deed sales, particularly in the Somali community. Many buyers in the East African Muslim community avoid paying or profiting from interest because of their religious principles. Investors have been offering them contracts for deed as an “interest free” way to purchase a house and sidestep a traditional bank loan.

But several Somali homeowners said they purchased homes without understanding their contracts, which included huge down payments and balloon payments, some of which soar into the hundreds of thousands of dollars. The homeowners said they had been misled, and they told reporters they feared having to walk away from their homes and the money they’d invested.

Contract-for-deed home sales lack many of the consumer protections of a bank-backed mortgage loan. Homes can be sold for tens of thousands of dollars above their current market price, which makes them difficult to resell or refinance. If the purchaser misses a payment, the seller has the power to evict in as little as 60 days.

Based on the reporting, Sen. Tina Smith, D-Minn., convened a Senate subcommittee hearing in July on the issue, characterizing the contracts as “designed to fail.” She and other senators called for more consumer protections.

Home sellers and investors who use contracts for deed say that they provide a needed, alternative pathway to homeownership for some buyers, and that, when properly used, the transaction is a safe financial instrument. They deny abusive practices.

While contracts for deed are legal, sellers can run afoul of the law by charging excessive interest rates, targeting minority groups with unfair contract terms or using deceptive tactics to lure buyers. The attorney general’s office declined to say what, specifically, officials are investigating. In addition to complaints from the Somali community, Iris said, the attorney general’s office has received a large number of reports of questionable practices being used within the Hispanic community.

Mohamed Goni, executive director of the Central Minnesota Community Empowerment Organization, said he has heard stories about allegedly deceptive tactics used by some contract sellers. Goni’s organization is a nonprofit serving the Somali community in St. Cloud, about an hour northwest of the Twin Cities.

“It’s a way of robbing or putting people into more poverty,” he said. “In central Minnesota specifically there’s a huge, huge housing problem, so it’s really encouraging to see the AG stepping in and doing an investigation.”

Stories about problematic contracts-for-deed practices have been around for years, said Jessica Aliaga-Froelke, CEO of Hispanic Solutions Group in Bloomington. Several Hispanic clients told her they bought homes using a contract for deed because they had bad credit, could not get traditional mortgages or did not have Social Security numbers.

Aliaga-Froelke said the buyers were led to believe that after making huge cash payments for a period of time, they could refinance their loans at a later date.

“They are told, ‘Here, you can have your house,’ but technically they don’t know what they’re signing,” she said. Contract-for-deed sellers “know these people will never be able to refinance with a bank.”

Roxanny Armendariz, a financial counselor with Neighborhood Development Alliance in St. Paul who also works primarily with the Hispanic community, said she hopes the attorney general looks into the role that real estate agents play in pushing buyers toward contracts they can’t afford. Real estate agents sometimes connect homebuyers who don’t qualify for a bank loan with investors who do contract-for-deed sales in bulk. The investor purchases the home through their business or limited liability company, then resells it to the buyer at a price markup.

“They do want to hold these LLCs responsible, but what about the realtors involved? That is the piece that needs to be called out,” she said.

The attorney general’s office declined to provide further details about its investigation. The office said anyone wishing to submit a complaint about contracts for deed can fill out its Tenant Report Form online, or call 651-296-3353 or 800-657-3787.

by Jessica Lussenhop, ProPublica, and Joey Peters, Sahan Journal

A Prominent Museum Obtained Items From a Massacre of Native Americans in 1895. The Survivors’ Descendants Want Them Back.

1 year 1 month ago

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This story is part of The Repatriation Project, a series investigating the return of Native American ancestral remains.

One afternoon earlier this year, Wendell Yellow Bull received a call from a longtime friend with word of a troubling discovery.

Objects from one of the most notorious massacres of Native Americans in U.S. history were in the collections of the American Museum of Natural History, his friend said. Some of them appeared to be children’s toys, including a saddle and a doll shirt.

Memories of what Yellow Bull had been told about the incident throughout his life came rushing back.

Yellow Bull is a descendant of Joseph Horn Cloud, who survived the 1890 massacre at Wounded Knee. He recalled being told that members of the U.S. Army’s 7th Cavalry Regiment surrounded and killed more than 250 Lakota people, including five of his relatives. And in the days that followed the incident on the Pine Ridge reservation in southwestern South Dakota, people had taken clothing, arrows, moccasins and other objects as trophies.

Word that a New York museum held children’s toys from that day was a tangible reminder of the indiscriminate killing.

“That wasn’t even war, it was just brutal killing,” Yellow Bull, who is a member of the Oglala band of the Lakota and lives on the Pine Ridge reservation, told ProPublica.

Yellow Bull (Dawn E. LeBeau for ProPublica)

On the phone that day, his friend asked if he wanted to try to bring the objects home.

He immediately said yes. Lakota descendants believe mourning over the massacre cannot end until the belongings of those who were killed are returned and spiritual ceremonies are conducted.

“If they are from the killing field, they need to come back,” he recalled telling her.

The objects’ long separation from the tribes whose members were at Wounded Knee underscores a key way in which the Native American Graves Protection and Repatriation Act has failed to bring about the expeditious return of cultural artifacts to Indigenous communities.

While the 1990 law requires federally funded institutions to notify descendant tribes in detail about Native American human remains they hold, its rules and procedures for cultural objects are so lax that tribes often are unaware of what was taken and where it’s held. Museums have taken decades to return human remains, delaying efforts to return cultural items. In addition, the law didn’t provide adequate funding for Indigenous communities to pursue repatriations. These factors have led to decadeslong delays for many tribes to reclaim objects that are rightfully theirs.

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NAGPRA “wasn’t crafted to be kind or help us along in our grieving process,” said Alex White Plume, who led the Oglala Lakota tribe’s repatriation efforts in the early 1990s and also has relatives who were killed in the massacre. “It was another attempt to keep us from getting our artifacts that were taken off dead bodies, and not only just at Wounded Knee, but it happened all across the Plains.”

Since NAGPRA’s passage, the AMNH has communicated sporadically with the Oglala Lakota, including sending a notification in November 1993 regarding hundreds of objects in its collections that might be affiliated with the tribe. The vague descriptions of the artifacts made no mention of Wounded Knee.

The museum said in a statement that it provided more detailed information about the Wounded Knee objects in 1997, when a group of Oglala Lakota, who also go by the name Oglala Sioux, met with museum officials and reviewed collections selected by tribal representatives. Other tribes with ties to Wounded Knee, such as the Cheyenne River Sioux, have also met with the museum.

“Periodic consultations with the Oglala Sioux on collections that are of interest to the Tribe have continued since then over various channels,” the statement said. The museum did not provide additional detail about its talks with the Oglala Lakota but said the tribe had not made a request for repatriation, which it described as “multi-year engagements in which museums are guided by the requests and priorities of the relevant tribe.”

Despite the communication between the tribe and the AMNH, the museum has yet to repatriate anything to the Oglala Lakota.

Left to Right: Wounded Knee survivors and brothers Daniel White Lance, Joseph Horn Cloud and Dewey Beard “We Basically Didn’t Know What We Had”

With the passage of NAGPRA, federally funded institutions faced a daunting mandate to document their collections. Some had never conducted a full inventory. And the nation’s oldest museums had, during the 19th and early 20th centuries, built massive encyclopedic collections by funding excavations and expeditions and encouraging soldiers and others to take Native American objects from battlefields.

At the time of NAGPRA’s passage, the AMNH, one of the country’s oldest and largest museums, had approximately 250,000 objects in its North American archaeological collection. It formed an Office of Cultural Resources with a registrar and two additional staff members to do the work. Other staff members also pitched in, according to the museum’s 1992 annual report.

James W. Bradley, a former director of the Andover, Massachusetts, museum now known as the Robert S. Peabody Institute of Archaeology, said in a NAGPRA training video: “We basically didn’t know what we had, and we had pretty good catalog control. But intellectual control — knowing what it was, making it available — we really didn’t know.” The law forced the museum “to do what we just had never gotten around to doing, which is to clean up our mess, find out what we had collected, what we had excavated,” he said.

For human remains, the law mandated a detailed accounting, including where they had been excavated and which present-day Indigenous communities might rightfully claim them. Lawmakers had initially wanted a similar item-by-item inventory of cultural items and sacred objects — which could include items like those taken from Wounded Knee, according to Congressional testimony. But such a requirement was seen as too onerous and expensive, so museums’ initial notices about objects sometimes mentioned only who had donated the item. Many would require additional research to decipher.

A 1993 memorandum from the National Park Service regarding NAGPRA outlines the details museums and federal agencies were advised to include in their documentation of Native American cultural items and sacred objects being considered for repatriation. (United States Department of the Interior)

“When these summaries reached tribal nations, there was not enough information about the origins of the objects, or the way in which the objects were cataloged, or even what the objects specifically were to enable people in those nations to know how to start reclaiming it,” said Margaret Bruchac, a University of Pennsylvania anthropology professor emerita who has worked as a repatriation consultant to museums and tribes.

Bruchac said “tribal nations did not have inside knowledge of museum cataloging systems, and museums did not have sufficient cultural knowledge about tribal materials. So it’s as though they were speaking entirely separate languages.”

The burden of researching the origin of the objects, some of them hundreds of years old, fell to tribal communities, White Plume said. If there’s a record that an object was from the Oglala Lakota, it should be given back without hesitation, he said, “yet they’re sitting there waiting for us to describe in detail the item that we want back.”

Among the notifications the AMNH sent to the Oglala Lakota was one, dated Nov. 16, 1993, listing hundreds of objects in such broad categories as “dress and adornment,” “ritual and recreation” and “unspecified/unknown.” Among them were the four relics from Wounded Knee.

A ritual and recreation item was cited as donated by Edgar Mearns in a 1993 NAGPRA summary provided by the American Museum of Natural History. (American Museum of Natural History)

Despite guidance from the National Park Service, which oversees the NAGPRA program, that museums reveal how they acquired the objects, the AMNH offered only two clues about their origin. In an entry classified as “dress and adornment,” it mentioned “Sioux: Bigfoot’s band” and the donor’s name, Edgar Mearns.

“A Responsibility to Fulfill”

As the United States confined tribal nations to reservations, a movement began among Native Americans in 1889 called the Ghost Dance religion. Through dances and ceremonies, some lasting days, they called on their ancestors to help restore their way of life. When it reached the Great Plains — where the government had seized more than 9 million acres of Lakota land — the nonviolent Ghost Dance had the “surrounding country in a state of terror,” according to an 1890 newspaper account.

The Bureau of Indian Affairs considered the Ghost Dance a threat and dispatched the military to enforce a ban on the practice. On Dec. 15, 1890, Indian Police were searching for Sitting Bull, a Hunkpapa Lakota chief, to question him about his involvement in the Ghost Dance. After encountering him at his home on the Standing Rock Reservation, the officers killed the chief, escalating tensions.

About two weeks later, Mnicoujou Lakota Chief Spotted Elk, who was also known as Big Foot, surrendered with his band to members of the 7th Cavalry. On Dec. 29, soldiers ordered the band of people, who had settled near Wounded Knee Creek, to turn over their weapons. A Lakota man’s weapon discharged, setting off a flurry of gunfire as adults and children ran for cover.

Horn Cloud, Yellow Bull’s great-grandfather, was 16 years old at the time of the massacre and later described what he witnessed to a researcher and writer named Eli Seavey Ricker. Soldiers had surrounded the Lakota when the gunfire erupted. “The shooting was in every direction. Soldiers shot into one another,” Horn Cloud told Ricker. As the Lakota fled, some defending themselves by grabbing weapons they had surrendered. Many sought refuge in a nearby ravine and “some ran up the ravine and to favorable positions for defense,” he told the researcher. When the shooting stopped, Horn Cloud had lost his parents, two brothers and a niece.

An Army captain, whose account was recorded in a Jan. 3, 1891 letter to an Army assistant adjutant general, said he arrived to find fresh wagon tracks and evidence that “a great number of bodies” had been removed from the site. The 8th Infantry buried 146 people in a mass grave, including 82 men and 64 women and children. “The camp and bodies of Indians had been more or less plundered,” the captain wrote.

A doll shirt donated to the AMNH by Mearns (American Museum of Natural History Anthropology Database)

A soldier named Frank X. Holzner was among those who gathered objects from the killing field, including a toy saddle, a doll shirt, beaver bones, an adornment piece and a bear claw, according to the museum’s handwritten accessions register. The AMNH’s 1895 annual report shows Mearns donated these objects to the museum that year. The museum record doesn’t mention how Mearns had obtained them.

The Army’s initial reports of Wounded Knee described it as a battle. But as more details emerged, including accounts of the killing of women and children as they ran away, the soldiers’ actions were criticized and the commander was investigated. (There have been periodic calls to rescind Medals of Honor awarded to 7th Cavalry troops. And in 1990, Congress apologized for the massacre.)

In the years that followed, Horn Cloud would camp at the site, sleeping on the graves of his lost family members to connect with them, a relative told the National Park Service in a 1990 interview. Horn Cloud and his brother, Dewey Beard, sought compensation from the government for the survivors of Wounded Knee. And Horn Cloud led the effort to erect a stone monument on the site in 1903. The marker lists some of the victims with an inscription, written by Horn Cloud, that says in part: “Many innocent women and children who knew no wrong died here.”

The cemetery marking the mass grave on the Wounded Knee site (Tara Weston for ProPublica)

Today, Wounded Knee is marked by a large red sign describing the incident and a small cemetery that was built over the mass grave. The cemetery is surrounded by a chain-link fence that is dotted with prayer offerings — tobacco wrapped in cloth. Last year, the Cheyenne River Sioux and Oglala Lakota tribes purchased 40 acres surrounding Wounded Knee to preserve as a sacred site. A bill before Congress would place the land into a trust status that would prohibit its sale without congressional and tribal approval.

On a recent afternoon, Yellow Bull, wearing a T-shirt reading “Wild Oglalas,” stood near the mass grave and talked about how generations of his family have honored the ancestors who lost their lives there.

Yellow Bull, a Marine veteran, father of six and local county commissioner, is determined to continue preserving the memory of Wounded Knee, he said, including improving the site, protecting it from development and reclaiming the objects that were taken from those who were killed.

“I still have a responsibility to fulfill,” he said.

After the Battle of Wounded Knee, only a small number of Big Foot’s Mnicoujou people remained alive. (John C.H. Grabill/Library of Congress/Corbis/VCG via Getty Images) “A Lot of Hurdles”

Cassie Dowdle, a NAGPRA manager for the 900-person Wilton Rancheria tribe, based south of Sacramento, said she has seen inequities in the resources tribes have for pursuing repatriations.

It’s Dowdle’s sole job to contact institutions across the country and use a database to track progress toward repatriation. When she met with representatives at California State University, Sacramento not long ago, she and museum staff sifted through more than 80 bankers boxes to inventory each object. During similar museum visits Dowdle has discovered collections that were never reported to the tribe and pieced together collections that had been separated and housed at various museums.

Wilton Rancheria recently added a staff member to help Dowdle and plans to soon add another. But not all Indigenous communities have such resources. Dowdle, a descendant of the Tule River Yokuts, calls it “unfair.”

“There’s a lot of hurdles, and I’ve seen a lot of tribes, where they ran out of resources,” she said. “They either felt defeated or didn’t have the bandwidth for it.”

The park service provides some grants to fund consultation and repatriation work to improve communication between the institutions and Indigenous communities, including researching museums’ collections. But some tribes don’t have the resources to navigate the grant writing process.

This year, the NPS awarded $3.4 million in grants to museums and tribes, the most since 1994. Even so, grants won’t cover the entire cost of a repatriation, said Rosita Worl, president of Sealaska Heritage Institute and a Tlingit citizen.

She estimates that successful repatriations can run to $100,000 or more. When the tribes represented by Sealaska Heritage have made a claim on an object, they’ve hired a researcher and sometimes sent a group to view it. If there’s a dispute with the institution, the tribe must hire a lawyer, and the costs can quickly increase. Worl said a disagreement over the proposed repatriation of a Teeyhíttaan Clan hat cost her organization $200,000. Ultimately, a full repatriation didn’t occur, and the Alaska State Museum retains partial ownership of the hat. The museum confirmed that a partial repatriation occurred.

“It’s outrageous that the tribes still have to go up against all of this,” she said.

For tribes that can’t afford a dedicated repatriation specialist like Dowdle, it usually falls to a historic preservation officer to navigate the process. Preservation officers are required by federal statute to manage historic properties and preserve cultural traditions. Those responsibilities often keep them “in triage mode,” making it difficult to also take on repatriation work, said Valerie Grussing, executive director of the National Association of Tribal Historic Preservation Officers.

“There’s an official list of duties as mandated by the National Historic Preservation Act, and repatriation is not one of them,” she said. “They already are having to pick and choose what’s a priority for their community.”

Chip Colwell, a former senior curator for the Denver Museum of Nature & Science who oversaw repatriations, said the funding and power imbalance between museums and tribes was evident in his work. Colwell said his museum’s staff tried to compensate for these inequalities by reaching out to tribes and offering resources and guidance, even when a tribe hadn’t contacted them. The museum’s administration also recognized that the notices they had sent to tribes soon after the passage of NAGPRA were inadequate, and used grant funding to collaborate with tribes on reissuing more detailed summaries of some of those objects. This led to the discovery of things they’d missed.

When the repatriation process fails, it’s frequently because museums are not “taking enough responsibility — moral responsibility — for finding ways forward with tribes,” Colwell said. “And then tribes often just don’t have the resources.”

In the case of objects from a massacre, Colwell wondered why a law is needed for a museum to return them. “I would hope that the American museum, in this case, is just trying to do the right thing,” he said, “and not pretending to be handcuffed by the law.”

There are signs that the AMNH is shifting its mindset. Last week, the museum announced steps toward a “new ethical framework” for its human remains collection, which includes individuals from Native communities. The museum will remove exhibits that include human remains and will devote more resources to reviewing its human remains collection, which includes increasing its “engagements with descendant communities.”

“It Doesn’t Belong to the Museum”

The Oglala Lakota don’t have a full-time repatriation specialist or permanent historic preservation officer. The work is instead a team effort by tribal officials and groups of Wounded Knee descendants.

“We don’t have the resources to go out and look for these items, we just hope that somebody tells us about them so we can go do it,” said Justin Pourier, who is coordinating the group’s efforts. Pourier, whose regular job is serving as a liaison between the tribal council and executive committee, is also filling in as historic preservation officer for the Pine Ridge reservation, which is roughly the size of Connecticut.

Pourier said he learned that objects from Wounded Knee were at the AMNH after Erin Thompson, an art crime professor, identified them while researching the museum’s annual reports. She contacted Yellow Bull’s friend, Mia Feroleto, an activist and magazine publisher who recently helped with the repatriation of more than 150 Lakota objects from the Founders Museum in Barre, Massachusetts. It was Feroleto who called Yellow Bull to tell him about the objects.

Yellow Bull, along with a tribal delegation and Feroleto, plans to meet with the museum’s officials to see anything that might be of interest to the Oglala Lakota.

It’s unclear what the tribe would do with the objects if they are returned. Yellow Bull said that decision will be made with other Wounded Knee descendants. But he is certain that the objects at the AMNH belong to and continue to represent the people who were killed, and should be returned so they can be properly mourned.

“It doesn’t belong to you or I, it doesn’t belong to the museum,” he said.

by Nicole Santa Cruz