ProPublica

by Annie Waldman and Aliyya Swaby

Sign up for ProPublica’s User’s Guide to Democracy, a series of personalized emails that help you understand the upcoming election, from who’s on your ballot to how to cast your vote.

This story was co-published with Gray TV/Investigate TV.

One in five Americans struggles to read English at a basic level, and without the necessary reading and writing skills, everyday tasks can be insurmountable. The routine challenges of low literacy take a toll on individual livelihoods as well as this country’s collective democracy. For people who struggle to read, the electoral process can become its own form of literacy test — creating impenetrable barriers at every step, from registration to casting a ballot.

Our reporting has found that helping people with low literacy skills to read their ballots at the polls enables them to understand what and who they are voting for and ensures that their votes are counted. But decades of voter suppression — particularly in the South — have made this kind of assistance difficult to access in many communities.

We wanted to better understand the relationship between literacy and voter turnout. For decades, academic and political researchers have studied the factors that influence voter participation, including the impact of educational attainment on whether people vote. But literacy skills are less commonly featured in elections research. There are few reliable databases documenting literacy rates in the United States. But in recent years, the National Center for Education Statistics has released more granular information on literacy levels, including estimates of reading skills at the county level. Using this data, we can ask more pointed questions about how literacy skills correlate with voter participation.

Data Sources

To understand voter participation rates across the country, we acquired county-level turnout data for the 2018 midterm election and the 2016 and 2020 general elections from Dave Leip’s Atlas of U.S. Elections. The election data comprises vote counts for more than 3,100 counties across the country. We compared the raw county vote totals with the citizen voting-age population in each county, drawn from U.S. Census Bureau estimates, for each election year. The citizen voting-age population includes all people 18 and older who are native or naturalized citizens, and the number is frequently used as a base figure in turnout calculations.

Some researchers prefer to use a different number as their denominator — the voting-eligible population, which is adjusted to remove those disenfranchised due to felony convictions, and sometimes also those ruled ineligible due to a mental disability. We chose to use a broader denominator so we could include all people who potentially could cast ballots if felony voting restrictions were lifted. Another requirement for voting in the United States is registration: All states, except for North Dakota, require eligible voters to officially register before they vote. We chose not to limit our analysis to registered voters, as the registration process can function as a major barrier for people with low literacy levels. We did not include U.S. territories, Puerto Rico or Alaska in our analysis, due to incomplete or unavailable data.

To understand variations in literacy levels across the country, we used modeled survey data from the National Center for Education Statistics, which was collected as part of the Program for the International Assessment of Adult Competencies (PIAAC), also known as the Survey of Adult Skills. The data includes state and county estimates of average literacy levels and is based on the results of surveys collected in 2012, 2014 and 2017. The survey assesses adults for a range of skills, including reading ability and comprehension, numeracy and digital problem-solving. It represents the most comprehensive picture of the nation’s literacy levels today. The county and state literacy estimates are produced using a statistical method called small area estimation, which, in addition to the survey results, incorporates additional covariate data, such as educational attainment and poverty figures, to allow for a better extrapolation of survey data to low-population areas.

There are limitations to using modeled, survey-based estimates to understand larger national trends. More reliable data could be derived from a survey that examined both literacy and voter participation or from a more comprehensive survey that doesn’t require external data points to bolster responses. At this time, those surveys do not exist, so the PIAAC data remains the best option for understanding variations in nationwide literacy rates. This data has regularly been used by both federal researchers and academics.

For our analysis, we compared counties with low estimated literacy rates to those where literacy was estimated to be proficient or better. We defined proficiency or nearing proficiency as people who, according to the National Center for Education Statistics, have, at a minimum, the skills to complete reading and writing tasks, such as comparing and contrasting information, paraphrasing and drawing low-level inferences. People with low literacy skills may be able to read a basic vocabulary and decipher short texts, but their reading comprehension abilities are severely limited. The National Center for Education Statistics defined adults with low literacy skills as those who tested at or below the lowest proficiency level of the national survey, or those who were unable to participate in the survey because of cognitive, physical or language barriers.

About 80% of American adults were assessed as proficient or nearing proficiency in reading, and 20% had difficulty completing literacy tasks, according to the national survey. While adults born outside the country are disproportionately represented among the lowest-skilled levels, two-thirds of adults with low reading skills were born in the United States. White and Hispanic adults constitute 70% of adults with low literacy, and Black adults were overrepresented, making up 23% of adults with low literacy while accounting for less than 13% of the total population.

Top-line Findings

If more people who live in counties with low literacy voted, especially in tight races, it could potentially sway the outcome of elections. Our analysis found that as the literacy rates in a county decline, voter participation also tends to decrease.

We plotted county-level voter turnout against the percentage of residents in each county with low estimated literacy levels, and again against the share with high estimated literacy levels, and we found inverse relationships between the two literacy groups. For the purposes of our calculations, the low literacy level was defined as the population that is at or below Level 1 in indirect literacy estimates, and high estimated literacy levels were defined as Level 3 or above. As the percentage of people with low literacy in each county increases, voter turnout tends to decrease (2016: r = -0.57, p < 0.0001; 2018: r = -0.57, p < 0.0001; 2020: r = -0.58, p < 0.0001). Conversely, as the percentage of people with higher literacy skills goes up, voter turnout increases (2016: r = 0.60, p < 0.0001; 2018: r = 0.60, p < 0.0001; 2020: r = 0.61, p < 0.0001 ). This trend appeared consistently for all three election years we analyzed: 2016, 2018 and 2020. The relationship between voter turnout and literacy levels does not appear to be a random pattern.

Counties With Lower Literacy Levels Often See Lower Voter Turnout Source: Literacy estimate data from the National Center for Education Statistics; election data from Dave Leip’s Atlas of U.S. Elections (2016 presidential election data) and the U.S. Census Bureau (Citizen Voting-Age Population Estimate, 2016). Note: The low literacy level used in county literacy calculations is defined as the population that is at or below Level 1 in indirect literacy estimates, according to the National Center for Education Statistics. Voter turnout is defined as the total number of votes in each election divided by the citizen voting-age population. (Graphic by Annie Waldman)

However, as the saying goes, correlation is not causation. While our analysis shows a valid pattern, our findings do not suggest that lower literacy rates cause lower turnout, or that higher literacy rates increase voter participation. We also do not know whether the adults who are not voting are the same adults as those with low literacy skills.

That said, there’s a robust body of research connecting educational attainment to voter turnout: “A person’s level of formal educational attainment is a very strong predictor of whether they vote in elections, especially nonpresidential elections,” said Barry Burden, a professor and the director of the Elections Research Center at the University of Wisconsin, Madison.

Recent data from the federal Current Population Survey supports this long-standing trend. Data on educational attainment and voter turnout from the 2020 Voting and Registration Supplement shows that among Americans with less than a high school diploma or its equivalent, the percentage who reported that they voted is similar to the share who said they didn’t vote. But with each additional level of educational attainment, the percentage of people reporting that they voted increases. For Americans with only a high school diploma who have not attended college, the percentage who said they voted was twice as big as the share saying they did not vote. For adults with only a bachelor’s degree, the group who said they’d voted was about nine times the size of the group that reported that they did not vote. And for adults with a master’s degree, about 17 times as many people reported voting as not voting. Given the deep link between education and turnout, the notion that literacy might have a similar connection is not unreasonable.

Some of the most consequential elections of our time have been determined by narrow margins — just tens of thousands of votes in a country of hundreds of millions of people. For example, in 2016, Donald Trump secured the presidency by winning Pennsylvania, Wisconsin and Michigan with a total margin of just under 80,000 votes. In 2018, Ron DeSantis won Florida’s gubernatorial election by about 32,000 votes. And in 2020, President Joe Biden prevailed by winning Arizona, Georgia and Wisconsin by about 40,000 votes combined.

Given how relatively few people can swing an election, we wanted to consider what the impact might be of people with low literacy skills staying away from the polls. We clustered counties across the country by average literacy level, producing three equal groups of about 1,030 counties each, and calculated average turnout for low-, medium- and high-literacy counties. For example, in 2020, across the United States, counties with low literacy levels had an average voter turnout of 58.8%, and those with high literacy levels had turnout of 73.1% on average. We then applied the participation rate of high-literacy counties (73.1%) to the total population of low-literacy counties to estimate how many votes those counties might be “missing.” We found that if counties with lower literacy levels had similar participation rates to high-literacy areas, turnout could increase by up to 7 million votes nationally. Of course, we cannot predict or assume for whom any additional votes would be cast.

Caveats

The purpose of this analysis was to gain a better sense of the relationship between turnout and literacy, rather than conduct a causal or inferential analysis. There are several limitations that could affect our understanding.

For our analysis, we relied on county-level data, and as it represents groups (i.e. counties) rather than individuals, we cannot be certain that the low-literacy people in each county were the same individuals who were not voting. Thus, one reason for the correlation between literacy and turnout could be that literacy is acting as a proxy for other factors that influence participation, like lower levels of income or a lack of social capital.

While literacy may impact voter participation, there are many other reasons why some parts of the country may cast fewer ballots. People do not vote for a number of reasons, including difficulty getting time off from work and limited options for transportation to the polls. Some people may not have much interaction with voter mobilization groups and others may feel disengaged from politics. And barriers in the process, like states disenfranchising people with felony convictions, may also impede voter participation. Some of these factors may also be influenced by an individual’s ability to read.

An important limitation of the Current Population Survey is that it relies on self-reporting, and individuals’ responses about whether they voted have not been verified against official voting records. Thus, the data is susceptible to misreporting. Some research has shown that higher socioeconomic or educational attainment levels may be associated with higher misreporting, which could affect the results.

Election participation is often influenced by local policies, and the correlation between literacy and voter turnout varies by state. While the majority of states exhibit moderate to strong relationships between voter participation and literacy, in a handful of states, there are weaker connections, which presents an intriguing path for a more comprehensive future analysis. There may be state-by-state differences in voting accessibility or ballot complexity that may also have varying effects on turnout.

In addition, the literacy data has limitations. As mentioned above, the National Center for Education Statistics developed a predictive model based on the results from its skills survey and a handful of auxiliary data points from the census, used to bolster the model’s predictive precision. These data points include, but are not limited to, high school diploma rates, poverty levels, racial breakdowns, health insurance coverage and fraction of the population working service jobs. These variables might confound the literacy variable’s relationship with turnout, possibly boosting the correlation.

The literacy data for counties with fewer residents may also have greater uncertainty than the data for more populous counties. These small counties may affect the results of the analysis, particularly in analyses done at the state level in states that have numerous small counties. These small counties, with fewer than 1,500 people, represent about 2% of all 3,100 counties in the data set. To assess their influence, we resampled the data, randomly drawing new estimates for each county, and reran the analysis 1,000 times. The findings did not significantly change.

One in Five Americans Struggles to Read. We Want to Understand Why.

by Aliyya Swaby and Annie Waldman

Sign up for ProPublica’s User’s Guide to Democracy, a series of personalized emails that help you understand the upcoming election, from who’s on your ballot to how to cast your vote.

This story was co-published with Gray TV/Investigate TV.

Faye Combs used to enter the voting booth with trepidation. Unable to read until she was in her 40s, she would struggle to decipher the words on the ballot, intimidated by how quickly the people around her finished and departed. “When the election was over, I didn’t even realize what I had voted for because it was just so much reading,” she said.

Combs’ feelings of insecurity and disorientation when faced with a ballot are not unusual. Voters with low literacy skills are more likely to take what they read literally and act on each word, sometimes without considering context, literacy experts say. Distractions can more easily derail them, causing them to stop reading too soon.

“I’ve seen people try to read [the ballot] left to right and end up skipping entire contests,” said Kathryn Summers, a University of Baltimore professor who has spent decades studying how information can be made more accessible. She has found that voters who struggle to read are also more likely to make mistakes on their registration applications, such as writing their birth date incorrectly or forgetting to fill in the check box that indicates they are a citizen, either of which could lead to their vote being rejected.

As a ProPublica investigation found, today’s election system remains a modern-day literacy test — a convoluted obstacle course for people who struggle to read. Though many people may require assistance with registration or at the ballot box, some counties and states have made it more challenging to secure help.

Experts say that redesigning both the registration and election processes to be more accessible will allow more people to vote without assistance and participate more robustly in democracy. Ballots and forms should be simply written and logically laid out, jargon should be stripped from instructions and ballot amendments and, if possible, new forms should be tested on a diverse group of constituents.

Such reforms can be expensive and time-consuming, which stops some states and municipalities from taking on the task, said Dana Chisnell, who co-founded the nonprofit Center for Civic Design to help states and counties develop accessible voter materials. “They may have old voting systems that they’re holding together with duct tape and baling twine because they can’t afford to replace them or there were other priorities in the county,” she said.

But numerous examples show that when such changes are made, more votes get counted. “If we make it better for people with low literacy, it will actually be better for everyone,” Summers said.

Improving Ballot Design

As ProPublica has written, bad ballot design can sabotage up to hundreds of thousands of votes each election year. After the confusing butterfly ballot infamously wreaked havoc in the 2000 presidential election in Florida, the federal government increased its oversight and regulation of local election administration, including by issuing voluntary guidelines for how ballots and election materials should look. But states and counties continue to wind up with miscast or uncast votes as a result of design failures.

In 2018, for example, Florida’s Broward County used a ballot where the names of Senate candidates were listed at the bottom of a column, under a long list of instructions.

In most of the state, where other ballot designs were used, the Senate race drew about the same number of votes as the governor’s race. But in Broward County, a Democratic stronghold, fewer people voted for Senate than for governor, which was the race listed at the top of the second column. It’s likely that many people simply missed the Senate race at the bottom of the page. This discrepancy amounted to around 25,000 votes that were never cast. Republican Rick Scott won the race by about 10,000 votes.

Improving design has resulted in fewer skipped races and rejected ballots. The Center for Civic Design has created free online guides for designing accessible forms, which are intended to help local election officials short on resources.

If the essence of democracy is making sure that everyone who is eligible can vote, the election process should lean toward inclusion and accessibility, said Whitney Quesenbery, co-founder and executive director of the center. “Someone who has decided to vote ought to have a fair shot at getting their ballot counted,” she said. “The way you make sure that it gets honored is by telling people what they have to do in a clear way.”

Accessibility experts like Quesenbery say that these changes can improve the voting process for everyone, but especially for voters with limited reading abilities.

In 2010, New York voters got confusing messages if they accidentally overvoted — that is, voted for too many candidates — using machines made by two companies, Election Systems and Software and Dominion. The electronic screen on ES&S machines featured a red button saying “Don’t Cast — Return Ballot” and a green button saying “Accept.” Similarly, the Dominion machines featured a red button labeled “Return” and a green button labeled “Cast.” It was unclear which button would actually allow voters to fix the problem and many pressed the green button, which submitted their incorrectly filled-out ballot and meant that their vote was not counted at all.

As a result of a lawsuit that the Brennan Center for Justice and other groups filed against New York election officials, ES&S changed the messages on its buttons before the 2012 election, but Dominion did not get final permission for similar changes in time. The new buttons on ES&S machines gave voters the option to either “correct your ballot” or “cast your ballot with mistakes” — a much easier choice to understand than the previous options. That election year, rates of overvoting declined on both machines, but ES&S machines saw twice as big a drop as Dominion machines.

ES&S spokesperson Katina Granger said the accessibility changes for that election show “the need to continually obtain real world feedback from both customers and usability experts.” Dominion did not respond to ProPublica’s emailed questions.

ES&S changed its message to be less confusing for voters who accidentally selected too many candidates. (Brennan Center for Justice)

In advance of the 2014 election, Florida’s Escambia County redesigned its absentee ballot forms to format instructions as a checklist on the outside of the envelope, add simple illustrations and place a colored highlight over the spot where voters were supposed to sign. Many states, including Florida, require absentee ballots to be rejected if a signature is missing or doesn’t match other records. The new design’s emphasis on providing a signature reduced the share of ballots that were missing a signature by 42% between 2014 and 2016, and reduced by 53% the share of ballots that were rejected even after voters were offered a chance to add their signatures.

The new ballot envelope being used in Florida’s Escambia County prompts voters to include a signature and date. (Center for Civic Design)

Similarly, New York redesigned its statewide absentee ballot template in 2020. The number of rejected absentee ballots in New York City decreased from around 22% in that year’s primary to just 4% by the general election.

New York’s newly redesigned ballot envelope more clearly marks where voters should sign. (Gotham Gazette) Fixing Voter Registration

Many states have redesigned their voter registration forms, making the very first step in the election process more accessible for voters with low literacy skills. In 2015, when Pennsylvania launched online voter registration for the first time, state elections officials worked with the Center for Civic Design to test early versions with residents of the state. Their input helped officials design final versions of both online and paper forms with simplified language and minimal text on the page. The sections on the paper application are more clearly defined, with the instructions on the left and the voter tasks on the right. Pennsylvania noticed a decrease in rejected voter registration forms since the launch of the new forms, according to Department of State spokesperson Grace Griffaton, but could not separate the effect of the simpler design from the launch of online registration.

Pennsylvania’s newly redesigned paper application features simpler language and minimal text on the page, compared to the previous version. (Pennsylvania Department of State)

States like Colorado, Vermont and New York have created similar designs.

This year, Vermont debuted its new online registration form, completed with assistance from the Center for Civic Design, according to Secretary of State Jim Condos. Election workers had struggled to read voters’ handwriting on the previous form, which featured cramped spaces where residents had to fill in their information. The new form is much easier to fill out and read. “It’s really about making sure the language is simple enough but to the point,” Condos said.

Vermont updated its voter registration form to include simpler language and more room for voters to write in. (Vermont Secretary of State) Learning From Other Countries

The United States has some of the lowest voter registration and turnout rates among its international peers. It also stands out for its relatively burdensome voting process. Many experts believe these two things are related.

Other industrialized countries with comparable or even lower literacy rates to the United States tend to have higher levels of voter turnout. One simple reason for their increased participation is that they make it easier to vote. Most of them have some form of compulsory or automatic voter registration in place, according to research from the Pew Research Center and the ACE Electoral Knowledge Network. Countries allow citizens to vote on Election Day without having to actively sign up beforehand, or they automatically register citizens who interact with government organizations, like motor vehicle departments or social service agencies. Other countries, like Australia, have gone further and made voting mandatory, and citizens who do not cast ballots may be subject to penalties.

Turnout Is Lower in the U.S. Than in Other Countries With Similar Literacy Scores The voting rate was calculated as the average turnout as a percentage of the voting-age population in each country’s two most recent presidential or parliamentary elections. Voting data was obtained from the International Institute for Democracy and Electoral Assistance, the U.S. Census Bureau and Dave Leip’s Atlas of U.S. Elections. Literacy data obtained from OECD Program for the International Assessment of Adult Competencies. Data was not available for all countries. (Lucas Waldron, ProPublica) Turnout Is Lower in the U.S. Than in Other Countries With Similar Literacy Scores The voting rate was calculated as the average turnout as a percentage of the voting-age population in each country’s two most recent presidential or parliamentary elections. Voting data was obtained from the International Institute for Democracy and Electoral Assistance, the U.S. Census Bureau and Dave Leip’s Atlas of U.S. Elections. Literacy data obtained from OECD Program for the International Assessment of Adult Competencies. Data was not available for all countries. (Lucas Waldron, ProPublica)

In nations with automatic registration programs in place, the percentage of people who are signed up to vote is substantially higher than in the United States, where only 67% of the voting-age population is registered. By comparison, in Canada, 93% of the voting-age population is registered to vote, and similarly, that number is 94% in Sweden and 99% in Slovakia, according to Pew. In the United Kingdom, where government officials seek out voters every year through nationwide canvassing, the registration rate is 92%.

Barry Burden, a professor and the director of the Elections Research Center at the University of Wisconsin, Madison, believes that in the United States, the registration step “is probably more of a deterrent to voter participation than we realize,” he said. “It’s a little challenging for most voters, but if a person doesn’t have the literacy skills or language skills to navigate that bureaucratic process, it could be a deterrent to even getting registered or getting a ballot in the first place.”

The United States is starting to shift its registration policies. Some states have initiated automatic voter registration programs, which use information from other government agencies to complete registration electronically unless people opt out. Since 2015, at least 15 states and Washington, D.C., have launched automatic registration programs, and the impact has been extraordinary — with new systems in place, registrations increased by 16% in Oregon, 27% in California and 94% in Georgia.

Allowing people to register on the same day they vote could increase participation, too. Voters who made errors earlier in the process would have another opportunity to register or fill out their ballots alongside election officials who could ensure their accuracy. As of 2012, states with same-day registration had, on average, 10% higher turnout than states without, according to the Center for American Progress.

Empowering Voters

Combs, who is now 78, no longer feels intimidated in the voting booth. She understands that there are many people like her, who have figured out ways to navigate the world without being able to read well enough to handle routine civic duties like voting.

At the age of 7, Combs was sexually abused by a stranger, a trauma that shadowed her childhood, she said, making it harder for her to remember the lessons she had learned in school. She pressured classmates for the answers to homework and exams, and her teachers passed her on from grade to grade. When she graduated from high school in Bakersfield, California, she said, she left with the secret that she couldn’t read. She was too ashamed to tell her husband until seven years into their marriage. She often brought him into the polling booth because she didn’t even know where to sign her name on the election forms.

Working as a manager of Berkeley’s Meals on Wheels program, Combs thought she was hiding her inability to read from her coworkers — until one day her secretary left a flyer on her desk about a local literacy program. She began learning with a tutor, strengthening both her ability to read and her desire to be more politically engaged. Since then, Combs has made it her mission to empower people to learn how to read and participate in democracy.

She now works with the Key to Community Project, which guides struggling readers through the voting process, helping them develop skills to research candidates and understand how elections work. The nonpartisan project, led by people who learned to read as adults, is an extension of California Library Literacy Services, the country’s first statewide library-based literacy program. Literacy advocates argue that states should contribute more to adult education in order to increase workforce skills and democratic participation. Combs counsels participants in the California program not to worry about taking as much time as they need to understand the ballot.

“I know what the shame is, but you have to move beyond that shame,” Combs said. “That attitude about ‘My vote doesn’t count’ needs to be banished.”

One in Five Americans Struggles to Read. We Want to Understand Why.

Asia Fields contributed reporting.

by Gordon Russell, The Times-Picayune | The Advocate

This article was originally appeared in The Times-Picayune | The Advocate, a member of ProPublica’s Local Reporting Network. Sign up for Dispatches to get stories like this one as soon as they are published.

The Jefferson Parish Sheriff’s Office has determined that the actions of a deputy captured on video last year, in which he grabbed a woman by the hair and slammed her to the ground, were “both reasonable and acceptable.”

The incident involved JPSO Deputy Julio Alvarado, a 17-year veteran, and Shantel Arnold, 34, a Black woman who is under 5 feet tall. It drew national attention after the brief video clip was covered by ProPublica, WWNO and The Times-Picayune | The Advocate.

State Sen. Gary Carter, a Democrat from New Orleans who is representing Arnold, said in a statement that the incident reflects the JPSO’s “well-documented history” of using excessive force against people of color. Carter, who said he is filing a federal civil rights lawsuit on Arnold’s behalf in the next few days, called on Sheriff Joe Lopinto to take stronger action.

“My hope is that Sheriff Lopinto sees Shantel Arnold’s federal complaint as an opportunity to turn the page on the dark history of the Jefferson Parish Sheriff’s Office,” Carter said, “and implement policies and procedures meant to protect all the people of Jefferson Parish, including women, African-Americans, and people of color, like Shantel Arnold.”

Lopinto, in an interview, strongly defended his handling of the case.

The incident occured after the deputy responded to reports of a street fight in River Ridge. Lopinto asserted that Arnold admitted “she pulled away” when Alvarado sought to detain her, and that resistance justifies the deputy’s actions. Arnold previously told investigators that she told the deputy she had just been assaulted, and then continued walking.

Deputy Julio Alvarado (The Times-Picayune | The Advocate)

“The reality is fights don’t look good,” Lopinto said. “Fights don’t ever look good. This is what happens in real life every day. We’re not looking for trouble. Trouble happened and we showed up.”

He noted that Arnold, who said she lost several plaits in the scuffle with Alvarado, did not initially file a complaint but is now “looking for a paycheck.” Lopinto also said the anonymously posted video was “selectively edited” to show only the part of the incident that cast the JPSO in an unflattering light. He suggested that footage of what happened before and after the 15-second clip — if it existed — would present a more nuanced picture. Sheriff’s deputies are not allowed to speak with the media. Arnold’s attorney declined to discuss the details of the case outside the courts.

Two former law enforcement officials who teach or testify in trials on police use of force were less enthusiastic about how Alvarado handled the situation after they viewed the video clip and read the JPSO report on the incident.

W. Lloyd Grafton, a former member of the Louisiana State Police Commission, said he believes the video “unquestionably” shows excessive force.

“He’s a huge man; she’s a tiny girl,” Grafton said. “He’s handling her like a rag doll.”

Joseph Giacalone, a former sergeant in the New York Police Department who teaches a course in the use of force at John Jay College of Criminal Justice, was less critical of Alvarado’s actions in the moment.

“It doesn’t say anywhere that police can use force, but they can’t pull hair,” he said.

Still, Giacalone criticized how the JPSO handled the matter, suggesting it might have been defused by the earlier arrival of a ranking officer or by body camera footage, which the Sheriff’s Office was not then collecting.

“Bodycams could have avoided a lot of this,” Giacalone said. “Police departments shouldn’t leave it up to the public to provide things that you should be providing.”

The bystander-shot video sparked an internal investigation, which led the JPSO to suspend Alvarado without pay for a week and put him on probation for a year.

The punishment was not imposed over Alvarado’s treatment of Arnold, but over his failure to file a report about an incident involving the use of force — in which he handcuffed Arnold but did not arrest her and then called for an ambulance. Alvarado’s superiors were not aware of the matter until a day later, when the video went viral, the report says.

Shortly after the video surfaced, Lopinto announced his office would conduct an internal probe, even though Arnold did not file a formal complaint. The report says Sgt. David Cañas, the lead investigator for the JPSO, interviewed six people: Alvarado and two colleagues, both of whom arrived on the scene after the use of force occurred, plus Arnold, her uncle and her stepfather.

Cañas’ report leans heavily on Alvarado’s account. Because Jefferson Parish deputies did not use body cameras at the time of the incident — they have since begun a limited rollout — the only video evidence of the encounter is the bystander-shot footage.

The report says the deputy responded to a melee involving roughly 20 juveniles. When he got there, it says, Alvarado was told that Arnold “had attempted to initiate a confrontation with a number of juveniles” and then fled. Arnold has said she was beaten up by the youths.

Alvarado had served Arnold with an arrest warrant a week earlier in connection with a car burglary, for which she eventually pleaded guilty. The deputy also said Arnold “is known to carry a concealed knife.”

The report says Alvarado spotted Arnold walking toward her family’s home.

He jumped out of his squad car and said, “Shantel, what’s going on?” the report says. Arnold, according to Alvarado, replied: “If you touch me, I’m going to f--- you up.”

Alvarado claims that Arnold, who is missing an eye and weighs less than 100 pounds, then put down a daiquiri cup she was holding, balled up her fists and began advancing toward him. Arnold and two witnesses told investigators she hadn’t instigated a confrontation.

Alvarado, the report says, “made the decision to accomplish two goals at once — first, to remove Shantel Arnold from the roadway for her safety by seating her on the ground until he was able to summon a medical unit, and second, to terminate her aggressive advance towards him.”

The report says the deputy tried to grab Arnold’s wrists, but they were slippery, and Arnold “was defiant and pulled away.” Alvarado claims this struggle went on for about three minutes before the video begins.

The video shows Alvarado holding Arnold by the wrist; she is lying on her back on the pavement. The deputy then grabs Arnold’s arm with his other hand and jerks her upward, lifting her entire body off the ground.

For a couple of seconds, the two disappear behind a parked car. When they come back into view, Alvarado is holding Arnold by the braids, and he appears to slam her into the pavement. He finally tugs hard, spinning her body around and flipping her onto her stomach, and he puts a knee on her back.

At that point, a second deputy, Manuel Estrada, arrived at the scene and handcuffed Arnold. They called an ambulance, and she was taken to East Jefferson General Hospital.

Citing medical records, the report says Arnold’s injuries — a busted lip and an abrasion on the arm — were minor. It blames the injuries on the juveniles who fought with her, although Arnold told investigators it was the deputy who caused her injuries. The report said that Arnold thought she had lost consciousness but that she refused a CT scan.

Alvarado has been named in at least nine lawsuits alleging excessive use of force during his tenure. That’s more than any other active JPSO deputy, according to a review by ProPublica and WWNO. Two of those suits were settled. One is still pending, and the others were dismissed.

Alvarado was demoted from sergeant to deputy in early 2020; Lopinto declined to specify why but said it was not a use-of-force issue.

While lawsuits are merely allegations, Giacalone, the former NYPD sergeant, said a pattern of such suits is a red flag. “When you have an officer with nine complaints, and then this video shows up, how long before you do something about it?” he asked.

Lopinto countered that Alvarado’s record simply reflects that he works a busy, high-crime beat. “It’s not like he’s getting a complaint every month,” the sheriff said.

It’s not a case of favoritism, Lopinto added, saying he hardly knows Alvarado.

For his investigation, Cañas went back to Richard Street in River Ridge to interview Arnold, her uncle, Tony Givens, and her stepfather, Lionel Gray, who both witnessed the incident.

Cañas wrote that Gray and Givens gave statements that “were so generalized that they possessed a ‘rehearsed’ tone.” The report adds that both “appear to purposely omit the moments prior to the onset of the video for fear that information would portray the culpable actions of Shantel Arnold.” Arnold’s lawyer said the courts should determine the credibility of witnesses.

Ultimately, the report’s conclusion that Alvarado used force in a way that was “reasonable and acceptable” is attributed to Sgt. Michael Pizzolato, the defensive tactics instructor at the JPSO’s training academy.

Pizzolato, according to the report, said the deputy’s decision to grab Arnold by the hair was acceptable because of his belief that Arnold was intoxicated and because her skin was slippery.

“The use of her hair was considered leverage to direct Shantel Arnold to her stomach allowing Deputy Alvarado to gain control of her movements and to ultimately affix handcuffs to her wrists and subdue her actions,” the report concludes.

by Jeremy Kohler

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.

The biggest private policing company in St. Louis is a who’s who of city police commanders, supervisors and lower-ranking officers.

Among the roughly 200 St. Louis police officers whose names appeared earlier this year on an internal list of officers who had sought and received approval from the St. Louis Metropolitan Police Department to moonlight for The City’s Finest were four of the six district commanders who hold the rank of captain. The list, obtained by ProPublica through a public records request, also included two of the department’s highest-ranking officers, Maj. Ryan Cousins, who oversees the department’s murder, rape and arson investigations, and Maj. Shawn Dace, who oversees South Patrol, which includes two districts. It’s not clear if all of those officers currently work for The City’s Finest.

Dace and the four captains, through the department, declined to comment.

Many of the city’s wealthier — and predominantly white — neighborhoods hire off-duty city police officers from companies like The City’s Finest to supplement patrols by the department, an arrangement that creates disparities in how the city is protected. That many top officers moonlight for a private company that exists to shore up the department’s crime-fighting shortcomings suggests deep troubles, experts said.

Peter Joy, a professor at Washington University School of Law in St. Louis, said there would be less demand for The City’s Finest and other companies if the police department was more effective.

“If there was less crime in those areas, The City’s Finest would have less business,” said Joy, an expert in legal ethics and criminal justice. “So, there appears to me to be a conflict of interest.”

Seth Stoughton, a professor at the University of South Carolina’s law school who has studied moonlighting by police, said officers’ dual roles can lead to real and perceived conflicts of interest.

“If you do your job as a public officer too well, you’re going to put your security company out of business,” said Stoughton, a former police officer. “I’m not saying that’s actually going to happen. But it certainly creates this perception.

“The question in the public’s mind is: Who are you actually doing this for right now?”

Because the organizational chart at The City’s Finest is independent of the police department’s command structure, high-ranking officers on the police force sometimes must take direction from their departmental subordinates while working at The City’s Finest. The chief operating officer for The City’s Finest, for instance, is a city lieutenant, yet several higher ranking command officers are under him at the company.

“I’ve got commanders that work every day in different contract areas, and they're like some of the best officers out there,” said Charles “Rob” Betts, who owns The City’s Finest. “They do great, great work and they’re very professional. It’s a good thing, and I think it encourages the other officers that work there. When they see a commander working side by side, it builds morale.”

Betts said he likes to assign leadership roles in his company to commanders “because they’re already in a supervisory role and they understand the importance of that supervisory role.” But some lower ranking officers also have leadership positions. “I have some that I just like their work ethic and they do great work.”

Betts said he had never received a complaint about a commander working for his company.

“I haven’t seen any unethical behavior and I wouldn’t want to be part of it,” he said.

Nate Lindsey, a former official with a taxing district in the Dutchtown neighborhood in the south section of the city, said the department has a culture that views policing almost as a private enterprise.

“Private companies,” he said, “are setting the agenda for what law enforcement looks like in the city of St. Louis.”

Too many police commanders, Lindsey added, are “out there doing secondary gigs as opposed to, say, spending their evenings answering emails to people that they serve within their actual district.”

But Jay Schroeder, the president of the St. Louis Police Officers Association, the police union, said the department’s command staff was, in his mind, simply trying to supplement incomes that lag behind those at other area departments. Police captains in St. Louis earn about $88,000 a year, while police captains in neighboring St. Louis County earn about $110,000, according to published payroll data.

Unlike patrol officers and sergeants, command officers in the city are not eligible for overtime. “These guys have tuition to pay and kids in college and all that stuff,” Schroeder said, “and they’re just trying to make ends meet like everybody else.”

Heather Taylor, the city’s deputy director of public safety, was making about $74,000 when she retired in 2020 as a sergeant after 20 years with the department. She makes about $99,000 in her new role, which she said she needed to shoulder heavy health care costs for her family.

“I couldn’t imagine right now being a sergeant and dealing with issues that I’m dealing with now with the pay that I was being paid,” she said. “I think that the story that probably will be missed within this story is why would any officers need to work secondaries as much as our officers work?”

The city declined to comment otherwise on the prevalence of police commanders working for private policing companies.

Some of the department’s highest-ranking officers sometimes spend their off hours performing tasks that their subordinates would typically do at their day jobs, essentially providing white-glove service to paying customers.

Documents obtained by ProPublica through an open records request show that Cousins sent emails to coordinate The City’s Finest’s response to such issues as a car abandoned on the street and a golf cart theft, trivial matters compared with the sorts of crimes he tries to solve for the police department.

At the time of the emails, Cousins was commander of South Patrol, an area that includes two of the city’s six police districts but does not include Soulard, where he worked for The City’s Finest as a project manager. It’s not clear who Cousins was on the clock for when he sent the emails. The department would not release data showing when he was working for the city.

Cousins said in an email that the department allowed him to work for a second employer and that his responsibilities for the company included scheduling officers for patrol, patrolling himself, attending Soulard meetings and advising officers for the company and the police department about ongoing crime issues.

He said that it was important to address even the smallest concerns residents bring because if they are left unaddressed they can lead to bigger problems. “Should I have allowed those concerns to languish and wait for someone to later address the issues instead of providing a timely response because it’s not as important as a robbery or a homicide?” he asked.

Capt. Michael Mueller served for more than four years as the commander of the department’s Fifth District, which straddles the Delmar Boulevard divide to include the upscale Central West End and several higher-crime neighborhoods to the north. That means he was responsible for making decisions about how to deploy resources across an area with massive disparities in wealth.

At the same time, he walked a foot patrol in the Central West End for The City’s Finest.

The Central West End neighborhood of St. Louis (Michael Thomas for ProPublica)

The neighborhood official who has managed Mueller’s patrols for The City’s Finest said that he doesn’t see any conflict. “He’s not working secondary for us because he’s the captain of a district,” said Jim Whyte, a retired city police officer who is executive director of the Central West End Neighborhood Security Initiative, which oversees The City’s Finest patrols. “We don’t care if we’re hiring a patrolman or a colonel; we’re hiring a police officer that has the powers of arrest that can enforce statutes and ordinances.”

On one occasion, in February 2020, Whyte — who is not a police department employee — suggested in an email that Mueller make an arrest in a trespassing case. A man had repeatedly gone into a cosmetics store in the Central West End where an employee had a restraining order against him. In an email to a police officer copied to Mueller, Whyte wrote: “I will pass that along to the secondary officers. Actually Captain Mueller will likely apprehend him quicker than anyone else.”

Whyte said that protecting the business and its employee from the trespassing suspect was important to the health of the neighborhood and “we don’t get the police response on trespassing.”

Mueller was recently transferred to another police district; he did not respond to a request for comment.

Stoughton, the law professor who has studied police moonlighting, said that a police officer who works as a privately hired officer in the same district where he is in command could have divided loyalties. As a commander, he might want to commit more of the police department’s resources to the area where he draws a second paycheck. But he also might want to hold back resources because his private employer’s business depends on a need for more policing there.

Campbell Security and Service Group, a smaller private policing company that competes with The City’s Finest for contracts, also employs senior command staff from the city. It works in a handful of neighborhoods.

Among the 60 city officers who have sought and been granted permission to work for Campbell are Interim Chief Michael Sack, Bureau of Professional Standards commander Maj. Eric Larson and three district commanders. One of those district commanders, Capt. Christi Marks, said she had not worked for Campbell in about five years. The others, through the police department, declined to comment.

Corby Campbell, the company’s owner, said senior department officials on his payroll worked both as private patrol officers and as consultants. “It can be anything from just a simple question to an idea, like, ‘What do you think?’” he said. “There are no time frames, it could be nothing for a month or two and I might have something I want to run by them.”

by Carson Kessler

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For the funeral industry, the COVID-19 pandemic has meant flush times. Revenues have surged at Service Corporation International, the largest such chain in the U.S., with more than 1,500 funeral homes and 400 cemeteries. And “COVID impact,” according to a recent investor fact sheet, helped SCI more than double its earnings per share between 2019 and 2021.

Prices for funerals have always been steep. Funeral homes charged a median of $7,848 for a viewing and burial last year, according to the National Funeral Directors Association, and $6,970 for a cremation. Those costs don’t include the charges from cemeteries, which can add thousands more. ProPublica recently investigated one cemetery whose charges could run into the tens of thousands of dollars.

The federal government has done little to regulate the industry. Thirty-eight years ago, the Federal Trade Commission tiptoed into this realm, mandating that funeral homes disclose their prices. But cemeteries, some of which are overseen by states, were exempted from those rules. For two years now, the FTC has been conducting a rare review of its rules and examining a wide series of proposals, including extending its rules to cemeteries, requiring that prices be posted online, and disclosing that embalming is not legally required. Presented with a series of questions about the status and timing of the process, an FTC spokesperson would say only “the review is ongoing.”

Joshua Slocum, executive director of the Funeral Consumers Alliance, the only national consumer organization that monitors the funeral industry, has been advocating for changes to the FTC’s Funeral Rule for decades. Regardless of what the agency decides, Slocum wants consumers to know their rights, as well as have a few tips at their disposal when preparing to put a loved one to rest.

This conversation has been edited for length and clarity.

Many people might be surprised to know that at least part of the death industry is regulated. What is regulated and what isn’t?

Let’s talk about the federal [rules] because that’s most important to the basics of what people need to know. There’s something called the Funeral Rule, a regulation from the Federal Trade Commission, which gives consumers particular rights, and they would be very wise to exercise these rights.

One, they have a right to get price quotes by phone.

Number two, when they go to a funeral home in person to talk about a funeral arrangement, they have a right to a printed, itemized price list — think of it just like a menu at a restaurant.

Number three, they have a right to pick and choose item by item. Funeral homes are not allowed to offer you only a package. They will try to offer you a package and they will often say, “You save money if you buy everything together in a bundle.” But just like all bundles, you have to take a look and see, is this actually something I would have spent money on, on its own? Am I really saving money? Or am I just getting a bunch of things that I wouldn’t have picked anyway?

What are the first steps to take after a loved one’s death?

Number one, remember that death is not an emergency. When death occurs, by definition, that means the emergency is now over. The worst thing that can happen has already happened. The person isn’t going to get any deader, to put it plainly.

Get on the phone and call at least five different funeral homes within a 20- to 30-mile radius of where the dead person is. Get price quotes. Take the time to at least look it over and compare some of the prices before you commit to having the funeral home remove the body. If the person dies at a hospital, which is more common, you have more options. Ask the hospital if the body can stay in the morgue for a couple of days while you make a considered decision about which funeral home to call.

Two, take stock of your budget. You need to know that figure. Decide ahead of time what you can comfortably afford. And for God’s sake, please don’t do this: “Oh, money is no object. It’s my mother. She deserves the best,” and then three months from now, you’ve got a $15,000 bill that you can’t pay.

What happens when you comparison shop?

Anytime you pick five or six funeral homes, all within the same city or region, and you canvass them, you will find that there’s a price difference of thousands of dollars for exactly the same service all within a service area available to you. And you will not know this because the vast majority of people will say, “Oh, well, we just use our family’s funeral home.” And I will ask them, “Why is that the one you always go to?”

The bottom line is nobody has a family car dealer, nobody has a family utility company, nobody has a family anything else. They compare prices and services. The problem here is that because this is the death transaction, and it’s a transaction we’re only going to sign a check for on average once in our lives, we don’t have practice with it. And because it is the most emotional business transaction we will ever encounter, many make the mistake of thinking of the funeral home in the same emotional category that their church lives in. That’s a mistake. Your funeral home is not your minister. Your undertaker is not your counselor. Your undertaker is your car dealer for death. And I do not mean that in an insulting way. I mean it in a straightforward business way.

How did it come to be that funeral homes are governed by some federal regulation, but cemeteries aren’t?

The cemetery regulation is so poor that I consider it an unregulated industry, even if it is technically regulated under state law.

Cemeteries before the 20th century were never considered a capitalistic, profit-making venture. They were, either by law or by community consensus, conceived of as doing a public good, something closer to what the church does. So they were seen as nonprofit community service entities that weren’t subject to regular business regulation. That changed in the 20th century when it did become possible in many parts of the country to run a for-profit cemetery.

But the regulations never caught up. The same kinds of deceptive practices that were documented that led to the Funeral Rule have always been going on at cemeteries.

I think there’s very little chance that the FTC is going to bring cemeteries under the funeral rule this time around. We’ve tried many times. There are complicated reasons for it. One of the reasons is that many cemeteries in many states are organized under nonprofit corporation law. The FTC does not have jurisdiction over that, which is an actual genuine, systemic problem.

What kind of deceptive cemetery practices are you referring to?

The same things as what funeral homes did before the law changed. The FTC rule doesn’t apply to cemeteries, so they don’t have to give out a printed price list. They don’t have to let you pick a la carte. Many cemeteries get up to nonsense games, like if you don’t want to buy that cemetery’s headstone, they get sore that they’re not getting that profit out of you. So if you go to a third-party monument dealer, the cemetery will tack on what they will call an “inspection fee” that just happens to be the exact difference in cost that they lost if you didn’t buy their stone.

What has changed now for the FTC to consider amending the Funeral Rule and what needs to happen for some of these proposals to be implemented?

Well, the FTC needs to act. It’s been two years since the FTC announced that they were reviewing the rule, and a review means considering changes. I don’t have a lot of inside knowledge, but what I can say is in communicating with the staff, I believe that they are taking this issue seriously. I believe that they are seriously considering updating the rule to mandate online pricing for funeral homes.

The current federal regulations entitle you to a paper price list if you show up in person at the funeral home. We believe that funeral homes should have to post their prices on their website. But until they do, you are probably going to have to telephone shop.

Do many funeral homes post their prices online, even though it’s not legally required at this point?

We, the Funeral Consumers Alliance and our partner organization, Consumer Federation of America, have done two surveys on the rate of online price posting. We did one in 2018, sampling 25 cities. We found only 16% of funeral homes posted their price lists online. We just did a new version of the survey, which was greatly expanded to a sample size of 1,046 funeral homes in 35 different states, and we only found 18% of them posting their prices. So no, most funeral homes hide their prices online.

Do you think the industry’s profits from COVID-19 will affect the FTC’s decision?

I think our perception and reaction to COVID has played roles in most things. One of the things that was really unfortunate for funeral consumers is that COVID was exactly the period when an online price list would have been most helpful to grieving families and we didn’t have it. People were afraid to go into businesses in person, or there were actually state-based restrictions about transacting business in person. So a lot of people were making arrangements over the phone or in some long-distance way.

The big corporations, which own hundreds of funeral homes and cemeteries across the country, are opposing changes to the rule — what’s their stated reason? What’s your take?

Things like, “We believe that this is a very personal transaction, and we believe it’s most appropriate for the price discussion to be had in the traditional manner, and consumers aren’t shopping for price anyway, so there’s no need for this.” That’s what they say. It’s not complicated. It’s simply that they don’t want to be regulated. From my point of view, they have a very weak case. First of all, requiring online posting of price lists literally costs the funeral industry $0. Do you know what it costs them? It costs them the time it takes to click that button that says “upload PDF.”

ProPublica asked SCI to comment on the FTC’s rules and Slocum’s characterizations of the company’s position. In a statement, an SCI spokesperson acknowledged that “we oppose additional federal regulations.” The company asserted that “the Funeral Rule has worked well at the federal level” and that “our industry is primarily regulated at the state level, and additional regulation at the federal level is unnecessary.” It emphasized the importance of “having a personal conversation with a licensed funeral director, who acts as the consumer advocate” and said that its research shows consumers believe “price is the least important consideration when comparing service quality, reputation, convenience of location and price.” It also stated that SCI’s pricing is “competitive and reasonable.”

Asked about its profits, SCI said, “As the largest provider of funeral, cemetery and cremation services in North America, we served many families who lost loved ones in the pandemic. The growth was driven by elevated COVID-19 mortality, which resulted in an increase in both funeral services performed and burials in our cemeteries.” The statement added that “we had to scale to serve our communities, often when other funeral homes were overwhelmed and simply could not do so.”

More broadly, how have multibillion-dollar conglomerates like SCI changed the funeral industry?

Here’s the reality: They still only have about 12% of the funeral homes in this country. And that’s been pretty steady over 20 to 30 years. In some cities, places like Seattle, many cities in Florida, where there’s a heavy concentration of elderly people, then SCI has a much greater percentage of the market share. That is true. In those places, SCI particularly tends to be the highest-priced funeral home in any market. So if it matters to you, find out who owns your local funeral home. Just because it still says McGillicuddy on the sign doesn’t mean Mr. McGillicuddy still owns it.

Are there practical things that consumers can do to bring the cost of a funeral down?

The most cost-effective thing is to choose a funeral home that already has reasonable prices. Your choice of funeral home is the No. 1 driver of cost. Once you choose a funeral home, look carefully at their offerings and see how much of it you can afford that’s within your budget. Remember that you can shop a la carte. So if your budget says $2,000, you need to face reality. $2,000 is not going to buy you a traditional funeral with embalming, public viewing of the body, metal casket, graveyard burial. You are not going to get that for $2,000 anywhere in the United States. That means your choice is going to be something like simple cremation, even if that’s not your favorite. People have to be realistic.

Is price negotiation ever an option? How would that work?

Yes, just the same way you would do it with any other business that you were negotiating with. They don’t have to haggle with you, but you have the right to do so. We get people who are like, “Well, the funeral home has already picked up the body and we do like this funeral home, but they’re more expensive than another one we found in town, we simply can’t afford it.” And my suggestion is talk to the funeral director and say, “Listen, you’ve taken good care of us before, we appreciate that you came to pick our grandmother up, but we literally cannot afford your price on this direct burial. We would love to give you our business. Can you meet your competitor’s price? We realize you don’t have to lower your prices. But we would like to do business with you. If you can’t lower your prices, we’ll have to have her body removed to a different place.”

And that’s OK to do?

Well, why wouldn’t it be OK? Here’s what I hear underneath this, and I think you’re channeling it correctly from people: What people are doing is asking for permission. But you’re not breaking a social rule. You’re not being cheap. I know what people are thinking: “I don’t want to do that. It’s gauche. It means I don’t care about my mother.” Stop that. That’s nonsense talk. If you showed how much you loved your mother by how much you spent on her funeral, you’d go bankrupt. Love cannot be expressed by money.

Lastly, what are some of the biggest misconceptions about navigating this process?

Most of what people think they are required to purchase is not true. For example, many people think embalming is legally required if you’re going to view the body. That is not true in any U.S. state. It’s also not true that embalming is required as a condition of being buried in the ground. These are in-house funeral home policies, not laws. So there’s very little that you are legally required to purchase. Basically, the only thing that has to happen, when a person dies, in order to satisfy the laws, there has to be a death certificate signed by a doctor, the body has to be buried, cremated or donated to anatomical science within a certain period of time, and that’s literally all that is required. Everything else is optional.

Go into this transaction knowing that although it’s emotional, you are a consumer, you get to decide what you put in your cart. You’re not obliged to buy these things. These are choices and you should make choices that fit your family’s budget and your family’s emotional preferences.

by Jeremy Kohler

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.

Hours after a burglary at a designer jeans store in St. Louis’ upscale Central West End neighborhood, at least 16 city police officers received an email alert with surveillance photos of the car believed to belong to the suspects — and an offer of a reward of at least $1,000 for any officer able to locate it.

The email was not from the St. Louis Metropolitan Police Department, the police force that employs them and that residents fund with their taxes. Instead, it was from a retired city police detective named Charles “Rob” Betts, who also employs them at his private company, The City’s Finest.

The City’s Finest is no mere security firm. With about 200 officers moonlighting for it, it’s the biggest of several private policing companies that some of St. Louis’ wealthier and predominantly white neighborhoods have hired to patrol public spaces and protect their homes and businesses.

These neighborhoods buy patrols from Betts’ firm and other private police companies because, they say, they do not get enough from a city police department that struggles to provide basic services.

Under department rules, officers have the same authority when working for these companies that they have while on duty, one reason their services are in such demand. They can investigate crimes, stop pedestrians or vehicles and make arrests. And the police department requires that they wear their police uniforms when they’re working in law enforcement or security in the city, creating confusion about who they’re working for.

The result is two unequal levels of policing for St. Louis residents and businesses. Low-income and minority residents do not have the resources to hire police through a private company, and the department has struggled to provide patrols in parts of the city that suffer high rates of violent crime.

Meanwhile, the more affluent neighborhoods, which are less affected by violent crime, have raised millions of dollars to pay companies like The City’s Finest for granular attention from the same officers the police department has said it doesn’t have enough of. Officials in some of those areas praise The City’s Finest. They credit it with suppressing crime and helping merchants stay in business.

Dwinderlin Evans, a city alderwoman who represents some of the areas of St. Louis with the highest crime rates, including the neighborhoods of The Ville and Greater Ville, said the private policing system is unfair, “especially when you have neighborhoods that can’t afford to pay for extra policing.”

What’s more, The City’s Finest has raised its pay to exceed the department’s overtime rate — in essence outbidding the police department for its own workforce. Betts, in fact, has been clear that his company has to pay more to attract city police officers who might otherwise opt to work overtime.

Competing With the Police Department for Officers

The owner of The City’s Finest, Charles “Rob” Betts, told members of the Euclid South Community Improvement District on Sept. 16, 2021, that his company had raised its pay to compete with the St. Louis Metropolitan Police Department.

(Audio provided to ProPublica)

Following questions from ProPublica, St. Louis Department of Public Safety Deputy Director Heather Taylor said the city planned a “complete review” of how off-duty officers are used and will hire a firm to “review for best practices that are going to be equitable to officers, the community and the city.”

Taylor acknowledged that, while working as a St. Louis police officer before retiring in 2020, she received an email offering a reward from The City’s Finest to work on a case. She said rewards for off-duty officers are “a practice we’re reviewing, that’s for sure.” ProPublica has identified four cases where The City’s Finest offered rewards.

Taylor said the bigger problem was low pay that makes secondary employment necessary. City police officers make a starting salary of $50,615, about 9% less than in neighboring St. Louis County and 13% less than in suburban Chesterfield.

Meanwhile, St. Louis Comptroller Darlene Green proposed boosting officer pay and benefits and bolstering community policing through a program called “Cops on the Block.”

St. Louis is far from the only U.S. city where neighborhood groups have hired off-duty officers. In Minneapolis, Atlanta, Kansas City and Dallas, neighborhood groups contract directly with local police departments or with the officers themselves. But in those cities, such patrols are typically managed by city officials and officers are accountable to department supervisors.

In other cities, such as Chicago, officers may work off-duty patrolling neighborhoods for private security companies, but they generally do not wear their police uniforms or represent themselves as police officers. The growing presence of off-duty officers in upscale Chicago neighborhoods has drawn concern from Mayor Lori Lightfoot, who said she didn’t want “a circumstance where public safety is only available to the wealthy.”

She added, “That’s a terrible dynamic.”

Experts in policing said they had never seen a system like the one in St. Louis. That system is “an extreme example of a pattern that can be found all across the country,” said David Sklansky, a professor of criminal law and procedure at Stanford University. “Public policing, for all its problems — and it has many, many problems — does represent a commitment to protect people equally, not based on their wealth or political power,” he said. “So the privatization of policing represents a retreat from that promise.”

People move along through the Soulard neighborhood. (Michael Thomas for ProPublica)

Even some officials in well-to-do neighborhoods acknowledge disparities the arrangement creates. “It’s kind of a screwed-up system,” said Luke Reynolds, chair of the special business district in the city’s Soulard neighborhood, known for hosting one of the nation’s biggest Mardi Gras celebrations.

Reynolds said that it was unfair that Soulard has “affluence compared to a lot of other neighborhoods and gets extra patrols. It’s kind of screwed up that the police department can’t do their job and doesn’t have enough people, yet they can staff secondary patrols.”

Mayor Tishaura O. Jones, interim Public Safety Director Dan Isom and interim Police Chief Michael Sack declined interview requests.

Public servants, including police officers, are generally prohibited from accepting gratuities or rewards. It is a felony in Missouri to offer a benefit to a public servant for any specific action they take in that role. The St. Louis police manual says officers cannot accept gratuities, rewards or compensation — unless they are for work outside the department.

While Missouri law does not address whether it is legal for an off-duty police officer to accept payments, courts in other states, including Oklahoma and Connecticut, have held that an off-duty officer accepting rewards or gratuities from private individuals for their actions within the jurisdiction that employs them runs contrary to public policy. In 1899, the U.S. Supreme Court held that it was against public policy for federal marshals to receive a private reward for capturing a fugitive, comparing it to extortion.

Seth Stoughton, a former police officer who is a professor at the University of South Carolina law school and has studied police moonlighting, called emails from The City’s Finest offering private bounties “wild.”

“Officers used to get rewards like this,” he said, “but we’re talking 100 years ago.”

Betts said in an interview that he considers the practice “aboveboard” and not unlike an officer being recognized for good police work at a luncheon. He also compared it to Crime Stoppers, the anonymous crime tip lines that provide rewards for information — although police in Crime Stoppers’ St. Louis region cannot receive rewards.

“It’s merely just an incentive, to just pay a little more attention to this for a little bit. Everybody’s got their plates full,” Betts said. “Our job as police officers is to solve crime and there’s a lot of stuff that gets lost in the shuffle.”

He added: “Everybody works better when you incentivize them.”

Betts works in the office of The City’s Finest in 2015. (Whitney Curtis for ProPublica)

St. Louis perennially has one of the nation’s highest rates of violent offenses among big cities, and, like most American cities, it has struggled to reign in crime. As a result, the performance of the police department is a point of almost constant conflict among city leaders. Some companies have even threatened to relocate because of crime.

The crime and violence, however, don’t occur evenly across the city. They are concentrated in the neighborhoods north of Delmar Boulevard, St. Louis’ well-known racial and socioeconomic dividing line. To the north of Delmar, nearly all of the residents are Black; more than half of residents south of Delmar are white. Home values south of Delmar are roughly seven times higher than those to the north, according to the city assessor.

Pockets of the north suffer from especially high rates of violent crime. In the city’s Sixth District, which contains about 35,000 residents in about 14 square miles, at least 76 murders were committed in 2020. That’s nearly as many as in the entire city of Minneapolis, a city of 430,000, and more than in Boston, with a population of 675,000, or Seattle, with a population of 735,000.

That same year, the Second District on the far south side of St. Louis, which has about 74,000 residents in 15 square miles, had just seven murders.

“It’s a crisis that we’re dealing with,” said Paul Simon, who owns a pet salon on the city’s north side. “Not only in the homes of the people that are in our community but the neighborhoods as well. We’re just in a desolate area. I can’t blame the police, because we have officers who are young and vibrant that are wanting to serve and protect, but the resources at the top” are not getting to struggling communities.

The O’Fallon neighborhood on the north side of St. Louis (Michael Thomas for ProPublica)

John Hayden, who served as chief from late 2017 until his retirement in June, said in public meetings that the department did not prioritize high-crime areas with its patrol plan. Instead, it deployed about the same number of officers to each of its six police districts. Those districts were drawn in 2014 to handle roughly equal volumes of calls for service — but without regard to the seriousness of the crimes.

Critics of the strategy said minor crimes are so pervasive in high-crime areas that victims typically do not bother to report them.

“If we prioritize them by violence, then some of you would have less officers in your districts, and some of you would have more,” Hayden told the aldermanic public safety committee in a videoconference in September 2020. “I think I would get a lot of resistance from some of the people that are on this call.”

Hayden said that day that he had tried to bridge the gap by supplementing patrols in the most violent areas with officers from specialized units. And he said that if he had more officers at his disposal, he would send them to areas with the highest violent crime rates, which “may not be something that everybody supports.”

The aldermanic committee advanced a measure that would have redrawn all six police districts and added a seventh to direct more officers to high-crime areas.

But Hayden told aldermen it was “not feasible” because the department would be spread too thin.

Hayden said in an interview that the ability of some neighborhoods to hire extra police while others cannot was simply “a matter of fact.”

Department leaders and the union that represents rank-and-file officers have for years portrayed the department as shorthanded, struggling to recruit and retain officers. Between 2015 and 2021, the department ran about 100 to 200 officers short of its authorized force of 1,340 officers.

Last year, Mayor Jones cut more than 100 unfilled positions. The department today has 1,053 officers, according to the Missouri Department of Public Safety. Even with job cuts, the force remains one of the largest in the nation per capita.

A longstanding complaint from neighborhood leaders is that officers are so busy responding to emergency calls that they seldom have time to engage with residents, build relationships in the community and act as a deterrent — to just be seen on the street.

Last October, about a dozen business owners in an area of the north side that includes the high-crime neighborhoods of Walnut Park East and Walnut Park West met at a restaurant with two St. Louis police officers. They expressed their frustration about the scarcity of patrols in their district. A reporter observed the meeting.

“We don’t even call you every time,” Tahany Jabbar, the chief operating officer of a chain of gas stations, told Sgt. Christopher Rumpsa and Lt. David Grove.

Rumpsa nodded and finished Jabbar’s thought: “You’d be calling all day.”

“To be honest, you guys don’t come,” Jabbar said. “No offense, but if someone’s not dying, you’re not coming.”

Rumpsa told Jabbar that when the city restructured its police districts in 2014, the Sixth District was meant to have 16 cars on the street at all times, but currently had far fewer.

“Patrol always has the least amount of resources,” Rumpsa said. “That’s the one thing they have got to change.”

ProPublica sought to observe The City’s Finest at work, after Betts suggested that a reporter ride along with some of his employees. The police department, however, blocked the request.

The department also blocked ProPublica’s access to data that would provide a picture of how the department deploys its officers. It declined to provide in-depth data on the activities of its patrol officers, which could have shown possible differences in how they respond in different neighborhoods.

But two groups of consultants did get access to that kind of information. Both concluded that the department does not put enough officers in high-crime neighborhoods.

The Walnut Park East neighborhood on the north side of St. Louis (Michael Thomas for ProPublica)

Teneo Risk, led by Charles Ramsey, who has headed police forces in Philadelphia and Washington, D.C., studied St. Louis’ police department in 2020 at the request of the area’s biggest publicly traded company, Centene. Teneo found the department lacked a comprehensive plan to address crime that left it “constantly in ‘fire-fighting’ mode,” leading to “persistent rates of crime and disorder.”

Its report said that in high-crime areas the department “finds itself chronically reactive to incoming calls for service, struggling to maintain sufficient numbers of officers on patrol, and lacking the resources to implement more community-based policing.”

Another group, Center for Policing Equity, studied the police department last year and found that while the department had “exceptional” response times to emergencies, officers in high-crime areas had little time for what is called proactive police work: deterring criminal activity with a visible police presence.

In two districts that lie mostly north of Delmar, the Center for Policing Equity found, officers were so backed up with calls they had little time for “a more comprehensive community-centered policing presence.” But in some areas with lower violent crime rates, the group said, the department was comparatively overstaffed.

Taylor, who retired from the police department as a sergeant in September 2020 and was hired as deputy public safety director after Jones became mayor in April 2021, said “a lot of things that we’re doing have changed” under Jones. She said the department has, in fact, sent more officers to work in areas struggling with high rates of violent crime.

Jay Schroeder, the president of the St. Louis Police Officers Association, the police union, said some officers feel the department has too many officers working in administrative roles. As the department has lost officers, he said, it has left more vacant positions in the patrol division, creating even more demand for private policing.

“The patrol division should be the division that has the most people and the most resources going to it, and it doesn’t seem like it’s been the focus over the last nine to 10 years,” Schroeder said. “As crime goes up, aldermen want policemen in their neighborhoods and the only way it seems they can get it is to pay” private policing companies.

“They’re paying to have policemen in their neighborhoods. That’s what we’ve come to.”

The headquarters of The City’s Finest near the Grove district (Whitney Curtis for ProPublica)

The sign over The City’s Finest’s headquarters off a busy St. Louis street in the city’s central corridor features a single word: POLICE. Many of its vehicles also feature the word POLICE and a logo that incorporates the St. Louis police badge. Other vehicles say SECURITY.

When there has been confusion among residents over whether the officers driving these cars are working on behalf of the city’s police department or a private company, The City’s Finest has tried to avoid drawing a distinction between the two. Speaking about his company, Betts once said it was “essentially an extension of the police department.”

It took decades for this mindset to become commonplace in St. Louis. Some city and neighborhood leaders have concluded private policing is the only way to get policing.

Betts said in an interview that private policing “allows an officer to focus in one particular area for the entirety of their shift, which puts a consistent police presence in that neighborhood.” He added: “We kind of look at ourselves as a force multiplier to the police department, and it’s at no expense to the city.”

Betts has even talked about rolling out a system to allow residents in the neighborhoods The City’s Finest patrols to bypass the city’s 911 system to contact a company officer to report an incident or request an escort. His company would then locate the nearest officer, using a GPS app on the officers’ phones, and direct them to handle the call.

A Number to Call for Private Police to Respond “In an Instant”

Betts told members of the Central West End North Special Business District on Sept. 17, 2021, that he wants to provide residents a direct number to his officers.

(Audio provided to ProPublica)

The city, according to financial statements and other records, has at least 15 districts that levy taxes to pay more than $2 million a year for private police patrols, which include most of the city’s central corridor and several prosperous residential areas on the south side. And more are signing on. The Holly Hills neighborhood, which has one of the lowest rates of violent crime in the city, voted in August to create yet another taxing district, which would raise about $400,000 a year from a property tax surcharge and spend 30% of that for private police.

Steve Butz, a Democratic state representative who helped organize the Holly Hills ballot initiative, said he and his neighbors believe the city is “becoming ungovernable.”

“Is it fair?” Butz asked. “Is it fair that wealthier people drive nicer cars, have better homes, have home security systems, get better health care, go to better schools? People with less resources get the lower end of the stick.”

Private policing in St. Louis dates to the early 1990s and the theft of a Bob Marley box set from West End Wax, an independent record store in the Central West End. Tony Renner, who was then an employee of the store, recalled chasing the shoplifter down Euclid Avenue as the store’s owner, Pat Tentschert, fired shots at the thief.

Central West End resident Jim Dwyer said that Tentschert showed up at a neighborhood meeting one day soon afterwards, pounded her fist on a table and said that more needed to be done to make the neighborhood safe. (Tentschert died in 2017.) He said an alderman “whispered in my ear afterwards” that the neighborhood could form a special business district. “And we did.”

The Central West End neighborhood of St. Louis (Michael Thomas for ProPublica)

Residents from the area voted to form the Central West End North Special Business District in 1992. Their goal: improving neighborhood safety, including by hiring their own private police officers.

“There are people who are envious of the presumed wealth and privilege of our neighborhood in particular,” said Dwyer, who now serves as the district’s chair. But, he said, “we’re not abusing anything.”

Around the same time, Adam Strauss, whose father, Leon Strauss, had redeveloped thousands of homes in the DeBaliviere Place neighborhood next to the Central West End, founded Hi-Tech Security. The company dominated private policing until 2009, when the St. Louis Police Board stripped Adam Strauss of his city security license for engaging in an improper chase and using unnecessary force to arrest two people who had been suspected of trespassing on a gated Central West End street. Adam Strauss declined to comment.

Then-Police Chief Isom told the St. Louis Post-Dispatch in 2009 he wanted the department to “have better control over where those services are and where those people are.” He added: “The idea would be there would be no middle person. So you would not have any private security company in the middle.”

But that never happened. Instead, private policing continued to grow. A new company — this one run by police officers — was starting to compete with Hi-Tech for neighborhood policing contracts. In 2007, Betts was a beat cop working in the Forest Park Southeast neighborhood near the Washington University medical campus. The university’s redevelopment arm was investing heavily to stabilize the surrounding area.

Some neighborhood leaders viewed the neighborhood’s stubborn crime and the presence of gangs as an obstacle to progress. According to Betts, Brooks Goedeker, who was then a community development specialist with the medical center, suggested that he add bike patrols conducted by St. Louis police officers. Goedeker did not respond to a request for comment for this story.

Although Betts’ online resume says he has owned the company since July 2007, when he was still on the force, he has said over the years that his mother owned the company. Since at least 2006, the police department has prohibited members of the force from having a financial interest in or acting as officers or directors of a private security company. Betts said he had to form his company “in a certain way to ensure that things weren’t being violated.”

Betts retired as a homicide detective in 2013 after being injured in a traffic accident on duty.

Charles P. Nemeth, author of the book “Private Security and the Law” and the retired director of the Center of Private Security and Safety at John Jay College in New York, said rules regulating officers owning security companies are important because “private security firms may deal with a criminal case or other matter in a distinctively different way than public policing may be required to handle.”

Nemeth, now the director of the Center for Criminal Justice Law and Ethics at Franciscan University of Steubenville in Ohio, said officers in uniform working for private companies is “very troublesome” because it blurs the basis of their authority. “This is a new one to me, and I’ve been watching this a long time,” he said.

Indeed, nothing suggested that an officer patrolling a Central West End sidewalk on a recent evening was moonlighting for a private company. Lt. JD McCloskey, who works as an aide to the St. Louis police chief, acknowledged to a reporter that he was working for The City’s Finest, though he was wearing his police uniform. He said his responsibilities that evening were to maintain a visible presence along a stretch with several businesses and “interact with citizens and businesses.”

McCloskey walks a foot patrol for The City’s Finest in the Central West End. (Whitney Curtis for ProPublica)

The private policing system puts law enforcement in the hands of interests that are not part of the city’s government and, as a result, are not accountable to taxpayers citywide.

The police department’s only oversight of private policing is screening employers of off-duty officers and auditing whether the officers work more than the maximum hours allowed: 32 hours a week total, or 16 hours a day including their eight-hour department shift. A state audit two years ago found the department didn’t adequately track moonlighting; since then, police have assigned officers to monitor the practice.

Officers on patrol for private police companies don’t necessarily go where crime is happening; they go where they’re paid to go. So it was that a burglary in the Central West End prompted a substantial reward offer from The City’s Finest and a search by several officers across St. Louis for the potential suspects.

The landlord of the burglarized jeans store was no ordinary resident. He was Sam Koplar, a prominent local developer. In addition to Koplar being a board member of one of the Central West End taxing districts that had hired The City’s Finest, his company separately hires officers from The City’s Finest to protect his properties in the Central West End.

Betts wrote in the email to officers that Koplar’s properties had been targeted by criminals three times in the previous year. He implored officers to “work any angle you deem appropriate” and even recruit fellow officers from an undercover task force to help find the car.

“Solving this case is very important to TCF and your help is much appreciated,” he wrote, using The City’s Finest’s initials. The email was sent to some of the officers’ department email addresses; among the recipients were two of the six St. Louis police district captains at that time.

This email to several St. Louis police officers from the owner of The City’s Finest includes a $1,000 reward to any officer who locates a car as part of a burglary investigation. (Email obtained from the St. Louis Metropolitan Police Department by ProPublica)

One of those captains, Michael Deeba, who also worked for The City’s Finest at that time, responded from his department email with a key detail: the plate of the wanted car. Another officer emailed the group from his email address at The City’s Finest that a license plate reading camera had detected the car on a street several miles away. A short time later, a suspect was taken into custody at an address near where the car had been seen, although it’s not clear if anyone was prosecuted for the break-in. It was also not clear if any officer was given the reward money.

Deeba, who was charged in April with stealing for allegedly moonlighting for another company on police department time, said that “the whole department,” including its last three chiefs, knew of the rewards. But he said neither he “nor my people would take such a reward.” He has pleaded not guilty to the stealing charge. Deeba has said the department placed him on forced leave; the Missouri Department of Public Safety said he was no longer employed by the city.

Koplar said in an interview that he doesn’t like paying for additional policing, saying the police department should provide adequate patrols. “But unfortunately,” he said, “the police department is stretched very thin.” He said the repeated break-ins at his property were frustrating. “We were exasperated. Our job as the property owner is to provide a safe environment.”

Betts said in an interview that offering a reward was warranted because it brought attention to a crime that the police department might not have devoted the resources to solve. “That business, that area, was a very important part of the business district of the Central West End,” he said. “It was hit three times, which ultimately cost the Koplar family to lose their client, which was detrimental to their business. And nothing was being done.”

Betts said he does not know how often he offered rewards: “It wasn’t like I was doing that every day. It’s usually for a high-profile crime or something that’s of great importance to our efforts.”

ProPublica discovered the rewards by obtaining emails between the company and some members of the department through an open records request. Only emails copied to police department email accounts were subject to the records request.

In another case, after Betts emailed a group of city officers to offer $250 for the arrest of a suspected prowler, a detective sergeant for the department responded on his department email that a “wanted poster shall be created” for the suspect. The detective sergeant, Renwick Bovell, did not return requests for comment.

This email from a St. Louis police detective sergeant indicates that a “wanted poster” would be created after the owner of The City’s Finest posted a $250 reward for any officer who arrests a suspected prowler. (Email obtained from the St. Louis Metropolitan Police Department by ProPublica)

Mary Fox, director of the Missouri public defender system, said she had “real concerns with a private organization saying, ‘Hey, if you arrest this person, we’ll give you money,’ when there has not been a judicial determination that the person should be arrested. For a police officer to arrest someone without a warrant, they have to have reasonable suspicion that a crime occurred and this is the person who committed the crime. And it sounds like they are just taking the word of the organization that’s reaching out to them without any investigation by themselves or their department. That’s problematic.”

Nate Lindsey is a former official for a taxing district in Dutchtown, a south city neighborhood that struggles with crime. In 2018, Dutchtown neighborhood officials tried to hire The City's Finest but could not afford to. “Even if a poor neighborhood that lacks resources goes as far as to tax itself to attempt to bring better policing resources into the streets, it’s going to struggle if it doesn’t have enough money to compete with deeper-pocket interests,” he said.

For city residents, he said, “the expectation is that the police department is making decisions with the public good in mind as a whole and that process isn’t affected by special interests or the amount of money that can be provided to either individual officers or companies like The City’s Finest,” he added. “They’re not doing that now.”

by Megan Rose

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Despite a 2016 law requiring more transparency of court-martials, the U.S. Navy is refusing to release nearly all court documents in a high-profile case in which a sailor faces life in prison.

Seaman Recruit Ryan Mays, 21, has been charged with aggravated arson and hazarding a vessel in the 2020 fire that destroyed the USS Bonhomme Richard. Mays has maintained his innocence.

On July 12, 2020, a fire started on the amphibious assault ship as it was moored at Naval Base San Diego and raged for more than four days. The Navy was not able to put the fire out until the ship was so badly damaged that the service had to scrap it, a more than $1 billion loss.

Although the Navy has accused Mays of starting the fire, the service’s eight-month investigation found plenty of blame to go around. A more than 400-page report concluded that leaders, from those on board the Bonhomme Richard all the way to a three-star admiral, had failed to ensure the ship’s safety and allowed it to become a fire hazard. Fire response was also grossly mismanaged by leaders who had little understanding of how it should have worked, the Navy’s investigation found. Top Navy leaders called the dayslong blaze preventable and unacceptable.

Last week, the military judge in Mays’ case denied requests made separately by the defense and ProPublica to make the records public. Cmdr. Derek Butler sidestepped the defense’s claims — that the government was violating Mays’ Sixth Amendment right to a public trial — and ProPublica’s assertions of the First Amendment. Butler didn’t address the constitutional issues at hand and instead said he didn’t have the authority to release the records.

In July, ProPublica had first requested from the Navy’s Office of the Judge Advocate General all court records that have already been filed and discussed extensively in open court in the Mays case. That office denied access to all but two records already made public, refusing to release any more until the court-martial concludes — and only if Mays is found guilty. The court-martial is scheduled to begin Sept. 19.

In August, ProPublica, along with Paul LeBlanc, a retired Navy judge and lawyer, filed a motion asking Butler to release the documents, arguing that the First Amendment requires the government to make the records public. ProPublica also argued that the public has a strong interest in understanding how and why the government is prosecuting Mays and in ensuring he receives a fair trial.

“They’re attempting to put someone in prison for a very long time, and what they’re filing is hidden from the people,” LeBlanc said. “These documents are filed on behalf of the people of the United States, and the people of the United States should have the same right to see them and know what the government is doing on their behalf as they do in federal court.”

“How can anybody have any sort of trust and confidence in a system if it won’t let them read what prosecutors are saying on their behalf?”

In 2016, Congress passed a law requiring the military to make court-martial dockets, records and filings accessible to the public. The law was prompted in part by the military’s lack of transparency in sexual assault cases. Congress’ goal was to make court-martial records as available to the public as federal court records are.

The law specifically states that the military should facilitate access during “pretrial, trial, post-trial, and appellate processes.” But the Department of the Defense has decided that the law only applies once a court-martial is over. It is simply too hard to turn court-martial records over to the public while a trial is happening, Capt. Jason Jones, the prosecutor in the Mays case, wrote in his brief asking the judge to deny records to the public. Military courts don’t have a clerk to coordinate records, and unlike civilian courts, which are in one place, military courts have to operate in a fluid environment, such as a war zone, he said.

Butler also cited the 2016 law aimed at increasing transparency as why he didn’t have authority to release the records. He wrote that the law did not explicitly grant courts the power to release records but rather the secretary of the defense. He did not address ProPublica’s argument that he has the authority and obligation to release the records under the First Amendment, which Congress cannot take away.

ProPublica Deputy General Counsel Sarah Matthews said the news organization disagreed with Butler’s interpretation of the law and would next ask the top lawyer for the Department of Defense, Caroline Krass, to clarify what the law requires the services do.

The federal government has released the charge sheet and a search warrant that detailed the Navy’s case against Mays. By withholding all other records, including those favorable to the defense, the Navy is seeking to “shield the record in secrecy to its advantage,” Matthews wrote in the motion to Butler.

“Records like these are open in every other courtroom in America. These records aren’t sealed or restricted. They have been discussed in open court, in a proceeding that could send a man to prison,” Matthews said separately. “The Navy believes it can arbitrarily delay or even deny access completely to these records, something all the more troubling because Congress has passed a law demanding more, not less, transparency from our armed services in cases like this.”

by Robert Faturechi

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After Sen. Richard Burr, R-N.C., told his broker to sell off more than a million dollars in stock a week before the 2020 coronavirus market crash, he called his brother-in-law, Gerald Fauth. Immediately after, Fauth called his wealth manager to sell off almost $160,000 in stock.

Fauth sounded “hurried,” according to a witness cited by the FBI in newly released documents. In explaining why he wanted to dump the stock, Fauth suggested he had special knowledge.

I know a senator, he said.

That appears to contradict what Burr’s lawyer told ProPublica, when we broke the news that the senator and his brother-in-law sold stock on the same day. In that story, the lawmaker’s attorney denied Burr and Fauth had coordinated.

That detail and others were revealed this week, after a judge ordered the Justice Department to further unredact documents related to its insider trading investigation into Burr. Federal prosecutors closed that investigation without filing charges last year, but as of earlier this year, a civil investigation by the Securities and Exchange Commission remained ongoing.

Burr and Fauth could not immediately be reached for comment about the latest document release. In the past, Burr has denied trading on material nonpublic information, and Fauth has repeatedly hung up on ProPublica when asked about his trades.

Here’s a rundown of what’s new from the filing:

A Previous Transaction

Before Burr’s big stock dump on Feb. 13, 2020, the senator engaged in another transaction that suggested he anticipated investor concerns.

The day before his big stock sell-off, Burr purchased $1,189,000 in the Federated U.S. Treasury Cash Reserves Fund, about three-quarters of all the money he and his wife had in their joint account. That purchase had not been previously reported. “Investors often purchase U.S. Treasury funds to hedge against a potential market downturn,” an FBI agent noted.

Why Did Burr Trade?

When the scandal first broke, Burr denied his trades were motivated by inside information he learned as a member of the health and intelligence committees, but rather by news reports from CNBC.

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Though this section remains lightly redacted, the FBI appears to have interviewed someone involved in executing Burr’s stock sell-off. That person did not recall Burr mentioning CNBC.

The person said Burr cited the coronavirus, saying it could affect the stock market and cause problems with the supply chain, since American companies rely on Chinese suppliers. (Burr also apparently mentioned that the surge in support for Sen. Bernie Sanders as the Democratic presidential nominee was a risk to the market.)

Did Burr Have a Source?

The FBI’s application for a warrant to search Burr’s phone remains heavily redacted in places, but it cites extensive texts and phone calls with someone about the impending coronavirus crisis.

“In total, between January 31, 2020, and April 7, 2020, (redacted) and Senator Burr exchanged approximately 32 text messages, nearly all of which concerned, in one way or another, the COVID-19 pandemic,” an FBI agent wrote.

That person’s identity remains unknown.

But the exchanges Burr had with this person are part of the reason the FBI was alleging there was probable cause to believe “Burr used material, non-public information regarding the impact that COVID-19 would have on the economy, and that he gained that information by virtue of his position as a Member of Congress.”

One More Call

The day the scandal first broke, Burr was facing demands that he resign from left and right, including from liberal Rep. Alexandria Ocasio-Cortez and conservative Fox News host Tucker Carlson.

One of his first calls that evening? His brother-in-law.

According to the FBI, at 7:31 p.m. a call was placed from Burr’s cellphone to Fauth’s cellphone.

It lasted four and a half minutes. What was discussed is unclear.

At that point, it wasn’t yet publicly known that Fauth had dumped stock the same day as Burr. ProPublica broke that story two months later.

A week later the FBI asked a judge for a warrant to search Burr’s phone, news of which prompted Burr to step down as chair of the intelligence committee.

by Marek Mazurek, South Bend Tribune

This article was produced by the South Bend Tribune, a member of the ProPublica’s Local Reporting Network in 2018. Sign up for Dispatches to get stories like this one as soon as they are published.

A police officer in Elkhart, Indiana, who was seen repeatedly punching a handcuffed man in a 2018 video obtained by the South Bend Tribune and ProPublica pleaded guilty in a federal civil rights case last week.

The plea agreement calls for Cory Newland to be sentenced to 15 months in prison for his role in the incident, in which he and fellow officer Joshua Titus were seen on a security camera video beating Mario Guerrero Ledesma while the man was handcuffed to a chair in a detention area at the city police station.

Newland will also pay a yet-to-be-determined amount to Ledesma in restitution. His plea came less than a month before the case was set to go to trial.

“I knew at the time of the assault that my use of force on M.L. was unjustified and unlawful under the circumstances,” Newland said in his plea agreement, referring to Ledesma by his initials.

Jessica McBrier, a spokesperson for the Elkhart Police Department, said Newland resigned from the force on Aug. 30 — the same day U.S. Magistrate Judge Joshua Kolar accepted his guilty plea.

“The department has no further comment on any plea he entered in federal court,” McBrier said in an email to The Tribune.

Attorneys representing Newland did not respond to an interview request.

Titus has pleaded not guilty and is scheduled to go to trial later this month. Both officers were placed on leave in late 2018, and Titus is still on unpaid leave with the department, McBrier said.

Fallout From Video

The Tribune obtained the video of the incident in November 2018 as part of an ongoing investigation with ProPublica into practices within the Elkhart Police Department and Elkhart County Prosecutor’s office that led to wrongful convictions. The investigation also revealed 28 of the police department’s 34 highest-ranking officers had disciplinary records.

The video shows Ledesma, seated and wearing handcuffs, while Newland, Titus and other officers stand nearby.

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At one point Ledesma spits toward Newland. Titus and Newland immediately punch Ledesma in the face, causing him to fall backward onto the floor. Titus and Newland then jump on top of him and punch him repeatedly.

“I placed M.L. in a chair with his hands handcuffed behind his back and behind the back of the chair,” Newland said in his plea deal. "M.L. spat in my direction. I responded by punching him in the face, causing him to fall backwards onto the floor. Another officer, Joshua Titus, and I continued to strike M.L. repeatedly with our fists. M.L. was in handcuffs during the entirety of the time we were punching him.”

Ledesma had initially been arrested on suspicion of domestic battery. He later pleaded guilty and was sentenced to one year in jail, with 133 days of that sentence suspended.

Five months after the incident, Elkhart’s then-police chief, Ed Windbigler, gave both Newland and Titus reprimands but did not suspend or demote them. Speaking in 2018 to the city’s police oversight commission, Windbigler said the two officers “just went a little overboard” in subduing a person in custody, but he did not mention the fact the pair had punched a handcuffed suspect.

The Tribune obtained the video of the beating after that meeting, and the discrepancy between the video and Windbigler’s description of the incident was cited by the city in its decision to suspend Windbigler. He later resigned.

Newland and Titus were originally charged with misdemeanor battery in Elkhart County in November 2018. That case was put aside when the pair were indicted on federal civil rights charges in March 2019.

A sentencing date for Newland has not yet been set.

by Renee Dudley

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Thomas van Ruitenbeek’s life fell apart in 2012, when a psychotic episode and a diagnosis of autism derailed his pursuit of a digital communication degree at a university in Utrecht, the Netherlands. For the better part of a year, the 25-year-old wouldn’t respond when spoken to, his father said, and his blue, wide-set eyes revealed little cognition. He rarely left his parents’ duplex and filled his time studying daily newspapers, convinced they contained secret messages. Sometimes, he worked up the energy to paint miniature figurines from the medieval fantasy-themed board game Warhammer. Mostly, he did nothing.

The psychotic episode and the autism diagnosis locked him into a state of isolation that had been deepening since his childhood, solidifying his long-held belief that he was an outsider. Van Ruitenbeek’s parents took him to appointments with doctors and therapists. When he grew strong enough, they supported his return to work. He did simple tasks — mostly cutting and packaging yarn — at a job he obtained through the local mental health department. That was a far cry from his earlier aspirations of being a video game designer and hardly the life his parents had hoped he would have. They worried about what would happen when they grew old and could no longer look after him.

Then, during a meeting with his coach at the mental health department in 2013, van Ruitenbeek and his parents got an unexpected bit of hope. A short distance away, a first-time entrepreneur named Peter van Hofweegen and his business partner were figuring out how to launch an education and job placement program geared toward autistic young adults who were interested in computers.

The number of people diagnosed with autism is hard to ascertain, but the statistics that are available suggest it’s on the rise. An estimated 100,000 autistic Americans turn 18 every year, according to Drexel University’s Autism Institute, and a growing number of programs in the U.S. and elsewhere aim to employ tech-savvy autistic people.

But van Hofweegen’s program was something different. He and his partner sought primarily to recruit socially isolated, seemingly unemployable dropouts who almost certainly would be passed over even by employers who welcome candidates with neurological differences like autism. They wanted people who couldn’t make it on their own and had been “sitting for years in their parents’ homes,” van Hofweegen said. The number of students in his program would be small, but the stakes were large. If they could be doing meaningful, sophisticated work, what kind of a model might that provide for the uncounted numbers of people with autism around the world seemingly sentenced to constricted, unproductive lives.

The untested model drew skepticism even from other autism advocates, who viewed it as well-intentioned but overly idealistic. But van Ruitenbeek’s coach, Anita de Winter, saw it as a godsend. She had worked with hundreds of autistic adults who struggled to find meaningful work and become independent. De Winter described the program to van Ruitenbeek without betraying her enthusiasm. She didn’t want him to be disappointed if it didn’t work out.

“This might be for someone like you,” she told him.

Van Hofweegen’s path to autism advocacy traces back to 1996, when his first child was born. The boy, named Thijs, sustained an injury during birth and was diagnosed with cerebral palsy. Doctors told van Hofweegen and his then-wife that Thijs might never walk or talk. But with the help of specialists, he learned to both move and speak.

Peter van Hofweegen’s son Thijs (Courtesy of Mathilde Dusol)

Thijs went far beyond that. After proclaiming a desire to learn how to swim at age 5, and taking seven years to pass his basic swimming test, Thijs persisted through intermediate and advanced levels alongside much younger classmates. When he swam the 50-meter freestyle test to pass the advanced level, he earned a standing ovation from the other students’ parents. Van Hofweegen never forgot that moment. (He continued to ponder it even as Thijs developed into a competitive swimmer and won a silver medal in the men’s 400-meter freestyle at the Paralympic Games in 2016.) It showed what a person could accomplish with the right support and accommodations.

While helping out at an event in 2012 for people struggling with unemployment, van Hofweegen met Frans de Bie, an IT guru and fellow volunteer. A year earlier, de Bie had sold his 40-person tech company. Like van Hofweegen, de Bie drew inspiration from his personal life. He had grown up alongside foster siblings, and he understood the transformative power of a supportive environment. He also was motivated by his son and daughter, who have dyslexia.

The new friends hit upon an idea. Van Hofweegen had read a survey saying 20,000 Dutch people were not participating in the workforce because of their autism. Perhaps they could start an organization that would help autistic people interested in technology to find work. After more than 25 years in management roles at hotels and at a temporary-job placement agency, van Hofweegen quit his job. A short time later, in late 2013, he and de Bie incorporated an organization they called ITvitae.

Van Hofweegen, left, with Frans de Bie (Thana Faroq for ProPublica)

The Dutch have a saying: “God created the earth, but the Dutch created the Netherlands.” That’s because for centuries, the country’s citizens reclaimed land from the North Sea using their iconic system of dikes, canals and windmills. About a third of the country’s fertile land is below sea level. The Netherlands, half the size of South Carolina, remains among the world’s leading economies in part because its people have maximized its geographical resources.

And so it was culturally ingrained in van Hofweegen and de Bie to maximize the country’s human resources. Partly because de Bie was familiar with the unmet demand for IT jobs in the Netherlands, a gap currently estimated at 100,000, and because the country has a robust tech sector, the co-founders wanted to focus on that area.

The two men saw ITvitae — the name is an amalgam of “information technology” and “curriculum vitae,” which they pronounce ee-tay-vee-tay — as a way to fill tech-sector jobs and strengthen the Dutch economy as much as they considered it a social enterprise to lift up autistic people who felt excluded from the job market.

Common traits found in autistic people often prevent them from being hired or even applying to jobs in the first place. They may struggle to interpret social cues, pause frequently when speaking, exhibit disruptive eccentricities or avoid eye contact. Yet employers have found that other characteristics make them excellent employees. They tend to be thorough and fastidious, have the ability to go deep on specific topics and focus for prolonged periods of time. Those traits lend themselves to careers in technology and cybersecurity, among many other fields.

Van Hofweegen and de Bie envisioned a six-month course focused on preparing students to be software testers — a natural fit for autistic people, who tend to be methodical rule-followers. As the students embarked on coursework, van Hofweegen would find employers by cold-calling IT and software companies as well as by tapping the connections of his board members.

The co-founders believed ITvitae could generate revenue primarily by charging employers a recruiting fee for each hire. De Bie believed employers would be willing to pay because the amount he proposed was less than the typical cost of specialized, third-party technical training for new or existing employees.

The first challenge was finding students. After winding their way through various government agencies, van Hofweegen and de Bie found de Winter, who worked near where they lived. “Do you know these types of people?” van Hofweegen asked her in 2013 after laying out the vision for ITvitae. She replied, “How many do you want?”

As the co-founders prepared to interview about 30 candidates for 11 slots, de Winter explained the potential pitfalls. Autistic people tend to process language literally, she told them, and might be unable to respond to classic prompts. The question “what do you hope to get from your time at ITvitae?” might elicit a blank stare. That’s because, to an autistic person, there’s no basis for what the outcomes of the new program might be. Alternatively, the list of answers could be endless and paralyzing. They needed something concrete and technical to discuss. So de Bie concocted a simple tool that would serve as a discussion topic and gauge applicants’ computer interest: He asked the candidates to draw maps of their home computer networks and be prepared to describe them.

Van Hofweegen and de Bie were full of enthusiasm. But, as they continued to talk with de Winter, they realized how much they still had to learn about the very people they wanted to help. They were, perhaps, in over their heads.

For as long as he could remember, van Ruitenbeek knew he was different but felt that he couldn’t let other people know that. It was as if he were “living undercover,” he said. He was constantly afraid that asking the wrong question would cause him to be bullied, so he never asked questions. While his twin sister played with other children, he withdrew to solitary activities, learning to design his own websites on topics ranging from outer space to dinosaurs. But his life took a darker turn after his psychotic episode in Utrecht.

Van Ruitenbeek had planned to spend the summer day catching up on coursework when suddenly he began to feel that he was outside his own body. His vision narrowed and his mind compelled him to follow what he believed were secret hand signals made by strangers, which eventually directed him to a bar to order a draft Heineken. He then lurched outside the bar in a stupor. Van Ruitenbeek rambled in halting, slurred speech when his sister and father reached him by phone. Frantic with worry, Henk van Ruitenbeek drove through Utrecht and eventually found his son standing on a sidewalk, staring vacantly. He got him in the car and took him home.

In the aftermath, with a new diagnosis of autism, van Ruitenbeek believed his life was over. He had thought it was not rational or even possible to set goals for himself. Then de Winter mentioned ITvitae, and he knew he badly wanted a slot there. The ITvitae interview, he later said, was “like a ticket out of my situation.” More nervous than he had ever been, he told himself: “I have to make it. I have to do my best.”

The interview, which took place in late 2013, was difficult for everyone. Although van Hofweegen and de Bie were pleasant and upbeat, van Ruitenbeek felt he was in “hostile territory.” Then again, everything beyond his parents’ home seemed that way at the time. He stuttered severely when describing his recovery from psychosis, and it took him an uncomfortably long time to utter a single sentence. He was visibly perspiring. “This isn’t working,” de Bie thought.

When de Bie pivoted to the network drawing and other technical questions, the interview shifted. Van Ruitenbeek stuttered less. De Bie, impressed by his remarks about website design, decided before the interview ended that van Ruitenbeek should have a space at ITvitae.

De Bie thought it was obvious that van Ruitenbeek — and most of the other candidates — had raw computer talent. Van Hofweegen welled with tears. “What are these wonderful people doing at home?” he wondered.

Advocates for people with autism in the United States often ask the same question. Parents of autistic teenagers describe the “cliff” of high school or college graduation, marked by the struggle to navigate the transition from years of special education and support to independent working life. Firm data is hard to come by, but some estimates suggest millions of autistic American adults are unemployed or underemployed. Of those who find work, most are in low-wage and part-time jobs, according to Drexel’s Autism Institute.

At the same time, demand for workers with technical skills has far outpaced supply. In the cybersecurity field alone, the U.S. faces a shortfall of more than 225,000 workers, according to CyberSeek, an organization that provides job market data. The number of available tech-related jobs in the U.S. nearly doubled from 2020 to 2021, analytics company Datapeople reported.

Over the past decade, a variety of opportunities for autistic adults in the U.S. — ranging from technical training and job placement programs in various cities, to targeted hiring and retention efforts at large employers — have aimed to bridge the tech workforce gap. But the results so far have been modest, said Michael Bernick, a San Francisco-based attorney who has written two books on employment strategies for the neurodiverse.

That’s partly because many initiatives expect job candidates to have higher education, credentials and the ability to work with minimal support, said Bernick, who was director of the California labor department from 1999 to 2004. “They are looking for people who have significant tech skills,” he said. “Of that group, not all are college graduates, but they’re also not the long-term unemployed, sitting in their parents’ basements.” Someone like van Ruitenbeek wouldn’t have stood a chance.

One widely publicized initiative is the Neurodiversity @ Work Employer Roundtable, a collection of about four dozen private employers — including Microsoft, SAP, Google and more — that foster neurodiversity hiring programs. Participating companies offer screening and interview processes to accommodate autistic candidates; about 1,200 neurodiverse candidates have gotten jobs with Roundtable employers over the past decade, said Neil Barnett of Microsoft, a leader of the group. Barnett, who has discussed the initiative with Bernick, hopes that Roundtable employers will continue to expand their hiring of neurodiverse candidates with a variety of skills, including outside of tech.

Autistic adults who are interested in computers represent just a sliver of autistic job seekers, according to the national advocacy organization Autism Speaks; Bernick puts the figure around 10% to 15%. Due in part to prominent figures such as Elon Musk, who has said he has Asperger’s syndrome, which is now considered a type of autism spectrum disorder, and pop culture caricatures of socially awkward workers in Silicon Valley, the notion that autistic people inherently possess extraordinary tech competencies has become a cliché. Bernick said he once had hopes of a tech career for his own autistic son. But his son had neither uncommon skills nor a deep interest in computers.

While the 10% to 15% estimated by Bernick may seem like a small slice relative to popular perception, efforts to employ that group are nonetheless important, especially given the dramatic need in the tech sector, advocates and researchers said. Bernick said programs in the U.S. should expand their efforts to find autistic job seekers who have computer capabilities but lack the credentials — precisely the types of people van Hofweegen and de Bie recruited for their inaugural class.

In February 2014, after a six-month stint cutting yarn, van Ruitenbeek rode his bicycle to ITvitae’s space for the first day of class. He was nervous. In social settings, he always felt as though he were “from another planet,” he said. Here, though, he was surrounded by people who felt the same way.

Shortly after their arrival, de Bie assigned the students to assemble the furniture they would be using. When he returned several hours later, he found they had put it together flawlessly. He asked how everyone was getting along and discovered that none of the students had bothered with introductions. De Bie was surprised and amused; he was still learning how autistic people function.

Van Ruitenbeek and other students in ITvitae’s first class assemble furniture. (Courtesy of Frans de Bie)

Van Hofweegen and de Bie, who refused to use the word “disability,” told the students they had “different operating systems” than the neurotypical people they grew up with. It helped to reassure them that they belonged in the classroom, and eventually the workplace, as they all began to “learn how to learn again” following what for some was years away from school, van Hofweegen said. De Bie eased the students into a school setting by leading a training on basic Microsoft programming, networking and security. That was followed by a 40-day course on software testing offered by an organization that issues certifications for technical specialties in the Netherlands.

After only a short time, van Ruitenbeek said he began to feel “at home for the first time in my life.” He enjoyed his coursework and excelled at it. He gradually began interacting with other students as he felt more at ease and less afraid of making social mistakes. When he grumbled about commuting by bike, a classmate offered to drive him to and from ITvitae. Van Ruitenbeek gladly accepted.

Yet, for all his progress, van Ruitenbeek continued to face obstacles. Conversation remained difficult due to his stutter, and he lacked the energy to work the 32-hour week that most employers expected of ITvitae’s graduates. Sometimes his father worried it was all too much for him. He was one of three students for whom van Hofweegen struggled to find a job.

When the coursework drew to a close, the students took a formal exam to be certified in software testing. Van Ruitenbeek breezed through the questions, except for one that confounded him: None of the multiple choice answers were technically correct. So he selected the answer that he suspected the test-maker wanted. He picked correctly and scored 100%. “It was my first achievement,” van Ruitenbeek said. “I could do something.”

A short time later, a director from the testing company visited ITvitae and van Hofweegen told him that a student had spotted a mistake in the exam. Van Hofweegen, who has an uncanny ability to sense an opportunity and pounce, suggested that van Ruitenbeek could be a test reviewer. The company invited him to join a small group of volunteers who look over exams for accuracy and clarity. Van Ruitenbeek readily agreed. To prepare, he plowed through a textbook on ethical hacking.

The work led him to his next self-discovery: Ethical hacking was fun. Once unable to set goals for the future, van Ruitenbeek now dreamed of a career in cybersecurity. He would hunt for hidden vulnerabilities in software and networks, and prevent them from falling prey to malicious hackers.

Following the success of their first class, van Hofweegen and de Bie recruited another class, then another, each with a maximum of 14 students. After the first year, with steady revenue generated mainly from fees paid by employers, the co-founders began taking salaries, and they hired additional staff. ITvitae’s mission spread to autistic job seekers and their supporters across the Netherlands.

As the organization grew, van Hofweegen and de Bie relocated ITvitae to a floor in a former monastery, which had been converted into offices. The founders thought its tree-shaded walking paths and seclusion would impart a serenity that the students needed. The organization also began offering new courses in software development, data science and cybersecurity, all specialties in high demand. Students delighted in being able to focus exclusively on topics that fascinated them, a luxury — for many of the students, a necessity — that traditional educational settings couldn’t provide.

Certain similarities emerged among ITvitae’s students. Before joining, nearly half had been sitting at home, unemployed and socially isolated, for longer than two years. Many passed the time playing video games and lost track of whether it was day or night. They told van Hofweegen and de Bie they felt worthless and never fit in; many reported having been bullied and struggling through periods of depression.

ITvitae turned away about two-thirds of applicants, most frequently because of untreated mental health issues. Other candidates simply weren’t ready. One 2022 applicant said he hadn’t left his home for 10 years and spent most of his time gaming. “It was such a big thing for him to be here” for the interview, de Bie said. “But then traveling regularly, studying in a group, doing exams — that would have been too heavy for him. I had to tell him it’s not the right time.”

Male students at ITvitae outnumber female students 10 to 1, both because autism is more prevalent in men and more likely to go undiagnosed or misdiagnosed in women. Many experience sensory challenges, such as headaches if the light is too bright or if there’s too much noise. One student was distracted by the sound of blinking eyelashes. Most struggle to varying degrees with communication.

To help both prospective employers and job candidates work through the inevitable miscommunications, ITvitae staff members accompanied students to job interviews. Saskia Meeuwessen, who was hired as the CEO of ITvitae as it expanded, recalled joining a student at an interview for a cybersecurity job with the Dutch National Police. The interviewer asked the candidate to introduce himself. The student froze: It wasn’t a question he had practiced. Nonetheless, he was later invited for a second meeting with an interviewer who was more experienced in interacting with autistic people.

That interviewer sat down and, with no social niceties, asked, “When I type www.google.nl, what happens?” Meeuwessen thought to herself, “Well, Google shows up, what a silly question.” But the candidate had a completely different reaction, launching into nuanced details about internet servers and connections. For 90 minutes, Meeuwessen “sat there, listening to stuff that I really didn’t understand,” she said. The candidate was hired on the spot.

Thanks in part to its gradually sloped coastline, the Netherlands is a popular landing spot for the underwater fiber optic cables connecting the United States and Europe. Fast, reliable and inexpensive internet connectivity has fostered a flourishing tech sector. But that connectivity has negative consequences, too. Hackers who can’t rely on the fragile internet connections in their home countries use servers in the Netherlands to commit crimes.

To counter these hackers, the Dutch National Police established an elite force called the High Tech Crime Unit, or HTCU. The unit has become renowned both for its success disrupting the operations of cyberattackers and for its innovative culture, which for years has included hiring unconventional candidates, including those with autism.

In 2017, at van Hofweegen’s urging, the HTCU brought on a graduate from ITvitae. He proved to be an open-source intelligence wizard. Another graduate followed. Then the floodgates opened, and about 30 ITvitae graduates were eventually hired to jobs in regional police squads, where they handle data analysis, digital forensics and other technical specialties.

The National Police’s embrace of a neurodiverse workforce extended beyond its partnership with ITvitae. Its most renowned hiring initiative for autistic employees began with a 2016 murder case.

A 50-year-old Turkish man had been shot more than 30 times in the Dutch city of Leiden and died two days later. The National Police collected surveillance camera footage and quickly identified the suspects. Their work also seemed to link the murder to a number of cold cases in Amsterdam. The National Police took over those investigations, inheriting 1,700 hours of camera footage. Watching the tapes was a marathon of drudgery that none of the National Police detectives wanted to take on.

One National Police detective, Jory de Groot, happened upon an idea. De Groot, who has a foster brother with Down syndrome, volunteered with a group that organized trips for young adults with disabilities. On a weekend shortly after the murder, she led a group of people with autism. De Groot, then 26, described her job to one participant on the trip and mentioned the painstaking work of watching security footage. Some autistic people excel at recognizing small details, the woman told de Groot. They might love the very task that neurotypical detectives loathe.

De Groot then contracted four people from AutiTalent, a Dutch job placement organization for autistic people. She prepared her colleagues, advising them against asking typical get-to-know-you questions, and set up a radio-free office in a quiet corner of their building.

When the autistic contractors arrived, the National Police detectives tested their abilities by having them watch the footage collected in the Leiden murder. The detectives had already watched the tapes, which included the days leading up to the shooting, and knew precisely when the suspects would be seen on the day of the shooting.

Before long, one of the contractors spotted a suspect on the tape — but not when the detectives expected. The contractor found the suspect casing the crime scene the day before the attack. The detectives had missed it. “It was really important evidence that we overlooked,” de Groot said. Eventually, the two suspects were convicted in the Leiden murder.

As word of the feat reverberated through the National Police, requests for more AutiTalent contractors flooded in. Eventually, 50 autistic people were working as “camera footage specialists,” a newly created role, across the National Police. De Groot’s original team grew to six people, who increasingly talked with one another and with their police colleagues as they became more comfortable. The contractors joined detectives from the start of investigations, rather than stepping in after they were already in progress, and took part in briefings. Additional contractors from AutiTalent became “audio specialists,” who transcribed interrogations and wiretaps.

Jory de Groot, second from right, with her team of camera specialists (Courtesy of Jory de Groot)

The high profile of the contractors led some members of the National Police force to speak out about their own autism, which they’d previously hidden. The outpouring prompted de Groot to work with those employees and an advocacy organization to establish an “Autism Embassy” at the National Police. Now about a dozen workplace “ambassadors” — employees with autism who volunteer for the role — offer an ear and advice to both autistic colleagues and their managers.

The National Police’s embrace of autistic contractors has been partially driven by government-proposed targets, accompanied by subsidies, for industry and government to hire 125,000 people who have difficulty finding work because of a disability. That sort of government-centric approach is unlikely to occur in the U.S. Still, law enforcement agencies in the U.S. could draw lessons from the Dutch experiment, said Michael Bernick, the attorney who has focused on employment strategies for autistic people.

Amid ITvitae’s successes, van Ruitenbeek was still floundering. He had enjoyed his time as a volunteer test reviewer in 2014, but it didn’t lead to a job. A subsequent internship with a computer security consultancy also didn’t land him permanent employment. Yet another internship, with an organization that maintained supercomputers, failed when he experienced a psychotic episode in late 2016.

It happened when van Ruitenbeek was commuting to the company’s Amsterdam office by train. He knew public transportation was a stressor for him, but he thought he could push through it. He couldn’t. That day, he believed everyone on the train was talking about him. He didn’t fully lose control, as he had in Utrecht. Still, he realized he couldn’t continue to commute and work normally with the organization any longer. He quit.

It had been more than two years since his ITvitae graduation, and van Ruitenbeek was again feeling hopeless. He mostly stayed at his parents’ home, where he tinkered with developing his own video game. He sometimes rode his bike to ITvitae’s offices — “just as a place to go,” he said — where he read books on cybersecurity and tried to ground himself.

Van Ruitenbeek happened to be at ITvitae one day in late 2017 when Pim Takkenberg, then a director at the Dutch cybersecurity firm Northwave and a former leader of the National Police’s High Tech Crime Unit, was there. Earlier that year, Takkenberg had overseen the development of a training program for ITvitae’s cybersecurity students. During the visit, van Hofweegen, ever scouting, made a request: “Pim, I have a person here, who is extremely vulnerable but extremely brilliant. I want you to talk to him.”

After a brief chat, Takkenberg agreed to give van Ruitenbeek a “hack test” to assess his aptitude for penetration testing. The prospect alone was enough to help van Ruitenbeek regain some hope. A few months later, on exam day, Takkenberg instructed him to find vulnerabilities in a piece of software, which hackers could exploit to attack the hypothetical client. Takkenberg jokingly warned him not to cheat. Van Ruitenbeek took him literally, assuming he meant not to research anything on the internet. In reality, using the internet would have been allowed, even expected.

Van Ruitenbeek found the main vulnerabilities. Takkenberg was impressed but remained skeptical. Van Ruitenbeek still had trouble with conversation, and he was able to work only three days a week. Addressing the doubts, van Hofweegen said: “You want a problem solved. He communicates better with computers than with people. In a technical world, it’s not so bad.”

Takkenberg offered him a trial six-month internship. But he needed someone who could work 40 hours a week. They found a compromise. Van Ruitenbeek would start with three days a week, then gradually increase to five days. Northwave also allowed van Ruitenbeek to work from home occasionally, a major concession before the pandemic. He went on a special diet and began exercising to improve his health and boost his energy. He was determined to have a permanent place at Northwave, where he might finally gain the independence and fulfillment he’d long chased.

Over their nearly nine years together as business partners, van Hofweegen and de Bie proved there was space in the labor market for people who had been overlooked by employers and who previously thought themselves to be shut out of the workforce. Since 2014, ITvitae has graduated and placed nearly 500 students in technical jobs spanning sectors from agriculture to chip manufacturing to law enforcement. Bernick called that total “striking” and said, “We don’t have any company in the United States that comes near that number, even over a 10-year period.”

De Bie’s early assessment that employers would be willing to pay a fee to hire ITvitae’s graduates proved to be right. It costs the equivalent of $30,000 to educate, coach and find employment for each student. About a third of that is generated from tuition while the remainder comes from the employer.

As ITvitae’s Meeuwessen points out, autism doesn’t end when students gain employment. That’s why the organization provides regular coaching to help graduates navigate changes — anything from a new manager to a schedule shift — they perceive as disruptive and unsettling. “As soon as something happens, they start to doubt. If there’s doubt, they get unstable and that’s bad,” Meeuwessen said. “Most are doing just fine after many years, but it’s a process.”

For all the success, there have been setbacks. Even with coaching, some students struggle. ITvitae occasionally hears from an employer that a former student has stopped showing up to work and hasn’t responded to messages, sometimes for weeks. “We go to their houses,” van Hofweegen said. “We knock on the door. We call the parents. And we still can’t make them understand why they need to communicate with their employers.”

A few times, the problems have been far more dire than an inability to show up at work. De Bie keeps a photo on his desk of a talented software programmer who specialized in a language called C#. After his graduation, he was hired by a prestigious global corporation. His coach regularly checked in, and, by all appearances, his first few months at the company were successful. Then came word that the student had taken his life, one of three graduates to die by suicide. Even before graduating, the programmer had obtained an illegal drug from China with the intention of overdosing. He waited to take it. He wanted to finish his education and get a job to prove that he was capable of success. “For him, that was enough,” van Hofweegen said.

When van Ruitenbeek started at Northwave in 2018, being in an office with other people scared him. Takkenberg knew that van Ruitenbeek wouldn’t be comfortable speaking to clients or even colleagues right away and tried to smooth the transition. He and his team organized roles that accommodated van Ruitenbeek and other ITvitae graduates “in doing the things they’re good at and not doing the stuff they really hate to do.” So, after van Ruitenbeek rooted out the vulnerabilities in a network, another colleague would meet with the client to explain the findings. Through a government program for people who need work accommodations, de Winter helped van Ruitenbeek borrow a car so he could avoid the stress of public transportation.

Van Ruitenbeek found an accepting culture at Northwave. He began to confide in colleagues, who looked after him. As van Ruitenbeek’s trust in them grew, he started asking questions and giving more than yes and no answers. He successfully pursued a notoriously difficult, globally recognized certification for his line of work, which Takkenberg said was a “big sign” that the intern’s abilities were exceptional. Once the internship ended, Takkenberg gave him a permanent job sniffing out gaps in software that could make it vulnerable to being penetrated by malicious hackers. “He is one of the best pen-testers we have,” Takkenberg said. “Because of his talent to focus and stay focused, he always will find the small details.”

Van Ruitenbeek in Northwave’s offices (Thana Faroq for ProPublica)

Shortly after van Ruitenbeek started in his permanent position, he and Takkenberg discussed his goals for his first year. They decided van Ruitenbeek should find a CVE, short for common vulnerabilities and exposures, security flaws in software that are formally and publicly cataloged. Takkenberg was ecstatic when, by the midyear check-in, van Ruitenbeek had uncovered six. “OK, that goal is done,” Takkenberg said. “For the rest of the year, let’s focus on your social skills.”

A short time later, van Ruitenbeek attended a company golf outing. Takkenberg, who retains the rough-around-the-edges demeanor of an ex-cop, joked that van Ruitenbeek would probably excel despite never having played. “We know you read eight books in a month for fun, Thomas,” he teased. “So you probably read a book about how to golf to prepare for this.” Van Ruitenbeek was able to recognize that Takkenberg was joking, something he’s sure would have eluded him in the past. It was a revelation.

Then, during a weekend retreat with his team, van Ruitenbeek carted along some records and a record player. Music had long been a passion that allowed him to express himself when he lacked the words to do so. One evening, he worked up the courage to play records for about 15 of his colleagues. The airy, electronic music helped everyone relax. Word of his talent spread, and the next day, he found himself DJing a barbecue for Northwave’s entire cyber unit, more than 50 people.

Takkenberg decided to splurge on a DJ booth for Northwave. He dubbed van Ruitenbeek the company’s official DJ and assigned him to play music at its Friday afternoon happy hours. Van Ruitenbeek became the center of Northwave’s social gatherings.

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When COVID-19 hit, van Ruitenbeek found himself longing for the company of colleagues. “I mostly miss the casual chats,” he said of the days that he works from home, about half his schedule these days. “That is the biggest change of my life since Northwave,” he said. “Social development. Now I am outgoing.”

Van Ruitenbeek has started mentoring a new autistic employee. He also began working with Northwave’s sales team to write proposals and even meet with clients. That’s not to say there aren’t challenges. But now, when the workload feels too heavy, or he senses he’s becoming over-stressed, van Ruitenbeek asks for help. “I used to think I had to shoulder it on my own,” he said.

Van Ruitenbeek with a colleague at Northwave (Thana Faroq for ProPublica)

Now 35, van Ruitenbeek is becoming financially independent. He received a promotion and raise. He leased his own car and, in 2021, with help from his family, van Ruitenbeek purchased a one-bedroom apartment just a short walk from them. Giving a tour of his new home, he showed off the view of a pond beyond the sliding doors of his living room. He had carefully organized scores of records on shelves below his DJ equipment. Tucked away in a corner, he displayed the artifacts of his period of isolation: shelves filled with the Warhammer figurines he painted as he recovered from his psychosis.

If you meet van Ruitenbeek today, you wouldn’t likely guess his history. Compact and ruddy, he makes eye contact when he speaks — in fluent English when he was interviewed for this article — and is often self-deprecating and quick to smile. His easy banter with his father, a reliable source of support, encouragement and protection, was unimaginable in the aftermath of his psychosis a decade ago.

When he entered the working world, van Ruitenbeek had to consciously mimic social behavior and speech that he observed in peers. Over time, though, being social gradually became second nature. He felt like a foreign language student who once had to rehearse sentences in his mind but eventually spoke the new language fluently.

In April, van Ruitenbeek attended the graduation of this year’s cybersecurity class at ITvitae’s monastery, sitting among the new graduates’ families and friends on a drizzly afternoon. An ITvitae manager named Jessica van der Ploeg told the 11 new graduates, who were going on to jobs at global bank ING, consulting giant Deloitte and the Dutch Ministry of Defense, “The job market is waiting for you, for your talent and for who you are.”

Van der Ploeg acknowledged that many incoming ITvitae students feel shut out of society because of their autism, just as van Ruitenbeek once did. Alluding to an analogy ITvitae often uses to describe the communication gap between people with autism and their neurotypical peers, she said, “It’s us Windows users who sometimes don’t know how Linux works.”

Van Ruitenbeek listened intently. At various points in his life, he had been unable to express emotion. Now he had tears streaming down his face.

Van Ruitenbeek with Pim Takkenberg, who brought him on at Northwave, after the ITvitae graduation ceremony (Thana Faroq for ProPublica)

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by Lomi Kriel, ProPublica and The Texas Tribune, and Zach Despart, The Texas Tribune

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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, Sept. 13, 2022: Five days after this story was published, USA Today posted an interview with Col. Steve McCraw, who leads the Texas Department of Public Safety. When asked why none of the 91 state troopers who responded to the Uvalde elementary school shooting took control during the chaotic standoff, McCraw said, “I wish we would have.”

Ever since the Uvalde elementary school shooting left 19 students and two teachers dead, blame for the delayed response has been thrust on local law enforcement. The school police chief was fired and the city’s acting police chief was suspended.

But the only statewide law enforcement agency, the Texas Department of Public Safety, has largely avoided scrutiny even though it had scores of officers on the scene. That’s in part because DPS leaders are controlling which records get released to the public and carefully shaping a narrative that casts local law enforcement as incompetent.

Now, in the wake of a critical legislative report and body camera footage released by local officials, law enforcement experts from across the country are questioning why DPS didn’t take a lead role in the response as it had done before during other mass shootings and public disasters.

The state police agency is tasked with helping all of Texas’ 254 counties respond to emergencies such as mass shootings, but it is particularly important in rural communities where smaller police departments lack the level of training and experience of larger metropolitan law enforcement agencies, experts say. That was the case in Uvalde, where the state agency’s 91 troopers at the scene dwarfed the school district’s five officers, the city police’s 25 emergency responders and the county’s 16 sheriff’s deputies.

The state police agency has been “totally intransparent in pointing out their own failures and inadequacies,” said Charles A. McClelland, who served as Houston police chief for six years before retiring in 2016. “I don’t know how the public, even in the state of Texas, would have confidence in the leadership of DPS after this.”

Instead of taking charge when it became clear that neither the school’s police chief nor the Uvalde Police Department had assumed command, DPS contributed to the 74-minute chaotic response that did not end until a Border Patrol tactical unit that arrived much later entered the classroom and killed the gunman.

“Here’s what DPS should have done as soon as they got there,” said Patrick O’Burke, a law enforcement consultant and former DPS commander who retired in 2008. “They should have contacted [the school police chief] and said: ‘We’re here. We have people.’ They should have just organized everything, said, ‘What are all of our resources?’ And they should have organized the breach.”

DPS has fought the release of records that could provide a more complete picture of the role state troopers played during the mass shooting. Agency officials declined to answer repeated questions from ProPublica and The Texas Tribune for more than three months, citing an ongoing investigation. On Tuesday afternoon, DPS officials said they had referred five responding troopers to the agency’s internal affairs division, the Office of Inspector General, for an investigation into whether they broke any department policies. Two have been suspended, according to DPS.

DPS also released a July email in which its director, Col. Steve McCraw, said the agency would “provide proper training and guidelines for recognizing and overcoming poor command decisions at an active shooter scene.” The agency has refused to share its active shooter policies and training manuals.

The latest moves by DPS come a week after reporters from ProPublica and the Tribune sought comments from the four appointed members of the Public Safety Commission, which oversees the agency, about the response by state troopers.

DPS did not identify which officers were being investigated or detail potential wrongdoing.

Previously, agency officials referred reporters to comments made by the head of DPS during a June legislative hearing in which he largely blamed the Uvalde school district’s police chief, Pete Arredondo, for the failed response.

During that testimony, McCraw told lawmakers that the time it took for law enforcement to rescue teachers and students at the elementary school was an “abject failure.” He called Arredondo the only obstacle between armed police and the teenage shooter while dismissing the idea that DPS could or should have taken control of the emergency response.

“I’m reluctant to encourage or even think of any situation where you’d want some level of hierarchy where a larger police department gets to come in and take over,” McCraw said.

Col. Steve McCraw, the head of DPS, speaks during a news conference outside Robb Elementary School on May 27. (Marco Bello/Reuters)

Yet, DPS has sprung into action time and again when disaster strikes in Texas, which has proved key during mass shootings and public emergencies, local officials across the state said.

More than three decades ago, for example, state troopers helped local law enforcement confront a gunman after arriving within minutes of a shooting at a Luby’s Cafeteria in Killeen, about 60 miles north of Austin. The shooter killed himself after a brief exchange of gunfire.

“They knew that people were dying, and so they acted,” said Suzanna Hupp, a former Republican state representative whose parents died during the 1991 Luby’s massacre. She said that didn’t happen in Uvalde, adding that “clearly there was a command breakdown there.”

In a 2013 chemical explosion in West, about 70 miles south of Dallas, state troopers immediately took control of the law enforcement response at the request of the county’s emergency management coordinator. And in the 2018 shooting at Santa Fe High School, about 30 miles south of Houston, state troopers quickly fired at the gunman, according to local law enforcement officials who initially responded. The rapid engagement by school police and DPS was key to the gunman surrendering, district and county officials said.

“DPS had a tremendous role in Santa Fe of stopping the killing because they were among the first to arrive and they actually did what they were supposed to,” said Texas City Independent School District trustee Mike Matranga, the district’s security chief at the time of the shooting. He added that, in Uvalde, DPS supervisors “should have essentially asked [Arredondo] to stand down due to his ineffectiveness and taken over.”

Police experts and lawmakers pointed to clear signs that they believe should have alerted emergency responders that no one was in control. Arredondo, who resigned from his elected City Council seat in July and was fired from the school district on Aug. 24, remained inside the hallway on the phone during the shooting. He said he was trying to find a key to the classroom that the gunman was in. Investigators later determined that the door was likely unlocked. The school police chief did not identify himself as the incident commander and told The Texas Tribune he never issued any orders; his lawyer later said his firing was unjust. In a letter, Arredondo’s attorneys said the police chief “could not have served as the incident commander and did not attempt to take that role” because he was on the front lines.

Separately, no command post was set up outside of the school, which lawmakers noted should have been an indicator to responding officers that no one was in charge.

About 45 minutes after the gunman began shooting, a U.S. Border Patrol SWAT team, known as BORTAC, arrived at the scene. The unit typically handles dangerous situations involving migrants. Its responsibilities do not include responding to school shootings, but Paul Guerrero, the team’s acting commander, told the House committee that issued the legislative report that he chose to act after arriving and encountering the disorganized scene.

Guerrero requested surveillance through classroom windows, retrieved a door breaching tool from his car, ordered officers to set up a medical triage for victims and organized an assault team that consisted of several agencies. Eventually, he led about a half-dozen officers into the classroom and a Border Patrol agent killed the gunman at 12:50 p.m. No state troopers or school police were on that team.

Guerrero could not be reached for comment, and a spokesperson for Customs and Border Protection did not answer questions about the agency’s response, saying it was conducting a review.

According to the House committee report released in July, “the attacker fired most of his shots and likely murdered most of his innocent victims before any responder set foot in the building.” But the report said that given the information known about “victims who survived through the time of the breach and who later died on the way to the hospital, it is plausible that some victims could have survived if they had not had to wait 73 additional minutes for rescue.”

The disconnect over who should take charge and when exemplifies a need for detailed planning and frequent training between larger law enforcement agencies and smaller departments, police experts told ProPublica and the Tribune.

People gather at a memorial in front of Robb Elementary School on May 30. (Kaylee Greenlee Beal for The Texas Tribune)

Larger agencies with more personnel, equipment and training should have agreements with school districts that clearly state that they will assume command upon arriving at critical incidents that include active shooters, hostage situations and explosive devices, said Gil Kerlikowske, a former Seattle police chief and CBP commissioner until 2017. He and other experts said that even if school police are designated as the lead, the role of every law enforcement agency in the region should be specified.

San Antonio, one of the state’s biggest police departments, has such agreements with local school districts and universities that name the bigger city police agency as the incident commander in the event of a mass shooting. After the Uvalde shooting, San Antonio police Chief William McManus met with school officials in his city and reminded them that his agency would take charge in an active shooter situation.

McManus, whose officers arrived in Uvalde after the gunman was killed, said in an interview that because of the confusion at the scene, he felt the need to emphasize how his department would respond to such an incident in San Antonio.

It is unclear what, if any, involvement DPS or another law enforcement agency had with the Uvalde school district’s mass shooting plan because those governmental bodies declined to release such documents or answer questions. The state police did not have a written memorandum of agreement with the school district outlining its role in such situations, according to DPS records.

Alfred Garza III, who lost his only child, 10-year-old Amerie, during the Uvalde shooting, wonders if his daughter could have been saved had law enforcement, including DPS, acted faster. Her death was largely due to blood loss from gunshot wounds to her torso, according to a preliminary autopsy report.

“They can sit there and point fingers at everybody else and say that they weren’t responsible or they don’t have any accountability over what happened,” Garza said of DPS. “They were there, too, and they didn’t do shit.”

Diana Olvedo-Karau, who was a secretary in the Uvalde school district’s transportation department before retiring in June and has three nephews who attended Robb Elementary at the time of the shooting, was shocked when she watched body camera footage and learned for the first time “how many DPS officers were there.”

She said she and others trusted DPS to act more decisively during the city’s worst tragedy. The state agency has a major presence in the city of more than 16,000 residents because of Gov. Greg Abbott’s border security initiative, Operation Lone Star, which has deployed thousands of state National Guard members and DPS troopers to the border. (It is separately being investigated by the Department of Justice for alleged civil rights violations. The governor’s office has said arrests and prosecutions under Operation Lone Star are “fully constitutional.”)

Olvedo-Karau said most residents believed McCraw when he placed the blame almost solely on local police. Now, she said, she and other residents feel betrayed after seeing where DPS troopers were in relation to the shooter and how early some arrived.

“To not take any responsibility for the fact that they were there early on, earlier than a lot of the local law enforcement agencies, and to shift the focus and the blame onto the local organizations doesn’t speak very well of them and is in many ways very unethical,” she said.

A group of DPS officers, left, were among other law enforcement personnel at the scene of the shooting. (Marco Bello/Reuters)

Uvalde school police failed to follow their own policies, which outlined that in an active shooter situation, Arredondo would become the “person in control of the efforts of all law enforcement and first responders on the scene,” according to the state House committee report. But the report also stated that school police “were not the only ones expected to supply the leadership needed during this tragedy.”

“Hundreds of responders from numerous law enforcement agencies — many of whom were better trained and better equipped than the school district police — quickly arrived on the scene. Those other responders, who also had received training on active shooter response and the interrelation of law enforcement agencies, could have helped to address the unfolding chaos. Yet in this crisis, no responder seized the initiative to establish an incident command post,” the report states.

While the report was among the first to acknowledge that failures in the response extended beyond local law enforcement, it did not name specific agencies.

National emergency protocols teach that the first officer at a critical scene typically becomes the incident commander because that person has the most knowledge about the developing situation. But often that role will be transferred as officers with higher ranks or from larger agencies who are more equipped to oversee the broader law enforcement response arrive, experts said. Typically that happens when the initial incident commander requests help, but it can also occur if other supervisors or officers with different agencies note that the scene is not under control and speak to the first responder.

Any DPS supervisors should have immediately asked their troopers who was in command, said Bob Harrison, a former California police chief and homeland security researcher at the RAND Corp., a national think tank. If they responded that “he’s inside the building, we can’t get a hold of him, I would say, ‘Let’s send somebody in to get him,’” while organizing the external police presence, Harrison said.

The Texas Rangers, which are part of DPS and report to McCraw, are leading a statewide probe into the flawed reaction by law enforcement. After the state House report last month, DPS announced a separate investigation into the role state police played in the Uvalde response.

But McCraw’s willingness to focus blame primarily on local law enforcement before the results of any investigation has raised questions about the agency’s objectivity. In three news conferences in the days following the shooting, McCraw and a DPS regional commander spoke at length about the response of local police without mentioning the role of state troopers.

Abbott, who appoints the members of the commission that oversees DPS, has largely not mentioned the agency’s actions in the shooting. When the House investigative report was released, he said that its findings were “beyond disturbing” and that critical changes were needed, but he did not single out any person or agency.

McClelland, the former Houston police chief, characterized the fact that the Texas Rangers are investigating the law enforcement response as “a fix from day one.”

The DOJ is also reviewing the response of all law enforcement officers at the request of Uvalde Mayor Don McLaughlin. McLaughlin, who did not respond to phone calls seeking comment, has accused McCraw of continuing to “lie, leak” or otherwise misstate information to “distance his own troopers” from criticism of law enforcement conduct that day. McCraw has denied that his agency leaked information and said he is committed to holding his own troopers accountable.

DPS has declined to explain the whereabouts and actions of the majority of its troopers during the shooting, but agency officials noted that eight entered the school before noon and quickly left when they saw the hallway full of police.

Body camera footage released by the Uvalde Police Department shows that at least one DPS officer was outside of the school within four minutes of the shooting.

At 11:37 a.m., after the gunman fired more than 100 rounds, Uvalde Police Sgt. Eduardo Canales, a commander of the local SWAT team, stumbled outside. With blood on his hands after a bullet fired by the gunman grazed his ear, he encountered DPS Sgt. Juan Maldonado, a 23-year veteran of the state agency and public information officer for the region.

“Dude, we got to get in there,” Canales told Maldonado, who, according to DPS, drove one of his closest friends, Ruben Ruiz, an Uvalde school district police officer, to the campus that morning. Ruiz’s wife was a teacher at the school.

“DPS is sending people,” Maldonado replied.

Emergency responders help students escape through windows at Robb Elementary during the shooting. (Courtesy of Pete Luna/Uvalde Leader-News)

Eleven minutes later, Ruiz told officers that his wife had called him and told him she had been shot. But officers continued to treat the situation as if they were dealing with a barricaded suspect instead of an active shooter. The latter situation requires that the first action by officers, no matter their rank, should be to immediately “stop the killing.”

It’s unclear how many officers from which agencies knew that Ruiz’s wife was still alive in the classroom. Lt. Mariano Pargas, the acting Uvalde police chief, told the House committee that he heard Ruiz say his wife was injured inside as well as a dispatcher say, over the radio, that 911 calls were coming from the classrooms. He said officers did not attempt to enter the rooms because “they were waiting for other personnel to arrive from the Department of Public Safety or BORTAC, with better equipment like rifle-rated shields.” Pargas, who is also an Uvalde County commissioner, is suspended pending an investigation. Pargas did not respond to requests for comment.

In another interaction, DPS Special Agent Luke Williams rushed inside shortly before noon, disregarding a “request that he assist at the perimeter,” according to the state legislative report.

Williams heard someone ask whether there were children inside the classroom with the gunman and interjected: “If there’s kids in there we need to go in.”

An unidentified law enforcement officer responded that “whoever was in charge would figure that out.” Williams then left to evacuate children from other classrooms in the school.

City police body camera footage and information from DPS put at least a dozen troopers, including members of the state police’s most elite squad, the Texas Rangers, outside the school within 30 minutes of the gunman firing. The body camera footage, along with bystander video and photographs, shows troopers mostly helping to evacuate children and assisting local police with preventing residents from entering the school.

County Commissioner Ronald Garza said DPS was the agency with the best resources and most experience that arrived at the school within minutes. Troopers should have taken charge, Garza said.

“I wish they would have stepped up. And that didn’t happen,” he said. “The audio, the video, the pictures, pretty much speak for themselves.”

In fighting the release of records, DPS officials have said that they are following guidance from Uvalde County District Attorney Christina Mitchell Busbee, who has indicated that disclosure of such information could taint an ongoing investigation.

Busbee told ProPublica and the Tribune that she opposes the public release of information as she evaluates whether crimes were committed by people other than the shooter. But she has noted that, despite her objection, McCraw publicized key details when it suited him or his agency. She did not answer questions about whether she planned to prosecute law enforcement officers.

ProPublica, the Tribune and a consortium of media outlets have filed a lawsuit seeking to compel DPS to release records about the agency’s response. The news organizations argue that DPS is wrongly claiming the ongoing investigation exception to the state’s public records law because the guilt of the gunman, who is dead, is not in dispute, and authorities say the 18-year-old acted alone. The news organizations also sued the city of Uvalde, the school district and the county sheriff’s office, asking a judge to force them to release records including body camera footage, emergency communications and active shooter planning documents.

Both lawsuits are pending.

When Uvalde students this week returned to school for the first time since the shooting, they were joined by more than two dozen DPS troopers. In a news release announcing that troopers will be assigned to the school district, Abbott and McCraw said the assignments came at the request of Uvalde’s school superintendent, Hal Harrell, and were part of an effort to ensure that children and teachers feel safe.

Tina Quintanilla-Taylor, the mother of 9-year-old Mehle, who escaped the shooting at Robb Elementary, said she finds the message from the state offensive given DPS’ role in the failed response.

The mother said she is sending her daughter to online school this semester because Mehle is terrified of returning to class. But Quintanilla-Taylor said she worries about her 6-year-old son, who needs special education, and so must return in person.

She said she doesn’t trust DPS to keep her son safe.

“They were the elite governing force that failed us,” she said.

A DPS officer blocks the road leading to Robb Elementary School. (Sergio Flores for The Texas Tribune)

by Beth Hundsdorfer, Capitol News Illinois, and Molly Parker and Brenden Moore, Lee Enterprises Midwest

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

Illinois Gov. J.B. Pritzker called patient abuses at the Choate Mental Health and Developmental Center in rural Anna “awful” and “deeply concerning,” and he said the future of the facility depends on correcting poor conditions.

Pritzker’s comments at a news conference on Tuesday came on the heels of articles published Friday by Capitol News Illinois, Lee Enterprises and ProPublica outlining a history of egregious patient abuses and other employee misconduct at Choate.

At least 26 employees over the past decade have been arrested on felony charges in relation to their work at the facility, and internal investigations have cited dozens of other employees for neglecting, exploiting or humiliating residents, lying to investigators, or failing to report allegations of mistreatment in a timely manner. In some cases, investigations have languished for years as accused employees have continued to receive their full pay while on administrative leave.

At least one advocacy organization called for the state to close Choate in the wake of the reports. Amie Lulinski, executive director of The Arc of Illinois, an advocacy organization for people with developmental disabilities, said the details of abuse and neglect are “appalling” and called on the state to move residents out of the facility and into smaller community-based living arrangements such as group homes.

Pritzker said the state isn’t currently planning to close Choate, but he didn’t rule it out if safety issues aren’t addressed.

“The question is, can we prevent that in the future? And if not, then obviously that’s not a facility that should remain open,” the governor said in response to a reporter’s questions at an unrelated event in downstate Decatur.

Meanwhile, he said, the “state has an obligation to the people that it serves at that facility right now” and is concentrating on upgrades to the facility and ensuring that appropriate services and personnel are in place. In a statement to reporters last week, Marisa Kollias, a spokesperson for the Illinois Department of Human Services, which runs Choate, said that the problems there are the result of “longstanding, entrenched issues” and that the department has taken “aggressive measures” to address them.

Choate Mental Health and Developmental Center. At least one advocacy organization called for the state to close the facility. (Whitney Curtis for ProPublica)

The push to close facilities like Choate is controversial, and some residents’ parents are advocating for less severe measures to address safety concerns.

In 2017, a Choate employee was arrested on a felony battery charge and later pleaded guilty to misdemeanor battery for punching Rita Burke’s son in the abdomen, breaking two of his ribs. But Burke, who is the president of Friends of Choate, an organization that represents parents, guardians and other supporters, said the fact that the employee was swiftly removed from patient care and prosecuted is a sign that the facility takes cases of abuse seriously.

After researching their options nationwide, Burke said, she and her husband relocated from Georgia to Illinois over 30 years ago to place their son at Choate. At the time, Georgia offered extremely limited support for adults with disabilities, she said. She feels that her son, who is intellectually disabled and has a severe behavior disorder, is better off at Choate than he would be in a privately operated small group home. Abuses, she said, unfortunately happen at facilities of all sizes across the country.

“Our belief is our facility is working to make it safe and to get rid of people who are a danger to our individuals,” she said. “We couldn’t be more in sync with them on that score.”

State Sen. Jil Tracy, R-Quincy, agrees that the facility shouldn’t be closed. Her 55-year-old brother lives at Choate. He has profound autism and diabetes that requires constant monitoring. If left unchecked, his blood sugar levels could cause him to have behavioral outbursts, get sick or even die.

Tracy’s brother has tried living in group homes, but his health problems coupled with his autism have made those places a bad fit. At Choate, he gets the close monitoring that he needs and Tracy’s 94-year-old mother, who is his legal guardian, can visit often, Tracy said.

“Yes, there have been horrible instances there, but Choate provides a niche in care,” Tracy said. “Changes do need to be made because these facilities are absolutely necessary, but we need to make them as safe as possible and as nice as possible.”

Choate, a 270-bed facility on the outskirts of Anna, about 120 miles southeast of St. Louis, serves people from across Illinois with intellectual and developmental disabilities, mental illnesses or a combination of disorders. Patients can enter voluntarily or be placed there by a guardian, or a judge may order them to Choate for treatment after finding they’re at risk of harming themselves or others. Choate also houses Illinois’ only forensic unit for people with developmental disabilities found unfit to stand trial or not guilty by reason of insanity in criminal proceedings.

The IDHS Office of the Inspector General, which investigates employee misconduct, looked into 1,500 allegations at Choate over a 10 year period ending in 2021. That’s more than at any other facility in the state. Of those, 800 involved physical abuse, 600 involved mental abuse and 100 involved sexual abuse. The inspector general substantiated the allegations in about 5% of the claims, in line with other facilities. But the number of allegations per year has increased, and Choate has faced repeated criticism from the inspector general, the local prosecutor and state police for employees interfering or attempting to derail investigations into wrongdoing.

State Sen. Terri Bryant, R-Murphysboro, whose district includes Choate, blamed some of the issues at the facility on broader failures of the state of Illinois. It can take months for job applicants to navigate the state’s bureaucratic hiring process, and by the time an offer is made, “sometimes what you’re left with is the folks that couldn’t get a job anywhere else,” she said.

The OIG is woefully understaffed, she added, resulting in dozens of employees accused of abuse or neglect unable to work their regular duties for months or years until investigations into their actions are closed and they’re either fired or cleared to return to patient care.

“The (OIG) does not have enough investigators,” she said. “It’s inexcusable.”

In a statement, the OIG said it intends to augment its investigative efforts, specifically looking at the root causes of abuse and neglect at IDHS facilities. The OIG will also identify and address programmatic or systemic concerns needed at a facility.

Even when the OIG has recommended changes at Choate, they have often been slow to happen, if they happen at all. The office recommended that cameras be installed at Choate 21 times over the last six years, internal records show. In response to mounting calls to address safety concerns at Choate, IDHS announced in June that it would install 10 cameras, though later the department clarified they would go outside the facility.

Senior IDHS officials told reporters that they raised the idea of placing them inside in common areas such as hallways and group rooms, but that some parents and guardians rejected the idea, citing privacy concerns.

The news organizations’ reports included emails from the former security chief of Choate seeking to bring troubling conditions to IDHS Secretary Grace Hou’s attention over a year ago. Barry Smoot, who retired in December, asked for a meeting, and Hou initially agreed, but one was never scheduled. Smoot said in a later interview that he felt his concerns were blown off, and that he was troubled by the department’s slow response.

Pritzker said on Tuesday he couldn’t speak to how quickly Hou acted to address concerns at Choate. “I will say that speaking up and speaking out, when you see something that’s wrong, is exactly the right thing to do,” he said. “Making sure that there’s responsive people on the other end, and that again, we have transparency and investigations that take place — that’s the right thing to do, and that’s what we’re going to make sure happens.”

Kollias, the IDHS spokesperson, previously said that the agency determined, “based on information gathered” after the secretary’s initial response to Smoot, “that it was inadvisable for IDHS management staff to communicate with him any further.” The department did not provide more details.

Lulinski, the executive director of The Arc of Illinois, said more than a dozen other states no longer operate institutions for people with intellectual and developmental disabilities, opting instead for group homes.

“Only Texas has more of these settings than Illinois. Over 1,600 people remain in institutions and thousands more are on the waiting list for community services,” Lulinski wrote in a statement in response to the stories. “Illinois has an opportunity to do better but it is going to take political will to do so.”

by Andy Kroll and Justin Elliott, ProPublica, and Andrew Perez, The Lever

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

This story was co-published with The Lever.

In the mid-2000s, Barre Seid had begun thinking about how to leave a legacy. Riding the personal computer boom, the Chicago-based electronics magnate was on his way to becoming a billionaire. Seid, who considers himself a libertarian, now had the means to pursue a bold project: “attack philanthropy.”

To Seid, that meant looking for ways to place financial bets that had the potential to make epochal change. With little public notice, Seid became one of the most important donors to conservative causes during an era that saw American politics and society shift sharply to the right.

New reporting by ProPublica and The Lever, based on emails and interviews with people who know Seid, sheds light on one of the country’s least-known megadonors, revealing how an intensely private billionaire has secretly used his wealth to try to influence the lives of millions.

Seid has funded climate denialism as well as a national network of state-level think tanks that promote business deregulation and fight Medicaid expansion. He’s also supported efforts to remake the higher education system in a conservative mold, including to turn one of the nation’s most politically influential law schools into a training ground for future generations of right-wing judges and justices.

Last month, The Lever and ProPublica as well as The New York Times detailed how Seid secretly handed a $1.6 billion fortune to a key architect of the Supreme Court’s conservative supermajority that recently eliminated federal protections for abortion rights.

Steven Baer, a longtime friend and former adviser to Seid, said the businessman has long been “the major patron” for the Heartland Institute, a small Chicago-area think tank which for decades has attacked mainstream climate science. A top executive at Seid’s former company, Tripp Lite, served as the chairman of the group. Among the recent claims on the institute’s website: “US Temperature Readings Are Junk, Negating Climate Science” and “96% of U.S. Climate Data Is Corrupted.”

“Barre did not need the quick win,” explained Baer in a recent interview. “He believes that if you take the long-odds shot and it pays off, it’s huge.” Baer said that Seid summed up his approach as “attack philanthropy.”

Seid, who turned 90 in April, is exceedingly secretive. In one email obtained by ProPublica and The Lever, he described himself as prone to “anonymity paranoia.”

Seid was so insistent on remaining in the shadows that he sometimes went by a pseudonym, variously given as Ebert or Elbert Howell. He and his staff at Tripp Lite would give the Howell name as the CEO of the company to outside salesmen and in business information registries, according to testimony Seid gave in a federal lawsuit.

“I get harassed a lot by telephone calls from security salesmen and the like and the source of it is mailing lists,” Seid said in the testimony, adding: “It’s a way of deflecting salesmen.” Seid did not respond to requests for comment for this story.

It’s impossible to know the full extent and details of Seid’s giving over the years because the law allows many nonprofits to keep their sponsors secret. But tax records previously obtained by ProPublica show that between 1996 and 2018, he made at least $775 million in donations to nonprofit groups. Almost all of that money was given anonymously.

As Seid got older, he knew that he needed a plan for what to do with his vast wealth, according to Baer. Seid, who has no children, knew that donating his billion-plus fortune could have a generational impact if put in the right hands.

“The question was,” Baer said, “how does he try to steer history?”

“He Did Not Want to See and Be Seen”

Forty years ago, Seid was a little-known business executive based in Chicago who was scarcely on the radar of major political operatives and party committees. His electronics company, Tripp Lite, sold surge protectors and other gear from a cramped space in Chicago’s River North area.

As the company flourished at the dawn of the personal computing era, Seid had started to write a few checks to political groups such as the Republican National Committee. He also began donating to a local Republican group that, under Baer’s leadership, had restyled itself as a force to purge the GOP of its more moderate elements.

Baer had never heard of Seid but decided to introduce himself after he noticed the businessman’s donations to his group. Baer brought a copy of Chris Matthews’ memoir “Hardball” to an early meeting. He recalled that Seid kept the book in his office for many years afterward, taking inspiration not from an ideological perspective but as a useful primer on bare-knuckle politics.

Baer described Seid as “this quirky fellow who has a very good sense of humor and is very self-effacing.” But when he’s running his company, Baer added, “he can be terrifying to his subordinates. Not because he’s a bad person or a mean person, but because his mind works so whip-fast smart, you can be hit with a bunch of quick logic and questions, and you might be left stammering.”

According to Baer, Seid took great pains to monitor all aspects of Tripp Lite’s business. Seid would even go line by line through the company’s vast list of products, pen in hand, changing the prices of individual items. “He did not delegate that to anybody,” Baer said.

When it comes to ideology, Baer said the businessman was “a William F. Buckley, National Review, capital-C conservative but with a little tilt toward Cato Institute libertarianism.” Seid himself has referred to the “basic libertarianism” at the core of his politics, according to an email obtained by ProPublica and The Lever.

Even after he had become known in conservative circles as a major donor and an extremely wealthy man, he expressed intense aversion to attending political events.

“Barre would say, ‘I will pay you so I don’t have to go to your black-tie dinner,” Baer recalled. “He did not want to see and be seen. He was not that type of donor.”

Financing Climate Denial

Soon after the turn of the century, Seid began to take an intense interest in combating what he labeled “junk science,” according to Baer.

Baer, who worked as a contractor for Tripp Lite for several years, said Seid funded research and activism against the ban on the chemical insecticide DDT instituted by President Richard Nixon, which critics claimed had led to the death of millions because of the spread of malaria-carrying mosquitoes.

Seid also became convinced that leading practitioners of climate science are wrong when they blame global warming on the carbon emissions of human beings. Baer said he had already introduced Seid to Joseph Bast, then the head of the Heartland Institute, which challenged the scientific consensus on human-caused climate change. Seid became “the major patron” of the organization, according to Baer.

Some donations by Seid to Heartland two decades ago were previously known, but the extent of his ties to the group have not been reported.

About a decade ago, Seid asked his close friend, Tripp Lite chief financial officer Chuck Lang, to join the Heartland Institute’s board of directors, Lang’s wife, Susan, said in an interview. Lang was elevated to chairman of the board shortly before he died in 2018.

“Barre Seid deserves his privacy, but I can say this: He is a very intelligent and generous man,” said Tim Huelskamp, a former U.S. representative from Kansas who served as the Heartland Institute’s president from 2017 to 2019.

The Heartland Institute did not respond to a request for comment.

Seid has also funded the State Policy Network, a group of influential state-level think tanks that push for deregulation and tax cuts, according to an email written by a friend of Seid’s. The head of the group once compared it to IKEA, The New Yorker reported, offering state think tanks a “catalogue” of successful projects, including opposing health care subsidies and imposing new voting restrictions. The network has also opposed efforts to expand Medicaid coverage.

A spokesperson for the State Policy Network declined to comment on the organization’s donors.

Seid, who was raised by Russian Jewish immigrants, has also been a donor to pro-Israel causes. A glimpse of those efforts came in 2010 when Bar-Ilan University in Israel awarded him an honorary degree, citing his “fervent commitment to setting forward a strong case for the State of Israel” and “support for programs which help develop the ability of Israel’s future leaders to persuasively communicate Israel’s positions and concerns.”

Bar-Ilan University also gave Seid’s wife, Barbara, an honorary degree the following year.

While Seid has long funded causes aligned with Republican orthodoxy, his company broke with the Trump administration over its trade war with China. Whether motivated by Seid’s deep libertarianism or simply Tripp Lite’s concern for its bottom line, the company sued the Trump administration in September 2020 after being hit with tariffs on electronic components it imported from China.

The sharply worded complaint attacked the administration for its “prosecution of an unprecedented, unbounded, and unlimited trade war impacting over $500 billion in imports from the People’s Republic of China.” Tripp Lite’s lawyer on the case, Ted Murphy of the firm Sidley Austin, declined to comment. The case is still pending.

At the time of the lawsuit, Seid’s business empire was in flux: He was working to convert his sole ownership of the company in Tripp Lite into what would be the biggest one-time political advocacy donation in U.S. history. He transferred the company to a dark money group created in April 2020 and run by conservative operative Leonard Leo, before it was sold for $1.6 billion in March 2021, as The Lever and ProPublica reported. The structure of the transaction allowed Seid to avoid as much as $400 million in taxes, according to tax experts.

Seid views himself as a libertarian, but he has entrusted his legacy to Leo, a staunch social conservative committed to curtailing reproductive rights. Leo, a longtime executive at the conservative legal group the Federalist Society, helped select five of the six Supreme Court justices who recently struck down federal protections for abortion rights.

Asked about Seid’s decision to give his business empire to Leo, Seid’s friend Baer explained that Seid, like the billionaire donor Charles Koch, understands the need to unite the conservative movement to change the direction of the country.

“A Full-Ride at Scalia Law”

As part of his long-term project, Seid has shown a particular interest in shaping colleges and universities.

Seid has funded Hillsdale College, a small Christian liberal arts school in Michigan, according to Susan Lang, the widow of Seid’s friend and Tripp Lite executive. Hillsdale is known both for its great books curriculum, which is centered on reading the classics of the Western canon, and also for being a feeder of staffers and ideas factory for the Trump administration.

He has forged a particularly close relationship with George Mason University, helping turn the school into an incubator for conservative legal scholars, lawyers and judges.

Activists have long suspected that Seid was the anonymous donor who gave $20 million in 2016 to rename GMU’s law school after the late Justice Antonin Scalia. The donation was brokered by Leo, the Federalist Society executive.

Six Supreme Court justices attended the renaming ceremony, and several have taught courses there in recent years, including Clarence Thomas, Neil Gorsuch and Brett Kavanaugh.

The new emails, obtained through a public records request by ProPublica and The Lever, appear to confirm that Seid made the donation. The then-dean of the law school, Henry Butler, emailed Seid in 2019 with a personal update “on progress that we made at Scalia Law since the naming gift,” explaining that it had inspired another, larger donation. “Thank you for your generous support,” Butler added. (Butler and a spokesperson for GMU did not respond to requests for comment.)

In response, Seid said he would “discuss this with Leonard shortly,” apparently a reference to Leonard Leo. He then asked the dean for a personal favor: helping his nephew get into law school.

“Separately, do you still have useful connections at Northwestern Law? I have Nepot with LSAT 167,” Seid wrote, using an archaic term for nephew.

“Happy to try to help at Northwestern. I have several good friends on the faculty at Northwestern,” Butler wrote, then added: “Please tell him that he has a full-ride at Scalia Law where he can take courses from Justices Thomas, Gorsuch and Kavanagh [sic]. Onward and Upward!”

A February 2019 email exchange between businessman Barre Seid and Henry Butler, then the dean of the George Mason University law school. (Obtained by ProPublica)

At GMU’s law school, one of Seid’s longtime influences is Frank Buckley, a law professor and conservative columnist, and the two have a long-running breezy email correspondence. In August 2020, Seid wrote to Buckley: “You need to keep being a public intellectual for the U.S.”

This year, Buckley had to take a step back from the public realm, deleting his Twitter account after he referred to Supreme Court Justice Sonia Sotomayor as a “stupid Latina.” (Buckley later apologized, writing, “I regret that my foolish remarks have caused great sadness.”)

Buckley did not respond to a request for comment.

Buckley, who had written Donald Trump Jr.’s 2016 Republican convention speech, confided to Seid in an August 2020 email: “Btw just between us girls I’m writing Don Jr’s convention speech again.” That speech, delivered in the wake of the George Floyd protests, claimed: “Small businesses across America — many of them minority owned — are being torched by mobs.”

In a November 2021 email to Buckley and others, Seid expressed interest in the University of Austin, the education project started by former Times opinion writer Bari Weiss.

Seid wrote a stream-of-consciousness take comparing the new effort to his alma mater, the University of Chicago, and referencing his longtime interest in great books curricula.

“Not U of C, Not enough $$$, High profile names, President from great books,” Seid wrote. “Can it succeed, and make a difference???”

Do you have information about Barre Seid or Leonard Leo? You can reach Andy Kroll at andy.kroll@propublica.org, Justin Elliott at justin@propublica.org and Andrew Perez at aperez@levernews.com.

by Marilyn W. Thompson and Jenny Deam, research by Mollie Simon, illustrations by Kitra Cahana, special to ProPublica

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Last spring, a year after COVID-19 had first ripped through the United States, Republican lawmakers in Montana doubled down.

They passed the nation’s most extreme anti-vaccination law. Not even nurses in a cancer ward could be required to get the shots.

Less than three months later, the delta wave slammed into Big Sky Country.

Inside one hospital just over a mile from the statehouse, doctors were forced to make the kinds of choices Americans had long feared.

This is a story about what can happen when politics trump public health.

Vicky Rae Byrd had a sinking feeling.

As she scrolled through her phone on election night, her pick for president — Joe Biden — seemed to have a slight edge. Byrd was too stressed to turn on the local news. Her husband sat down with her in their living room, and the couple settled on some sitcom.

Vicky Byrd

Montana had long voted Republican in presidential elections. But it had a Democratic governor for the past 16 years, and that was almost certain to end. Ending with it, Byrd feared, would be the state’s aggressive response to COVID-19.

Byrd, 58, with long silver hair, had been sounding early warnings as director of the Montana Nurses Association, which lobbies for the state’s 18,000 nurses, many of them unionized. She’d been a nurse herself for 33 years, most of them at St. Peter’s Health in Helena, working in pediatric cancer.

“Nurses are really good at foreseeing,” she recalled. “I’m like, shut down before it gets here! Then, one case gets here, and I’m like: ‘Shut down, hold down the state. Keep me safe.’”

By that fall, many voters were fed up with departing Gov. Steve Bullock’s mask mandate and stay-at-home order. Small businesses complained they were suffocating, Montana’s economy was struggling and efforts to control the virus were colliding head-on with the state’s deeply ingrained belief in personal freedom.

As election night wore on, Byrd kept sneaking glances at her phone. She saw votes piling up for the Republican candidate, multimillionaire businessman Greg Gianforte, who was running against Bullock’s lieutenant governor, Mike Cooney. A Donald Trump acolyte who’d gained national attention for pleading guilty to assaulting a reporter on the eve of his 2017 election to Congress, Gianforte had called for the speedy development of COVID-19 vaccines but answered few questions about how he’d fight what he called “this invisible enemy.” He had, however, made it clear he supported personal responsibility over mandates.

The governor’s office in the Montana Capitol

Days after a decisive victory, Gianforte appointed a 21-member panel to guide him on COVID-19. Determined to recharge the economy, his wide-ranging picks included a refinery executive, a local Best Western operator and the owner of a pizza restaurant and casino. Dr. Scott Gottlieb, the former commissioner of the federal Food and Drug Administration, added national gravitas.

Missing from the long list of names were any officials from the state public health agency who had been running the COVID-19 response. Among them was Jim Murphy, a veteran of almost 33 years at the state’s Department of Health and head of its communicable diseases division.

Under Bullock, Murphy had helped deliver daily COVID-19 updates. But in conference calls with the governor-elect’s office and the new coronavirus panel, he sensed “pretty much instantly” that public health was not the priority. The calls, Murphy remembered, “focused more on the perceived overresponse” to COVID-19.

(Gianforte declined requests for an interview, and his press secretary, Brooke Stroyke, said she wouldn’t respond to “biased, gotcha” questions about the governor’s actions, which she said have been “widely covered.”)

State epidemiologist Jim Murphy felt like he had to defend public health to the governor-elect’s COVID-19 task force.

One conference call turned tense when the head of the task force, a conservative former state senator named Kristin Hansen, questioned Murphy about the validity of state data on COVID-19 infections and deaths.

“Some of us spoke up to offer the public health side of the story,” Murphy recalled. “That wasn’t always well received.”

When Gianforte took office on Jan. 4, 2021, Montana had avoided the worst of the pandemic. About a thousand residents had died, slightly less per capita than the national average. And the state had just started rolling out vaccines under a plan worked out by Murphy and his team.

Almost immediately, Gianforte began rolling back COVID-19 restrictions. He won applause from businesses by lifting Bullock’s order restricting their hours. A month later, amid a lull in the state’s COVID-19 cases, he allowed an indoor mask mandate to expire; state medical officer Dr. Greg Holzman resigned the next day.

Gianforte got his first Pfizer shot the day he opened vaccines to all adults, weathering criticism from some far-right conservatives for calling the shots “safe and effective.” But even as Montana’s vaccination rate began to sputter, Gianforte again emphasized that getting vaccinated was a personal choice.

As Byrd watched Gianforte with concern, she and her small staff were also trying to track Montana’s GOP-controlled Legislature as it considered a flurry of public health measures. One that initially escaped her attention was introduced by a new legislator, Rep. Jennifer Carlson.

Carlson had pressed the Legislature even before COVID-19 to do away with vaccine mandates. The mother of five, who has a biomedical science degree, had given all of her kids the typical childhood vaccinations. But one child, she recalled, had suffered a severe reaction. Soon after she took office, Carlson introduced legislation that she said she got help drafting from the leader of a popular Facebook group, Montanans for Vaccine Choice.

Her legislation gave the unvaccinated standing as a “protected class,” making it illegal to discriminate against them. No employers could require vaccinations of any kind. The language covered all vaccines, including measles, mumps and other standard childhood vaccinations.

There were no exemptions for people working at hospitals.

A mobile vaccination site organized by St. Peter’s Health

The legislation worried Murphy. But he said that the governor’s office told him and other state health officials to stay out of the debate.

“We were told we had to be neutral,” Murphy recalled.

The bill caught fire, particularly after a hospital in Great Falls announced its plan to terminate unvaccinated employees. Gianforte, responding to complaints from alarmed hospitals and other health care providers, sent amendments back to the Legislature that he said “strengthened” the bill. It would at least allow hospitals to ask employees if they were vaccinated so they could make adjustments. But if unvaccinated staffers felt they were being discriminated against, they could sue.

The Old Supreme Court chamber in the Montana Capitol

The amended bill sailed through the GOP-heavy House and Senate in the session’s final days. Gianforte signed HB 702 into law on May 7, the same day he signed another bill restricting the authority of local public health agencies to impose COVID-19 restrictions.

Carlson told ProPublica she was quickly deluged with calls. Legislators in other states asked how she had pulled off a “miracle.” Other callers left messages saying she would be responsible for more deaths.

“Nobody wants to be called anti-vax. Nobody wants to be accused of killing grandma,” she said. “I honestly don’t think the government should be in charge of your lives.”

The Montana Medical Association and others sued in federal court, arguing that health care providers receiving federal funding are required to vaccinate their workers. Byrd’s group joined the suit. She noted in an affidavit that when St. Peter’s hired her, it required proof of vaccination “as a condition of employment.”

Byrd remembers thinking: “I don’t go to the governor’s office for my colonoscopy. Certainly you shouldn’t go to the governor’s office to have him lecture you on what immunizations you should or shouldn’t get.”

Mountains as seen from Helena, the state capital The Surge

By July, less than three months after Carlson’s bill became law, the delta variant began to spread across Montana.

Vaccine hesitancy remained high. Early in the pandemic, residents of the state capital, Helena, stopped at 8 p.m. to howl at the moon in a salute to health care workers. Now staffers faced verbal, even physical abuse, often over intake questions about vaccination status and wearing masks.

St. Peter’s posted a warning in the entryway “Aggressive Behavior Will Not be Tolerated.” Almost overnight, nurses “went from heroes to zeros,” Byrd said.

Gianforte warned that delta was highly contagious and urged citizens to protect themselves, but he again emphasized there would be no mandates.

St. Peter’s doctors and nurses signed a letter on Sept. 1 pleading with Montanans to get vaccinated. One of them was Charlotte Skinner, a nurse and a mother of two who works in the St. Peter’s emergency room and is an officer in the hospital’s nurses union. Earlier in the pandemic, Skinner had volunteered to appear at a press conference with Bullock, where she delivered an impassioned speech calling for an end to “partisan bickering” and urging the state to “embrace science.”

Afterward, a friend warned Skinner not to look at her Facebook messages. She peeked in to find “shocking stuff,” she recalled, including one commenter who “said he wanted to scalp me and my family.”

St. Peter’s

Vaccines remained a flashpoint even among staffers, about a quarter of whom declined to get one. Skinner said word spread quickly nationwide that Montana was a state where unvaccinated medical workers could work with legal protections. Perhaps unintentionally, she said, it became a “recruiting tool.”

By early September, COVID-19 hospitalizations were climbing quickly. Hospitals in Billings and Missoula warned they were overloaded. Non-COVID-19 patients were competing with COVID-19 patients for resources. The critical care units at St. Peter’s were at 100% capacity.

At St. Peter’s request, Gianforte sent National Guard troops to help, detailing 10 guard members to the 99-bed hospital. Among their tasks was helping exhausted nurses flip struggling COVID-19 patients onto their stomachs so they could breathe more easily. Staff scrambled to deliver ICU-level care in other units as beds dwindled.

By then, despite his state’s unfolding calamity, Gianforte had said on Twitter that Montana would take the vaccine fight national by challenging what he called Biden’s “unlawful and un-American” vaccine mandate.

St. Peter’s was so crowded that nurses had little time to spend with patients, even in the ICU. “Turn. Make sure the vents are on. Go on to the next person,” as Byrd described it.

To handle surges, Montana’s state health agency had revised its guidance on when a hospital should declare “crisis standards of care,” a designation that protects overwhelmed facilities from liability when they can no longer offer normal services and must consider rationing care.

A state official announced the directives on Sept. 15, saying he hoped hospitals would never have to use them.

One day later, St. Peter’s president and chief medical officer, Shelly Harkins, called a video press conference. The hospital was already meeting all of the criteria — long emergency room wait times, scarce equipment and medications, and no vacant beds, including in its eight-bed ICU.

Shelly Harkins, St. Peter’s president and chief medical officer

A former Air Force physician, Harkins joined the hospital in 2017 after running a health system in Indiana. Harkins had a light-hearted side. She had played keyboard in a band called Leather Moose. But now, Harkins delivered the blunt reality.

COVID-19 patients filled every available bed, and St. Peter’s was running out of medication to treat them. The hospital was splitting up doses of some medications between patients and using seven times its normal amount of propofol, a sedative that can help ease the agony of the terminally ill.

Harkins was invoking “crisis standards of care,” she said. She was clear about what patients and their families could expect to see. “We are giving our staff permission to not do it all. The hardest thing they will do in their careers is not giving the care they are used to giving, but they simply can’t.”

“JEEZ!” someone in the background exclaimed.

Crisis standards would impact not just COVID-19 patients but anyone needing care. Some decisions would require a kind of battlefield triage, applying standards that had been crafted by a national advisory board in 2009 after the H1N1, or swine flu, epidemic. The guiding principle would be to try to save the greatest number of lives. That could mean giving a scarce resource, like an ICU bed or a ventilator, to a person thought to be most likely to survive.

The prospect of rationing health care has long terrified Americans. Republicans used it as a pillar of an early fear-mongering campaign against President Barack Obama’s Affordable Care Act, when Sarah Palin and then others falsely claimed the legislation would create “death panels.”

Harkins’ work in family medicine and palliative care had prepared her to be direct but reassuring. “We are still very much here to provide care to our community, and we are doing absolutely all we can to keep all services open,” she added during the announcement. “True emergencies will always receive priority.”

A nurse treating COVID-19 patients at St. Peter’s

But the strain on St. Peter’s staff of 1,700 was escalating. Instead of monitoring one or two desperately ill COVID-19 patients, nurses were caring for five or six.

Byrd’s association set up an email inbox for nurses to anonymously vent. “I no longer look forward to what impact I might make every shift. Instead, I steel myself to simply survive another day at the bedside without breaking down in front of the patients,” wrote one.

Harkins said that the hospital had more than 200 staff vacancies at the time. She told ProPublica the hospital was short of staff throughout.

When COVID-19 first began its march across America, the hospital had set up a 13-member Scarce Resources Committee to help doctors wrestle with tough decisions if things ever got bad. It included doctors, administrators and the hospital chaplain.

It was only called twice in nearly a year and a half. After delta hit, the committee convened six times in just over a month.

A COVID-19 patient is transferred from the ER to a private room at St. Peter’s The Call

Around lunchtime one day in the middle of October, Harkins got an urgent text from an emergency room doctor.

“I need help,” the doctor pleaded.

A COVID-19 patient with dangerously low oxygen levels had just arrived by ambulance. The woman was severely obese, which put her at high risk. “As soon as she hit the room, we knew if we don’t act rapidly she will be dead soon,” recalled the ER doctor, who later spoke with ProPublica on the condition of anonymity.

The doctor wanted to transfer the patient to the ICU. But the unit was full.

Harkins quickly convened a video meeting of the Scarce Resources Committee. As doctors began to weigh in, the committee realized the crisis ran deeper. There were an additional four critically ill patients in other parts of the hospital who also should be transferred to the ICU.

The math was brutal: Five patients and zero beds.

A nurse tends to a COVID-19 patient at St. Peter’s

The committee began the process spelled out by an allocation algorithm in Montana’s crisis standards of care guidelines. Factors like age and preexisting conditions were fair to consider, but vaccination status was not.

Harkins quarterbacked as the committee deliberated: How old? Other serious health conditions? How long in the hospital? What is the latest status?

One critically ill non-COVID-19 patient had a serious heart condition. “I feel the heart patient will not survive. How do you feel?” one doctor asked. Everyone agreed that the heart patient would not get an ICU bed and could be treated in another unit.

After about 20 minutes, the committee decided the woman in the emergency room had the most urgent need and should go to the ICU. They could make a bed available by moving a dying patient too ill to survive to another unit. But they had promised the patient’s family they would wait until everyone arrived to say their goodbyes before removing life support. One family member was not there yet. The hospital was running out of time.

Suddenly, a piercing code blue alarm sounded in the emergency room. “Wait a minute, guys,” an attending physician told the committee. “The patient is coding.”

Then, “the patient has died.”

The committee took a moment to absorb the news. Then it began deliberating again. The call lasted an hour. In the end, the terminal ICU patient’s family members were able to gather to say their goodbyes. When that bed was free, another patient discussed during the call was moved into the ICU but died a few days later.

Of the five patients who had been vying for a bed, four ultimately died.

“Under normal circumstances we would have moved all five into the ICU,” Harkins later told ProPublica. “But we just couldn’t.”

Hospital chaplain Kimberly Pepper, a member of the St. Peter’s Scarce Resources Committee

Being forced to make such profound decisions changed Harkins and others on the call.

Kimberly Pepper, the hospital chaplain who served on the committee, described seeking solace in the “thin places,” a Celtic belief that there are spots where the distance between heaven and Earth is at its slimmest. Hers was in the Montana mountains. She noticed her hikes had become longer and longer.

Harkins said hospital staff had found their “cry spots” to deal with the anguish. Hers was in an empty office.

“The human psyche,” she said, ”was not built for this.”

St. Peter’s The Patients

The virus was forcing cracks in the hospital’s usual care.

Nurses at St. Peter’s had to bathe patients and clean rooms to make up for the large number of nursing assistants who had quit. Kari Koehler, who was serving as the acting chief of nursing during the surge, told ProPublica that the exodus had left the hospital with two assistants per shift instead of the desired 10.

Donna Burrell, a 66-year-old grandmother and former Little League president who worked as a clerk for the Helena school district, arrived at St. Peter’s emergency room in early September with COVID-19-related respiratory failure. A doctor called her daughter, Kima Rosling, to explain that ICU space was unavailable and “may be limited elsewhere throughout the state,” according to medical records.

For Rosling, the next days were chaotic. Burrell was transferred to the ICU when her oxygen levels dropped, then transferred back to a step-down unit.

A doctor prescribed a medicine to control Burrell’s high blood sugar, which can lead to stroke, heart attacks or kidney failure. But a doctor’s note in her file said the order “did not go through” at first and the condition escalated.

Burrell was also having trouble keeping on her oxygen mask. A doctor noted in her records that he told her family “we are in no position to ensure that she keeps it on 24 hours a day.” The medical team told the family it would have to step in to help.

Burrell kept asking doctors when she could go home, and the family discussed transferring her to a rehab facility. But her condition took a sudden turn. Burrell told her daughter and husband that she fell and hit her head during the night while trying to walk to the bathroom.

There was no notation of a fall in Burrell’s record, and Rosling said she complained to a head nurse. Nursing notes show that Burrell was placed on a bedpan.

Burrell’s oxygen levels declined and soon she was back in the ICU, her organs failing. Rosling knew her mother wanted to fight to stay alive and gave doctors permission to intubate her.

But Burrell died at 6:24 a.m. on Oct. 7, after a month of treatment.

First image: Kima Rosling holds a photo of her and her mother at a football game. Second image: Rosling lights a candle to commemorate her mother.

Rosling said she realizes that her mother came into St. Peter’s at a terrible time, but she believes her care was lacking and that the medical team should have treated the fall more seriously. Rosling said tracking her mother’s care was a “day-to-day war.”

St. Peter’s administration declined to comment on treatment of individual patients, citing privacy laws. But the hospital said that even amid the chaos, it offered quality care to all patients.

Family members of other patients told ProPublica that it was clear the hospital was under stress. Alarms seemed to be beeping endlessly and medical staff were visibly fatigued. Doctors sometimes told them that drugs and beds were in short supply. The chaos, the family members said, only heightened the anxiety of having a loved one in the hospital and, in some cases, their grief.

St. Peter’s

Jodi Raue said her concern over her 84-year-old mother’s swift decline after a serious fall was made worse by a lack of communication with doctors about their decision to move her mother out of the ICU. While her mother had a do not resuscitate order signed several years earlier, Raue remains upset that her mom’s last days were not more orderly and peaceful.

“I don’t know why they didn’t tell me,” Raue said. “It wouldn’t have changed anything for my mom, but it would have been transparent.”

Harkins said in a statement earlier this year that the hospital tried to keep families in the loop about treatment decisions, but it depended on individual circumstance and situation, especially during the crisis.

“We are confident,” Harkins wrote, “that our actions helped us focus on the most important task at hand: saving lives.”

Helena The Politics

As overwhelmed doctors and nurses struggled to keep their patients alive, Montana’s red state politics pushed their way into the hospital.

On Oct. 10, St. Peter’s admitted 81-year-old Shirley Herrin, an iconic figure in state GOP politics who had supervised secretaries for Republicans in the Montana Senate. St. Peter’s was treating her for COVID-19, but Herrin’s daughter, Susan Williams, objected to the treatment.

Williams wanted her mother sent home where she could take ivermectin and hydroxychloroquine, drugs then widely promoted as possible treatments by right-wing media and President Donald Trump. She accused St. Peter’s of declining to discharge her mother and of blocking the paperwork needed to give her medical power of attorney. (The hospital later denied this.)

St. Peter’s refused to prescribe the unproven drugs. But Herrin’s daughter wouldn’t back down.

Williams said she and an aunt got ivermectin tablets, typically used to treat parasites, from an outside physician and dissolved them into a frozen drink — a “Frostie.” A nurse delivered the concoction, not knowing it was spiked, to Herrin’s bedside for five days before discovering it.

Later, after Williams confronted staff about moving her mother to another room without explanation, a doctor called hospital security. Williams was asked to leave the building and retreated to the parking lot, where she called a top official in the Montana attorney general’s office, Kristin Hansen.

Hansen was the same politician who had been head of Gianforte’s COVID-19 task force and questioned the state’s statistics. She jumped into action.

Hansen dispatched a Montana Highway Patrol trooper to the hospital, according to a later state report, and the trooper interviewed Williams. Hansen also called a friend near Herrin’s bedside. The friend put the call on speaker and hospital staff heard Hansen warning that St. Peter’s could face “legal ramifications.” More pressure came from a former Republican state senator, who called the hospital to complain about Herrin’s treatment.

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The attorney general himself, Austin Knudsen, contacted a hospital lobbyist to set up a phone call with St. Peter’s CEO and other top administrators. He texted a hospital board member that he was ready “to send law enforcement in and file an unlawful restraint charge.”

From her hospital bed, Herrin wrote to her doctor asking that Williams be allowed to give emotional comfort. In Herrin’s final hours, her daughter said she rubbed her feet with an ivermectin salve. Herrin died Oct. 26.

After the attorney general’s actions were reported by the Montana State News Bureau, Knudsen’s press secretary issued a statement defending his office. Knudsen told a local reporter the notion that his office had abused its authority was “absolute, utter nonsense.”

A spokesperson from the attorney general’s office told ProPublica a state report “made it clear” that neither Knudsen nor Hansen threatened anyone.

The hospital said in a statement to ProPublica: “These officials have no medical training or experience, yet they were insisting our providers give treatment for COVID-19 that are not authorized, clinically approved, or within the guidelines established by the FDA and the CDC. In addition, they threatened to use their position of power to force our doctors and nurses to provide this care.” (Read the full statement).

It’s not clear what became of the attorney general’s inquiry into St. Peter’s, but the spokesperson said Williams’ complaint about St. Peter’s “is still under review.” Hansen asked an investigator from the fraud division to look into the matter. Williams also said she met with Knudsen in his office in late April. The county sheriff authorized an autopsy of Herrin.

Williams, who gained local attention with a talk radio interview on her mother’s case, insists that St. Peter’s withheld lifesaving treatment — and tried to push her to expensive therapies. She told ProPublica she still blames the hospital for her mother’s death.

Shirley Herrin’s grave in Helena The Lessons

What happened at St. Peter’s fits a broader national pattern that researchers are only beginning to understand as the virus continues to mutate and spread. Americans have died not simply from COVID-19 but also potentially from gaps in care that the pandemic caused.

One study last year found as many as 1 in 4 COVID-19 deaths early in the pandemic may have been due to strained hospital resources rather than the infection itself. One of the study’s authors, National Institutes of Health clinician and researcher Dr. Sameer S. Kadri, noted at the time it was a “truly humbling statistic.”

Kadri told ProPublica recently that, on reflection, the study’s shocking finding is “probably an underestimate.” Avoidable deaths also may have included people hospitalized for other problems, like heart attacks and trauma.

A study from this year found particularly higher mortality rates among those treated in rural hospitals, smaller hospitals and hospitals not affiliated with medical schools.

Experts say part of that can be attributed to overstretched staff and not enough medical resources to go around. “We’ve had increased mortality because of microdecisions,” said Dr. David Scales, a sociologist and practicing physician at Weill Cornell in New York.

A nurse at St. Peter’s preparing to enter a COVID-19 patient’s room

A hospital can often guard against risks because it has many layers of defense, arranged “like Swiss cheese,” said Scales, who studies patient safety. But “sometimes the holes line up” and accidents occur. “If you are admitted to the hospital while it’s overwhelmed, you’re at higher risk.”

Hospitals can lower that risk. The Cambridge Health Alliance, which runs two hospitals north of Boston, has won attention for its proactive approach to handling its own COVID-19 surge in the spring of 2020. It moved rapidly to set up a coordinating COVID-19 Incident Command System, expanded its ICU beds into other hospital wards and redeployed large numbers of staffers.

Dr. Maren Batalden, the hospitals’ chief quality officer, said Republican Gov. Charlie Baker backed them up by issuing an order suspending nonessential services. Later, when vaccines became available, Baker issued an order mandating them — with religious and health exemptions — for all state executive department employees and nursing home staff.

“We had the opposite of anti-vaccination. We had vaccine mandates,” Batalden said.

COVID-19 is a common enemy, but it has struck a divided nation. “Ideally, we would have bound ourselves together to protect ourselves and one another,” Batalden said. “Instead, in many places, the virus illuminated and heightened our divisions, exposing the fact that our lack of social cohesion makes us collectively vulnerable.”

A growing body of research shows that death rates were significantly higher in red states like Montana because of lower vaccination rates.

William Hanage, an epidemiologist and researcher at the Harvard T. H. Chan School of Public Health, said that “political lean” has emerged as one of the best indicators for COVID-19 death rates — as much as obesity or advanced age.

“Viruses don’t care how you vote,” he said. “If you allow lots of people to become infected at once, it will crash health care.”

One recent study by the Brown University School of Public Health and others estimated that 1,464 Montana COVID-19 deaths — about 1 in 3 — could have been prevented if every eligible adult had been vaccinated.

“Montana is a very good example of a state that has seen consistent undervaccination, and as a result every third life could have been saved,” said the study’s co-author Stefanie Friedhoff, associate professor of health services, policy and practice at the Brown University School of Public Health.

Harkins, the St. Peter’s chief medical officer, is a lifelong Republican. She calls herself “MAGAfan” on Instagram. But she has seen divisions in her own family over the need for vaccines. It’s exhausting and heartbreaking. “It didn’t have to be like this,” she said. “Conservatives are on the wrong side of this.”

Jim Murphy, a former top public health official in Montana, at home The Aftermath

The surge at St. Peter’s hospital has long since receded. But a residue of distrust remains. Some families say they have not fully recovered and blame the hospital for substandard care. There is no evidence that medical care at St. Peter’s was any worse than at any other hospital hit by the delta surge, and data about patient care is still unavailable.

“In retrospect, there is no denying that it was an unprecedented time, the hardest most of us have seen in our careers,” said Harkins in a recent emailed statement in response to questions from ProPublica. “But we cannot understate how our caregivers’ response, sacrifice, and willingness to share their time and talents saved many local lives.”

Meanwhile, Gianforte and his attorney general, Knudsen, have continued fighting the Biden administration’s vaccine policies. Gianforte sent a letter to unvaccinated health care workers in February encouraging them to consider using religious exemptions from vaccine requirements.

Murphy left his state health department job in June 2021 and charged later that Gianforte’s office had nixed an outreach campaign to get teenagers vaccinated. Murphy and other health officials and experts launched a private effort to promote student vaccinations.

“I’m a little frustrated and a little discouraged by what I see in some of our political leadership,” Murphy said. “They’re patronizing people because it’s necessary to get their votes, instead of taking the time and educating the population about why we need to do some of the things we need to do.”

The Montana Capitol at night

Bullock, who lost his 2020 bid for a U.S. Senate seat and now serves as court-appointed monitor over Purdue Pharma, still remembers the days when as governor, he knew the location of every available ventilator in the state, the daily death toll and the number of infections. He talked weekly to anxious governors from both political parties who, despite different leadership styles, were equally desperate for solutions.

He recently watched his parents recover from COVID-19 and knows that the virus is not over. The challenge, he said, is to minimize politics. “Do the best you can, informed by science advisers, and whether you like it or not, that’s what you signed up for,” he said of a governor’s role.

An ongoing federal court case will decide whether unvaccinated Montana health care workers are protected from federal mandates if they work at facilities funded by the federal Centers for Medicare and Medicaid Services.

Byrd, who just recovered from a mild second bout with COVID-19, and other plaintiffs won a small victory in March when a federal judge enjoined a key provision of Montana’s anti-vaccination law, saying it could do “irreparable harm” to physician’s and provider’s offices.

Vicky Byrd

In a pointed Facebook message, one state lawmaker warned Byrd’s association to drop the lawsuit and “don’t mess with the will of the legislature.”

In June, the head of Montana’s state health agency stepped down, and Gianforte replaced him with a former lobbyist and Republican congressional staffer.

Montana’s vaccination rate remains well below the national average. In the latest CDC data, just under 58% of residents are fully vaccinated, ranking 39th in the nation.

About the Reporting

ProPublica interviewed administrators and staff at St. Peter’s hospital, families of patients who died there, former Montana state officials, current lawmakers, public health experts, medical ethicists, and researchers over the course of 10 months. We also reviewed state documents, research reports, medical records, death reports and 911 call records. St. Peter’s granted interviews in October and November 2021 and issued emailed statements in recent months. Decisions by the hospital’s Scarce Resources Committee were traumatic, some of whom recounted the difficulty in interviews with ProPublica. Citing patient confidentiality, they declined to name the patients involved or the ultimate outcome of their cases. ProPublica pieced together some of the details through death records and interviews. Photographer Kitra Cahana spent a week documenting COVID-19 patient care at St. Peter’s in November 2021 and returned to Helena in July of this year. The resulting photo illustrations are composites of multiple documentary photographs.

We Want to Talk to People Working, Living and Grieving on the Front Lines of the Coronavirus. Help Us Report.

Chris Hendel contributed research. J. David McSwane and Sam Wilson contributed reporting.

Art direction and visual editing by Andrea Wise and Lisa Larson-Walker. Design and development by Lena V. Groeger and Andrea Wise.

by Molly Parker, Lee Enterprises Midwest, and Beth Hundsdorfer, Capitol News Illinois

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

Over a year ago, the security chief at Choate Mental Health and Developmental Center in southern Illinois sent an email to the head of the state agency that operates the facility, warning her of dangerous conditions inside.

“What I am presently seeing occur at Choate and hearing occur at other facilities concerns me more than it has my entire career,” Barry Smoot, a decades-long IDHS employee, wrote to Illinois Department of Human Services Secretary Grace Hou on May 26, 2021. Among the recommendations he wanted to make: that cameras be installed inside the facility.

Hou responded that same day, agreeing to meet.

But no meeting took place. Instead, Hou suggested Smoot start by sharing his concerns with her chief of staff, Ryan Croke, and the director of the Division of Developmental Disabilities, Allison Stark, according to records of the exchange. But those meetings never happened, either. (Stark left the agency in July.)

An excerpt from Smoot’s email (Obtained by Capitol News Illinois and Lee Enterprises Midwest)

It would take more than a year, and some high-profile arrests related to abuse at the facility, before the agency unveiled a plan to address poor conditions at Choate. This June, Hou sent a letter addressed to “stakeholders” in which she publicly acknowledged safety concerns at Choate for the first time. The agency, she said, would be rolling out a series of reforms in response to “serious allegations about resident abuse and neglect” at the facility located at the edge of the small town of Anna.

The reform plan, she wrote, includes hiring four additional security officers, installing 10 surveillance cameras on the facility grounds, having staff undergo new training and increasing the presence of senior IDHS officials inside the residential units. Her letter referenced safety issues that arose “in the last year” but offered no other specifics.

Illinois Department of Human Services Secretary Grace Hou (Jerry Nowicki/Capitol News Illinois)

At least 26 Choate employees have been arrested on felony charges over the past decade, according to reporting published today by Capitol News Illinois, Lee Enterprises and ProPublica. Of those, the local state’s attorney has filed charges against more than a dozen, including three administrators, since 2019, when Hou was appointed IDHS secretary by Gov. J.B. Pritzker. (Charges have been dropped against two of the administrators charged with official misconduct and obstruction of justice.)

Marisa Kollias, a spokesperson for the agency, said the facility is working expediently to implement these reforms, but she cautioned that it will take time to implement all aspects of the plan. Senior IDHS officials told reporters in an interview last week that the enhanced training and monitoring have been underway for months and, to date, the department has hired one of the four new security officers. The department ordered the cameras this summer, but they are on backorder and no date has been set for installation, the department officials said.

In a statement, Kollias said that the agency determined, “based on information gathered” after the secretary’s initial response to Smoot, “that it was inadvisable for IDHS management staff to communicate with him any further.” The department did not provide further details.

Choate Mental Health and Developmental Center (Whitney Curtis for ProPublica) Camera Controversy

Smoot was not the first to raise alarms. The inspector general’s office at IDHS has repeatedly cited the facility for failing to adhere to rules regarding reporting and investigating abuse and neglect allegations.

IDHS’ inspector general recommended the installation of cameras in the course of 21 investigations into abuse and neglect allegations at Choate between fiscal years 2015 and 2021, according to a review of internal records by the news organizations. Each time, Choate officials responded to the inspector general that it was “not an option due to budget concerns.”

This summer, advocates and insiders praised Hou’s announcement that IDHS would finally install cameras.

But in response to reporters’ questions, Kollias, the agency spokesperson, clarified that the cameras would go outside the facility.

One former investigator with the inspector general’s office, when told of the plan to put cameras outside, called it “a waste of money and time.” Almost all abuse and neglect allegations stem from incidents that occur inside.

“This is all being done for show,” said former Office of the Inspector General Supervisor and Choate Unit Director Charles Bingaman, who retired from IDHS in 2013. “I predict that it will have no real impact on patient safety.”

Senior IDHS officials acknowledged to reporters in an interview last week that the inspector general had previously recommended interior cameras.

But placing cameras in interior common areas on a residential unit requires the consent of every resident who lives in that unit, or their guardian, per guidelines from the federal Centers for Medicare & Medicaid Services, which partially funds Choate. Placing them outside does not require consent.

Kollias said that officials met virtually this month with organizations led by parents of residents in IDHS’ developmental centers, including Choate, who informed the agency they do not want cameras inside the facilities.

The Office of State Guardian— which handles the personal, financial and legal affairs of people who require a guardian because they are developmentally disabled, elderly or mentally ill — represents 22 patients at Choate. An office spokesperson said the department did not object to cameras inside the facility and continues to have conversations with IDHS regarding their installation. A senior IDHS official, who spoke to reporters on condition that her name not be used, said that the installation of cameras outside Choate is a “pilot program” to try to help with the issue of residents leaving the facility without authorization and improve security on facility grounds.

A Long History of Problems

States across the nation have closed dozens of large facilities like Choate in the past 20 years, following a 1999 U.S. Supreme Court decision that ruled it is unconstitutional to segregate people with disabilities from the rest of society. But Illinois has been a holdout. It houses more people with developmental disabilities in large institutions, and spends more to operate those institutions relative to statewide personal income, than almost every other state in the nation, according to a review of data compiled by researchers with the University of Kansas.

For years, the state has also failed to intervene when serious abuse patterns are found inside its institutions. Since the late 1990s, state and federal overseers have told Choate to do more to protect and serve its residents.

In 1992, the American Civil Liberties Union sued the state of Illinois on behalf of patients, alleging that poor conditions at state-run psychiatric hospitals violated patients’ rights to safety and medical care. Five years later, a report commissioned by the ACLU found that Choate had a culture of staff intimidating and abusing patients. In one case, a patient who had a colostomy as the result of a gang rape was repeatedly punished by staff for urinary and fecal incontinence, according to the report. That same year, the parties settled the case with the state of Illinois, which agreed to enhance staffing and training.

In 2005, after two patients died from neglect at Choate, Equip for Equality, a federally designated legal advocacy organization for people with disabilities, found numerous unsafe conditions and poor treatment of residents. The advocacy group — which had been appointed by the state to monitor conditions at the facility — cited issues such as the way Choate staff used restraints to control residents, tactics that Equip for Equality called “extraordinarily excessive” and said were in violation of state and federal law. In its report, the organization called Choate’s practices “archaic.”

In response to Equip for Equality’s findings, the U.S. Department of Justice’s Civil Rights Division launched an investigation and warned the state in 2009 that the Choate staff’s failures to help residents successfully transfer out of the facility into community living arrangements violated the Americans with Disabilities Act. The facility had further failed to protect them from harm and provide adequate health and psychiatric care, the DOJ found.

Excerpt from a DOJ report about Choate issued in 2009 (Department of Justice document)

Stacey Aschemann, a vice president with Equip for Equality, expressed disappointment that so little has changed since her organization’s and the Department of Justice’s investigations.

Equip for Equality began once again monitoring conditions inside Choate in early 2021. Those monitoring activities included stationing employees inside the facility; interviewing staff, residents and their guardians; and reviewing records.

Based on that monitoring, Aschemann said, the abuse and neglect of residents by staff continues to be a “serious concern.” Equip for Equality will continue to monitor the facility to determine whether the changes Hou announced in mid-June adequately address the safety and quality concerns raised by the organization, Aschemann said.

Smoot said leadership’s slow response to the serious issue he encountered left him deeply troubled. But it was not the first time he had sought to bring problems within IDHS to the attention of senior leadership.

Prior to his role at Choate, Smoot worked as an investigator for the IDHS inspector general, probing allegations of abuse and neglect of disabled adults who lived in their homes.

After leaving the OIG, Smoot worked security at IDHS facilities, ending his career at Choate.

Earlier this year, he self-published a book, “Failure to Protect,” outlining many of his concerns about the inspector general office’s weak oversight authority and how he felt the agency had failed the residents at state-run facilities like Choate.

In December, on the last day of his 20-year career with IDHS, he sent Hou an email to let her know that no one had followed up with him.

This time, there wasn’t a response, according to records of the email exchange obtained by reporters. Smoot said he wasn’t expecting one, but he hoped someone would heed his warning and take his advice. “Without any time left, it was a Hail Mary pass,” Smoot said in an interview.

Alex Mierjeski and Gabriel Sandoval contributed research.

by Beth Hundsdorfer, Capitol News Illinois, and Molly Parker, Lee Enterprises Midwest

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

As Blaine Reichard rose from a breakfast table at the Choate Mental Health and Developmental Center in southern Illinois, a worker ordered him to pull up his sagging pants.

A 24-year-old man with developmental disabilities, Reichard was accustomed to workers at the state-run residential facility telling him what to do. But this time he didn’t obey.

“I’m a gangsta! This is how we do it where I am from!” responded Reichard, who, despite his street-tough defiance, still slept with a teddy bear.

Investigators who later came to the scene of the 2014 incident heard various versions of what happened next. But multiple witnesses told the Illinois State Police that shortly after this exchange, Reichard was taken to the floor, held down by four mental health techs and repeatedly punched in the face, according to a 700-page state police investigation obtained under the Freedom of Information Act.

Reichard cursed and spat, trying to fight back. His resistance was met with more blows, according to witness accounts. Reichard, whose diagnoses include autism, would later tell police it felt like he was hit 100 times.

Multiple employees, including a doctor, told investigators that Reichard’s injuries were the worst they’d ever seen. One tech told police she vomited at the sight of his injured face.

Located about 120 miles southeast of St. Louis, Choate serves people with the most profound disabilities in the state. In 2009, the U.S. Department of Justice’s Civil Rights Division had cited Choate for failing to protect residents from physical and psychological abuse and other harm. The federal agency stopped short of suing the state of Illinois — a step it has taken against other states — and closed its investigation in 2013, saying in a report to Congress that Illinois officials had made adequate improvements.

The Reichard beating happened the next year, just before Christmas. While it is one of the most egregious examples of abuse of a Choate resident in a decade, a monthslong investigation by Capitol News Illinois, Lee Enterprises and ProPublica has found that the incident is one of many instances of mistreatment at the rural facility managed by the Illinois Department of Human Services.

Reporters from this team filed more than 50 public records requests, reviewing thousands of pages of internal documents from IDHS and its inspector general; the Illinois State Police; officials in Union County, where the facility is located; and other entities.

The documents and interviews with current and former employees and advocates, and with residents and their guardians, revealed a systemic pattern of patient abuse, neglect, humiliation and exploitation.

Over a 10-year period running through 2021, the state police opened at least 40 criminal investigations into alleged employee misconduct at Choate, more than at any of IDHS’ other facilities in Southern Illinois.

Using court records and Illinois State Police case files, reporters found that at least 26 Choate employees were arrested on felony charges over roughly the same time period, including four who were connected to the Reichard case. Employees have since been accused of whipping, choking, punching and raping residents.

Among the more recent arrestees are four employees who were accused of choking and beating another Choate patient in 2020, leading to felony battery charges. Two have pleaded guilty to misdemeanor battery charges in exchange for probation sentences and two cases are still pending.

In 2020, an employee was charged with felony battery, for allegedly taking off his belt and using it to repeatedly whip a resident. Then, earlier this year, an employee was charged with criminal sexual assault of an intellectually disabled person who lived at the facility. And in another 2022 case, an employee was charged for allegedly grabbing a nonverbal patient with the mental capacity of a 15-month-old by the neck and punching him in the back of the head as a security officer watched, according to court records. These three cases are still pending.

Over the years, advocates have called for the facility to be closed. “It’s a purely political decision to keep Choate open,” said civil rights attorney Thomas Kennedy, who has provided legal services to Choate patients on and off for decades. “It’s not about helping people. It’s not about habilitating or rehabilitating people. It’s about keeping jobs in the community. Period. They have failed miserably at any other mission.”

Choate Mental Health and Developmental Center in rural Anna, Illinois, was built more than 150 years ago. (Whitney Curtis for ProPublica)

In a statement to reporters, IDHS spokesperson Marisa Kollias acknowledged the seriousness of the concerns at Choate. She said that the problems are the “result of longstanding, entrenched issues dating back decades” and that the agency has “taken aggressive measures over the past several years to unravel them.” That includes increasing staffing and training and appointing Equip for Equality, an independent legal advocacy organization, to monitor conditions inside the facility, just as IDHS did in response to troubling conditions there nearly 20 years ago.

A spokesperson for the Justice Department provided the news organizations with the congressional report announcing its official exit from Choate, which included a commitment to continuing to monitor conditions there. She declined to answer additional questions.

Strapped to His Bed for Hours

As the beating of Reichard continued, one of the employees shouted for restraints. Reichard was dragged to his room and bound to his bed with black nylon straps around his ankles, wrists and chest.

An IDHS record included in the police report showed that for almost two hours, mental health tech Mark Allen sat just an arm’s length away from Reichard. Allen had been accused of harming residents on seven previous occasions since he started his employment at Choate in 2011 — and had been cleared to return to work each time.

Blaine Reichard with his dog, Frankie. (Courtesy of Amanda McIntosh, Reichard’s mother)

Colleagues would later tell Illinois State Police investigators that Allen was volatile and moody. He told them he was an Iraq War veteran diagnosed with post-traumatic stress disorder.

A fellow resident who walked by the room told police that he saw Allen continue to pummel Reichard’s face even after Reichard was strapped down on his bed. The crime scene photos show blood splattered on the floor and walls of his bedroom.

Allen threatened Reichard with death if he reported that employees had beat him up; made fun of him for not having a girlfriend; and punched him again in the jaw, nose and eyes, Reichard told state police in an interview.

While Reichard was still restrained, Allen sent a text message to a colleague. The text, later obtained by police, read, “we just got done strappin Blaine in… I f***** his world up this morning.” “U guys always do lol…,” she responded.

An image of Reichard’s bed that was included in the police report. Closer images show blood splatter on the floor and the wall. (Illinois State Police report obtained by Capitol News Illinois and Lee Enterprises Midwest)

Fifteen months passed before anyone was arrested. In March 2016, Allen was charged with three felony counts of aggravated battery and intimidation. In October 2016, charges were filed against three other Choate employees, Curt Ellis, Justin Butler and Eric Bittle, who were all accused of helping Allen conceal the abuse and lying to the police.

Within a month of being charged, court records showed Ellis cut a deal, agreeing to plead guilty in exchange for a misdemeanor conviction for failing to report the matter to authorities. Bittle and Butler followed suit within three months.

Nearly seven years to the day after Reichard’s assault, Allen pleaded guilty to a felony, but not for beating Reichard. He pleaded guilty to felony obstruction for destroying evidence by throwing away the bloody towel he’d used to mop up Reichard’s blood. He was sentenced to two years of probation.

Until now, the Reichard case has never been covered in the press. It also did not serve as a deterrent to the alleged mistreatment of residents by employees at Choate.

“The Perfect Victim”

People from across Illinois come to live at the 270-bed facility on the outskirts of the small town of Anna, Illinois. It serves people with intellectual and developmental disabilities, mental illnesses or a combination of disorders. Patients can enter voluntarily or be placed there by a guardian, or a judge may order them to Choate for treatment after finding they’re at risk of harming themselves or others. Many end up living at Choate for years.

Nearly 15% of Choate residents with developmental disabilities have diagnoses in the severe or profound range; about 10% are nonverbal.

“In essence, many of these individuals can be ‘the perfect victim’ for a crime because it is easy to cast doubt on someone who has mental challenges or can’t give a statement due to their mental health status,” said Tyler Tripp, the state’s attorney in Union County.

Choate houses the state’s only forensic unit for people with intellectual and developmental disabilities who have been accused of a crime and found either unfit to stand trial or not guilty by reason of insanity. That’s the unit where Reichard, who had been arrested for attacks on his family, police and medical personnel, initially lived; he was moved to the less restrictive “step-down” unit in 2014. Though Choate includes a small psychiatric unit, a review of records shows that most of the alleged mistreatment has involved patients with developmental and intellectual disabilities.

Records from the IDHS inspector general’s office — the internal watchdog charged with investigating wrongdoing at the state’s facilities — show the office investigated more than 1,500 reports to its hotline that alleged patient abuse or neglect by employees at Choate over a 10-year period ending in 2021. That’s more than any of the 12 other facilities operated by IDHS, some of which have more patients than Choate. Those reports include roughly 800 claims of physical abuse, 100 of sexual abuse and 600 of mental abuse, financial exploitation or neglect.

Internal investigators found about 5% of the cases to be substantiated, roughly in line with the statewide substantiation rate. But advocates acknowledge that while residents of the state’s facilities sometimes file false reports, Choate in particular has faced repeated criticisms from the inspector general, prosecutors and state police for interfering in their investigations into alleged wrongdoing.

The number of abuse and neglect allegations from Choate reported annually to the agency’s inspector general has been steadily climbing for a decade. There were more than 200 reports in fiscal year 2021, the latest period for which data was available. That was more than double the number from fiscal year 2012.

In addition to the charges of violence, Choate employees have been the subject of hundreds of other allegations, according to reports from IDHS’ Office of the Inspector General and Union County court files. Among the substantiated allegations are instances when staff tortured and humiliated patients, including one who was marched naked in front of peers as punishment for taking too long in the shower, and another who was forced to drink an entire cup of hot sauce.

The substantiated allegations also include incidents of employees using racial and homophobic slurs, sending sexually inappropriate text messages to a patient, and bribing residents with treats to give the employees foot and shoulder massages, according to OIG reports.

In OIG cases brought between fiscal years 2015 and 2022, employees have also been accused of various forms of neglect, including sleeping on the job and failing on multiple occasions to protect clients with pica, a dangerous disorder that causes people to ingest inedible objects.

In one case, a patient was rushed to a hospital after swallowing a razor blade; while there, under the care of a Choate employee, the patient removed two batteries from a heart monitor and swallowed them. Hospital staff reported that the employee’s feet were propped up, his headphones were on and he was playing on his cellphone.

Kollias, the IDHS spokesperson, said the agency is concerned about the volume of reports of abuse and neglect at Choate, but added that the high number of allegations could also be a sign that staff and residents report potential misconduct at a higher rate than people at its other facilities.

Delayed Consequences

For approximately 48 hours, there was no call to a doctor to treat Reichard’s injuries. There was no call to the OIG hotline to report the abuse, a call that the law dictates must be made within four hours of the discovery of an incident. At least three shifts of workers came and went without raising an alarm, the police report showed.

When security arrived on the unit Monday morning to follow up on an anonymous report, Reichard, his face bruised and swollen, greeted the officer with outstretched arms and said, “Look what they did to me,” according to an employee who was on the unit that day but who is not authorized to speak publicly.

Blaine Reichard’s initial statement, which was given to a Choate security officer, is included in the Illinois State Police investigation file. (Illinois State Police document obtained by Capitol News Illinois and Lee Enterprises Midwest)

In an interview with a reporter, Allen acknowledged that Reichard had been assaulted but maintained he was not the one who did it. He declined to answer further questions. Butler did not respond to calls placed to a phone number provided by a family member, or to messages sent through Facebook. Reporters sent messages to Ellis and Bittle through Facebook and through a union representative seeking comment; the union representative said both men had been made aware of the story and had been provided with contact information for a reporter, though they did not respond.

While the four men were initially charged with felonies, no one was ultimately held criminally responsible for the beating.

The news organizations’ investigation found that this was not the only incident in which consequences were delayed or minimized. The investigation found that employees who abuse residents or engage in other misconduct face few serious consequences. IDHS does not track employee arrests at its mental health and developmental centers.

Court records show that 22 other employees have faced felony charges since the four arrests in the Reichard case. Of those, 11 pleaded guilty in exchange for their charges being reduced to misdemeanors or were sentenced to probation in lieu of charges, seven have cases pending, and four had cases dismissed.

None of those charged have served prison time.

Allen holds the distinction of being the only employee at Choate convicted of a felony related to patient maltreatment in at least a decade.

Yet neither he nor the other three Choate employees convicted in the Reichard case have been fired. Ellis and Butler were almost immediately placed on leave, as was Bittle when the charges were filed. After pleading guilty, the three returned to work at Choate, mowing lawns, cooking or doing laundry. About three years ago, their status returned to administrative leave. They no longer do any work at Choate, but they still receive a state paycheck today. Since the incident, taxpayers have paid the trio more than $1 million combined. Their annual salaries range between $50,000 and $54,000, IDHS records show.

The three are also receiving their scheduled raises, health insurance benefits, vacation time and service credit toward their pensions. Per their plea deals, their court fees amounted to $807 each, $350 of which was a fine.

John “Mike” Dickerson, the unit supervisor on duty the day of the assault, participated in restraining Reichard, according to police records. Though he was not charged in the Reichard beating, Dickerson was reassigned to mow grass at the facility two years later, records show.

Between when the incident occurred in 2014 and when he retired in December 2017, he received $168,000 in salary, plus insurance and credit toward his pension. He receives $39,000 a year in state pension benefits. Dickerson, reached at home, declined to comment.

IDHS senior officials told reporters in an interview that Allen’s coworkers and supervisor were outliers in terms of the amount of time they spent on paid administrative leave. But agency records obtained via the Freedom of Information Act show 26 Choate employees were on paid leave as of the end June, the last month of the state fiscal year. Eleven have been on paid leave for more than a year. Some of these cases involve employees who were charged with crimes or are under criminal investigation.

IDHS’ spokesperson said administrative reviews by its inspector general typically do not proceed until any criminal investigation is concluded.

“Regrettably, some investigations, which can be conducted by the Illinois State Police, the IDHS OIG, or both, and the prosecutorial decision whether to charge an individual have taken years to complete,” IDHS’ statement read.

A supervisor with the OIG’s office wrote in a May 2020 email to Inspector General Peter Neumer that the internal investigation will rule that the abuse charge against Allen is substantiated, as are the charges against the other three for egregious neglect for “not stopping the abuse, colluding and failing to report,” according to emails obtained by the news organizations. His email from more than two years ago asked if it would be possible to proceed with closing out the case because “it has gone on too long already.”

Senior officials within IDHS and its OIG who spoke to reporters declined to elaborate further on the details of the investigation. With Allen’s guilty plea this past December, the investigation is nearing completion, and depending on the results, IDHS will either pursue discipline or return Butler, Bittle and Ellis to work, the agency’s spokesperson said in a statement.

State police said in a statement that abuse cases are challenging to investigate due to a lack of witness cooperation and corroborating evidence.

While Allen was suspended without pay when he was charged in 2016, he remained on the state payroll during the 15-month period between the time of the incident and the time he was charged, collecting nearly $56,000 while on administrative leave, IDHS records show. He received nearly $2,000 in three additional payments between 2016 and 2019. As a part of his plea deal, Allen agreed to pay fines and court fees of $2,874.

Reichard was discharged from Choate after the assault, but he was readmitted three years ago after he attacked his mother. Deemed by a judge to be unfit to stand trial, he lives in the Sycamore Unit, the same building where the assault occurred.

Alex Mierjeski and Gabriel Sandoval contributed research.

by Max Blau, graphics by Shane Loeffler

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By the spring of 2020, the century-old industrial plant on Birmingham’s 35th Avenue was literally falling apart. Chunks of the metal doors fronting several of the 1,800-degree ovens — which heat coal to produce a fuel called coke — had broken off and tumbled to the ground.

With the doors damaged, the toxic chemicals they were supposed to contain within the ovens leaked out at an accelerated rate. The fumes should still have been captured by a giant ventilation hood that had been put in place to suck up emissions. But that system was broken, too, causing plumes of noxious smoke to drift across the city’s historically Black north side, as they had done so many times before.

Months earlier, a regulator with the Jefferson County Department of Health had sent a letter warning the plant’s owners that they could soon be cited for failing to prevent pollution from escaping from the ovens in different ways.

“It seems inevitable,” the letter said.

But in the months that followed, the company that had recently bought the plant told regulators it was unable to make millions of dollars worth of necessary repairs to the oven doors and ventilation hood, records and interviews show. The delays carried a tremendous cost: Nearby residents were once again being exposed to dangerous levels of cancer-causing chemicals.

No Southern city has experienced a longer and more damaging legacy of environmental injustice than Birmingham. As coke production fueled the city’s rise — powering plants that made everything from cast-iron pipes to steel beams — white leaders enacted housing policies that forced Black people to live in the most hazardous communities. Dr. Martin Luther King Jr. once called Birmingham America’s “most thoroughly segregated city,” and the evidence of oppressive pollution was blatant. The air in north Birmingham residents’ lungs and the soil beneath their feet became more contaminated than in nearly any other corner of America.

Generations of business leaders amassed fortunes by cooking coke without regard to the pollution raining down on neighboring communities. With few exceptions, each plant owner left the facility in worse shape than they found it, passing off costly upgrades to the subsequent owner, who then passed them on to the next. This pattern was able to continue, in part, because powerful industry lobbyists fended off the kind of proposals and policies that better protected communities in other states. Nowhere was that more apparent than at one of the country’s worst-polluting plants, on 35th Avenue in Birmingham.

It was here, in an area with one of America’s highest poverty rates, that the ultrawealthy owners of a coal company named Bluestone Coke spotted a financial opportunity. Bluestone belongs to the family of Jim Justice, the coal baron who became West Virginia governor in 2017. The Justices had racked up tens of millions of dollars in unpaid bills with smaller companies it did business with, according to a ProPublica investigation in 2020. (Forbes dubbed Gov. Justice the “deadbeat billionaire” because of these debts.) After a close business associate suddenly had to offload his Birmingham coke plant in 2019, the Justices bought the decrepit facility, which would prove to be a ready-made customer for the coal their company mined in several Appalachian states.

The Justices, like the owners of other remaining coke plants, sought to preserve the plant’s last years of revenues at a time when steel mill owners around the country were replacing coke-fueled furnaces with cleaner electric ones. To do so, they would cut corners on maintenance on creaky ovens, even though that would dramatically heighten the odds of increased pollution.

In July 2020, after the 35th Avenue plant was found to have released excessive levels of toxic emissions on most days that year, Jefferson County inspectors cited Bluestone for a series of violations. The health department was considering a fine of nearly $600,000, a penalty that’s small compared to fines that regulators in other states have issued for similar infractions but large by Jefferson County’s standards. In fact, it would have exceeded the fines issued to all Birmingham-area industrial sources over the previous decade. Instead of finalizing a settlement that would’ve fined Bluestone, though, Jefferson County scrapped it.

Over the course of the next year, Bluestone committed so many more infractions that it could have owed maximum penalties exceeding $60 million, according to legal filings. The violations got so bad that in August 2021, nearly two years after Jefferson County had warned that citations would be “inevitable,” the health department denied Bluestone’s request to renew the site’s permit. The Jefferson County Board of Health sued the company for damages, alleging that its operations were “a menace to the public health.”

Bluestone appealed the decision to deny its permit renewal and was initially able to stay open, releasing toxic chemicals into the surrounding communities well into the fall. But repeated problems with its equipment forced Bluestone to idle its coke ovens last October. Only then did it promise to make the major repairs needed to renew its permit.

ProPublica has learned that the Jefferson County Board of Health and Bluestone recently entered talks to settle the lawsuit. If Bluestone makes overdue repairs to its pollution control equipment and pays a penalty of $850,000 — less than 2% of the maximum possible fine — the company will be able to apply to renew its permit, according to sources who did not want to be named because the settlement is still being negotiated. If the head of the Jefferson County Department of Health approves the permit, Bluestone can resume its production of tens of thousands of pounds of coke each year.

Jordan Damron, a press secretary for Gov. Justice, did not respond to ProPublica’s request for comment. Bluestone attorney Robert Fowler, who declined to answer ProPublica’s questions, wrote in an email that the company is committed to “achieving compliance with all local, state, and federal environmental laws.” Bluestone said it has spent millions of dollars to improve the plant and told regulators that it has the funding to make additional repairs. Wanda Heard, a spokesperson for the health department and the health board, declined to answer most questions for this story. Jason Howanitz, a senior air pollution control engineer for the department, said in a statement that he and his colleagues “work with residents and industry to ensure violations are handled swiftly and effectively to prevent violations from escalating.”

The chronic problems with the plant have spurred Birmingham Mayor Randall Woodfin to draft an unprecedented and as-yet-unfunded plan to buy out and relocate hundreds of neighboring residents. But launching the effort could take years — unless industrial companies like Bluestone, and the agencies tasked with regulating such plants, help to right the historic wrongs that plague the city’s north side.

“Bluestone hasn’t been a responsible operator,” Woodfin told ProPublica. “They’ve been blatant. They’ve been disrespectful. Bluestone doesn’t give a damn about people.”

Throughout the 20th century, Birmingham was a hub for iron and steel production, which used coke to fuel smelters.

With that industry came rampant pollution. Nowhere is that more apparent than the neighborhoods surrounding the coke plant on 35th Avenue.

Aerial imagery from 1947 shows emissions billowing from the 35th Avenue site over the adjacent neighborhood of Collegeville.

The toxic air pollution has persisted — ProPublica’s in-depth nationwide analysis of an EPA model shows that industrial plants in recent years have emitted chemicals that raise the risk of cancer.

Residents told the EPA that for decades this plant and others gave away dirt containing toxic chemicals to residents. In 2011, the EPA designated the area a Superfund site and launched a major effort to remove contaminated soil from affected properties.

The toll of this pollution falls disproportionately on Black residents, who were historically forced into these neighborhoods by redlining, or the denial of loans based on location, and other racist housing practices. Pollution has sickened residents and suppressed their homes’ property values.

Residents like Lamar Mabry live with the dread of what the pollution may be doing to them. Mabry fears that letting his grandchildren play in his backyard could harm their health.

(Map by Shane Loeffler. Sources: OpenStreetMap, Mapbox, Maxar, USGS, EPA, University of Richmond's Mapping Inequality project)

On a recent summer afternoon, Lamar Mabry stepped past colorful toys strewn across the living room floor and went into his backyard. He pointed toward the far end of the nearly 1-acre lot containing several homes belonging to his family, at the five-bedroom brick house where he had grown up, just 600 feet from Bluestone’s front gates. From the front yard there, he could see the plant’s smokestack. As the years passed, pollution from the plant stained the house’s white facade a dark charcoal.

Lamar Mabry stands on his back deck. (Octavio Jones for ProPublica)

Since the late 1970s, Mabry has been complaining about the pollution from the coke plant and other sites clustered around his historic Black community of Collegeville. The 71-year-old contractor built his current house on the family land, and he and his late wife raised their younger children there. He now helps out with his grandchildren, who visit him often.

The neighborhood where Mabry once played in the streets and where his family gardened vegetables is now filled with abandoned homes and vacant lots. When the plant was running, the smell of pungent chemicals often killed his appetite and at times made him feel dizzy. In a legal filing before the Bluestone plant idled, Mabry said that the toxic emissions from the coke ovens left him “depressed” because his grandkids couldn’t “go outdoors during the summer months because of the pollution.”

First image: Mabry’s view of the Bluestone coke plant from his family’s property. Second image: A late 1970s Birmingham News article in which Mabry notes pollution covering his home. (Octavio Jones for ProPublica and The Birmingham News)

He also worries his yard is too contaminated for his grandchildren to safely dig in the dirt. The EPA believes dirt that was given away by local industrial companies in the mid-20th century was spread by residents throughout their neighborhoods — and often contained toxic chemicals. Mabry’s older brother, Charles, who had worked at the 35th Avenue coke plant, brought truckloads of that dirt home to level their yard. Mabry said that in the early 2010s, the EPA sampled his soil but only tested the edges of his yard and didn’t find enough pollutants there to excavate it and replace it with clean soil. (The EPA excavated the yards of both of his neighbors, as well as hundreds of other nearby properties.)

Still, no matter how much pollution fell from the sky or lay beneath his feet, Collegeville had always been home. So for a long time, Mabry clung to the idea that he would die in the only community where he’s ever lived, even after he heard more neighbors’ stories of children with asthma and seniors with chronic obstructive pulmonary disease. As the years passed, though, seven of his 14 siblings were diagnosed with cancer. “I’ve got a lot of death certificates,” he said. Enough, in fact, that he recently and reluctantly began to weigh the idea of moving, in hopes of finding a safer place for his grandchildren, all under the age of 14.

“My five grandkids, that’s my whole pride and joy,” Mabry said. But it’s still not an easy decision. “It will hurt me. All my memories are here.”

Mabry and other residents of Birmingham’s north side are worried that if Bluestone is allowed to resume operations at the plant, the government officials who had promised to protect them before will fail to do so again. It is a pattern they knew all too well, a pattern as old as the city itself.

James Withers Sloss

The decade after the Civil War ended, a Confederate colonel named James Withers Sloss created a business empire in Birmingham on his belief that nearby coal deposits were vast enough to revive the region. Like many of his contemporaries, he built his companies on a system of racist labor practices. He invested in mines that shipped coal to Sloss Furnaces downtown, where freed Black people worked the city’s most dangerous ironworking jobs for the lowest pay. In 1883, Sloss told lawmakers that he relegated Black people to those positions because they had more of “a fondness for” that kind of work than white people did. Historian W. David Lewis later wrote that Sloss and other post-Civil War industrialists had turned Birmingham into “an iron plantation in an urban setting."

When Sloss cashed out by selling his flagship iron furnace for $2 million — more than $60 million in today’s dollars — the investors who bought it relied on forced labor. They paid sheriffs to lease prisoners — many of them descendants of formerly enslaved Black people who were facing trumped-up charges by white people — to mine coal to pay off their fines.

Sloss Furnaces, Birmingham, 1906 (Library of Congress, Prints &amp; Photographs Division, Detroit Publishing Company Collection)

The investors boosted production so much that by the early 20th century the amount of iron forged in Alabama surpassed that of Pennsylvania. To honor Birmingham’s rise, civic boosters paid the Sloss-Sheffield Steel & Iron Company to supply iron for a 56-foot-tall statue of Vulcan, the Roman god of fire and forge, that would stand atop nearby Red Mountain. But in the valley below, Birmingham was heavily obscured by smoke from the growing number of iron and steel mills.

In 1913, city commissioners banned companies from firing up their plants more than three minutes an hour. But after a Sloss-Sheffield executive was arrested for defying the ordinance, local industrialists pressured the commissioners into weakening the restriction and convinced state lawmakers to strip the city of its power to limit industrial pollution. Sloss-Sheffield’s lobbying later helped the company land a military contract so large that it decided to build a new coke plant on 35th Avenue.

Sloss-Sheffield Steel and Iron Company’s By Product Coke Ovens delivery truck, parked by Woodrow Wilson Park in downtown Birmingham in an undated photo (Oscar V. Hunt/The Birmingham Public Library)

Though Alabama would end convict leasing in 1928 — abolishing the practice once exploited by Sloss-Sheffield — Black employees worked in fear of white foremen. “They called you a n----- and you did what they told you to do,” a Sloss-Sheffield worker from the 1920s to the 1940s later said in an oral history interview. “It would make you angry and you’d fret over it but you did it anyway because you didn’t have a choice.”

The year after World War II ended, a 22-year-old dockworker named John Powe came home from overseas and headed to Birmingham to find a job that would support his growing family. Like many rural Black southerners, Powe’s search for opportunity beyond tenant farming — the work his father had done in rural central Alabama — drew him to the industrial mecca, which had grown sevenfold since the turn of the century to more than 260,000 people. After briefly working for another company, he followed his older brother to Sloss-Sheffield.

Working as a laborer at Sloss was “rough,” Powe recounted in his own oral history interview, conducted in 1984. “When I first came out there I stayed on the job for 36 hours.” He added: “I feel lucky to be able to walk around.” Each shift presented potential dangers, from the risk of explosions to toxic chemicals. After a decade on the job, Powe lost a portion of his foot in a workplace accident.

John Powe Describes His Work at Sloss-Sheffield (UAB Libraries, The University of Alabama at Birmingham)

By the 1940s, pollution from Sloss-Sheffield facilities and dozens of other plants across Birmingham was becoming hard for some city officials to ignore. Federal aviation officials blocked funding to expand the city’s airport because of excess smoke and dust, and medical leaders refused to build a tuberculosis hospital in Birmingham. In response, Sloss-Sheffield vowed to lower emissions. But those voluntary efforts failed to protect workers, who were found to have “high disease and death rates,” according to a 1946 report published by health officials in Jefferson County.

Redlining and the city’s racial zoning law prohibited Black people from moving into white neighborhoods. Powe — along with three of his brothers, who each worked for Sloss-Sheffield — moved to one of the few places he could: a short walk from the coke plant, in the tightknit neighborhood of Collegeville. His oldest son, John Henry Powe, remembers his dad coming home from work in the 1950s covered in soot from head to toe and handing his dirty work clothes to his wife, Ruby, who washed out the chemical stains by hand. The particles also landed on neighbors’ cars, leaving a fine layer of soot that covered the hoods like pollen in the spring.

John and Ruby Powe (Courtesy of Theresa Powe Pittman)

Julia Powe, one of Powe’s nieces, remembers other, more direct threats to her family, beyond those posed by the coke plants. She felt her house rattle after terrorists bombed the nearby home of Bethel Baptist Church Pastor Fred Shuttlesworth, who organized civil rights demonstrations at his sanctuary. Theophilus Eugene “Bull” Connor — a notorious public safety commissioner with close ties to the Ku Klux Klan — ordered the arrest of hundreds of Black children, including Powe’s daughter, Queen, during a protest to end segregation.

While Black residents fought to desegregate the city, many white families moved “over the mountain,” to suburbs with safer air. Researchers found that remaining Birmingham residents were exposed to so many pollutants — such as cancer-causing polycyclic aromatic hydrocarbons — that breathing the air was equivalent to smoking two and a half packs of cigarettes a day. From the early 1960s to the early 1970s, the Birmingham area saw emphysema death rates spike by 200 percent, so bad that one federal official declared Birmingham’s air quality to be the worst in the South.

For years, Julia Powe said, her mother wanted to move away from the city’s north side because of its toxic air. But there was nowhere they could afford to go.

“We made do with what we had,” Powe said. “We had to go along to get along.”

By the fall of 1971, Birmingham’s pollution had triggered a full-blown public health crisis. Skyscrapers disappeared behind a hazy blanket of smog. As Marvin Gaye’s environmental anthem “Mercy Mercy Me (The Ecology)” was broadcast over radios nationwide (“Where did all the blue skies go? / Poison is the wind that blows”), editors at the Birmingham Post-Herald printed a front-page “pollution count” tracker that told families like the Powes and the Mabrys how much toxic air they would breathe.

Smog in north Birmingham, 1972 (LeRoy Woodson/EPA/National Archives)

Jefferson County officials, stripped of their powers by the state, could only request that plant owners slash emissions. Alabama Gov. George Wallace — best known for proclaiming “segregation now, segregation tomorrow, segregation forever” in response to public school desegregation — delayed naming anyone to a state commission that was supposed to decide how to meet standards set by the Clean Air Act of 1970. That federal law empowered the newly created EPA to improve air quality nationwide.

After Birmingham companies continued to ignore requests that they voluntarily reduce emissions, Jefferson County officials persuaded the EPA to ask a federal judge to shut down 23 industrial sites. The judge agreed, lifting the hazy blanket from the skyline. In the weeks ahead, Wallace’s appointees finally met, and they soon created new pollution regulations.

Over the next five years, the quality of Birmingham’s air dramatically improved. But a pocket of toxic emissions stubbornly remained along the city's north side, in part because of the coke ovens so close to Mabry’s and Powe’s homes.

Child playing in Birmingham, 1972 (LeRoy Woodson/EPA/National Archives)

The thick black smoke that drifted into communities not only contained particulate matter that made it harder to breathe, but also carcinogenic pollutants invisible to the human eye. By the late 1970s, the EPA concluded that “little doubt is left” regarding the cancer risk of emissions from the 60 coke plants then operating in the U.S. Yet each successive presidential administration, facing pressure from steel execs concerned about rising costs, refrained from using its power to protect communities against those emissions. In the mid-1980s, President Ronald Reagan withheld funding for regulators to curb coke plant emissions. In 1990, President George H. W. Bush signed into law an overhaul of the Clean Air Act that mandated stronger emissions controls but granted coke plants three decades to meet the full requirements of the tougher law. And in the final week of President Bill Clinton’s term in 2001, the EPA loosened controls on pollution from coke plants.

“Coke ovens became a classic example of a very old technology that was never forced to modernize,” said Jane Williams, chair of the Sierra Club’s National Clear Air Team, who advises communities impacted by coke oven emissions.

How Toxic Air Escaped Bluestone’s Plant Because of Delayed Repairs

Coke is supposed to be made by heating coal in a sealed oven for many hours with minimal leaks. But when Bluestone didn’t properly maintain its plant, it led to the excessive release of hazardous air pollution.

First image: The orange streak seen from outside the coke oven indicates that its door frame may be warped due to prolonged exposure to high temperatures. Second image: Damaged doors allow toxic gases to leak out of the coke ovens. Sometimes, the gas combusts into flames, a sign that excessive emissions may be escaping from the ovens. Third image: The exhaust hood typically minimizes toxic emissions. Below it, a rail car, which carries hot coke away from ovens, has two broken panels — letting emissions bypass the hood directly above. Fourth image: Plumes of smoke escape from coke ovens as a result of insufficient maintenance of the plant. (Source: Jefferson County Department of Health Inspection Report, OSHA Inspection Records and Max Blau/ProPublica)

By the early 2000s, the EPA acknowledged in a report to Congress that federal regulations alone wouldn’t stop toxic air pollution in Birmingham and other cities considered America’s worst hot spots. A top EPA official informed Jefferson County regulators that their department had lax coke ovens emission standards that fell short of those in other states. But nothing happened. (Howanitz, a Jefferson County regulator, said in a statement that the EPA’s summary of the county’s standards was an “oversimplification” that “does not accurately reflect the rules of Jefferson County.”)

Birmingham’s northern cluster of aging industrial plants, along with the disinvestment and blight accelerated by the pollution they emitted, had spurred an exodus. From the 1970s to the 1990s, Collegeville’s population shrank from 7,000 to under 4,200 residents. Though Powe and his brothers would spend their golden years in Collegeville, most of their children, including John Henry and Julia, moved elsewhere.

John Henry Powe stands on the street where he grew up in Collegeville. (Octavio Jones for ProPublica)

“The businesses moved out, then the people moved out,” said John Henry Powe, who relocated 10 miles northeast to the suburb of Center Point. “People wanted better.”

Residents like Mabry who chose to stay soon learned of another pollution threat. In 2005, the company that then operated the 35th Avenue plant, Sloss Industries Corporation, discovered the presence of cancer-causing contaminants in soil sampled in adjacent neighborhoods. The discovery came on the heels of a 16-year EPA-mandated investigation to determine the extent to which dozens of contaminants had leached out of disposal pits on the roughly 400-acre coke plant site.

It took another four years for the EPA to ask Sloss Industries’ successor, Walter Coke, to sample soil near additional homes and schools. That testing found concerning levels of toxic contaminants, including arsenic and polycyclic aromatic hydrocarbons, at roughly two dozen of those sites. The EPA quickly informed school officials that contaminants had elevated cancer risk above what the environmental agency deems acceptable.

Walter Coke voluntarily dispatched bulldozers to several schools to remove the toxic dirt and replaced it with clean soil. But company execs hoped to limit their additional cleanup costs. Chuck Stewart, Walter Coke’s president, told the EPA that assigning blame to his plant alone was “profoundly misleading.” He argued that contamination came from “multiple sources” in a part of town where more than 75 plants had operated since the late 19th century. Given the legacy of the industrial corridor, he urged EPA officials in 2011 to get other companies “to the table to discuss any cleanup.”

Around that time, the EPA declared portions of neighborhoods around the 35th Avenue plant a Superfund site, which allowed the agency to spend millions of dollars to clean up the hazardous pollution. In 2013, the EPA named four more companies — including Walter’s top rival, Drummond — as “potentially responsible” for the remediation costs. Soon after, EPA officials sought to add the area to its National Priorities List, a designation that allows the agency to pool more resources that can accelerate such cleanups.

Residents living in the 35th Avenue Superfund site meet each month with Charlie Powell (right), founder of the community advocacy group People Against Neighborhood Industrial Contamination, to discuss their concerns about the area’s toxic air and soil. (Charity Rachelle for ProPublica)

Fearing a $100 million cleanup bill, Drummond’s vice president convinced Democratic state representative Oliver Robinson to fight the NPL designation. After thousands of dollars were secretly funneled to his foundation by a nonprofit run by the Drummond vice president, Robinson hired a friend to get northside residents to sign a petition expressing concern that being placed on the NPL would lower their property values. A lawyer working with Drummond’s vice president used information collected by Robinson to draft talking points, which Republican officials used to publicly oppose the NPL designation.

The tidal wave of backlash they fomented was successful. The EPA dropped the NPL effort in 2015. EPA spokesperson Brandi Jenkins said in a statement that the agency’s “decisions regarding cleanups are not influenced by lobbying interests.”

Robinson later pleaded guilty to federal corruption charges related to his campaign against the NPL effort. The Drummond vice president was convicted for his role. Hank Asbill, a lawyer representing the Drummond vice president, said in an email that his client “did not get a fair trial and was wrongly convicted.” A lawyer for Robinson did not respond to a request for comment. Drummond representatives also did not respond to a request for comment.

That winter, EPA contractors excavated the soil around a red brick house owned by lifelong Collegeville resident Jimmy Smith. The 82-year-old had worked for U.S. Pipe, which had once owned the 35th Avenue coke plant, for more than four decades. The EPA’s excavation followed its discovery of unsafe levels of arsenic and polycyclic aromatic hydrocarbons in Smith’s front yard. After that, he became convinced that the polluted air and soil had caused the cancer that afflicted his family. His mother died from lung cancer, and he lost his oldest daughter to multiple cancers.

Longtime Collegeville residents Chester Wallace (left) and Jimmy Smith (right) stand in front of the former Carver High School. After the EPA excavates contaminated soil from properties in the Superfund site, the agency stores it under a white tarp until it can be hauled away to a disposal site. (Lynsey Weatherspoon for ProPublica)

It was all but impossible for Smith to know the extent to which the cancer-causing chemicals had contributed to his family members’ illnesses, though federal health officials say that long-term exposure to such chemicals increases cancer risk. By the time a backhoe arrived to dig up the toxic soil, Smith thought, it was time to go.

“Once we realized the severity of the pollution, what it was doing to us, what it had been doing to us, we moved out of there,” Smith said.

Six months after EPA contractors excavated Smith’s yard, Walter Coke's parent company filed for bankruptcy. When a company called ERP Compliant Coke acquired the 35th Avenue plant the following winter, 33-year-old environmentalist Michael Hansen felt what he called a “twinkle of hope.” Hansen, whose nonprofit the Greater-Birmingham Alliance to Stop Pollution had urged the health department to address residents’ concerns about pollution, believed the plant’s change in ownership could signal a new era. ERP’s owner, Tom Clarke, had vowed to plant millions of trees on old industrial sites he’d bought elsewhere to offset their carbon footprints. Hansen had also heard a rumor that Clarke might decommission the plant and convert the property into a land trust to restore it.

However, as Hansen drove through Collegeville in the ensuing months, he could smell the scent of burning rubber and mothballs, telltale signs of coke oven emissions. The sight of plumes of smoke became so common that GASP staffers sent complaints to the health department. But Jefferson County regulators said they never found enough evidence of violations to fine ERP. The plant kept polluting under ERP’s ownership until Clarke ran into financial trouble. In 2018, he missed a loan payment for another of his properties. Following that, his bankers called the full note due immediately. Clarke, who once volunteered to help the Justices confront their long list of mining violations, sold the Birmingham plant to Bluestone. (Clarke and his attorney did not respond to multiple requests for comment.)

Jim Justice announces on May 11, 2015, that he is running for governor of West Virginia. (Chris Tilley/AP Photo)

As the Justices folded the Birmingham plant into their business empire’s future plans, they slashed the costs of running the site. In January 2020, Bluestone laid off dozens of employees, leaving the plant with fewer than 100 workers, according to their union president. Yet once COVID-19 swept the nation, the company applied for PPP loans, claiming that it would protect the jobs of more than 150 people. ProPublica’s PPP loan database shows that federal officials approved $4.6 million in loans and eventually forgave the full amount. Fowler, the Bluestone attorney, declined to comment.

The plant’s purchasing manager, meanwhile, said in a deposition that he was told to ask 50 contractors if they would accept reduced payments for services they had already performed. Everyone from coke oven part makers to fire extinguisher distributors sued Bluestone to get their full payments. (As of July, ProPublica had found that judges had ordered Bluestone to pay in nine lawsuits and had dismissed nine others. It’s unclear how many of the dismissals occurred due to settlements. Eight cases were still ongoing.) Bluestone even delayed payments to contract inspectors who compiled emissions data for the Jefferson County Department of Health.

“It takes an incredible amount of maintenance to keep one of these plants running,” said Erik Groth, an environmental specialist who said Bluestone owes him more than $10,000 for emissions monitoring. “When essential services started disappearing, like toilet paper in the bathrooms, I prepared for the worst.”

Hansen, for his part, was alarmed that Bluestone had not paid the taxes needed to get a business license. If the family wouldn’t take care of the most basic of operational obligations, Hansen reasoned, the company was unlikely to invest in fixing the problems that led to the health department violations.

Since Jefferson County was not regularly conducting toxic air monitoring, GASP collected samples of its own. Shortly after Bluestone arrived in Birmingham, Hansen’s group found evidence of two chemicals often released by coke plants, benzene and naphthalene, at levels that elevated cancer risk. In late 2020, GASP partnered with an expert to place air monitoring devices on church windows and at schools less than half a mile from the coke ovens. After three months collecting samples, Wilma Subra, a Louisiana-based environmental health expert who advises the EPA on community concerns, reviewed the results for GASP. She concluded benzene, naphthalene and other toxic chemicals were present at levels high enough to have an “extensive and severe” impact on the health of nearby residents.

Following Jefferson County’s denial of Bluestone’s permit in August 2021, a leader with the economic development nonprofit Birmingham Business Alliance emailed health department regulators on Bluestone’s behalf to find a way to “resolve their problems regarding air quality.” The following month, Jay Justice — Gov. Justice’s son, who is the head of Bluestone — reached out to one of Jefferson County’s top air pollution regulators to schedule an in-person meeting. He wrote that he was looking “to develop a pathway forward that can allow the plant to continue to operate, provide jobs, pay taxes, and be a great environmental steward while doing so,” according to an email obtained by ProPublica. (The health department’s Howanitz said that he and other air pollution regulators never met with BBA employees or Jay Justice because of the pending litigation. Neither the BBA nor Justice responded to multiple requests for comment.)

(Email obtained by ProPublica)

One week later, a Bluestone attorney named Alan Truitt stepped inside a courtroom in downtown Birmingham. Truitt, a seasoned defender of corporate polluters, urged the judge assigned to Bluestone’s appeal to give the company more time to repair the plant. Truitt had warned in an emergency filing that if the plant shuttered — even temporarily — it would be damaged beyond the point of repair. He pleaded for the judge to act in a way that would avoid the “permanent loss” of jobs for hard-working Alabamans.

The judge decided to let Bluestone stay open until the appeal was finished. Less than a month later, however, the company suspended production after most of the plant’s coke ovens had broken down.

When asked by a West Virginia TV reporter at a press conference last November about the violations leading up to the shutdown, Gov. Justice shifted blame to previous owners, noting that the “plant had been bankrupt, for all practical purposes, bankrupt two different times prior to us getting it.”

Gov. Jim Justice Vows “To Do the Right Stuff”

A clip from a November 2021 press conference concerning violations at Bluestone Coke’s 35th Avenue plant

Watch video ➜

Despite Gov. Justice’s vow at the press conference “to do the right stuff,” his family was notorious for amassing huge debts that often went unpaid, according to lawsuits. Plaintiffs including miners and the U.S. Department of Justice have won judgments or forced settlements worth more than $128 million against the family’s companies, according to a 2020 ProPublica investigation. Mounting debts slowed the company’s progress to reopen the Birmingham plant. In the three years since the Justices bought the plant, vendors have sued Bluestone for more than $8 million over unpaid bills for equipment, utilities and services provided.

This past May, at a hearing that concerned nearly $900,000 owed to the city for unpaid business license taxes and fees, Bluestone lawyer James Vercell Seal told the judge that the company is “doing a lot of infrastructure improvements” to get the plant running again. That same day, Seal told another judge that Bluestone was “unable to pay” its $1.8 million water bill because the plant was “not producing” any coke. This double standard frustrated vendors. “I feel like a bill collector,” a water utility attorney told the judge.

When word spread that the Jefferson County Board of Health might settle with Bluestone for less than $1 million, experts familiar with the coke plant’s operations struggled to understand why the penalty was so low. Stan Meiburg, a former EPA Acting Deputy Administrator who now runs Wake Forest University’s Center for Energy, Environment, and Sustainability, said the proposed $850,000 settlement is a “steep discount” from a maximum penalty that exceeds $60 million. (Howanitz said in a statement that the health department “does not comment on specific penalty calculations.”)

If the settlement is finalized, only a few options will remain to protect the people of north Birmingham, according to experts. The head of the Jefferson County Department of Health could deny Bluestone a permit if the company doesn’t fix enough of the problems with its pollution control equipment. If the department fails to do that, Meiburg said, the EPA could intervene by ordering the company to install toxic air monitoring and pay more fines to deter it from repeating its past violations.

Bluestone publicly declared it had spent “tens of millions of dollars” to make the plant “more compliant.” But experts say that figure is far too low: Rebuilding the 35th Avenue plant’s coke ovens, they say, could cost more than $150 million.

“Bluestone should never be given another permit,” said one coke plant expert familiar with the plant’s operations, who did not want to be named out of fear of retribution. “It’s bad for residents. It’s bad for workers. Nobody would win except for Bluestone.”

The temporarily closed Bluestone Coke plant (Octavio Jones for ProPublica)

With each day that passes, the idea of moving away from Collegeville becomes easier for Mabry — but the act itself becomes more difficult. Repeated failures to control emissions from high-polluting plants have contributed to the decimation of his neighborhood’s property values. Homes in Collegeville have sold for as little as $1,000.

Mabry said the four-bedroom house he built with his own hands is worth much less than it should be, effectively trapping him there. That house, along with his childhood home and several other structures on the property, would cost about $350,000 to replace, according to his homeowners insurance policy. But when he recently got an appraisal on his property, it was valued at around $75,000.

Birmingham Mayor Woodfin, who has an ambitious plan to buy out property owners near the plant for a fair price, has seen signs of harm to these communities — Collegeville in particular — throughout his life. He attended elementary school less than a mile from the 35th Avenue plant and as a teenager lived at his aunt’s house, a short walk from Carver High School.

In 2018, during his first year as mayor, Woodfin toured part of the Superfund site near the old Carver High, where EPA officials in recent years have stored mounds of toxic dirt removed from people’s yards. After seeing the neighborhood remain in that condition for that long, Woodfin wanted to do more as mayor. He said his staff has since crafted a $37 million blueprint known as “The Big Ask” to address some of the damage to north Birmingham. The 60-page document, which has not yet been released to the public, calls for more than $19 million to pay for property buyouts within the Superfund site. Another portion would help renters, including those in Collegeville’s public housing complex, relocate. Millions of dollars more would be spent to revitalize the area for those who want to stay.

The map of the portion of north Birmingham where residents would be eligible for buyouts in the leaked “Big Ask” plan. Only owners of the properties shaded light blue would qualify for buyout offers. (City of Birmingham document obtained by ProPublica)

While Woodfin supports Birmingham funding part of The Big Ask, he believes the city should not pay for the buyouts alone. But no other government agencies have come to the table. Heard, the spokesperson for the Jefferson County Board of Health, wouldn’t say if it would devote the fines collected from a Bluestone settlement to help fund the proposal. The EPA said it doesn’t plan to help fund the relocation of residents. The agency pointed out that it has so far spent $45 million on the Superfund cleanup efforts and intends to spend up to $100 million total, covering the full cost of reducing health risks from contaminated soil. President Joe Biden’s bipartisan infrastructure bill is providing $3.5 billion to the EPA for accelerating cleanups at Superfund sites, but agency officials said much of the initial $1 billion installment is meant to clear the backlog of work at previously unfunded sites.

Woodfin said plant owners in north Birmingham should pay their fair share of The Big Ask. Corporations across the country, from Juliette, Georgia, to Murray Acres, New Mexico, have bought out residents after dangerous chemicals leaked out of waste sites. But the odds of Bluestone contributing are slim, considering that the company has told the EPA that it doesn’t even have the money to cover the cost of protecting residents from future harm by cleaning up the legacy waste of the 35th Avenue plant.

But even if Woodfin finds funding for The Big Ask, it only covers buyout offers for a third of the more than 2,100 properties in the Superfund site. When ProPublica pointed out that the plan excludes most property owners in Collegeville, Woodfin acknowledged that everyone in the Superfund site should be eligible. Unless the plan changes, Mabry, whose property is closer to the 35th Avenue plant than almost every other resident, will be left out.

Mabry walks through his hallway lined with family photos. (Octavio Jones for ProPublica)

Alex Mierjeski, Maya Miller, Ken Ward Jr. and Lylla Younes contributed reporting.

by Craig Silverman and Bianca Fortis

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

To his more than 150,000 followers on Instagram, Dr. Martin Jugenburg is Real Dr. 6ix, a well-coiffed Toronto plastic surgeon posting images and video of his work sculpting the decolletage, tucking the tummies and lifting the faces of his primarily female clientele.

Jugenburg’s physician-influencer tendencies led to a six-month suspension of his Ontario medical license in 2021 after he admitted to filming patient interactions and sharing images of procedures without consent. He apologized for the lapse and is currently facing a class-action lawsuit from female patients who say their privacy was violated.

But on Spotify, Apple Music and Deezer, and in roughly a dozen sponsored posts scattered across the web, Jugenburg’s career and controversial history was eclipsed by a new identity. On those platforms, he was DJ Dr. 6ix, a house music producer who’s celebrated for his “inherent instinctual ability for music composition” and who “assures his followers that his music is absolutely unique.”

It’s an unconvincing persona — perhaps even less so once his “music” is played. But it was enough to secure what he wanted: a verification badge for his Instagram account.

The coveted blue tick can be difficult to obtain and is supposed to assure that anyone who bears one is who they claim to be. A ProPublica investigation determined that Jugenburg’s dubious alter ego was created as part of what appears to be the largest Instagram account verification scheme ever uncovered. With a generous greasing of cash, the operation transformed hundreds of clients into musical artists in an attempt to trick Meta, the owner of Instagram and Facebook, into verifying their accounts and hopefully paving the way to lucrative endorsements and a coveted social status.

Since at least 2021, at least hundreds of people — including jewelers, crypto entrepreneurs, OnlyFans models and reality show TV stars — were clients of a scheme to get improperly verified as musicians on Instagram, according to the investigation’s findings and information from Meta.

Verified Spotify profiles for MTV “Siesta Key” stars Mike Vazquez and Lexie Salameh were removed after ProPublica reached out. (Screenshots by ProPublica)

In response to information provided by ProPublica and the findings of its own investigation, Meta has so far removed fraudulently applied verification badges from more than 300 Instagram profiles, and continues to review accounts. That includes the accounts of Mike Vazquez and Lexie Salameh, two stars of the MTV reality show “Siesta Key.” Rather than get verified for their TV work, they were falsely branded online as musicians in order to receive verification. They lost their badges approximately two weeks ago and did not respond to requests for comment.

Jugenburg did not respond to a phone message left at his Toronto practice or to emails detailing evidence that he had paid for his Instagram verification. He has told media outlets he intends to vigorously defend himself against the class-action suit.

The scheme, which likely generated millions in revenue for its operators, illustrates how easily major social, search and music platforms can be exploited to create fake personas with real-world consequences, such as monetizing a verified account. It also underscores how Instagram’s growth and cachet combines with poor customer support and lax oversight to create a thriving black market in verification services and account takedowns for hire.

Influencers, socialites, models, businesspeople and all manner of clout chasers rely on Instagram to flaunt their lifestyle, generate income and establish a personal brand. Some influencers and models told ProPublica they face a barrage of impostor accounts trying to run scams to trick their fans. They also run the constant risk of malicious actors fabricating evidence and filing user reports to convince Instagram to ban their accounts. They see a badge as one of few options available that can help them protect their accounts and business. Others covet the blue tick as a status symbol. The result is a steady supply of well-heeled customers willing to pay five figures to get verified. (Meta is reportedly working on enhancing its customer support.)

The verification scheme identified by ProPublica exploited music platforms like Spotify and Apple Music, as well as Google search, to create fake musician profiles. The songs uploaded to client profiles were often nothing more than basic looping beats or, in at least one case, extended periods of dead air. They credited composers with nonsense names such as “rhusgls stadlhvs” and “kukyush fhehjer.” The Meta employees tasked with reviewing the musician verification applications apparently failed to listen to the tracks or look too closely.

The people running the scheme also purchased articles promoting fake artists and their music on websites, including hip-hop publications like The Source and ThisIs50.com, a music and culture site affiliated with rapper 50 Cent. They often bought fake comments and likes for clients’ Instagram posts to make the accounts look popular and purchased fake streams for songs on Spotify, according to two sources with direct knowledge of the operation. One source said some clients were told to rent a recording studio and post photos on Instagram that made it look like they were working on music. (The Source and ThisIs50.com did not respond to emailed requests for comment.)

“You can make a Spotify account or Apple Music account and boost the streams and get fake music press very cheap. It’s quick and easy,” said the source, who asked not to be named due to fear of retaliation.

A Spotify spokesperson said the company identified artificial streams, which are often generated using bots, on many of the 173 profiles provided by ProPublica. The company has removed more than 100 of the artists from its platform.

“Fraud is an industry-wide issue that we take very seriously,” Spotify spokesperson Zachary Kozlak said. “Spotify invests heavily in automated processes and manual reviews to prevent, detect, and mitigate the impact of artificial activity on the platform. We’ve removed the content in question we found to be manipulated.”

Apple Music did not respond to multiple requests for comment, but it has removed music from the profiles of many of the dubious artists identified by ProPublica.

Using domain registration records, corporate and banking documents, information from online platforms, and interviews with clients and people with knowledge of the scheme, ProPublica was able to identify the person at the center of the plot. He is a Miami-based aspiring DJ and would-be crypto entrepreneur named Dillon Shamoun. With little or no interference from Meta, Shamoun built a verification-for-pay juggernaut while also burnishing his own image by using the same digital manipulation techniques he offered to clients.

Shamoun appears to have hawked his Instagram verification services to a cadre of Miami nightlife impresarios, restaurateurs, jewelers, models and others. He also transformed his model-influencer girlfriend and his older brother, a mortgage broker, into musical artists in attempts to secure account verification.

In phone interviews with and text messages to ProPublica, Shamoun, an athletic, bearded 26-year-old, denied any involvement in the scheme and said he does not sell account verification services. He said he works on FanVerse, a crypto startup that enables creators and influencers to sell NFTs of themselves, among other projects.

“People know who I am and my character and what I do for business, and it has nothing to do with Facebook or Instagram,” he said.

After being provided information by ProPublica, Meta confirmed Shamoun’s key involvement in the fake musician verification scheme. It banned him from its platforms and removed his Instagram and Facebook accounts. The company said that Shamoun’s scheme was a sophisticated operation and that Meta works to thwart the sale of fraudulent services to users of its platforms.

“Scammers selling fraudulent services continue to target online platforms across the internet, including ours, and constantly adapt their tactics in response to industry detection methods,” said a Meta spokesperson, who asked not to be identified due to security concerns related to this story’s subject matter. “We urge people to keep vigilant and never pay for verification status because it violates our Terms. Whenever we identify a scheme like this, we take action - and that means not only will someone who’s paid for verification lose their money, they’ll lose their verification status, as well.”

When asked if any Meta employees or contractors were involved in the scheme, the spokesperson said they can’t comment on internal personnel matters or investigations.

A falling out between Shamoun and a business partner, combined with scrutiny from Meta and ProPublica’s investigation, has unleashed a vicious round of finger-pointing that exposed the underworld of social media manipulation and verification services.

In response to questions from ProPublica, Shamoun said the scheme is all the work of Adam Quinn, a prominent Instagram creator who previously worked with mega-influencer and boxer Jake Paul, and who has collaborated with musicians and celebrities for online promotions. Quinn’s Instagram account had more than 2 million followers when it was removed by Meta in June. The company sent him a cease-and-desist letter that month accusing him of selling account verification services, running celebrity giveaways that inauthentically boosted followers for Instagram accounts and offering to reactivate disabled Instagram accounts for a fee.

The Meta spokesperson said the company had collected evidence of Quinn’s involvement in selling verification services before its recent move against Shamoun for the fake musician scheme.

In comments to ProPublica and in a legal letter sent to Meta, Quinn acknowledged he sold account verification in partnership with Shamoun. He denied being personally involved in account reactivation, and he said his giveaways were in line with Meta’s rules and did not result in fake followers. An archived version of his company’s website lists a menu of “Instagram Growth Packages” ranging up to $7,500 and promising to deliver 100,000 followers using the giveaway model.

Quinn said he had used his connections and Instagram account to refer clients to Shamoun and had received a portion of the resulting fees. Clients typically paid $25,000 to verify an account, though Shamoun has at times charged more than $100,000, according to Quinn. He provided ProPublica with a bank document showing wire transfer information for Shamoun’s company, as well as two agreements from this year that said Quinn and Shamoun were partners in a “Social Media Verification” business. One agreement, signed in June, stipulated that Shamoun’s company was responsible for the client work to “ensure successful Verifications.” A source close to Shamoun, who asked not to be named to avoid jeopardizing their current job, verified the authenticity of the agreements but claimed Quinn was the one submitting fake musician verification requests. The language of the agreements appears to dispute this claim, as do Meta’s findings.

ProPublica also obtained a copy of a business proposal from Shamoun’s company, Rumor LLC, that pitched a range of online marketing services, including social media verification.

In his lawyer’s letter to Meta, Quinn denied submitting fake musician accounts to the company for verification. He said Shamoun created and controlled the process and handled the submissions. He also accused Shamoun of supplying information to Meta in an effort to get Quinn’s and Quinn’s girlfriend’s Instagram accounts removed in June.

“I believe that I am a victim of circumstance here, being unjustly attacked by someone not only violating Meta’s terms and conditions, but abusing the system put in place to prevent people like him from doing what they do,” Quinn’s letter said.

The implosion of the scheme has left Quinn and Shamoun banned from Instagram and other Meta platforms and has put an end to their lucrative business partnership. It has also left more than 300 recently de-verified clients angry that they paid tens of thousands of dollars for nothing.

For his part, Shamoun insisted that any information linking him to the scheme was fabricated by Quinn in order to frame him.

“As stated, I’m a very influential individual in Miami, that’s why I’m being framed by someone who’s now a ghost online,” he wrote.

Shamoun said he had over 70 pages of evidence showing Quinn is responsible for the entire scheme, as well as other types of platform and account manipulation. When asked to share that evidence with ProPublica, he said he could not because he is bound by unspecified nondisclosure agreements. Shamoun also said he is working with Netflix on producing a film or series based on the documents.

“I’m going to make something even bigger than ‘The Tinder Swindler,’” he said, citing a recent hit Netflix documentary about a scammer who dated women and made off with their money.

Netflix did not respond to a request for comment.

Battle for the Badge

The criteria determining who is eligible for verification are not always clear-cut, but Instagram says accounts must be authentic, unique, complete and notable.

Besides offering clout, a blue check mark provides social proof that the account holder is who they say they are. Verified account holders may also get access to new features before they’re available to the general public.

Meta’s policies forbid users from selling account verification as a service and from misrepresenting their identity in order to receive a badge. But people have been selling Instagram verifications for years. A 2017 Mashable article reported that people were paying thousands for a blue tick.

As demand for verification rose over the years, Meta developed verification criteria for various categories of people or brands, including music, fashion and entertainment. This scheme shows how those criteria can be used as a road map by people like Shamoun.

Shamoun “had the most volume out of anybody,” said a source who has bought verification for clients and frequents the dark web chats and Telegram channels where people offering the service congregate. The source, who asked not to be named in order to protect their Instagram accounts, said Quinn’s high profile also helped bring a steady flow of clients to the operation.

Among those clients were multiple performers on OnlyFans, a popular platform among adult entertainers who can charge users for access to members-only photos, video and communications. One model, who said she declined an offer from Shamoun to get verified, told ProPublica that OnlyFans performers in particular see value in verification. She said they are often targeted by extortion schemes whereby hackers file false reports and get a model’s Instagram accounts removed, and then offer to reactivate the account for a fee. The OnlyFans model spoke on condition that her name not be used, as she feared reprisals for speaking out.

“A lot of people will impersonate you if you’re an OnlyFans girl and put a link up and pretend to be you” in order to scam fans, she said, adding that she feels Instagram is more strict about content posted by OnlyFans performers, and that losing an account could result in a drop in revenue.

Making a Fake Musician

DJ Dr. 6ix’s Spotify profile was removed after ProPublica reached out to the company. (Screenshot by ProPublica)

Jugenburg’s online profile as DJ Dr. 6ix is typical of the work done by the operation: a raft of paid press articles extolling the DJ’s musical genius, false claims about his popularity and background, profiles on major music platforms like Spotify, Apple Music and Deezer, and songs that often consist of a simple looped beat.

“Umbrella”

On Spotify and other music platforms, Jugenburg had five songs with titles such as “Umbrella,” “Mysteries” and “Next Party.” One of the songs showed it had been streamed close to 60,000 times, but included 90 seconds of dead air and credits an apparently made-up writer: “gbfred gtfrde.” The source with direct knowledge of the operation said fake Spotify streams were bought for songs to make clients look convincing if a Meta employee ever checked. Spotify removed DJ Dr. 6ix’s profile after being contacted by ProPublica.

DJ Dr. 6ix’s Spotify bio claimed he was featured in publications such as “EDM.com, The Source, & Billboard.” Jugenburg does not appear on EDM.com or in Billboard, but he was featured in an apparently paid article on The Source. It falsely describes him as a Los Angeles-based artist and says his song “Umbrella” has “firmly established himself as one of the most well-known musicians of his generation.”

Articles about Dr. Martin Jugenburg’s alter ego, DJ Dr. 6ix, were placed on music websites to help get his account verified. (Screenshots by ProPublica)

That same line appears in at least nine other apparently paid articles about other likely Shamoun clients. On those and other occasions documented by ProPublica, his operation apparently reused the same article text and simply swapped in different artist and song names.

The lack of effort put into the paid articles wasn’t an accident. The operation also reused songs for clients. It was an assembly line for Instagram verification. The source with knowledge of the process said the goal was to secure a badge for a client in 30 to 45 days.

.bb-aside p { margin-top: 5px; } .bb-aside h2 { margin-bottom: var(--spacing0); } Anatomy of a False Verification Scheme Step 1

A client creates content showing them in designer clothing, at luxury locations or in a recording studio to make them look like a musician.

Step 2

Spotify and Apple Music profiles are created for the client, basic songs are uploaded with album art, and fake streams are purchased to make their songs appear popular.

Step 3

Paid articles about the client’s songs are published to add further legitimacy.

Step 4

The client posts their lifestyle and music content, spacing it out over time. Engagement in the form of likes, comments and followers are purchased for the posts, providing evidence of popularity.

Step 5

Google’s search engine indexes the client’s music and articles, then automatically generates a “knowledge panel” that brands the person as a musical artist when someone searches for their name.

Step 6

In final preparation for verification, a client edits their Instagram bio, feed and highlights to emphasize their musical career.

Step 7

The client’s Instagram account is submitted to Meta for verification. If everything goes as planned, they’ll receive a blue check and the account protection and status it affords.

Here’s how it worked: The first step is to have a client produce photos in lifestyle poses and situations that made them appear to be an artist or someone with a high cultural status. Client profiles reviewed by ProPublica often showed people posing in front of expensive cars, in designer clothes or near private planes. In some cases they appeared behind or near a DJ booth or in a recording studio.

As clients produced their content, Shamoun and his small team commissioned articles and music for them. Many paid articles featuring fake artists are credited to Lost Boy Entertainment, a PR firm. Cofounder Christian Anderson confirmed that the articles placed for the fake musicians, and for Shamoun, were paid placements, or what he called “advertised press.” He said he wasn’t sure who paid for them because they were likely purchased via his company's account on Fiverr, an online marketplace.

“After this has been brought to our attention we are working on taking many of these articles down already. We weren’t aware of the end goal,” he said in an email.

As for the songs, the source with knowledge of the operation said basic beats can also be purchased on Fiverr. With music in hand, the music and artist profile information was uploaded to Spotify, Apple Music and other platforms.

Clients were then told to start posting their content on Instagram. The operation also purchased fake likes and comments on Instagram posts that featured music content. The source said they were unaware of any instances where Instagram flagged likes or comments as potentially inauthentic.

“If you’re an Instagram employee with a heavy workload, are you really gonna check the comments on every submission?” they said.

The source said they also worked to ensure a client’s Google search results would present them as a musician. Google itself proved helpful in this regard. Once articles and music profiles were indexed by Google’s search engine, the site generated a “knowledge panel” in search results for the person’s name. The box appears next to search main results and identifies the person as a musical artist, offering links to their online profiles and music. In the eyes of Google, the client was now a real musician.

A Google spokesperson said that close to 80% of the 173 people identified by ProPublica as likely Shamoun clients were labeled musicians in these auto-generated knowledge panels. The company said because these individuals had profiles on Spotify and Apple and were the subjects of articles, they met the criteria to be labeled as musical artists. It’s not Google’s responsibility to determine whether the artists are legitimate, according to company spokesperson Lara Levin. As of now, these people remain marked as musical artists when you search for their names on Google.

Google automatically generated musician “knowledge panels” for Vazquez and Salameh. (Screenshots by ProPublica)

The source said Shamoun claimed his actual costs for each verification submission amounted to roughly $1,500. He typically charged clients $25,000 for each verified account, making the operation hugely profitable, they said. Meta kept approving fake musicians, and the clients kept coming.

“Jungle”

One client is Alfredo Troia, who sells custom jewelry out of a Pembroke Pines, Florida, shopping mall and goes by the moniker Goody the Jeweler. His verified Spotify profile had a total of seven songs and 180 monthly listeners prior to being removed by the company. While all of his music is electronic, his profile image shows him sitting next to an upright piano, reading what appears to be sheet music. Writing credits for his music list names such as “wehkuudhs wehdgjg,” “trudbkds prosbhkdfs” and “caddfhjksf probfbksd.” His song “Jungle” also sounds the same as DJ Dr. 6ix’s “Umbrella.” He did not respond to requests for comment. He lost his Instagram badge, and his music was also removed from Apple Music and Deezer.

“Despair”

Akop Torosian, a bakery and gym owner, had four songs on his Spotify page under the name No Limit Boss. One track, “Despair,” which sounds like an audio sample played on loop for more than four minutes, was described as an “opus” in a likely paid March article published by Muzique Magazine. (Muzique did not respond to emailed requests for comment.)

In June, Torosian was arrested at Los Angeles International Airport on a complaint of attempted murder after he allegedly threatened one of his employees with a weapon. He pleaded not guilty in that case. The arrest came days after Torosian was accused of making racist comments about a Mexican juice vendor. In 2015, he was sentenced to three years of probation for a weapons charge related to a triple shooting. His Spotify profile was recently removed, and his Instagram badge was recently revoked by Meta. He did not respond to requests for comment.

Several OnlyFans models were also verified as musicians. Desiree Schlotz, Hannah Palmer and Lauren Blake boast a total of 4.7 million followers on Instagram, and each had songs, music profiles and paid articles presenting them as musicians. All three lost their Instagram badges, and Spotify removed their songs. They did not respond to requests for comment.

Nicky Gathrite and Tara Electra (whose name in corporate records is Tara Niknejad) are the co-founders of Unruly, an LA-based agency representing models and OnlyFans performers. They were also falsely verified as musicians. Both recently lost their badges.

In a phone call, Gathrite denied any knowledge of the paid verification scheme. When asked if he’s really a musician, he said, “If you Google me you can see that I am.” Google searches on his name brought up an automatically generated knowledge panel describing him as a musical artist. Electra did not respond to a request for comment.

Gathrite's company, Unruly, has also had connections with FanVerse, the Shamoun startup that sells NFTs of models and influencers. Shamoun's company, which was then called FansOnly, was listed as a sponsor of Unruly's Halloween party last fall. (Gathrite, through an attorney, denies a personal relationship with FanVerse.) Mike Vazquez, the “Siesta Key” star who lost his badge after being falsely verified as a musician, is a partner in FanVerse.

Gathrite did not respond to follow-up questions sent by email, and Vazquez also declined to comment. Shamoun did not respond to questions about his connections to Vazquez, Gathrite and Unruly.

“From a Sales Guy to a Music Sensation”

Shamoun seemed a natural fit to oversee the manufacturing of dubious musical artists.

He grew up in the Detroit area and has performed as a DJ under the name “Not Dillon.” As early as 2020, he began placing paid articles to promote himself and his ambitions in the music industry. Like those discussing his clients, the articles made exaggerated or false claims about Shamoun’s accomplishments.

“From a sales guy to a music sensation, Dillon is breaking records with his music and has established himself as an emerging name in the industry today,” reads a January 2020 article placed on an Indian news website.

Dillon Shamoun’s verified Spotify profile was removed after ProPublica contacted the company. (Screenshot by ProPublica)

Another apparently paid article from the same month on a different Indian website claimed Shamoun had “over 10 million streams on the music which he has created.” His two songs as Not Dillon on Spotify have less than 200,000 streams, and an old SoundCloud account in his name has six songs with less than 1,000 total plays. ProPublica could not find evidence of significant audience interaction on other platforms.

Over the next two years, his questionable claims of fame and success grew.

Back in 2020, online articles said he had played at a handful of music festivals. Shamoun’s website claimed he was involved in “branding and playing 12 of the world’s most reputable music festivals.” When he spoke to a ProPublica reporter this month, he claimed to have sold a major music festival to Live Nation. He declined to name the festival or provide additional information to back that up. It appears any supposed windfall from that sale may have been minor: Records show that a Dillon Shamoun with an address that matches public records for the aspiring DJ received a Payroll Protection Program loan of $18,540 in April 2021. Loan data lists Shamoun as working in “Marketing Consulting Services.”

Shamoun’s personal site also claimed he has two certified gold records, and that he planned to release music with top artists Tyga and Tory Lanez in 2021. There’s no evidence of any of that. Shamoun did not reply to questions about the PPP loan or his claims about gold records and working with major artists. His website was taken offline after ProPublica reached out. Management for Tyga and Tory Lanez could not be reached for comment.

Shamoun’s musical career exists in a haze of dubious claims, but there’s overwhelming evidence connecting him to the Instagram verification scheme, which he denies all involvement with. Multiple former clients confirmed that he sold verification services, and Shamoun is also listed in Whois records as the owner of close to 200 web domains featuring the names of people who have dubious musician profiles created by the scheme. There’s djdrsixmusic.com for the plastic surgeon, as well as melodymoralesmusic.com, the website of Shamoun’s girlfriend. She recently lost her verification badge as part of Meta’s move against fake musical artists, and her account, @mell, is no longer active. Morales’ three songs were removed by Apple and her account was taken down by Spotify after ProPublica reached out. Her website was also taken down after a reporter contacted Shamoun. In a text message, she declined to comment.

Shamuon also owns the domain name djtylerrumor.com. His older brother Tyler Shamoun, a Detroit mortgage broker, was branded in paid articles and on Spotify and other platforms as DJ Rumor in a failed attempt to receive verification. Tyler Shamoun did not respond to emails or messages containing a detailed list of questions.

In text messages and phone calls, Shamoun kept citing one piece of evidence against his former partner: the fact that lawyers working for Meta sent Quinn a cease-and-desist letter in June. Shamoun said the lack of action by Meta against him showed he was not involved. “If it were true, I’d be in the same predicament Meta put the actual person in,” he said, referring to Quinn.

On Aug. 16, four days after Meta was contacted by ProPublica, the company sent Shamoun a cease-and-desist letter and banned him from its platforms for selling account verification services.

“As a result of our investigation, we’ve sent a cease-and-desist letter and removed related fraudulent verifications on our platform,” said the Meta spokesperson.

Days later, Shamoun messaged a prospective client with an offer: He could get their Instagram account verified for the low price of $15,000.

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Clarification, Sept. 3, 2022: This story was updated to clarify the nature of the connection between Nicky Gathrite’s company, Unruly, an agency representing models and OnlyFans performers, and a startup by Dillon Shamoun, FanVerse, which sells NFTs of models and influencers.

by Topher Sanders

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One year ago this week, the remnants of Hurricane Ida swept through the Northeast, causing flash floods and laying bare one of the dangers of stormwater drainage systems. In New Jersey alone, at least five people were sucked into open pipes and culverts. Four of them died.

After ProPublica’s story about the long-neglected problem of dangerous storm drains and their toll of at least three dozen deaths since 2015, federal and local officials were moved to action.

This April, the Department of Housing and Urban Development added an “important consideration” to its guidance for HUD housing developments: Those doing environmental assessments should consider whether nearby stormwater infrastructure includes “measures like grates or fencing to prevent drownings during floods.”

HUD officials said they made the change after reading the ProPublica article and speaking with featured officials from Denver’s Mile High Flood District. The Denver district has for years preached the importance of installing grates on some inlets to prevent people from getting sucked in when the area floods and stormwater rushes toward an open drainage pipe, which is often out of sight below the waterline. The Mile High district has developed criteria that cities and towns can use to determine which openings might be dangerous enough to warrant a covering.

Holly Piza, research and development director with the Mile High Flood District, said the HUD move could save lives. “It’s fantastic that the [grate] research has gotten this intense attention on a national level,” she said. “This research can save lives if we have the attention of those that can help increase awareness and make a difference.”

Her organization, along with Colorado’s Larimer County Dive Rescue Team, Colorado State University’s Hydraulics Lab and the engineering company AECOM, are now researching detailed metrics that municipal engineers could use to decide exactly how to position a grate and which type of grate would best fit a given drain. Once the research is complete, HUD officials said they will consider whether to incorporate it into their trainings on environmental assessments or floodplain management.

Piza also said that officials from several municipalities reached out to the Denver district in the past year to ask about how to secure their drains.

The number of storm drain deaths continued to rise in 2022. In June, a 10-year-old boy, his father and another man were killed in Milwaukee when they were pulled into a large drainage culvert after heavy rains. The boy fell into the ditch while chasing a soccer ball. His father and the other man jumped in to save him.

And in Germantown, Tennessee, a youth football coach died in early August when he went into a storm drain to help save one of his players. The boy and his father, who also jumped into the drain, survived.

Dhanush Reddy was pulled into a drainage pipe in South Plainfield, New Jersey, during the remnants of Hurricane Ida. He died. (George Etheredge, special to ProPublica)

One community featured in ProPublica’s story has apparently not taken any action. ProPublica revisited South Plainfield, New Jersey, where two men were pulled through an underground pipe during Ida, and saw no apparent safety improvements. Middlesex County officials, who are responsible for the maintenance of the pipes, refused to answer questions; they also declined last year.

Communities that push back against grates often say the cost of putting them in and maintaining them is prohibitive. They also frequently cite the grates’ potential to exacerbate flooding if they get clogged with debris.

But two other New Jersey communities featured in the story have taken steps to prevent future tragedies.

In Maplewood during Ida, a father of two was pulled into a drainage system as he tried to clear debris from the inlet. He and his neighbors had complained for years about the pipe’s danger. Maplewood had to receive permission from New Jersey’s environmental department, which regulates tributaries and waterways, before it could grate the opening. The state was initially against the measure, but changed course after the death. The pipe is now covered with a grate.

And in Passaic, a large culvert has twice generated national news by pulling people in during flooding. In July 2020, DoorDash driver Nathalia Bruno was swept through the culvert after she fled her car during a flash flood, but she survived. Bruno recounted her harrowing story in news accounts, and city officials talked about installing grates and warning signs. But local engineers pushed back, saying grates would get clogged and lead to more flooding.

Then, during Ida a year later, best friends Nidhi Rana, 18, and Ayush Rana (no relation), 21, abandoned their flooded-out car and were sucked into the same drain that had pulled Bruno in. They died.

Like Maplewood, Passaic had to get approval from the state’s environmental department before it could move forward with any remedies. The city proposed grates similar to those suggested by the Denver flood district, along with fencing; both measures were rejected due to concerns about clogging and flooding, said Mayor Hector Lora.

According to Lora, the state now appears to be open to a grate system that would completely cover the culvert and could actually be walked on.

Lora said finding a remedy is a must.

“I don’t know how I stand in front of the community and tell them after having three individuals go through there that we still can’t do anything about it,” he said.

by Alison Burdo and Michelle Brunetti Post, The Press of Atlantic City

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

A Superior Court judge in New Jersey has struck down a state law granting Atlantic City’s casinos tens of millions of dollars in tax breaks, saying that the measure was passed on dubious grounds and violated the state Constitution.

The ruling, handed down Monday, deals a blow to Gov. Phil Murphy and the state’s legislative leaders, who fast-tracked the legislation through the Legislature last year. It is also a rebuke to the gaming industry, which had argued the bill was needed because it was struggling amid the COVID-19 pandemic.

At issue in the court case were changes to a local taxing program known as PILOT, or payment in lieu of property taxes. Since 2016, instead of paying property taxes, each casino has paid a share of an industrywide assessment that was distributed to Atlantic City, its school district and the county to fund various operations. The number was calculated based on the prior year’s total gaming revenue. But last year, the industry pressed for and won a key legislative change to that formula, excluding online gaming — a fast-growing sector of its business — from the program. The alteration reduced the gaming companies’ total PILOT liability this year by $55 million — revenue cuts that disproportionately impacted Atlantic City, one of the state’s most distressed cities.

A conservative nonprofit group called Liberty and Prosperity 1776 challenged the constitutionality of the law, saying the state’s founding document bars preferential tax treatment. The state countered that the new law was exempt from that prohibition because it served a “permissible public purpose.” On Monday, Atlantic County Assignment Judge Michael Blee sided with the nonprofit, potentially increasing casinos’ tax bills and sending tens of millions of additional dollars into local coffers.

“This Court finds that the Amendment was enacted to aid the casino industry and not for a public purpose,” Blee said in his decision.

At the time the bill was passed, state lawmakers and industry leaders argued that despite soaring online gaming revenues, the change was necessary to prevent financial peril. “We are risking four casinos closing,” said then-state Senate President Steve Sweeney, without providing specifics.

But, as The Press of Atlantic City and ProPublica reported in June, the casino industry was already rebounding from a pandemic slump as it argued for tax relief. Even as the industry claimed fiscal trouble, it had its best year in more than a decade: Casinos in Atlantic City reported roughly $767 million in gross operating profit in 2021. Financial reports show that revenue from in-person gambling has surpassed pre-pandemic levels. Through the first six months of 2022, the most recent data available, the city’s nine casinos reported $339 million in gross operating profits, or 17% more than the same period last year.

“There is no evidence to suggest that casinos could not meet their PILOT obligations under the Original Act,” Blee wrote. The legislation, he concluded, was advanced “to aid what was actually a resurging industry.” That echoed the findings of The Press of Atlantic City and ProPublica investigation, which calculated what each casino’s tax liability would have been had the PILOT law remained unchanged.

Gaming analysts and former regulators then examined that analysis and told us that Atlantic City’s nine casinos could have weathered their increases and remained open.

The Casino Association of New Jersey declined to comment on the ruling, citing its policy of not discussing pending litigation. The organization previously told The Press of Atlantic City and ProPublica that last year’s changes to the PILOT law were necessary. “Failing to adjust the PILOT would have resulted in egregious, inappropriate, and inequitable taxes for any industry, let alone an industry that is still fighting to recover from COVID-19,” the group said in a statement.

Seth Grossman of Liberty and Prosperity said Tuesday he was happy with the judge’s decision to vacate the amendments to the PILOT program and leave the original law in place. “The bottom line is when you have tough economic times, every business is affected,” he said. “So to say you’re going to give one industry a break by making everybody else pay more, that’s not helping the economy. It’s just helping one ‘ailing’ industry.”

He also said he expects some “intense litigation” to be waged over the judge’s ruling.

Indeed, Alyana Alfaro Post, a spokesperson for Murphy, told The Press of Atlantic City and ProPublica on Tuesday that the state “plans to appeal Judge Blee’s decision and is optimistic that it will be overturned.”

The ruling is the second to come down against the PILOT law in recent months. A judge had previously sided with Atlantic County in a separate lawsuit alleging that the state had violated the terms of a 2018 consent agreement that guaranteed the county a certain percentage of the industry’s overall PILOT payment. The county had asserted that the change in the PILOT formula would cost it about $5 million a year.

This month, Blee awarded millions in damages to Atlantic County and required the state to cover attorney fees and other costs. The state is appealing that decision, and on Monday it won a stay from the court on the damages while the case works its way through the appeals process.

Taken together, the decisions in the two cases leave the imminent tax obligations of the casino industry unclear. State regulators, who bill and collect PILOT payments, did not immediately return a request asking for clarification.

Atlantic County Executive Dennis Levinson, who urged Murphy to veto the PILOT bill last year, said that this week’s court decision is another signal that state lawmakers should have left the PILOT program alone.

“Had the governor responded to our concerns about the PILOT amendment prior to and after its passage during a lame duck session, four days before Christmas, this could have all been avoided, saving the taxpayers of New Jersey hundreds of thousands of dollars,” Levinson said in a statement Tuesday.