ProPublica

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.

Inside the Enterprise Center, the St. Louis Blues hockey team was losing a home game to the Edmonton Oilers. Outside, a man named Alvin Cooper was lying on a venting grate on a 38-degree night.

A St. Louis police sergeant asked him to move, according to an officer’s December 2018 report. Cooper refused. The sergeant and the officer pointed to signs that said “No Trespassing” and “No Panhandling.” Cooper said, “I ain’t going nowhere.” The officers tried to handcuff Cooper, one of them using “nerve pressure points on his jaw and behind his ear,” the other delivering “several knee thrusts” to Cooper’s right leg.

The officers arrested Cooper and booked him on charges of trespassing and resisting arrest. Two weeks later, a city prosecutor dropped the resisting arrest charge, while Cooper pleaded guilty to trespassing and signed an agreement offered to him by the prosecutor saying that as a condition of his probation, he would stay out of downtown St. Louis for a year.

The neighborhood order of protection, as the agreement is called, meant that Cooper could be arrested if he so much as set foot inside a 1.2-square-mile area — more than 100 city blocks — that is home to many of the organizations that provide shelter, meals and care to St. Louis’ homeless people.

The agreement Alvin Cooper signed meant that he could be arrested if he entered a 1.2-square-mile part of St. Louis. However, that area is home to many of the organizations that provide shelter, meals and care to the city’s homeless. (Municipal Division of the Circuit Court of St. Louis)

Other American cities order people to stay away from specific individuals or places, and some have set up defined areas that are off-limits to people convicted of drug or prostitution charges. But few have taken the practice to St. Louis’ extreme, particularly as a response to petty incidents, according to experts in law enforcement.

Seattle and some of its suburbs, including Everett, have blocked off certain areas of their cities as “exclusion zones” where people who have been convicted of drug or prostitution offenses can be arrested. The practice has long been criticized by civil rights advocates, but city leaders say it has helped reduce crime.

Cincinnati once barred people convicted of drug offenses from its own “exclusion zones.” But a court struck down the practice as a violation of the constitutional freedoms of association and movement, and the U.S. Supreme Court in 2003 let that ruling stand. The Chicago suburb of Elgin adopted rules in 2016 that ban people who have repeatedly caused nuisances from some sections of the city, but it has been enforced sparingly.

In St. Louis, neighborhood orders of protection affect large swaths of the city and are typically in effect for a year or two, although some orders have had expiration dates in 2099, according to records obtained by ProPublica. A person who violates an order may face a fine of up to $500 or be sentenced to as long as 90 days in jail.

Victor St. John, an assistant professor of criminology at Saint Louis University, said even limited bans may have a dire impact “in terms of individuals not being able to engage with family members or friends.”

“It’s a restriction on resources that are publicly available to everyone else,” he said, adding, “I haven’t heard of entire neighborhoods.”

Yet just how rare the practice is across the country is difficult to assess, in large part because it has not been closely tracked. University of Washington professors Katherine Beckett and Steve Herbert, who have studied Seattle’s efforts, said in their 2009 book, “Banished: The New Social Control in Urban America,” that banishment is “rarely debated publicly” and that cities’ tactics are “largely deployed without much fanfare.”

“I think part of the problem is that these legal tools are very much under the radar,” Beckett said.

This 2019 St. Louis police report indicates that an officer stopped a “reoccurring nuisance” who had been barred from the city’s downtown through 2099. (St. Louis Metropolitan Police Department incident report)

When neighborhood orders of protection are employed in St. Louis, critics say that they are too often used against people with mental health issues or who may be homeless, and that banishing an individual from a large section of the city may violate their civil rights. They say the orders fail to address the underlying problems contributing to their behavior.

Instead, they simply move problems from one part of the city to another.

The ACLU of Missouri said that it had explored a lawsuit to challenge the practice a decade ago but eventually did not because the organization did not have enough information and did not have consistent contact with a potential plaintiff.

“City courts violate the constitutional rights of Missourians when they issue broad, arbitrary banishment orders untied to any legitimate governmental purpose,” the group said in a statement. “The fact that such orders are used against people who have committed harmless, petty crimes only makes plain that the orders are about inconveniencing the vulnerable, and not about public safety.”

Some people have been barred from multiple neighborhoods. Some have been arrested for violating their bans multiple times within a few days.

“It reeks of redlining,” said Mary Fox, the longtime lead public defender in St. Louis who now heads the state’s public defender system. “It reeks of everything that happened before the Civil Rights Act went through — just allowing them to keep certain people out of their neighborhoods.”

Neighborhood orders of protection are another way policing in St. Louis is employed on behalf of the wealthy and against those most vulnerable. A ProPublica investigation showed how residents of affluent city neighborhoods hire private policing companies to patrol public spaces and protect their homes and busineses, creating dramatic disparities in how local law enforcement is provided.

Private policing and neighborhood orders of protection often go hand in hand, with private police officers doing much of the work to enforce the orders, according to emails obtained by ProPublica.

The city’s Municipal Court paused issuing neighborhood orders of protection at the start of the pandemic — not because of any policy change but because the process requires the defendant to appear in court and city courts are closed to in-person proceedings.

But police have issued citations for violations of the orders as recently as July 2021, records show. Some defendants also face active court cases for alleged violations. Moreover, a city ordinance authorizing the orders remains in effect, and St. Louis police are under orders to collect evidence that can help prosecutors pursue orders of protection.

St. Louis Municipal Administrative Judge Newton McCoy said in an email that defendants may be subject to neighborhood orders of protection “on a case by case basis” as a condition of probation “if they repeatedly commit offenses in certain neighborhoods.” He said court officials are “working to determine next steps for when all in-person municipal court hearings will resume.”

The banishments require the consent of the defendant, but some lawyers question whether defendants really have any choice but to sign. In one instance, a man was arrested for trespassing while gathering on a city sidewalk with friends across the street from a downtown homeless shelter. He agreed to stay out of downtown but was subsequently arrested for a violation and served three months in jail, a case highlighted by the St. Louis Post-Dispatch.

“I don’t think the actual terms of the neighborhood order of protection were clear to my client,” said Maureen Hanlon, an attorney for the public-interest law group ArchCity Defenders. “It states that he consented to it, but he was unrepresented at the time.” She entered the case after his incarceration for violating the order, “which, on paper, he agreed to, but in reality, I really question whether or not someone can agree to an order like that without counsel.”

ProPublica was not able to determine how many neighborhood orders of protection have been issued over the past two decades. Court cases are typically sealed after the successful completion of probation. It was also unclear if any remained in effect.

Megan Green, who on Nov. 8 was elected president of the city’s Board of Aldermen and is the city’s second-highest ranking official, said she has long heard from advocates for the homeless who say the orders make it difficult for the city’s most vulnerable people to receive meals or other services.

Green said she wants to study the use of neighborhood orders of protection to “understand the implications. And if we need to take a look at a revision, I think, potentially do that.”

“If you are banning somebody from downtown from the area where services are, that makes it that much harder to address the needs,” Green added. She said she also found it problematic that “if you’re just banning somebody from a certain area, and never addressing the behavior, chances are that behavior just moves to another block or another neighborhood.

“So I’m not sure how effective something like this is at achieving what folks are going for, either.”

Neighborhood leaders and police officials have defended neighborhood orders of protection as a tool for residents and businesses to make their streets safer by sending a message to criminals that they are not welcome.

St. Louis police Sgt. Charles Wall said the department merely enforces the orders once they’re issued.

Jim Whyte, who manages a private policing initiative in the city’s upscale Central West End, said neighborhood orders of protection are “used all over the city to kind of address these very problematic people.”

Whyte said that the orders were sometimes difficult to enforce. “If the person was involved in panhandling or a crime incident, I’d call the prosecutor and say, ‘Hey, this guy was down here Thursday violating the order.’” Whyte said that the prosecutor would ask if there was an arrest and he would say “like, ‘No, there weren’t any police around.’”

In those cases, Whyte said, prosecutors would not support charging the person with a violation.

Cooper could not be reached for comment. His mother, Karen Johnson, said her son, now 39, has suffered from schizophrenia since graduating from high school. His use of prescription medication, she said, led to reliance on street drugs and a life that spiraled into homelessness. During his ban from downtown, he moved out of the city and stayed with a family member in suburban Cool Valley. The court’s action to ban her son from downtown was “wrong,” his mother said. “That’s where he was getting a lot of help — the downtown area.”

This fall, she said, he was shot and wounded in an assault while he was living in a hotel.

The impetus for neighborhood orders of protection is murky. The St. Louis Board of Aldermen in 2003 unanimously passed the ordinance laying out penalties for violating orders, but it’s not clear if they existed before. Three of the bill’s four living sponsors — Jay Ozier, Dionne Flowers and James Shrewsbury — said they do not remember what prompted the measure. The fourth, Craig Schmid, could not be reached. None remain on the board.

“Particularly if you’re talking about it in terms of panhandling or something like that, I don’t see how I could have been in favor of it,” said Ozier, who served from 2002 to 2003.

The language in the ordinance suggests it was aimed at drug offenders. “Whereas, the illegal distribution, possession, sale and manufacture of controlled substances continues to plague our neighborhoods,” it reads. But in practice, the police in St. Louis have used the orders of protection more broadly.

To obtain an order, a representative for a neighborhood must document that a person who has been arrested has repeatedly caused trouble there. A prosecutor can use this statement as part of the neighborhood’s request for the order of protection. The prosecutor can then offer the agreement to the defendant, typically in exchange for dropping one or more charges against them.

The text of the order — with specific boundaries of the banishment area — is then added to a St. Louis-area criminal justice database, which can be accessed only by police and court officials. When police officers run the name of a person who has been issued an order of protection, the database will alert the officers.

For several years, neighborhood leaders viewed the orders as a tool for taking back their streets — sending criminals a message that they are not welcome. In 2014, for instance, about 50 residents of the city’s Tower Grove South neighborhood successfully petitioned a Circuit Court judge to order a carjacking suspect to stay away as a condition of release. “The show of solidarity from the residents of Tower Grove South played an important part in the positive outcome of today's hearing,” the neighborhood’s website boasted. “Congratulations TGS!”

As late as 2015, the website for the city’s top prosecutor, Jennifer Joyce, featured a page where residents could view the names and photos of people who had been banished under neighborhood orders of protection.

The circuit courts, which handle misdemeanors and felonies, have not issued a neighborhood order of protection at least since progressive prosecutor Kimberly M. Gardner succeeded Joyce in 2017. But the practice has persisted in Municipal Court, where defendants face infractions, typically do not have lawyers and cases receive little public scrutiny.

St. Louis police are under orders to help prosecutors seek and obtain neighborhood orders of protection. (Special order from the Office of the Chief of Police, City of St. Louis Metropolitan Police Department)

Some cases can linger for years, as police repeatedly seek and enforce neighborhood orders of protection against the same people with little evidence that the orders are effective. In a report in 2017, a St. Louis police officer wrote that he was working for the department’s downtown bike unit and trying to combat a “rise in quality of life violations” downtown. He said a motorist complained about homeless people outside the city’s Dome, where the NFL’s Rams used to play.

One of the men the motorist pointed to was Gary Accardi, who the officer said was a “well-known panhandler,” according to his report. Accardi was holding a cardboard sign that said: “Homeless, Please help. God Bless.”

Four years earlier, in 2013, police had cited Accardi five times for violating a neighborhood order of protection, and he had spent 10 days in jail. As the officer approached, he wrote in his report, Accardi ran away yelling, “I don’t want to go to jail!” The officer wrote that he caught up with Accardi and put him on the ground to get him under control.

Accardi was charged with panhandling, resisting arrest and impeding traffic. Weeks later, Accardi agreed in municipal court to stay out of downtown St. Louis for one year.

Gary Accardi agreed to this neighborhood order of protection in 2017. (Municipal Division of the Circuit Court of St. Louis)

Over the next few years, the order against Accardi was repeatedly extended and he was cited for violating it 17 times from July 27 to Oct. 17, 2018; on two occasions during that stretch he was cited twice in the same day.

In April 2019, while St. Louis Cardinals fans packed Busch Stadium downtown for opening day, police officers spotted Accardi outside the stadium and issued him a summons for violating the order.

Accardi was issued a summons for violating a neighborhood order of protection on April 5, 2019. (St. Louis Metropolitan Police Department incident report)

The next day, Accardi was rifling through a trash can outside the stadium and another officer cited him yet again for the violation.

Accardi was again cited on April 6, 2019, the day after a previous citation. (St. Louis Metropolitan Police Department incident report)

Stephanie Lummus, a lawyer who has represented Accardi in some of his cases, said a judge in 2020 declared him incapacitated and placed him under a guardianship. The guardian, she said, ordered her not to speak on his behalf.

Lummus said she frequently appears in municipal court on behalf of clients with cases on the court’s mental health docket — a special court day designed to match vulnerable people with services that can help them.

“I would sit there and wait for my client,” she said. “And I’d watch these people on the mental health docket sign these neighborhood orders of protection unrepresented, not knowing what the hell was going on. And I was just like, This is not the place for that, you know. These people are on the mental health docket for a reason. Why are you doing this?”

In some St. Louis neighborhoods, private police companies have enforced neighborhood orders of protection. Minutes from a 2018 meeting of a downtown community improvement district indicate that a private policing contractor had pursued neighborhood orders of protection for 25 “persistent offenders.”

Officers working off-duty for The City’s Finest, St. Louis’ biggest private policing company, have enforced neighborhood orders of protection in the Central West End, emails show.

“Neighborhood orders of protection are legal and issued by the courts,” the firm’s owner, Charles “Rob” Betts, said in an email. “If you have an issue with it you should probably discuss such with the court system that issues them. Or better yet, talk to the residents and businesses that are severely affected by aggressive panhandling.”

Whyte’s office, which serves as a substation for The City’s Finest in the Central West End, had a bulletin board where the names of people with neighborhood orders of protection are posted. That way the private officers know whom to look for, emails obtained by ProPublica through a public record request show.

Whyte recalled the case of a woman with chronic drug problems who he said was a persistent panhandler in the Central West End and who had been accused of petty theft. Neighborhood leaders sought to banish her after she created repeated problems.

“We were seeking an order of protection against her because she didn’t live in the neighborhood, didn’t work in the neighborhood,” he said. “She had tallied up a number of incidents and police contacts.”

He said the neighborhood never sought the orders “as an immediate action, it was always used as kind of, ‘Well, we have no other choice.’”

In the fall of 2018, the clock had run out on neighborhood orders of protection against some people who had been banished from the Central West End. Whyte wrote to Richard Sykora, a lawyer for the city who was in charge of pursuing the orders in municipal court.

“Many of our NOP’s have expired and unfortunately many of our problem people have returned to the CWE area,” Whyte wrote, adding, “We would appreciate you looking into obtaining NOP’s on the following subjects.”

Whyte described one person as having “been observed buying narcotics” and another as having stolen a tip jar from a coffee shop. One was “mentally unstable” and “very disruptive at local businesses.” Another had repeatedly violated a previous neighborhood order of protection and, Whyte wrote, “continues to be a persistent panhandler.”

Yet another, Whyte wrote, had been working with an organization that offers behavioral health services but he “has resumed aggressively panhandling.”

An email from Jim Whyte, who manages a private policing initiative, to Richard Sykora, a lawyer for the city, asks about obtaining neighborhood orders of protection. (Emails obtained by ProPublica)

Sykora wrote to Whyte a few days later saying he would seek new neighborhood orders of protection against most of the people Whyte had listed. In one case, Sykora told Whyte, the judge had made only half the neighborhood off-limits so the person could get to his job without breaking the law. Whyte told Sykora that he had checked with the employer and the defendant didn’t really work there. “Could we get the order modified?” he asked.

Sykora did not respond to a request for comment.

Whyte’s requests led to some of those people being banished again. They could be arrested on sight for setting foot in the 1.9-square-mile neighborhood. And some of them were.

Whyte said the neighborhood has sought orders for people that were “running amok in the Central West End neighborhood. They wouldn’t heed any other warnings by the police, they wouldn’t conform, their behavior was antisocial.”

“The reality is they don’t go to other neighborhoods” after being ordered to stay out of the Central West End, he said. “They don’t care about the order of protection.”

Whyte said that since in-person court hearings have stopped, the neighborhood had hired a homeless outreach coordinator to try to address vagrancy in the neighborhood.

One person the neighborhood has banished was Lorse Weatherspoon, a homeless man with a history of petty crimes. He was arrested in the Central West End in 2018 on suspicion of trespassing and burglary after a private policing company posted a $250 reward for his arrest. It isn’t clear what happened with those charges, but the city charged him with five violations of his ban from entering the neighborhood.

“Lorse Weatherspoon was responsible for a crime a night,” said Jim Dwyer, chairman of one of the Central West End business districts that hires private police.

Whyte said residents would send him surveillance video of prowlers, “And I’m like, ‘Oh, that’s Lorse Weatherspoon trying to see if he can get a bike out of your garage or steal your lawn mower.’”

Neil Barron, Weatherspoon’s lawyer, said the order was a “blatantly unconstitutional violation of a person’s right to freely travel.”

“Think about all the money used on this,” he added. “Does it solve the problem? Does it make the community safer? Does it help Lorse Weatherspoon rehabilitate himself? No, it doesn’t.”

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by Mick Dumke

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.

Update, Nov. 30, 2022: This story has been updated to include a statement from a Joe Mansueto spokesperson, who reached out after the story was published.

For months, Chicago Mayor Lori Lightfoot has pushed a controversial plan to turn over public housing land to a professional soccer team owned by an influential billionaire.

In mid-November, that billionaire owner of the Chicago Fire Football Club, Joe Mansueto, donated $25,000 to the mayor’s reelection campaign.

And now, a member of the City Council is asking the city government’s top watchdog and ethics officials to investigate whether the contribution violates prohibitions on pay-to-play politics.

“I believe this represents a gross & familiar abuse of power and, at a minimum, a potential violation of the City of Chicago’s Governmental Ethics Ordinance,” Alderman Raymond Lopez wrote in a letter to Deborah Witzburg, the city’s inspector general, and Steve Berlin, executive director of the city’s Board of Ethics. Lopez cited sections of the ordinance that prohibit gifts and political contributions meant to influence official decisions.

Mansueto, though an ally, had never given to Lightfoot’s political fund before his Nov. 17 contribution, according to election disclosure records. (Mansueto’s family foundation has donated to a number of cultural and nonprofit entities, including ProPublica.)

On Wednesday, Lightfoot’s campaign spokesperson praised Mansueto and fended off the criticism.

“Mr. Mansueto has been a socially responsible leader in Chicago’s business community, investing in our neighborhoods and supporting a range of philanthropic initiatives. We are proud to have his support for our grassroots campaign,” spokesperson Christina Freundlich wrote in a statement.

She added: “Government decision-making is firewalled from political campaign activities, and our team executes a rigorous vetting process on every contribution to ensure we have complied with all campaign finance rules and laws.”

A spokesperson for Mansueto did not address the campaign contribution but stressed that the business leader is committed to the city. “Joe believes in investing in historically disinvested parts of Chicago, a vision he shares with Mayor Lightfoot as a way to lift up the city as a whole,” the spokesperson wrote in a statement

Mansueto made the donation the same week Lightfoot released the first ads in her bid for reelection against 10 challengers in February. And it came as officials work to finalize a deal that would let Mansueto’s team take over 23 acres of valuable land that have long been set aside to house low-income families.

At Lightfoot’s behest, the Chicago Housing Authority agreed to lease the site to the Fire so the team can build a new training facility. But the Lightfoot administration and the CHA have kept many of the key details secret. The CHA did not conduct a formal bidding process, and it has refused to release a copy of the proposed agreement or show how it determined the value of the land.

Lopez is one of Lightfoot’s leading council critics, but in September he sided with her and voted in favor of a zoning change the Fire needed to build the new practice facility. He said in an interview that he still supports the Fire’s project but wrote the letter with “disdain” for the mayor’s decision to accept the campaign donation.

“I look forward to the independent investigation by the IG,” he said.

On Wednesday, as Lopez sent his letter, CHA residents and housing advocates protested the land deal outside the headquarters of Morningstar, the investment research firm that Mansueto founded and serves as executive director.

by Stephen Engelberg

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

On Oct. 28, ProPublica and Vanity Fair published a story about an interim report on the origins of COVID-19 released by the Republican oversight staff of a Senate committee. The interim report was the product of a far-reaching investigation into the question of how the pandemic began, and we wanted to give readers an inside view of the team’s work and share independent experts’ views of its findings.

The debate over COVID-19’s origins has been contentious from the start, and the report’s conclusion that the pandemic was “more likely than not, the result of a research-related incident” triggered criticism. Scientists, China observers and others questioned the Senate team’s findings and our reporting about them.

Over the past several weeks, reporters and editors at both publications have taken a hard look at those criticisms.

Our examination affirms that the story, and the totality of reporting it marshals, is sound.

We re-interviewed some of our original sources and reached out to other specialists to address questions that were raised about the work we did to put in context the evidence cited by the interim report. In particular, we took a close look at how Toy Reid, a State Department political officer on loan to the committee, translated a Chinese Communist Party branch dispatch that was cited in both the interim report and in our story as evidence that staff at the Wuhan Institute of Virology (WIV) may have been responding to a biosafety hazard or breach.

We commissioned three Chinese language experts with impeccable credentials who were not involved in the original story to review Reid’s translation. They all agreed that his version was a plausible way to represent the passage, though two also said they would have translated the words to refer to the dangers of day-to-day lab operations. The third produced a translation that was in line with Reid’s. All agreed the passage was ambiguous. We have updated the story to underscore the complexity of interpreting that dispatch.

We have added additional context to the story. We have also identified two factual errors inconsequential to the premise of the story. They have been corrected.

It remains clear that in 2019, the WIV was addressing serious safety issues while scientists there faced pressure to perform. Risky coronavirus research took place in laboratories that lacked the maximum biocontainment safeguards, according to the interim report.

A series of WIV patents and procurement notices “suggest that the WIV experienced persistent biosafety problems relevant to the containment of an aerosolized respiratory virus like SARS-CoV-2,” the interim report says. On Nov. 19, 2019, the same day a senior government safety official arrived at the WIV to discuss what a meeting summary described as a “complex and grave situation currently facing [bio]security work,” the WIV sought to procure a costly air incinerator. One expert told us such equipment could be used as a “quick fix” if the HEPA air filtration system had failed in some way. A few weeks after that procurement notice, the WIV filed a patent application for an improved device to contain hazardous gases inside a biological chamber, like ones used to transport infected animals.

The interim report described the WIV’s struggles to find disinfectants that were effective enough to kill dangerous pathogens without corroding metal. In November 2020, with the pandemic well under way, the WIV filed a patent application for a new disinfectant. The patent said existing disinfectants corrode metals in ways that could allow pathogens to escape, “resulting in loss of life and property and serious social problems.”

The director of the WIV’s highest-level biosecurity lab acknowledged in September 2019 that some Chinese facilities researching dangerous viruses had “insufficient operational funds for routine yet vital processes.” Dr. Gerald Parker, a biosecurity health expert and adviser to the interim report, said he found such revelations “a recipe for disaster.” He added: “You further couple that with an authoritarian regime where you could be penalized for reporting safety issues. You are in a doom loop of pressure to produce, and if something goes wrong you may not be incentivized to report.”

We continue to see our story as a measured exploration of the array of questions raised about the WIV’s laboratories. The possibility that a biosecurity breach at the WIV occurred, and sparked the pandemic, remains plausible.

We plan to keep reporting on this issue and expect new evidence to emerge. It is our view that both the natural-spillover and laboratory-accident hypotheses for the origin of the COVID-19 pandemic merit continued investigation. Given the human toll, which continues to mount, it is imperative that we continue this work.

For those who want to know more details about our exploration of issues raised, our reporting methodologies and conclusions, we are providing more information below on:

• Translations and interpretations.
• The corrections and added context.
• Our thoughts on exploring the lab leak theory.

More on the Translations and Interpretations

After the Vanity Fair-ProPublica story appeared online, questions began to emerge on social media about Reid’s translation of a key passage of a Chinese Communist Party branch dispatch dated Nov. 12, 2019, on the WIV website. According to Reid’s translation, it begins by pointing out that the lab works with dangerous pathogens and that once the test tubes are opened, “it is just as if having opened Pandora’s Box.” While the lab had “various preventive and protective measures,” it was nonetheless important to “avoid operational errors that give rise to dangers.”

The next phrase was the focus of the criticism. It appeared in bold letters in the interim report:

“Every time this has happened, the members of the Zhengdian Lab [BSL4] Party Branch have always run to the frontline, and they have taken real action to mobilize and motivate other research personnel.”

Our story shared Reid’s thought process. We wrote:

“Reid studied the words intently. Was this a reference to past accidents? An admission of an ongoing crisis? A general recognition of hazardous practices? Or all of the above?”

Reid recognized that there was an ambiguity in the phrase he translated as “Every time this has happened.” Did the word “this” refer to the daily dangers of doing experiments in a lab that handles deadly pathogens? Or did it point to the “operational errors that give rise to dangers”?

Before we published our story, Reid told us he found the passage to have a defensive tone. In the story, we quote Reid as concluding, “They are almost saying they know Beijing is about to come down and scream at them.”

Seven days later, on Nov. 19, a senior Chinese official arrived from Beijing to the WIV for a small, high-level safety training. A meeting summary said that the official had come bearing important oral remarks and written instructions from China’s senior leaders, including General Secretary Xi Jinping, related to “the complex and grave situation currently facing [bio]security work.”

To Reid, the mention of instructions from party leaders and reference to a “complex and grave situation” reinforced that the Nov. 12 dispatch was an attempt by the party branch to deflect criticism for something that had gone awry, as he explained.

We interviewed three experts on Chinese Communist Party communications before publication and shared with them the dispatches as they appeared in Chinese on the WIV website. We conducted the interviews on background to get their candid input. They expressed concerns regarding personal safety, given the sensitivity of the subject matter. All agreed with Reid’s interpretation that the safety training on Nov. 19, 2019, as described in the meeting summary, appeared to be urgent, nonroutine and related to some sort of biosafety emergency.

To assess the criticisms of Reid’s work that were raised after the story was published, we commissioned three Chinese translators, each with more than a decade of experience. One has translated for officials at the highest levels of the American and Chinese governments. We wanted their objective view of what the passage said, so we asked them to translate it and did not mention the interim report. After they had done that, we went back and asked them to review Reid’s translation from the report.

All three of their translations were different from one another’s and different from Reid’s. Yet, each agreed that Reid’s translation was one plausible way to translate the passage into English. Our translators looked at the Chinese characters that Reid had translated to read “Every time this has happened” and instead said they read them to mean “on such occasions” or “at every such an occasion.”

Before one of the translators was told what Reid had written, she said she thought the word “occasions” referred to when lab workers make mistakes that lead to hazards — an interpretation that mirrored Reid’s. The two others said they thought “occasions” referred to something more routine: opening test tubes for experiments. The language in Chinese, all three agreed, was ambiguous and could be read either way.

Some readers noted that the Nov. 12, 2019, passage actually appeared in August 2019 in a party publication. The existence of the earlier reference, they argued, proved that its repetition in November meant that it could not refer to a biosecurity emergency at that time.

We took a close look at the August 2019 post and asked our translators and the experts we consulted to do so as well. While the posts were very similar, the version uploaded on the WIV website in November 2019 was slightly different. It included additional language after the sentence that compared opening test tubes of viruses in the lab to opening Pandora’s box. The translator we commissioned who had the most experience rendered the additional language as follows: “These viruses are untraceable both coming and going, and although there are various protective measures, it is still necessary for lab workers to operate very carefully in order to avoid creating dangers through mishandling.” The translator was puzzled by the August post because without the language added in November, “it sounds as if they are leading the charge to open Pandora’s box,” she said. “If I were reading it, I’d be scratching my head.” That additional sentence, she said, “means that they go to the front lines to show everybody to be careful and not to cause errors that would be dangerous.”

One of the experts we consulted before and after publication, a former senior U.S. intelligence official, said the language added in November 2019 gave the post a defensive posture and was consistent with Reid’s analysis that party members were responding to some type of incident. The Chinese idiom that Reid translated as “come without a shadow and leave without a trace,” he said, “is a nice phrase to describe something that sneaked up on you and there was no way to defend against it. They’re basically saying to whoever this is being delivered to: ‘We didn’t see it coming. We did the best that we could to deal with the problem.’”

More on the Corrections and Added Context

There are two sentences in the story that have been corrected.

We reported that a Chinese military vaccinologist who had in the past collaborated with the WIV, Zhou Yusen, was the first to apply for a patent for a vaccine against COVID-19. The interim report stated that Zhou “was the first to patent a COVID-19 vaccine on February 24, 2020.” In fact, other researchers around the world sought patents before Zhou’s Feb. 24, 2020, filing.

However, it was the timing and nature of Zhou’s patent application and subsequent research papers that raised questions for interim report researchers.

In our review of early SARS-CoV-2 vaccine patent filings, the U.S. patent applications we found that predated Zhou’s were provisional applications, a number of which forecast experiments they planned to do in the future. Many of these applications were for vaccine candidates proposing to use a technology like mRNA. Such applications could be filed with the SARS-CoV-2 genetic sequence in hand and minimal experiment data.

By contrast, Zhou filed a full patent application for a different kind of vaccine that required more upfront work before its submission. Our story says, “In his patent application and in subsequently published papers, Zhou documented a robust research and development process that included both adapting the virus to wild-type mice and infecting genetically modified ones with humanized lungs.” We have updated the story to make clear why Zhou’s work stood out to the interim report researchers.

In our article, we quoted two independent experts and one adviser to the interim report about when they thought Zhou’s research was likely to have begun. After reviewing the patent and the papers, two said that they thought Zhou would have had to have started this work no later than November 2019. Jesse Bloom, a virologist at the Fred Hutchinson Cancer Center, said he believed Zhou’s timetable was feasible since his team had substantial expertise and ongoing work developing similar SARS-related coronavirus vaccines, but only if “everything went right.”

We have also corrected the sentence stating that Gabriel Gras was the last French expert at the WIV. We have learned that at least one other French scientist came to the WIV after Gras left.

Elsewhere, we’ve clarified language. Our story said that party officials at the WIV’s top biosafety lab “repeatedly lamented” the problem of “the three ‘nos’: no equipment and technology standards, no design and construction teams, and no experience operating or maintaining [a lab of this caliber].” We found two references to this concept in party branch dispatches on the WIV website in 2019. These Chinese Communist Party dispatches, we reported, “are often couched in a narrative of heroism — a focus on problems overcome and challenges met, against daunting odds.” We have updated the story to clarify that authors of those posts referred to the “three ‘nos’” as a recounting of problems from early in the lab’s construction that they said had been overcome, rather than a reference to ongoing struggles.

However, one of the experts on party communications we consulted saw the inclusion of the “three ‘nos’” in WIV dispatches as a telling sign that these serious problems from the beginning were “part of the DNA of this lab.”

On Whether the Lab Leak Is a Question Worthy of Exploration

Our story and the interim report pointed to a pair of oft-cited scientific analyses of COVID-19’s origins, one of which concludes that the pandemic was likely the result of multiple zoonotic events in which “two distinct viral lineages” of SARS-CoV-2 that had been circulating among animals at a Wuhan market infected people there.

Michael Worobey, an author on both papers, undoubtedly speaks for many when he says that natural spillover is “the only plausible scenario for the origin of the pandemic.” We repeatedly heard the perspective that the scientific case on the origins of COVID-19 is closed and that exploring the possibility that the coronavirus could have leaked from a Chinese laboratory is something no news organization or government official should take seriously.

We believe the opposite, that it remains an essential avenue for exploration to prevent future pandemics. And as interviews with other scientists before and after publication have made clear, the question is far from resolved. In their view, there is not enough evidence to establish how the virus first reached the now-infamous Wuhan market or to assert that zoonotic spillover is the sole possible explanation for the pandemic’s origin.

Bloom, the virologist at the Fred Hutchinson Cancer Center, is among those scientists. “I’ve never seen anything as controversial as this in my field,” he said. “The amount of toxicity is out of control. Each side feels uniquely wronged. To me, it remains an open question.”

The story noted that the interim report also left this question open: “The authors of the interim report do not claim to have definitively solved the mystery of COVID-19’s origin.” And the story also said the interim report is “no likelier” than studies of a zoonotic origin to “close the book on the origins debate, nor does it attempt to.”

Bloom believes the findings of the interim report and the story reinforce a need to continue to explore all possible causes of the pandemic. At the same time, he recognizes that the reactions to these investigations underscore the difficulty of having a dispassionate conversation about these questions. “Right now, this whole topic is so politically fraught, it’s hard for people to give objective assessments,” he said. “We may need an independent commission to get to the bottom of this.”

by Ian MacDougall

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

To hear some tell it, a Supreme Court case set for argument on Dec. 7 could spell the end of democracy in the United States. If the Republicans who brought the case, Moore v. Harper, prevail, state legislatures will effectively be free to override the votes of their citizens in presidential elections, the doomsayers predict. That might allow a future presidential candidate to undo an election, much as Donald Trump attempted, but failed, to do in 2020.

The Atlantic warned that the “Court’s right-wing supermajority is poised to let state lawmakers overturn voters’ choice in presidential elections.” The Guardian opined that a ruling in favor of the GOP would mean that “whether Republicans win or lose elections via the popular vote will not matter because they will be able to maintain power regardless.” And Slate called Moore v. Harper “the Supreme Court case that could upend democracy.”

Those fears are overblown. They ignore other legal protections that would prevent the theft of a presidential election. A state legislature can in fact choose which electors to pick, legal scholars generally agree, as those bodies routinely did in the early days of the republic. But a legislature has the power to decide to handle a vote that way only before citizens begin casting ballots in a given election.

“No matter what the Court decides” in Moore v. Harper, as New York University law professor Richard Pildes has put it, “it would still not mean state legislatures could choose simply to ignore the popular vote in their state and appoint presidential electors themselves after the election.” Federal law, for example, requires states to choose their electors on Election Day. And several federal courts have held that after-the-fact changes raise questions of due process and equal protection. A state legislature can’t simply swoop in after the voting and rewrite the rules for a completed election because it didn’t like the outcome.

Still, Moore v. Harper has major implications for other aspects of elections, including gerrymandering. The case arises from a fight over redistricting by the Republicans who control both chambers of the North Carolina General Assembly. This year, the state’s Supreme Court, voting in line with its 4-3 Democratic majority, ruled that the legislature’s congressional district map was a partisan gerrymander that violated the North Carolina Constitution. Ordinarily, that would be the end of the matter. Federal courts typically can’t second-guess a state court’s interpretation of its own laws.

But North Carolina’s Republican legislators found a way to get the case to friendlier terrain: the U.S. Supreme Court. They argued that the North Carolina court’s ruling violates the elections clause of the U.S. Constitution. That clause states that the “Times, Places and Manner” of holding congressional elections “shall be prescribed in each State by the Legislature thereof,” unless Congress overrides them. The North Carolina Republicans want the Supreme Court to bar state courts from interfering with state legislatures when it comes to congressional elections.

A ruling in their favor would effectively insulate partisan gerrymanders from legal challenges. It would also complicate how states administer elections and neutralize other parts of state constitutions that govern voting and elections, ranging from guarantees of ballot secrecy to automatic voter registration. An examination of the case, and the way it traces its origins both to local political battles in North Carolina and to the legal contest that decided the 2000 presidential election between George Bush and Al Gore, reveals a lot about how the exigencies of a political moment can shape the law for decades.

There’s plenty of irony here. Republicans fought for years to keep federal courts from examining partisan gerrymanders. They won that fight in a 2019 case, Rucho v. Common Cause, which also originated in North Carolina. Chief Justice John Roberts, writing for the conservative majority, declared that federal courts had no authority to review cases concerning partisan gerrymandering. But he went out of his way to note that alternatives remained: “provisions in state statutes and state constitutions can provide standards and guidance for state courts to apply.” Democrats in swing states had already begun to do precisely what Roberts suggested: bring cases under state laws in state courts, many of which remain receptive to Democratic views.

That has caused a case of apparent buyer’s remorse for Republicans. Having previously persuaded the court to stay out, many of the same legislators who succeeded in the Rucho case are back at the high court, begging the justices — now a 6-3 conservative majority — to reinsert themselves into the fight.

It's further proof that victories don’t always deliver the expected results, a lesson that applies to both law and politics. Republicans, for example, spent years challenging campaign finance restrictions and triumphed in a line of cases starting with Citizens United v. Federal Election Commission in 2010, only to see Democratic fundraisers exploit those rulings and outspend them in recent elections. (Whether this gusher of money in politics has been good for the country is an entirely different question.)

A similar phenomenon could occur if the Republicans prevail in Moore v. Harper, at least when it comes to redistricting. Harvard law professor Nicholas Stephanopoulos ran a series of simulations recently that projected voting outcomes if each state could gerrymander at will. He concluded that “nationwide, North Carolina is more the exception than the rule. Overall, Democrats would modestly benefit from a holding that state legislatures’ ability to draw congressional districts can’t be limited by state courts.” He projected that Democrats would net two to three congressional seats. If that turns out to be true, what’s good for North Carolina Republicans may not end up being good for all Republicans.

Many of the apocalyptic scenarios posited by Democrats trace their origins to the party’s calamitous Supreme Court defeat in Bush v. Gore in 2000. That case, not coincidentally, emerged from a state — Florida — where a Republican legislature was attempting to outmaneuver a state supreme court that was largely liberal. The Florida Supreme Court had ruled that the state constitution authorized it to extend the deadline for county election boards to complete ballot recounts in that year’s presidential election, which turned on the whisper-thin margin in Florida. Democrats saw the ruling as the ordinary interpretive work of a court; Republicans contended that it amounted to altering election rules after the fact.

Bush’s legal team appealed to the U.S. Supreme Court, primarily arguing that the state court had acted in violation of the presidential electors clause, a provision of the federal Constitution that resembles the elections clause in structure as well as name. Where the elections clause concerns congressional elections, the electors clause empowers states to appoint presidential electors “in such Manner as the Legislature thereof may direct.” That, Bush’s lawyers argued, prohibited state courts from altering election laws enacted by the legislature, as they contended Florida’s high court had done.

The U.S. Supreme Court’s Bush v. Gore opinion awarded the presidency to Bush on other grounds. But three justices — then-Chief Justice William Rehnquist and Justices Antonin Scalia and Clarence Thomas — issued a concurring opinion seen as the genesis of what is today called the independent state legislature theory.

There are many versions of the independent state legislature theory, but in broad outline, it holds that, by assigning legislatures the authority to set the rules for federal elections, the U.S. Constitution implicitly insulates those rules from ordinary state-level checks on the legislative function, like judicial review. As Rehnquist put it in his concurrence, “This inquiry does not imply a disrespect for state courts but rather a respect for the constitutionally prescribed role of state legislatures.”

Today, the Bush v. Gore decision is often conflated with parallel maneuvers by Republicans in the Florida Legislature, who began the process of voting to award the state’s electoral votes to Bush. But their strategy mostly turned not on the constitutional theory but on an obscure 1845 statute that allows state legislatures to pick their own presidential electors if their state has “failed to make a choice” for president on Election Day. (The 1845 law was mainly intended to accommodate emergency conditions, like natural disasters, legal scholars have found. But Florida Republicans argued that their state’s problems in 2000 amounted to a failed election. Congress is expected to do away with the law during the current lame-duck session.)

The independent state legislature theory didn’t catch fire. In fact, a Supreme Court majority — the four liberals plus Justice Anthony Kennedy — rejected it the one time the high court addressed it head on, in a 2015 case that upheld the constitutionality of Arizona’s independent redistricting commission.

But the theory made a comeback, courtesy of four members of the Supreme Court’s conservative bloc, in the run-up to the 2020 presidential election. In several potential swing states, like Pennsylvania and North Carolina, Democrats had persuaded state courts to adjust election rules to address complications created by the COVID-19 pandemic and postal delays — in many cases, extending the date by which mail ballots had to reach election officials. When Republicans appealed, the U.S. Supreme Court declined to intervene. But Justices Samuel Alito, Neil Gorsuch and Brett Kavanaugh, at times joined by Thomas, all wrote versions of the same thing in opinions that did not carry the weight of precedent. As Gorsuch put it in one such passage: “The Constitution provides that state legislatures — not federal judges, not state judges, not state governors, not other state officials — bear primary responsibility for setting election rules.”

Even as the independent state legislature theory largely faded from discussions of presidential elections between 2000 and 2020, it persisted in litigation over redistricting. With conservative justices skeptical that federal courts had the power to undo partisan gerrymanders, reformers — mostly aligned with Democrats — began to find success proposing ballot initiatives that would place redistricting in the hands of independent commissions. Democrats also turned to state courts to challenge restrictive voting and election laws, including Republican gerrymanders. State constitutions tend to be more expansive and easier to amend than the federal charter, and relying on state law insulated the cases from a Roberts court hostile to many liberal voting and election law claims. The independent state legislature theory was one of the only ways Republicans could get the U.S. Supreme Court to save them from Democrats’ state-level maneuvers.

Some of the fiercest redistricting battles were playing out in North Carolina. In the election of 2010, the GOP gained control of both chambers of the state legislature for the first time in over a century, due partly to a Republican operation targeting swing states ahead of the 2011 redistricting process. In their heyday, North Carolina Democrats were hardly gun-shy about gerrymandering, and the Republican majority approached redistricting with equivalent ruthlessness. Liberal advocacy groups and Democrats went to court, and for the next decade, redistricting litigation became a near-constant. In 2016, North Carolina Republicans suffered a serious setback: Their congressional district map was struck down as a racial gerrymander. So they pivoted to explicitly partisan gerrymandering, using data on voting patterns to dilute Democratic Party voting power.

More lawsuits followed. But the options narrowed in 2019, when the Rucho decision closed federal courts to opponents of partisan gerrymandering.

In North Carolina, redistricting for the present decade got underway in late 2021. Fed up with endless litigation, Republicans pledged to forego the use of data on race or party preference and to draw maps in transparent fashion — on computers in committee rooms, subject to public scrutiny via YouTube livestreams.

The process looked different, but the maps it produced did not. North Carolina’s electorate is very closely divided. Yet under the new congressional maps, Democrats would win only three of the state’s 14 congressional districts — four in a good year. Republicans would take the other 10 or 11.

How GOP lawmakers had managed to draw such slanted maps without partisan voting data remains a matter of dispute. But several state judges saw clear evidence of a gerrymander; one opinion called the maps “extreme partisan outliers,” creating so few competitive districts as to be “incompatible with democratic principles.” This February, the North Carolina Supreme Court ruled that the state constitution bars partisan gerrymandering of this sort. In response, lawmakers redrew the congressional map. But that, too, failed to pass muster. Following a process established by the legislature, the trial court then appointed special masters to redraw the map for the 2022 election; lawmakers could give it another crack afterward.

The resulting map reflected the roughly equal split between Democrats and Republicans in North Carolina. This fall’s House election yielded a delegation of seven Democrats and seven Republicans.

Over the past two years, many national Republicans have fixated on the independent state legislature theory. But in North Carolina, it was almost an afterthought until Republican lawmakers wanted a pathway to the Supreme Court.

At its core, Moore v. Harper boils down to what the Constitution means when it assigns each state’s legislature the task of regulating congressional elections: Does that mean the legislature is subject to the traditional oversight of state courts and the gubernatorial veto? Or does it mean the legislature acting alone, with no such oversight? If it’s the former, then laws setting the rules for federal elections are no different than any other laws. If it’s the latter, things get complicated.

If the elections clause was meant to exclude other parts of state government, then the most extreme version of the theory is also the most natural reading of the clause: Only the strictures of federal law can check how state legislatures regulate congressional elections. That position, however, is too extreme for all but Trump’s closest allies, like John Eastman, an architect of Trump's attempt to use the independent state legislature theory to retain power after the 2020 election, who filed an amicus brief advocating for it.

For their part, the North Carolina lawmakers maintain that state constitutions, as enforced by state courts, can’t impose substantive obligations or restrictions on the legislature’s power to regulate federal elections. This position reflects their principal concern: North Carolina Republicans waited a century to pry political power away from the Democrats, and they feel aggrieved that state courts keep interfering with the pursuit of their agenda.

The state’s GOP lawmakers see the case through local eyes, according to Pat Ryan, who until earlier this year served as deputy chief of staff to Phil Berger, the top Republican in the Senate. Ryan described the case as the latest parry in “a battle over separation of powers between the judicial and legislative branches.” That view is echoed by local Democrats and liberal activists. The Republicans didn’t really care about coup fantasists in the Trump camp, or even the national party’s broader ambitions and plans. “This is all about their fight with the judiciary,” Pricey Harrison, a Democrat on the House Redistricting Committee, told me. “They’re trying to figure out how to game the system.”

Many Republicans concerned with the national stage, meanwhile, have argued for a narrower version of the independent state legislature theory: State constitutions can limit how legislatures regulate federal elections, but only if they’re sufficiently specific.

That would operate to the benefit of national Republicans in two respects. First, it would let them undo recent state supreme court rulings that they dislike while retaining the ones they like. So, for example, rulings rejecting GOP gerrymanders not only in North Carolina but also in Pennsylvania rely on open-ended provisions in their state constitutions. By contrast, in New York, where the state’s high court overturned an aggressive Democratic gerrymander this year, the state charter contains an explicit ban on partisan gerrymandering. Second, it would give Republicans’ allies in the Supreme Court’s conservative bloc maximum flexibility to bend future election disputes the GOP’s way. The line between sufficient and insufficient specificity, after all, is in the eyes of the beholder.

Federalizing state lawmaking isn’t a natural right-wing position, and tellingly, many conservative legal luminaries of the past few decades have filed briefs opposing the independent state legislature theory in any form. “It is rare to encounter a constitutional theory so antithetical to the Constitution’s text and structure, so inconsistent with the Constitution’s original meaning, so disdainful of this Court’s precedent, and so potentially damaging for American democracy” in its effects on redistricting and election administration, reads the brief of the legal team representing individuals and advocacy groups opposing the North Carolina GOP. The legal team includes J. Michael Luttig, a former federal appeals court judge widely admired in conservative legal circles. Another conservative former federal appellate judge, Thomas Griffith, joined an amicus brief opposing the independent state legislature theory; yet another was backed by the co-founder of the Federalist Society, Steven Calabresi. Most legal scholars, historians and election officials — liberal or conservative — offer similar views.

Supporters of the independent state legislature theory rely chiefly on selective readings of earlier Supreme Court cases and attempt to play to the originalist preferences of some conservative justices. The historical record surrounding the drafting of the U.S. Constitution and early state charters offers little illumination. Still, the North Carolina lawmakers rely heavily on a document that many historians regard as a fabrication, written not during the time of the Constitutional Convention in the late 1780s but in 1818. As the brief Luttig joined puts it, “Casting about for an originalist response, Petitioners cite the so-called ‘Pinckney Plan.’ But that ‘Plan’ is a thoroughly discredited document concocted 30 years after the Convention.”

The frustration of the GOP lawmakers at the North Carolina Supreme Court’s Democratic majority is understandable on one level. The state court justices, in the case that led to Moore v. Harper, hang an awful lot on fairly thin reeds; they derive a prohibition on partisan gerrymandering from four very broadly phrased clauses in the state constitution. One reads, simply, “All elections shall be free.” (The frustration for North Carolina Republicans may ease in the near future: The GOP won two state Supreme Court seats in elections this month and come January, the court will have a 5-2 Republican majority. That suggests that, should the Republican lawmakers make yet another attempt at a gerrymander, they may receive a more favorable outcome.)

Yet more understandable still is the worry of those opposed to the independent state legislature theory — that the parochial concerns of one state political party will justify upending the regulation of federal elections nationwide.

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by Lisa Song

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The Environmental Protection Agency has granted the state of Mississippi $500,000 to conduct air monitoring in Pascagoula, a year after ProPublica reported elevated cancer risks from industrial air pollution in the city.

Residents in the Cherokee Forest subdivision had long complained of toxic fumes and persistent health problems including headaches, dizziness and nausea. The neighborhood is surrounded by industrial sites, including a Chevron oil refinery and a shipbuilding facility that Bollinger recently purchased from VT Halter Marine.

ProPublica’s unique analysis of air pollution data estimated that parts of the neighborhood were facing a dangerous overlap of hazardous emissions including chromium, nickel and benzene. Residents spent years filing complaints with the state, attending public hearings and reporting odors and symptoms, with limited results, ProPublica reported. Officials with the Mississippi Department of Environmental Quality took several air monitoring samples from the subdivision in 2016 and 2017, but did not continue testing despite finding concentrations that exceeded EPA guidelines on cancer risk.

In its series “Sacrifice Zones,” ProPublica used Pascagoula as a case study of one of the largest failures of environmental regulation: The lack of community air monitoring for hazardous pollutants and the rarity of regulators intervening when citizens complain of excess pollution.

The EPA recently announced community air monitoring grants to 132 recipients, including the Mississippi agency. State officials will use the grant to measure key pollutants in the Cherokee neighborhood and determine “whether air quality problems exist, the associated level of risk to the community, and opportunities to mitigate such risk including identification of possible sources of elevated concentrations.”

The Mississippi agency plans to conduct air monitoring for one year, communications director Jan Schaefer said in an email. It will monitor continuously for particulate matter and collect 24-hour samples of air once every six days to track other pollutants. Those samples will be analyzed for methane, reduced sulfur compounds, benzene and related toxic chemicals.

The locations of the monitors, the start date and other technical details have yet to be determined.

The yearlong monitoring plan will be much more extensive and rigorous than past air sampling conducted in Pascagoula. Experts say long-term, sustained monitoring like this is often required to prove the impacts of industrial pollution.

Chevron Pascagoula Refinery (Kathleen Flynn, special to ProPublica)

A “systematic study, if done correctly and transparently, will provide a much clearer view of what is going on and how levels track with activities in the plants,” said Dan Costa, a former EPA scientist who is now an adjunct professor at the UNC Gillings School of Global Public Health.

In an email, Schaefer said ProPublica’s reporting did not influence Mississippi’s decision to conduct monitoring.

But resident Barbara Weckesser, whose pleas for this very kind of monitoring went unheeded for more than a decade, said she believes ProPublica’s reporting “absolutely” helped propel the grant and has bolstered the ability of her group, the Cherokee Concerned Citizens, to finally get regulators and the public to listen.

“We now had something we could take that was concrete proof” of our experiences and that would tell people to “pay attention,” she said. This is the monitoring system “we should’ve had nine years ago,” she added. Weckesser said she’s grateful for what she hopes will be an improved process. “I’m hoping the EPA will be on top of it and do a little bit more than they have. And I think they will.”

Bollinger and the EPA didn’t respond to requests for comment. A Chevron spokesperson directed ProPublica’s inquiries to the Mississippi agency.

Jennifer Crosslin, a volunteer organizer with Cherokee Concerned Citizens, said she is cautiously optimistic, but worries about whether the results will be good enough to pinpoint a specific facility as a polluter. The neighborhood lies near numerous shipyards, chemical plants and a Superfund site. ProPublica’s analysis of EPA data shows that five of those facilities, including the Chevron refinery and Bollinger shipyard, release carcinogens that elevate cancer risk in the subdivision.

Crosslin said she hopes Mississippi officials will work with her group on the monitoring design. When she asked regulators for a copy of its EPA grant application, they told her to submit a public records request, she said.

Schaefer said the agency wants input from “all interested stakeholders” but can’t begin the community engagement process until it receives the funds promised by the EPA. The grant application is a public record, Schaefer added, and the agency is “more than happy” to provide it to any third party who requests the document through the legal process.

Weckesser said the agency’s plan to sample for benzene only once every six days allows polluters to time their emissions for when the monitoring canisters aren’t running: “Do you think those fools over there don’t know that?”

Costa said state officials could get around that by monitoring on a more random schedule and not publicizing when they plan to collect samples. He was heartened by the EPA grants and said the agency is routinely understaffed and forced to play whack-a-mole on industrial pollution.

“Our plan has not yet been developed but we do know it will not include the broadcasting of when samples will be taken,” Schaefer said in an email. “EPA must approve the details (including the sampling schedule) as they are responsible for the oversight of the $500,000 they are providing to us.”

The new data will add to a growing pile of evidence of problems with Pascagoula’s air. In April 2021, the EPA conducted extensive mobile monitoring there. Using infrared cameras, the agency spotted plumes of hazardous chemicals streaming from Chevron’s flares, tanks and other equipment. Researchers drove a vehicle with air monitoring equipment past various facilities and found spikes of benzene concentrations as high as 217 parts per billion near the refinery.

The CDC recommends limiting short-term benzene exposure to 9 parts per billion. The EPA, which requires refineries to conduct its own benzene monitoring along the boundary of each facility, expects annual average concentrations to stay below 2.7 parts per billion.

The EPA’s mobile monitoring provided a series of snapshots, with concentrations going up and down at different locations, Costa said. “If the levels stay zero or low, you can be reasonably assured there is little going on.” The results show “there’s lots of fugitive benzene, and benzene is just one of those slam dunk chemicals.” It’s been known for decades that benzene can cause blood cancers, he said, “and you have to invest in ways of keeping it contained or cleaning up the air.”

Costa was concerned enough about the results that he tried to discuss them with EPA staff. He emailed several senior staffers at the EPA regional office in charge of Mississippi and identified himself as the former National Program Director for the agency’s Air, Climate & Energy Research Program, Costa said. He never heard back.

ProPublica, too, inquired about a more detailed round of monitoring the EPA conducted in the wake of ProPublica’s questions about Pascagoula. The EPA regional office told ProPublica last year that it conducted additional monitoring in late summer 2021, using advanced equipment that could pinpoint the source of specific leaks. Those results have not been released, and the agency didn’t respond to questions about what they found.

“I’m sure if that kind of concentration of benzene were wafting over Arlington, Virginia, something would be done about it,” Costa said. In Pascagoula, an industrial city with legacy pollution and houses wiped out by Hurricane Katrina, the story is quite different, he said. “These are citizens of Mississippi that deserve respect and attention to a problem. And they don’t have the financial guns to make this happen.”

by Duaa Eldeib

After Dr. Karen Gibbins’ son was stillborn in 2018, doctors could not explain why it happened.

She underwent genetic testing, which came back normal, and an examination of her placenta, which her medical records show was “notable for the lack of evidence” of an infection or any abnormalities.

But Gibbins didn’t give up hope of finding an answer. She had also asked for an autopsy.

For Gibbins, a maternal-fetal medicine specialist at Oregon Health & Science University who has published research on stillbirths, her son’s death in her 27th week of pregnancy hit painfully close to home. Her expertise added urgency to her desire to understand what had gone wrong.

When the final autopsy results came back about six months later, she was stunned to learn that her son, whom she had named Sebastian, had a rare disease caused by her antibodies attacking the cells in his liver.

By then, Gibbins, who had a son at home, had learned she was pregnant again. She forwarded the report to her doctor, who started her on grueling weekly infusions of antibodies. When she suffered an unrelated complication at 32 weeks and began bleeding heavily, her doctor delivered her baby immediately.

Where there was silence after Sebastian’s birth, Everett cried when he was born.

Gibbins with her two living sons at her family’s home in Portland (Kristina Barker, special to ProPublica)

“If we had not had that autopsy,” Gibbins said, “my third child would have died as well.”

Researchers and national obstetric groups, including the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, have called on doctors and hospitals to offer a stillbirth evaluation, a systematic assessment that includes placental exams, genetic testing and autopsies.

But too often they are not done, making the already complex task of determining the causes of death even more difficult. In about one-third of stillbirths, the cause of death is never determined, according to a recent Centers for Disease Control and Prevention report.

Some doctors do not offer patients the postmortem exams after a stillbirth; some patients decide against them without fully understanding the potential benefits. The federal government doesn’t cover the cost of an autopsy after a stillbirth, though many experts say it should be viewed as a continuation of maternal care.

Research has shown that placental exams may help establish a cause of death or exclude a suspected one in about 65% of stillbirths, and autopsies were similarly useful in more than 40% of cases.

While placental exams, autopsies and genetic testing are all recommended, at the very least the placenta should always be tested, said Dr. Drucilla Roberts, a perinatal pathologist at Massachusetts General Hospital and professor of pathology at Harvard Medical School.

“It’s the heart and lungs of the baby” while in the womb, said Roberts, who added, “The placenta should definitely be evaluated in every stillbirth.”

But in 2020, placental exams were performed or planned in only 65% of stillbirths, the most recent CDC data shows. Meaning that in thousands of stillbirths that year, the placenta was thrown out without ever being tested.

Autopsies are performed in even fewer cases. Those exams, according to CDC data for 2020, were conducted or planned in less than 20% of stillbirths.

Experts blame the low rates on several factors. Because an autopsy often is performed in the days following a stillbirth, doctors and nurses have to ask families soon after they receive news of the death if they would like one. Many families can’t process the loss, let alone imagine their baby’s body being cut open.

What’s more, many doctors aren’t trained in the advantages of an autopsy, or in communicating with parents about the exam. Doctors also often don’t tell patients that, for example, families can still have an open casket funeral after an autopsy, because the incisions are done in such a way that they can easily be covered by clothing.

“I think a lot of times there can be misconceptions among providers,” said Dr. Jessica Page, an assistant professor and maternal-fetal medicine specialist at University of Utah School of Medicine and Intermountain Healthcare. And if doctors aren’t providing compassionate and informed counseling on the potential benefits of the exams, patients may lose the opportunity to learn why their child died.

“It impairs our ability to give them thorough counseling regarding risk in future pregnancies,” Page said. “It’s hard to reduce the rate of stillbirth if we don’t understand why they all happen.”

Page is working to help doctors better counsel patients about autopsies following a stillbirth, and she and Gibbins are planning to apply for a federal grant to develop a step-by-step tool to walk patients through the autopsy process.

The need for evaluations is underscored by the current stillbirth crisis. Every year more than 20,000 pregnancies in the U.S. end in stillbirth, the death of an expected child at 20 weeks or more. About half occur at 28 weeks or more, after the point a fetus can typically survive outside the womb.

But the stillbirth rate has received little public attention, which has been made worse by insufficient research and the experience of some mothers who have complained that medical professionals ignored or dismissed their concerns. One study found that nearly one in four U.S. stillbirths may be preventable.

In the summer of 2020, Kendra Skalski arrived for her doctor’s appointment with her hospital bag packed. It was a day before her due date, and she was uncomfortable and ready to deliver. Skalski asked her doctor what the earliest date was that she could have a scheduled delivery, but she said her doctor told her not before 41 weeks.

This was her first pregnancy, and Skalski said she didn’t know she could push back.

But hours before Skalski was scheduled to be induced, she realized she hadn’t felt the baby kick. She called her doctor’s office and was told to head in to the hospital early. Skalski said the person she spoke to didn’t sound worried, so Skalski wasn’t worried either.

“I just remember thinking everything was fine,” Skalski recalled.

At the hospital, the staff collected her insurance information. She laughed with her husband, a New York City firefighter, as she filled out the paperwork.

When the nurse struggled to find the baby’s heartbeat, Skalski thought the monitor was broken. She searched her husband’s face, staring intently at his eyes, hoping for reassurance. “Everything is going to be OK,” he told her.

Then a doctor confirmed that her baby, a girl she had named Winnie, didn’t have a heartbeat.

“This isn’t happening,” Skalski recalled saying. “This isn’t happening.”

Skalski couldn’t comprehend her loss, let alone the decisions she then had to make. Induce the delivery of her dead daughter or go home and come back in the morning? Vaginal delivery or cesarean? Burial or cremation? Placental exam or autopsy?

The doctor, she said, told her an autopsy likely wouldn’t find anything. Skalski also struggled with her own feelings of guilt; she wouldn’t be able to live with herself, she said, if the autopsy revealed that she had somehow caused her daughter’s death. And the thought of someone cutting open her daughter left her distraught. She said no to the autopsy.

She now regrets that decision. The doctor had asked her about the autopsy before she had even delivered her daughter, she said, and no one explained to her that she might want the results after the shock wore off.

“I wish that I had been more well-informed,” she said. “I wish that someone had said, ‘OK, this is nothing that you did. Let’s find out what it was.’”

Skalski said she chose Northwell Health, New York State’s largest health care provider, because of its reputation. A spokesperson for Northwell Health did not answer questions about Skalski’s care but said its hospitals follow ACOG guidelines and consider inducing a mother between 41 and 42 weeks, though doctors weigh a variety of factors, including communication with expecting mothers, “in order to provide the best possible care for each individual patient.”

In addition to possibly helping her understand why her daughter died at 41 weeks, the autopsy could have offered her and her doctors some clarity when she got pregnant again. Skalski became the inaugural patient of the Rainbow Clinic at Mount Sinai Hospital in New York City, the first of its kind in the U.S., which is modeled on similar clinics in the United Kingdom that employ specific protocols to care for people who have had a stillbirth.

In August, Skalski gave birth to her daughter, Marigold.

Although general pathologists can perform autopsies and placental exams, perinatal pathologists undergo specialized training to help them know what to look for in cases of stillbirth. By all estimates, the U.S. is currently suffering from a shortage of perinatal pathologists, said Dr. Halit Pinar, a longtime perinatal pathologist and professor at The Warren Alpert Medical School of Brown University. He worries that recruiting a well-trained perinatal pathologist after he retires will be a challenge.

“Perinatal pathology is not glorious,” he said.

Younger doctors know choosing another pathology specialty may be a more secure professional path, he said, but perinatal pathology is critical, and autopsies after a stillbirth are essential. Some of Pinar’s most rewarding moments have come from being able to provide closure to mothers and explain that they are not to blame.

When his team received a federal grant that covered autopsies through the Eunice Kennedy Shriver National Institute of Child Health and Human Development, which is part of the National Institutes of Health, the stillbirth autopsy rate reached around 95%, he said. Once funding ended, he said, the number of autopsies fell to around 30% to 35%.

Medicaid, he said, should consider paying for autopsies after stillbirths as an extension of postpartum coverage.

“If there is reimbursement, so that it’s not on the shoulders of the hospital budget, it is going to help,” Pinar said. “This is part of maternal care.”

Many larger academic hospitals absorb the cost of autopsies, but some families have said uncertainty around whether the cost of the autopsy was covered affected their decision not to have an autopsy done.

A spokesperson for the Centers for Medicare & Medicaid Services said federal payment for autopsies is not permitted because Medicare and Medicaid laws do not allow for their coverage.

The Stillbirth Health Improvement and Education (SHINE) for Autumn Act, a bill co-sponsored by U.S. Sens. Marco Rubio, R-Fla. and Cory Booker, D-N.J., seeks to improve stillbirth research by providing training in perinatal autopsies, but the legislation has not passed the Senate.

Even if a family wants an autopsy, it doesn’t guarantee that it will happen.

Stephanie Lee’s daughter, Elodie Haru Ansari, was stillborn last year.

Lee was 36 weeks pregnant, though her belly was so big people frequently asked if she was having twins. Still, medical records show Elodie weighed 3 pounds, 10 ounces at birth. Lee, a registered nurse, said her doctor had suspected her daughter might have had a birth defect where her esophagus did not develop properly.

Lee and her husband, Tunaidi Ansari, wrestled with so many unanswered questions that there was no doubt in their minds about the autopsy. Lee signed the paperwork to have one performed.

They waited for weeks to receive the results, but when they never arrived, she asked her doctor about the delay. The doctor called her, and only then, she said, did she and her husband learn that the hospital never performed the autopsy.

“We were promised an autopsy,” Ansari told the doctor. “We were promised every single thing to test for, and the most basic thing was the autopsy, which they said was done on the same day or the next day, and we don’t have it.”

As he spoke, Lee sobbed.

A hospital administrator later wrote Lee a letter that explained that the autopsy consent form was not sent to the correct office, and “as a result, the morgue was not made aware of the request for autopsy.” In light of the “break-down in communication,” the administrator said, the hospital was updating its procedures. “Although it is not possible to change the outcome in your case,” she wrote, “I want to assure you that all measures are being taken to prevent a circumstance like this from ever occurring again.”

Neither Weill Cornell Medicine, where Lee received her care while pregnant, nor NewYork-Presbyterian Alexandra Cohen Hospital for Women and Newborns, where she delivered her stillborn daughter, responded to requests for comment.

On a recent Friday, Lee, who is pregnant with her second child, gathered her family to celebrate what would have been Elodie’s first birthday. She hung a banner and balloons above a table filled with stuffed animals, flowers and photos of Elodie. In the center was a five-layered tteok cake, a Korean rice cake traditionally served when a child turns one.

Later that evening she held the urn with Elodie’s ashes next to her belly and said goodnight to both her daughters. The next morning, she ordered her coffee as usual, under the name “Elodie.”

Stephanie Lee and her husband, Tunaidi Ansari, are now expecting their second child. (Stephanie Mei-Ling, special to ProPublica)

Help Us Report on Stillbirths

by Lizzie Presser, photography by Parker Hill and Isabel Bethencourt for The New York Times

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This article was produced in a partnership between ProPublica and The New York Times Magazine. It is not subject to ProPublica's Creative Commons license until Dec. 28, 2022.

On a hot Texas morning in 2020, Giselle, who goes by G, slipped her arms into a borrowed blazer, flipped up the nose ring in her septum so it couldn’t be seen and walked into the Coryell County Courthouse. It was the first time she had ever been to court. She was 17, 11 weeks pregnant and already beginning to show. She was going to ask a judge for authorization to seek an abortion. Her lawyer had explained that she needed to prove that she was mature enough to make this decision. G squeezed her lips around her braces, reminding herself not to smile. She didn’t want the judge to see her as a child.

Because G was a minor, her access to an abortion was governed by the state’s “parental involvement” law. She could have either notified her mother or father and gotten consent, or she could have filed a petition in her home county, asking for what’s known as a judicial-bypass hearing. She had chosen to petition. In the carpeted courtroom, G explained that she didn’t know her father, who was investigated by Child Protective Services after being accused of molesting her when she was a toddler. Though the case was inconclusive and he denies abusing her, he eventually gave up his parental rights. G didn’t trust her mother, whom she viewed as unreliable and volatile. They had bounced among houses and boyfriends for stretches of G’s life. A year before, G packed up her things and left.

G at 16 in June 2019, on a trip to a lake with her friends (Archival photo by Parker Hill and Isabel Bethencourt)

When she discovered she was pregnant, she traveled to an abortion clinic in Austin, about 60 miles south of where she lived in Copperas Cove, a city of 37,000 where nearly everyone works on Fort Hood, the nearby military base. The clinic referred her to Jane’s Due Process, an organization that helps minors navigate judicial bypass. Ten days later, its staff found G a trained attorney. It took G a week to schedule a ride to meet with the lawyer, who asked about her grades, extracurricular activities, babysitting experience and which birth control method she would use in the future. Then, before her court date was scheduled, the District Court judge assigned to the case recused himself. Although he didn’t say why, many judges choose not to take a case in which they might have to approve an abortion. The clerk needed to book a visiting judge. Altogether, G had spent four weeks trying to get a hearing. And now, on June 18, 2020, four months shy of her 18th birthday, G knew that her future was at this judge’s discretion.

“Have you had to deal with your mom dealing with your braces?” her lawyer asked, hoping to show the judge that G couldn’t depend on her mother. Since she left home, G explained, her mother had been withholding payment on her braces, telling the orthodontist that G needed to cover the cost.

When her lawyer asked her why she was seeking an abortion, G said she didn’t think she would make a suitable parent. She had just graduated from high school and was working as a cashier at the H-E-B supermarket chain. Her goal right now was “taking care of myself and financial needs to the best of my ability.” She had broken up with her boyfriend, Cecil, after she found out she was pregnant, concerned that he wouldn’t be there for her. Neither of them believed that they were ready to raise a child. He didn’t make enough as a brick mason to move out of his parents’ house, and for a year, G had been crashing with friends. An abortion, she believed, would be “in the best interest of the fetuses.”

She had thought about adoption, she told the judge, but it was not for her. “I don’t feel like I can grow something in my body for nine months and then physically hand it away.” When her lawyer asked her what she expected after the abortion, G regurgitated the warnings from “A Woman’s Right to Know,” a Texas Health and Human Services pamphlet that her lawyer told her to study in preparation for the hearing: She would bleed, cramp and feel emotional and depressed. G told the judge that she had made a list of pros and cons in her journal: “Cons: Killing something growing inside of me. Guilt. Constant guilt from others. Pros: Continue life without being pushed back. Freedom.”

The judge said he had a few questions. “I probably misheard you, but I thought you said ‘fetuses,’ instead of ‘fetus.’”

G winced, annoyed with herself for using the plural. “It’s two,” she said. Twins. The judge wanted to know if she had received counseling at the abortion clinic. “Did they give you, for instance, any statistics about how many women regret or don’t regret it five, 10, 12, 20 years from now?” They hadn’t.

“I’m basically standing in the stead of your parents by making this decision,” the judge continued. “In doing so, I want to make sure that I would treat this as if you were my daughter.” G tried to control the muscles in her face. She didn’t want to reveal her frustration that this gray-haired man with deep-set eyes was imagining himself as her father, whom she had feared since she was a child. The judge explained that he wanted to take the long view, focusing on her health. This is a high-risk pregnancy, G thought, or at least that’s what the clinic told her. If he cared about my health, he would say yes to an abortion. “Obviously, it’s a monumental decision,” he said. “It’s a life-changing decision.”

The judge told G that he didn’t want to rule immediately. First, he wanted G to visit a crisis pregnancy center and have an ultrasound. He recommended two Christian organizations that counsel women to keep their pregnancies. G replied that she had tried to go to one in town, but it was closed because of COVID-19. The judge said he wanted her to try another. Under Texas law, the names of judges in bypass hearings typically remain unknown, so what the judge said next was striking. He gave G his cellphone number and told her to call him once she attended her appointment. “I’m a judge in Waco,” he said, adding that his name was David Hodges.

At 73, Hodges is retired, though he still fills in on cases. He served as a county-level judge until 2002, when he violated the state’s election code by running as a Democrat but voting as a Republican. The Democratic Party removed him from the ballot, and he stepped down as a full-time judge. Hodges has ruled on about a dozen judicial-bypass cases. He hates them, he told me — none of his peers want to be the arbiter in these hearings. He sees his role as similar to that of a jury determining whether a convicted criminal defendant “should be given life in prison or the death sentence,” he said. “I consider this decision to have that kind of weight.” He told me he didn’t want to impose his personal views about abortion on G — he believes that life begins soon after a fetal heartbeat — but he did want her to have an ultrasound, because “statistically, if the proposed mother is shown the ultrasound, they will change their mind and decide they don’t want to have an abortion.”

G knew none of this, but she was aware that crisis pregnancy centers opposed abortion. As she walked out of the courtroom, her lawyer tried to reassure her. “Maybe he is saying if you do this, he will grant it?”

The next morning, G caught a ride 50 miles south to a crisis pregnancy center, where a woman displayed her ultrasound on a large screen and turned up the volume of the fetal heartbeats, which sounded like galloping hooves. The woman read off the supposed risks of abortion — the chance of death, the likelihood of infertility — and printed photos titled “Baby A” and “Baby B.” G left the center frightened and angry and immediately called her lawyer to file an affidavit. “I am walking into this situation thankful for all the information and care I have received,” the document read. “I am asking the court to sign an order allowing me to have an abortion.”

That afternoon, G’s lawyer called her. Hodges had denied her petition, ruling that she wasn’t mature enough to make this decision. G could appeal, the lawyer said, but G’s mind was already replaying her testimony. She had stuck to the conventions of the bypass hearing, spinning a story about her life that portrayed her as an upright woman: She was studious and diligent at work; she could save money and pay bills. Now she just wanted to do it over. Her life was a mess, a loop of false starts, deferred plans and upheaval. All she wanted was to tell the judge the truth: She wasn’t mature enough to be a mother.

G holds a photo of herself taken during her pregnancy, “pretending to be happy,” she says.

Parental-involvement laws were some of the first abortion restrictions passed after the Supreme Court’s 1973 decision in Roe v. Wade, and they are one of the few on which voters across the political spectrum have long agreed, with roughly 70% of adults in favor of them. When the court ruled in June on Dobbs v. Jackson Women’s Health Organization, overturning Roe, 36 states enforced these statutes. Some require minors to notify a parent; others require them to get the consent of one or both parents. Several require that they do both. If a minor chooses not to involve a parent, she must prove to a judge that she is mature and well-informed enough to make a decision about abortion. Or, depending on the state, she can prove that having an abortion, or doing so without involving her parent, is in her best interest.

To their supporters, these laws are common sense: Parents have responsibility for their child’s well-being, and it’s reasonable that they be involved in ending a pregnancy. When Bill Clinton ran for president in 1992, he explained on MTV that he had signed a parental-notification law as the governor of Arkansas because, after an abortion, “who helps the kid pick up the pieces?” Teenagers, especially younger ones, may not be mature enough to make a well-thought-out choice about abortion, proponents argue. For the past century, the Supreme Court has also recognized the authority of parents to raise their children as they see fit — in their education, religion, health care. If a school nurse determines that a child would benefit from Advil, the nurse usually needs permission from the child’s parent before administering it. With a decision as charged as abortion, most parents similarly want to be consulted. Lawmakers say that requiring minors to engage their parents offers protection, honors a family’s values and encourages dialogue at home.

Critics of the statutes point out that most teenagers involve their parents in their abortion decision regardless of state law. Opponents are especially concerned for teenagers who live in homes that are abusive, neglectful or otherwise unsafe. The American Medical Association and the American Academy of Pediatrics have each noted that although a parent’s involvement is helpful in many cases, a mandate introduces the risk of violence or rejection for young people in unsupportive families. The Academy of Pediatrics also finds that it delays care. Youth advocates point to the hundreds of thousands of minors in the United States who don’t live with their biological or adoptive parents — those in foster care or staying with relatives. Or they talk about the rights that they believe young people deserve, regardless of whether their parents are dangerous. “It’s not just about young people as victims,” says Jessica Goldberg, who works for the reproductive rights group If/When/How on reducing barriers for young people and eliminating the statutes. “Forced parental involvement in the abortion decision ignores all young people’s bodily autonomy.”

The judicial-bypass procedure has been presented as a compromise, balancing the interests of teenagers and their parents. Almost every state that requires parental involvement includes the option for a minor to go before a judge instead. The compromise hinges on the belief that the hearings are fair, efficient and shielded from politics. In states where clinics connect teenagers with experienced attorneys and where the court staff is trained, the process can go smoothly. In others, it’s a crapshoot. The question of “maturity” is open to wildly different interpretations, particularly when assessed by a judge who answers to voters. In many counties, teenagers who try to file petitions find courts that are unprepared or biased; research surveys have shown that it’s common for staff to turn away callers or delay bypass hearings. Judges sometimes announce their intention to issue denials before the hearing or try to persuade teenagers to carry their pregnancy to term; in Alabama, one judge announced, “This is a capital case,” and suggested that the petitioner would be damned to hell. In a 2020 study on attorneys’ experiences in Texas, lawyers recounted regular activism on the bench. One judge told minors to “refrain from any sex prior to marriage.” Others appointed counsel who spoke out against abortion.

The most recent data indicates that about 90,000 minors become pregnant each year, and 25,000 end their pregnancies. Compared with adults, teenagers have a tougher time coming up with money for an abortion and, if they don’t have a car or a license, more trouble getting to a clinic. They are much less likely to have a credit card to order abortion pills online. Because their periods aren’t as regular, they tend to detect their pregnancies later. No one knows how many teenagers across the country can’t get abortions because of parental-involvement laws. There’s no count of those who are denied by judges or those who want an abortion but can’t come up with a way to travel or skip school or find a lawyer. Because the cases are sealed, even the number of bypass petitions filed each year is a mystery. Several lawyers told me that they know only the initials of their teenage clients, and many shred the files after hearings. Before the Supreme Court reversed Roe, in 12 states where some numbers were available — compiled by researchers, attorneys or public health departments — around 1,000 total petitions were filed yearly.

Legislators began passing parental-involvement laws in the mid-1970s, as liberals and conservatives came to believe that curbing teenage pregnancy would improve the economic lives of young women and cut costs for the government. But over the past several decades, evidence has suggested that instead of changing the sexual behavior of teenagers, these laws push many young women into motherhood before they want it. Given the Dobbs decision this summer, the consequences of these restrictions will most likely become more pronounced.

Without the protection of Roe, almost every state in the South and the Great Plains is expected to ban or severely limit abortion, denying access to both adults and minors. As state courts weigh in on abortion restrictions, the laws continue to shift; at the moment, 14 states are poised to protect the right to abortion and do not have, or do not enforce, parental-involvement laws (Alaska, California, Connecticut, Hawaii, Illinois, Maine, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Vermont and Washington). More than 20 still allow most abortions and also maintain parental-involvement laws. Several of these states — including Florida, Kansas, North Carolina and Pennsylvania — border regions of the country where abortion is being criminalized. They are among the closest options for teenagers in states with bans.

14 States Ban Most Abortions, and 22 More Require Teens to Get Approval From a Parent or a Judge

The 14 states, plus Washington, D.C., that allow minors to seek abortions without an adult’s approval are often hundreds of miles away from teens in the South and Great Plains.

Note: States are marked as banning all or most abortions if they have blocked abortions after the sixth week of pregnancy and are currently enforcing that ban; some additional states’ bans are not currently in effect due to litigation. This data is current as of Nov. 28, 2022. (Map combines data obtained by ProPublica with data published by If/When/How; map by Lucas Waldron, ProPublica)

The farther a teenager needs to travel to a clinic where they can consent to an abortion on their own, the less likely they are to end their pregnancy. From 1992 to 2015, as parental-involvement laws proliferated, the distance the average minor would need to travel increased from 58 miles to 454 miles. “You can see the country closing in on teens,” says Caitlin Myers, a professor of economics at Middlebury College who mapped this changing landscape in a recent paper. She estimates that in this time, parental-involvement laws were responsible for 108,000 additional teenage births.

As new bans take hold, driving distances will grow longer for many teenagers who want an abortion. An adult in Dothan, Alabama, for example, could travel 90 miles to Tallahassee, Florida, for the procedure. A 17-year-old would have two options: She, too, could go to Tallahassee, but she would have to file a petition, which the court would ask her to write herself before she is appointed an attorney. If she tried to visit an abortion clinic to learn the facts of the procedure, the clinic would refuse to schedule a consultation without judicial authorization. She would attend her bypass hearing, where a judge would expect her to know the medical risks of an abortion. The judge would have three days to decide how to rule. In many circumstances, the teenager would need to do this without alarming her parents by going missing. Her second option would be to travel to the nearest clinic in a state without a parental-involvement law — in Carbondale, Illinois, 590 miles away. Or, faced with these choices, she might weigh a third option: She could give up.

For Millions of Teens, Getting an Abortion Can Mean Traveling to Illinois, Washington, D.C., New Mexico or Minnesota Note: The distance from each county to the nearest abortion provider was calculated using the population center of each county and road networks generated by the HERE API. (Credit: Data analysis by Caitlin Myers; maps by Lucas Waldron, ProPublica)

After Hodges’ ruling, G didn’t know where to turn. She had told her friends that she was set on becoming the opposite of her mother, who had become pregnant with her — unintentionally — at 19. G grew up depending on government assistance for food and didn’t believe it would be fair to bring children into the world without financial security. She was scared of finding herself in romantic relationships like her mother’s, which sometimes led to catastrophe: G or her mother would call the cops, or the two would flee or kick the guy out. A former classmate of G’s mother, Brandi Rickert, who took them in at one point, told me that she worried about G when she was a child. Rickert could see that G wanted stability but that her mother was unable to provide it. G knew that her mother grew up in a violent home and that she was doing what she could to keep G safe. “She took hits for me,” G told me.

In G’s memory, though, her mother could turn dark in an instant. Jennifer Clark, the mother of one of G’s friends, told me that when the two briefly lived next door, she often heard G’s mother screaming, calling G “an attention whore,” “a piece of shit.” In the spring of G’s sophomore year, while she was in an online home-schooling program, G worked two jobs, including as a hostess at Razzoo’s, where she put in as many as 30 hours a week. She was expected to pay rent to her mother. (G’s mother says she never used that language or asked for G’s earnings, and she disputes G’s characterizations of her and how she parented.) That G was unusually self-sufficient, dreamy and also impulsive could put those around her off-balance. Sometimes G was a people pleaser, offering to cook or clean for Clark in a honey-sweet voice. Other times, she would shut down, refusing to talk to anyone. Occasionally, she would explode out of nowhere, throwing friendship-ending tantrums. “Well,” Clark said, “all that was learned behavior.”

Just before she became pregnant, G was finally hopeful about her future. Once she left her mother’s house, she reenrolled in high school, where the principal said that she worked harder than anyone on campus. “I didn’t know whether she wanted to be a short-order cook or a brain surgeon,” he told me, “but quite frankly, she could write her own ticket doing whatever she wanted to do.” G wasn’t yet thinking about her career. She wanted to party and celebrate her graduation, leave Copperas Cove, get an apartment of her own and comfortably support herself.

Since middle school, G identified as gay — all her relationships had been with girls, and she had envisioned building a life with another woman. Falling for Cecil had taken her by surprise. When they first got together, she recognized the ease she felt being in public with him, no longer nervous about leers or snide remarks. But she had always struggled to trust guys, and being with Cecil didn’t change that. “I still seem to keep thinking about my past, worried that it’s going to repeat itself,” she wrote in her journal. “I worry I wasn’t, won’t ever be, ready to be with a male.”

After her bypass hearing, G stopped eating and showering and responding to texts. She didn’t want people to know about her pregnancy; the few friends she told had ghosted her. “I’ve been alone my entire life, but being pregnant is an entirely other lonely cycle,” she wrote. “I don’t have drive, energy.” Her friend Shana, who was 36 and married with three children, was letting G stay in her living room on a mattress, which she had cordoned off with a bookcase and a shower curtain. Some days, Shana told me, she had to pull G out of bed and escort her to the front yard just to get some sunlight.

Shana and G on Shana’s property, where they both live

G hadn’t decided whether to challenge the judge’s ruling. She knew that Shana would respect whichever choice she made, but Shana believed that abortion was immoral, except in cases of rape or incest. She considered twins the ultimate blessing. In one outburst, which she later apologized for, Shana told G that she would be murdering two people. Cecil was no help with the decision. G thought that he was too irresponsible to offer guidance; he didn’t even clean his bedroom. Somehow the burden of figuring out what to do was falling to her, even though Cecil thought that he must have forgotten to put on a condom. G was paralyzed: She could appeal Hodges’ ruling with no certainty that it would be overturned, or she could accept the voices around her — Shana’s, the judge’s, the Christian counselor’s — that all wanted her to have the children. She had already spent weeks getting her first court date, and she couldn’t shake a sense of defeat. Overwhelmed, she decided that she wouldn’t decide. She preferred to ignore that this, too, was a decision.

After several weeks of nothing, G began to embrace her situation. She told Cecil that she was still pregnant, and they agreed that it was best to get back together to raise the twins. Knowing that she was afraid he would abandon the kids, Cecil promised that he never would. “It wouldn’t sit right with my conscience, and also, my mom would kill me,” he told me. In an effort to address her mood swings, G enrolled in counseling, telling her therapist that she worried she didn’t “even know what a healthy relationship looks like.” The pages of her journal turned to shopping lists with cost tallies: swaddling blankets, car seat head thing, breast milk bags, boobie ice packs. She started a photo album with ultrasounds and pictures of her belly. Every two weeks, Shana or Cecil drove her to the hospital in Temple, about 40 miles east, for a checkup. G’s slim frame was transforming: arms swelling, neck spasming, ankles pounding under new weight. In August, when G was five months pregnant, one of her doctors diagnosed the fetuses with syndactyly, a rare congenital condition characterized by fused fingers and toes. G wasn’t surprised; Cecil had it, and she adored his body, but she also understood that her children would need special attention.

G’s old journal, showing a list of expenses

G got a job at a day care center, which seemed like an ideal opportunity. She committed to muscle memory how to change a diaper and balance bottles to feed two infants at a time; she learned about choking hazards, the tricks to quickly mixing formula. The children’s bottomless energy, though, seemed to grate more on her than on her co-workers. The high-pitched shrieks, the sticky faces, the careless way their limbs flailed. Slowly, she realized she wasn’t irritated but envious. Without a “normal” childhood of her own, she resented the children who appeared to have one.

Eight dollars an hour was getting her nowhere, and she couldn’t handle more work on her feet. A friend told her that she could make extra money selling videos of herself on an app called Whisper. Buyers had a kink for pregnant women. At night, when Shana’s family was sleeping, she filmed herself, shielding her face with a red sequined eye mask. Cecil didn’t like it, but he couldn’t argue with her rationale. This was money she was making for their children, so they wouldn’t go without. She tried not to think about her own disgust. She had never wanted to sell her body, but soon she was bringing in as much as $400 a week. Like an actor, she imagined herself in a fictional story. “I’m a whole different character — this isn’t me.”

In November, G’s doctor recommended bed rest, advice that she took, though her employer didn’t provide paid leave. Her twins kept kicking her bladder, making her urinate spontaneously. She had gained more than 50 pounds, and she needed help just getting dressed; Shana bought her a foot-long shoehorn so that she could slip her feet into sneakers she couldn’t reach. On Dec. 9, 2020, 36 weeks into her pregnancy, G braided her long, caramel hair into pigtails, asked Shana for a final photo shoot while she held her bulging belly and drove with Cecil to the hospital to be induced. The epidural didn’t seem to work, her pain level hovering between a seven and a 10. Twenty-six hours later, G gave birth to twin girls. For what seemed like only a moment, the nurse placed them on G’s chest. They looked like wrinkly aliens. I’m supposed to be feeling something right now, she thought. She wanted a fierce, visceral love to take over, a tight grip of purpose. Instead, she felt empty.

Judicial-bypass hearings date back to a 1979 Supreme Court case, Bellotti v. Baird, in which the court declared Massachusetts’ parental-involvement law unconstitutional. The ruling rested on a previous decision that states cannot give parents “an absolute, and possibly arbitrary, veto” over a minor’s abortion. But in an unusual majority opinion, Justice Lewis F. Powell Jr. wrote that states could require parental involvement if they also allowed minors to go directly to a judge to ask for permission to end a pregnancy. He proposed that judges could be tasked with assessing whether the minor was mature enough to make the decision, though he conceded that maturity is “difficult to define, let alone determine.” A concurring opinion, written by Justice John Paul Stevens, scolded Powell for advising states on how to rewrite their laws, but legislatures began passing statutes that fell in line with Powell’s vision. The power to veto a minor’s abortion shifted from a parent to the state.

How the courts interpret maturity has since proved to be arbitrary. Judge Hodges told me that “of course it’s subjective.” He also said that part of his thinking in denying G’s petition was that he disagreed with her statement that she wouldn’t make a suitable parent. “My thought process was, You sound very mature to me, for a 17-year-old, living on your own, paying your own rent, making these decisions,” he said. “Sounded to me like she actually, probably would make a good parent.” His view was paradoxical: He believed that G was mature enough to raise two children, but he had ruled that she was not mature enough to decide if she was ready to be a mother. By law, the assessment of a teenager’s maturity should apply solely to her ability to choose whether to have an abortion — not to her ability to parent.

In Florida, for example, judges of bypass proceedings are asked to consider minors’ “overall intelligence,” “credibility and demeanor as a witness” and “emotional development and stability,” among other characteristics. In January, a 17-year-old who was planning to be a nurse was denied an abortion partly because she told the judge that her grade-point average was 2.0 and, at another point in the proceeding, said she was currently making B’s. “Clearly, a B average would not equate to a 2.0 GPA,” the judge wrote, concluding that her intelligence was below average. (An appellate court overturned the ruling, explaining that her current grades could have lifted her GPA.)

With Bellotti, the Supreme Court transformed abortion from the medical decision it was deemed to be in Roe into an act fraught with cultural meaning. If a teenager wanted to opt for a cesarean section, she didn’t need a parent’s approval — but if she wanted an abortion, she did. The state was forcing a parent’s involvement in one medical procedure but not the other. Shoshanna Ehrlich, a professor of gender studies at the University of Massachusetts, Boston, argues that it was here that the court provided one of the earliest hints that it was moving toward promoting birth over abortion. The maturity test was not about a teenager’s ability to weigh the benefits and risks of her medical choice. “If a pregnant teen on Monday says, ‘I want to be a mom,’ the teen is vested with full decision-making capacity,” Ehrlich says. “And let’s say she wakes up on Tuesday and says, ‘Wrong decision; I can’t be a mom.’ Then suddenly she is not an autonomous decision-maker. What happened between Monday and Tuesday? Did she lose her maturity?”

The Bellotti ruling came as teenage pregnancy was igniting public anxiety. The Alan Guttmacher Institute, then affiliated with the Planned Parenthood Federation of America, had released a report in 1976 that announced an “epidemic” of teenage pregnancy, a term that was quickly picked up by politicians and the news media. The discourse disregarded half the story. The teenage birth rate hit its peak that century in the 1950s, when adolescents were more likely to be engaged or married, and it was in decline by the 1970s. But the legalization of abortion had given rise to a new demographic measure, the pregnancy rate, which included births, miscarriages and abortions, and this measure for teenagers was rising. During the sexual revolution, more single women of all ages were having sex, more women were having abortions and more white women were having children without marrying. But teenagers, especially Black teenage girls, became a focus of concern.

Liberal reformers argued that teenage motherhood led to poverty, and they used the public attention to lobby for expanding reproductive health services and comprehensive sex education. Conservatives cited the Guttmacher report to try to shut down those programs. Not only did they take moral issue with sex between teenagers, but they also cast adolescent mothers as a drain on government funds. Parents, they argued, needed resources to control the sex lives of their teenage children. After the election of President Ronald Reagan in 1980, the conservative agenda prevailed.

Over the following decade, after restrictions on abortion multiplied across the country, the National Abortion Rights Action League hired consultants to shape a new campaign. Focus groups were most roused by the notion that the government’s abortion laws were interfering with the sanctity of the family, so the consultants gave NARAL a more relatable slogan: “Who Decides? You or Them?” As William Saletan describes in his book on the abortion wars, “Bearing Right,” NARAL staff members never thought the “you” in their slogan would be taken to mean parents rather than pregnant women, but the “you” was so flexible that it could refer to anyone in a family. When Democratic candidates started noticing the appeal of parental-involvement laws, many decided to support them; with NARAL’s new phrase, they could be “pro-choice” and “pro-parent” at the same time. Soon, politicians on both sides of the abortion debate — in Michigan, New Hampshire, South Carolina and Virginia — were rallying voters around mandated parental involvement. By the end of the 1990s, a majority of states had instituted the laws. About half of those states were blue.

In the weeks after G gave birth, she couldn’t summon a connection with her babies. She had moved into a bedroom in Shana’s house, and she noticed how Shana brightened while teaching the twins how to stick out their tongues. G wished that she lit up, too. When Cecil was over, he missed the goofy things G used to do, like weird dances and voices. “She didn’t really do that too much,” he told me. “She would say, ‘Stop, I’m not in the mood.’”

Pictures of G and Cecil in the girls’ room

For months, G and Cecil had been trying to find a place of their own in Copperas Cove, but without any credit history, they were poor candidates. In early 2021, they were finally approved for a big, two-bedroom Section 8 apartment, at $583 a month. Cecil was working as an overnight stocker at H-E-B and slept during the day; almost all of the parenting fell to G. At times, the babies’ giggles made her laugh, and she loved how, in the middle of their fits, if she sang opera-style, they would break out in smiles. Still, she was struck with rageful fantasies. Her primary care doctor had diagnosed her with postpartum depression, but medication wasn’t helping. Once, she found herself squeezing their fleshy bodies to stop them from crying. Sometimes, she was haunted by images of smothering them with a pillow or chucking them across the room. I shouldn’t be alone with these kids, she thought. I’m an unstable mother. She couldn’t tell anyone, and she was doing her best to control her anger. If Child Protective Services were called, she worried that her girls might be placed with someone who could not restrain herself. “You have to live with these fantasies,” she told me. “You’re told to shut up and deal with it.”

Although G had applied for Temporary Assistance for Needy Families, the safety net program for low-income parents, she was denied because their household income exceeded the $231 monthly threshold. Cecil covered the rent, fast food, utilities and their car payments, but G wanted an income of her own. Rachel and Michael Borego, the parents of a friend, offered to watch the babies at their home on the weekends, allowing G to get a job as a waitress. G kept asking Cecil to help clean, at least wash his own dishes. He complained about his exhaustion and her nagging; he felt that he had lost his dream to build a streetwear brand and that he couldn’t meet the impossible expectations of fatherhood. “I feel like a single mother already,” G wrote to Cecil in a letter. “I love you for just being there, holding me and giving me a slice of peace that I didn’t think existed, but I’m not happy.”

That spring, G found herself stuck on TikTok, addicted to videos about “the simulation theory” — a conspiracy that we’re all living in a kind of Matrix. G felt so cratered by her own powerlessness that the world around her had stopped feeling real. Even her ties to her former self were slipping away, she wrote in her journal. “I used to have fire in my eyes, I used to be the strongest fighter I know.” Now it seemed that her discipline, her ability to hustle for the future, was pointless. Cecil wished he knew how to give her motivation.

In September, G and Cecil broke up, but because G couldn’t afford to leave, she moved into the closet in the girls’ bedroom, sleeping on a mattress next to diapers. She watched herself slipping into behaviors she had seen in her mother: the bouts of anger, the deep retreats. “I’m trying to get me back,” she wrote. “I want to be bubbly, outgoing again.” Shortly after, G moved into the Boregos’ red brick home with the twins. She got a job at a call center, making $480 a week. The average cost of child care for one infant in Texas is about $190 a week; she couldn’t afford to send two. Instead, G and Cecil split the cost of a babysitter. Rachel, who worked in accounts payable, and Michael, a technician for AT&T, bought the girls clothes and books and toys.

For months, G had been doing her best to push down suicidal thoughts, but now they were coming back stronger and more frequently. “I know that my kids need me, but I need to be done.” After she drafted a goodbye letter to her girls and slipped it behind a framed sonogram, she knew she needed help. Rachel agreed to take care of the babies if G signed a power of attorney. On Nov. 11, 2021, a month shy of the twins’ first birthday, G checked herself into Canyon Creek Behavioral Health, a nearby psychiatric hospital.

At Canyon Creek, the sterile rooms were quiet and still. G talked with a doctor about her mother, whom she called her “birth giver,” and when she discussed her children, she agonized over not having “the mom gene.” A doctor diagnosed her with major depressive disorder and post-traumatic stress disorder, prescribing new medications. “I miss my girls,” she wrote. “Not the crying lol. But I miss their smiles, I miss their sweet hugs & when they lay their heads down (on me).” She was there, she reminded herself, so the twins could have a strong role model, but the shame of leaving, of taking time for herself, wouldn’t go away. “I feel like I’m hurting the girls by doing this, disappearing,” she wrote. “I feel like all I do is hurt them.”

Later that month, when G returned to the Boregos’ house, Rachel began to wonder if G wanted to be a mother. For G, it was no longer that simple. To prepare for Christmas, she had started working four jobs: taking orders at McDonald’s, cleaning the kitchen at Monty’s BBQ, delivering for DoorDash and selling plasma for extra cash. Even then, she wasn’t earning what she needed to raise her girls on her own; Cecil’s work schedule allowed him to take them only two days a week. In the thick of that stress, when she worried that her girls were absorbing her negativity, she hid in her bedroom to protect them from it.

In February, Rachel and Michael approached G with an idea. They could tell that she wasn’t happy, and they were willing to take care of the girls for six months if G wanted space to get her life on a steadier path. They could settle on a more permanent arrangement after that. They had fallen in love with the girls, they said, and if G wanted to relinquish custody, they would try to adopt them right away.

Despite G’s fear that the Boregos wanted to take the twins from her, she couldn’t deny that she felt relief. “I’m not ready to give the girls up,” G told the Boregos. She usually speaks with a flat affect, but Rachel noticed her eyes tearing up. She wanted to move out for a trial. She packed her bags and left that night.

G working a delivery shift at Papa Johns

Whenever G’s friends asked how she was doing, she was torn between the desire to say the truth — that she was angry at herself, the government that made her have children, the expectation that she would love being a mother — and the similarly strong desire to deflect, so she wouldn’t be seen as a bad mom. The times she tried to talk about her frustration, she knew she elicited disdain, as if she had done this to herself. Almost no one showed her sympathy for being a single teenage mother.

Self-destructive, dependent on the state, doomed to failure — those are the stereotypes that have come to characterize teenage mothers since the moral panic of the 1970s. But what both liberals and conservatives miss in their legislative efforts is the research that has left a growing group of sociologists, demographers and economists with a different conclusion about the relationship between early childbearing and poverty. Frank Furstenberg, an emeritus professor at the University of Pennsylvania, ran a three-decade-long study on teenage mothers, beginning in the mid-1960s; his first substantive results, which came in during the 1970s, challenged widely held assumptions, even his own. A great majority of youths who become pregnant are, like G, already living in low-income neighborhoods with underperforming schools and low-wage job prospects. The consequences ascribed to teenage mothers are not so much a function of becoming pregnant as they are a function of growing up in poverty. Teenage motherhood isn’t the root cause but rather an indicator.

Since the 1990s, the teenage pregnancy rate has declined drastically — more than 70% — in part because of less sex among youths and increased use of quality birth control. With the new combination of the Dobbs decision and entrenched parental-involvement laws, though, many social scientists expect that, for teenagers who do become pregnant, the birth rate will rise again soon. By and large, these mothers will be adolescents, like G, who grew up poor. What policymakers and researchers have not yet studied are the financial and psychological consequences of parental-involvement laws that force these teenagers into early motherhood.

Today many states that legally defend the right to an abortion for adults still limit that right for teenagers. Maryland enforces a soft version of parental notification, allowing physicians, rather than judges, to determine if a minor is mature enough to make this choice or if an abortion is in their best interest. But Colorado, Michigan, New Hampshire, Pennsylvania and Rhode Island all enforce standard parental-involvement laws. In some, legal networks have sprung up to help guide teenagers through the judicial-bypass process. The Women’s Law Project, which provides representation in Allegheny County in Pennsylvania, receives about two calls a week for help with hearings across the state, but Sophia Elliot, one of its staff attorneys, told me that there aren’t enough trained lawyers in most counties to meet the need. It’s not clear that all the teenagers who are looking for help ever find her organization. “There is always a question of, Who are we not seeing?” she told me. “Oftentimes, the failures in this system are silent.”

As the Supreme Court has shifted to the right in recent years, states have begun to diverge on parental-involvement laws. A few have tightened their restrictions — switching from laws that require parental notification to those that require consent, or mandating that teenagers file petitions in their home counties rather than in more progressive cities, or demanding that minors show “clear and convincing evidence” of their maturity, rather than a “preponderance of evidence.” But three states have liberalized their restrictions. Last year, Illinois repealed its parental-notification law. This summer, a Minnesota District Court judge ruled that the state law that required both parents be notified of their child’s abortion decision violated the state constitution. In Massachusetts in 2020, advocates including the state’s NARAL affiliate at the time tried to eliminate the law there. Although their effort fell short of a full repeal, Massachusetts did change its statute so that it now applies only to those who are 15 and younger.

Elizabeth Janiak, an assistant professor at Harvard Medical School whose research on the Massachusetts law helped inform the Legislature, told me that even changing the statute was politically challenging. Parental-involvement laws, she now believes, will not go away any time soon, even in firmly blue states. “From what we saw here in Massachusetts, and how sensitive this law was for legislators, it wouldn’t surprise me if these abortion restrictions were the last to go.”

G in her loft bed in November

When I visited G in May, she was living on Shana’s property in a one-bedroom camper, which the Boregos helped her buy. She was calmer than I had ever seen her, more focused. Twinkle lights dangled from the ceiling, and scented candles lined her dresser. The camper had no water yet, so G used the bushes as her bathroom, and because the roof leaked when it rained, she had lined the floor with towels.

We went outside, where G sat on a swing under the canopy of an oak tree. She wasn’t sure what to do. G didn’t have room for the girls in her RV. She had 83 cents in her bank account, and if her children were with her, she wouldn’t be able to feed or even bathe them. There was no way that she could give them what the Boregos could: a big house, their own bedroom, routine affection. She was waiting for a pro bono lawyer to answer her questions about possibly giving guardianship rights to the Boregos. She was scared that if she did, she might lose the girls forever, that she would regret this down the line, the same way she now regretted continuing her pregnancy. She would also have to talk with Cecil, who still cared for the girls two or three days a week and could petition the court for full rights. He’s capable of being more involved, so is he the better parent? she wondered. She was ashamed, she said. She was still doubting her ability to do the one thing her mother did do: keep her child. “I was never ready for this, and I knew that,” she said. “I tried telling people, and they didn’t listen.”

Her six-month trial with the Boregos ended in August, but G still wasn’t prepared to make a decision. Instead, she extended the trial, signing a new power of attorney. The Boregos have moved to a larger house, 30 minutes away, and every few weeks, G visits her children, though it’s painful to see them. When she walks through the door, the girls no longer run up to hug her. Their distance stings, but she knows that it stems from her absence. She keeps missing more firsts, she told me: their first steps, their first sentences, the first time one of them asked, “What’s up?”

Several weeks ago, G texted me in the middle of the night, worried: She could give up her parental rights, as her father did, or she could raise her children without the stability or the warmth that they deserve, as her mother did. In her own experience, both left her feeling abandoned, unloved. She didn’t know which one was worse.

G, with the twins and Rachel and Michael Borego

Are You in a State That Banned Abortion? Tell Us How Changes in Medical Care Impact You.

Doris Burke contributed research.

by Ava Kofman

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This story is exempt from our Creative Commons license until Feb. 3, 2023.

Over the years, Marsha Farmer had learned what to look for. As she drove the back roads of rural Alabama, she kept an eye out for dilapidated homes and trailers with wheelchair ramps. Some days, she’d ride the one-car ferry across the river to Lower Peach Tree and other secluded hamlets where a few houses lacked running water and bare soil was visible beneath the floorboards. Other times, she’d scan church prayer lists for the names of families with ailing members.

Farmer was selling hospice, which, strictly speaking, is for the dying. To qualify, patients must agree to forgo curative care and be certified by doctors as having less than six months to live. But at AseraCare, a national chain where Farmer worked, she solicited recruits regardless of whether they were near death. She canvassed birthday parties at housing projects and went door to door promoting the program to loggers and textile workers. She sent colleagues to cadge rides on the Meals on Wheels van or to chat up veterans at the American Legion bar. “We’d find run-down places where people were more on the poverty line,” she told me. “You’re looking for uneducated people, if you will, because you’re able to provide something to them and meet a need.”

Farmer, who has doe eyes and a nonchalant smile, often wore scrubs on her sales routes, despite not having a medical background. That way, she said, “I would automatically be seen as a help.” She tried not to mention death in her opening pitch, or even hospice if she could avoid it. Instead, she described an amazing government benefit that offered medications, nursing visits, nutritional supplements and light housekeeping — all for free. “Why not try us just for a few days?” she’d ask families, glancing down at her watch as she’d been trained to do, to pressure them into a quick decision.

Once a prospective patient expressed interest, a nurse would assess whether any of the person’s conditions fit — or could be made to fit — a fatal prognosis. The Black Belt, a swath of the Deep South that includes parts of Alabama, has some of the highest rates of heart disease, diabetes and emphysema in the country. On paper, Farmer knew, it was possible to finesse chronic symptoms, like shortness of breath, into proof of terminal decline.

When Farmer started out in the hospice business, in 2002, it felt less like a sales gig than like a calling. At 30, she’d become a “community educator,” or marketer, at Hospice South, a regional chain that had an office in her hometown, Monroeville, Alabama. Monroeville was the kind of place where, if someone went into hospice, word got around and people sent baked goods. She often asked patients to write cards or make tape recordings for milestones — birthdays, anniversaries, weddings — that they might not live to see. She became an employee of the month and, within a year, was promoted to executive director of the branch, training a staff of her own to evangelize for end-of-life care.

Things began to change in 2004, when Hospice South was bought by Beverly Enterprises, the second-largest nursing-home chain in the country, and got folded into one of its subsidiaries, AseraCare. Not long before the sale, Beverly had agreed to pay a $5 million criminal fine and a $175 million civil settlement after being accused of Medicare fraud. Its stock value had slumped, and Beverly’s CEO had decided that expanding its empire of hospices would help the company attract steadier revenue in “high-growth, high-margin areas of health care services.” Less than two years later, as part of a wave of consolidations in the long-term-care industry, Beverly was sold to a private-equity firm, which rebranded it as Golden Living.

It might be counterintuitive to run an enterprise that is wholly dependent on clients who aren’t long for this world, but companies in the hospice business can expect some of the biggest returns for the least amount of effort of any sector in American health care. Medicare pays providers a set rate per patient per day, regardless of how much help they deliver. Since most hospice care takes place at home and nurses aren’t required to visit more than twice a month, it’s not difficult to keep overhead low and to outsource the bulk of the labor to unpaid family members — assuming that willing family members are at hand.

Up to a point, the way Medicare has designed the hospice benefit rewards providers for recruiting patients who aren’t imminently dying. Long hospice stays translate into larger margins, and stable patients require fewer expensive medications and supplies than those in the final throes of illness. Although two doctors must initially certify that a patient is terminally ill, she can be recertified as such again and again.

Almost immediately after the AseraCare takeover, Farmer’s supervisors set steep targets for the number of patients marketers had to sign up and presented those who met admissions quotas with cash bonuses and perks, including popcorn machines and massage chairs. Employees who couldn’t hit their numbers were fired. Farmer prided herself on being competitive and liked to say, “I can sell ice to an Eskimo.” But as her remit expanded to include the management of AseraCare outposts in Foley and Mobile, she began to resent the demand to bring in more bodies. Before one meeting with her supervisor, Jeff Boling, she stayed up late crunching data on car wrecks, cancer and heart disease to figure out how many people in her territories might be expected to die that year. When she showed Boling that the numbers didn’t match what she called his “ungodly quotas,” he was unmoved. “If you can’t do it,” she recalled him telling her, “we’ll find someone who can.”

Farmer’s bigger problem was that her patients weren’t dying fast enough. Some fished, drove tractors and babysat grandchildren. Their longevity prompted concern around the office because of a complicated formula that governs the Medicare benefit. The federal government, recognizing that an individual patient might not die within the predicted six months, effectively demands repayment from hospices when the average length of stay of all patients exceeds six months.

But Farmer’s company, like many of its competitors, had found ways to game the system and keep its money. One tactic was to “dump,” or discharge, patients with overly long stays. The industry euphemism is “graduated” from hospice, though the patient experience is often more akin to getting expelled: losing diapers, pain medications, wheelchairs, nursing care and a hospital-grade bed that a person might not otherwise be able to afford. In 2007, according to Farmer’s calculations around the time, 70% of the patients served by her Mobile office left hospice alive.

Another way to hold on to Medicare money was to consistently pad the roster with new patients. One day in 2008, facing the possibility of a repayment, AseraCare asked some of its executive directors to “get double digit admits” and to “have the kind of day that will go down in the record books.” A follow-up email, just an hour later, urged staff to “go around the barriers and make this happen now, your families need you.”

Former AseraCare employee Marsha Farmer (Edmund Fountain for ProPublica)

That summer, Boling pushed Farmer to lobby oncologists to turn over their “last breath” patients: those with only weeks or days to live. At the time, Farmer’s 59-year-old mother was dying of metastatic colon cancer. Although Farmer knew that the service might do those last-breath people good, it enraged her that her hospice was chasing them cynically, to balance its books. The pressure was so relentless that sometimes she felt like choking someone, but she had two small children and couldn’t quit. Her husband, who had been a co-worker at AseraCare, had already done so. Earlier that year, after fights with Boling and other supervisors about quotas, he had left for a lower-paying job at Verizon.

Farmer’s confidante at work, Dawn Richardson, shared her frustration. A gifted nurse who was, as Farmer put it, “as country as a turnip,” Richardson hated admitting people who weren’t appropriate or dumping patients who were. She was a single mom, though, and needed a paycheck. One evening in early 2009, the two happened upon another way out.

The local news was reporting that two nurses at SouthernCare, a prominent Alabama-based competitor, had accused the company of stealing taxpayer dollars by enrolling ineligible patients in hospice. SouthernCare, which admitted no wrongdoing, settled with the Justice Department for nearly $25 million, and the nurses, as whistle-blowers, had received a share of the sum — $4.9 million, to be exact. Farmer and Richardson had long felt uneasy about what AseraCare asked them to do. Now, they realized, what they were doing might be illegal. They decided to call James Barger, a lawyer who had represented one of the SouthernCare nurses. That March, he helped Farmer and Richardson file a whistleblower complaint against AseraCare and Golden Living in the Northern District of Alabama, accusing the company of Medicare fraud. The case would go on to become the most consequential lawsuit the hospice industry had ever faced.

The philosophy of hospice was imported to the United States in the 1960s by Dame Cicely Saunders, an English doctor and social worker who’d grown appalled by the “wretched habits of big, busy hospitals where everyone tiptoes past the bed and the dying soon learn to pretend to be asleep.” Her counterpractice, which she refined at a Catholic clinic for the poor in East London, was to treat a dying patient’s “total pain” — his physical suffering, spiritual needs and existential disquiet. In a pilot program, Saunders prescribed terminally ill patients cocktails of morphine, cocaine and alcohol — whiskey, gin or brandy, depending on which they preferred. Early results were striking. Before-and-after photos of cancer patients showed formerly anguished figures knitting scarves and raising toasts.

Saunders’ vision went mainstream in 1969, when the Swiss-born psychiatrist Elisabeth Kübler-Ross published her groundbreaking study, “On Death and Dying.” The subjects in her account were living their final days in a Chicago hospital, and some of them described how lonely and harsh it felt to be in an intensive-care unit, separated from family. Many Americans came away from the book convinced that end-of-life care in hospitals was inhumane. Kübler-Ross and Saunders, like their contemporaries in the women’s-health and deinstitutionalization movements, pushed for greater patient autonomy — in this case, for people to have more control over how they would exit the world. The first American hospice opened in Connecticut in 1974. By 1981, hundreds more hospices had started, and, soon after, President Ronald Reagan recognized the potential federal savings — many people undergo unnecessary, expensive hospitalizations just before they die — and authorized Medicare to cover the cost.

Forty years on, half of all Americans die in hospice care. Most of these deaths take place at home. When done right, the program allows people to experience as little pain as possible and to spend meaningful time with their loved ones. Nurses stop by to manage symptoms. Aides assist with bathing, medications and housekeeping. Social workers help families over bureaucratic hurdles. Clergy offer what comfort they can, and bereavement counselors provide support in the aftermath. This year, I spoke about hospice with more than 150 patients, families, hospice employees, regulators, attorneys, fraud investigators and end-of-life researchers, and all of them praised its vital mission. But many were concerned about how easy money and a lack of regulation had given rise to an industry rife with exploitation. In the decades since Saunders and her followers spread her radical concept across the country, hospice has evolved from a constellation of charities, mostly reliant on volunteers, into a $22 billion juggernaut funded almost entirely by taxpayers.

For-profit providers made up 30% of the field at the start of this century. Today, they represent more than 70%, and between 2011 and 2019, research shows, the number of hospices owned by private-equity firms tripled. The aggregate Medicare margins of for-profit providers are three times that of their nonprofit counterparts. Under the daily-payment structure, a small hospice that bills for just 20 patients at the basic rate can take in more than a million dollars a year. A large hospice billing for thousands of patients can take in hundreds of millions. Those federal payments are distributed in what is essentially an honor system. Although the government occasionally requests more information from billers, it generally trusts that providers will submit accurate claims for payment — a model that critics deride as “pay and chase.”

Jean Stone, who worked for years as a program-integrity senior specialist at the Centers for Medicare and Medicaid Services, said that hospice was a particularly thorny sector to police for three reasons: “No one wants to be seen as limiting an important service”; it’s difficult to retrospectively judge a patient’s eligibility; and “no one wants to talk about the end of life.” Although a quarter of all people in hospice enter it only in their final five days, most of the Medicare spending on hospice is for patients whose stays exceed six months. In 2018, the Office of Inspector General at the Department of Health and Human Services estimated that inappropriate billing by hospice providers had cost taxpayers “hundreds of millions of dollars.” Stone and others I spoke to believe the figure to be far higher.

Some hospice firms bribe physicians to bring them new patients by offering all-expenses-paid trips to Las Vegas nightclubs, complete with bottle service and private security details. (The former mayor of Rio Bravo, Texas, who was also a doctor, received outright kickbacks.) Other audacious for-profit players enlist family and friends to act as make-believe clients, lure addicts with the promise of free painkillers, dupe people into the program by claiming that it’s free home health care or steal personal information to enroll “phantom patients.” A 29-year-old pregnant woman learned that she’d been enrolled in Revelation Hospice, in the Mississippi Delta (which at one time discharged 93% of its patients alive), only when she visited her doctor for a blood test. In Frisco, Texas, according to the FBI, a hospice owner tried to evade the Medicare-repayment problem by instructing staff to overdose patients who were staying on the service too long. He texted a nurse about one patient: “He better not make it tomorrow. Or I will blame u.” The owner was sentenced to more than 13 years in prison for fraud, in a plea deal that made no allegations about patient deaths.

A medical background is not required to enter the business. I’ve come across hospices owned by accountants; vacation-rental superhosts; a criminal-defense attorney who represented a hospice employee convicted of fraud and was later investigated for hospice fraud himself; and a man convicted of drug distribution who went on to fraudulently bill Medicare more than $5 million for an end-of-life-care business that involved handling large quantities of narcotics.

Once a hospice is up and running, oversight is scarce. Regulations require surveyors to inspect hospice operations once every three years, even though complaints about quality of care are widespread. A government review of inspection reports from 2012 to 2016 found that the majority of all hospices had serious deficiencies, such as failures to train staff, manage pain and treat bedsores. Still, regulators rarely punish bad actors. Between 2014 and 2017, according to the Government Accountability Office, only 19 of the more than 4,000 U.S. hospices were cut off from Medicare funding.

Because patients who enroll in the service forgo curative care, hospice may harm patients who aren’t actually dying. Sandy Morales, who until recently was a case manager at the California Senior Medicare Patrol hotline, told me about a cancer patient who’d lost access to his chemotherapy treatment after being put in hospice without his knowledge. Other unwitting recruits were denied kidney dialysis, mammograms, coverage for lifesaving medications or a place on the waiting list for a liver transplant. In response to concerns from families, Morales and her community partners recently posted warnings in Spanish and English in senior apartment buildings, libraries and doughnut shops across the state. “Have you suddenly lost access to your doctor?” the notices read. “Can’t get your medications at the pharmacy? Beware! You may have been tricked into signing up for a program that is medically unnecessary for you.”

Some providers capitalize on the fact that most hospice care takes place behind closed doors, and that those who might protest poor treatment are often too sick or stressed to do so. One way of increasing company returns is to ghost the dying. A 2016 study in JAMA Internal Medicine of more than 600,000 patients found that 12% received no visits from hospice workers in the last two days of life. (Patients who died on a Sunday had some of the worst luck.) For-profit hospices have been found to have higher rates of no-shows and substantiated complaints than their nonprofit counterparts, and to disproportionately discharge patients alive when they approach Medicare’s reimbursement limit.

“There are so many ways to do fraud, so why pick this one?” Stone said. This was more or less what Marsha Farmer and Dawn Richardson had been wondering when they filed their complaint against AseraCare in 2009. Now, working undercover, they imagined themselves as part of the solution.

In the absence of guardrails, whistleblowers like Farmer and Richardson have become the government’s primary defense against hospice wrongdoing — an arrangement that James Barger, their lawyer, describes as placing “a ludicrous amount of optimism in a system with a capitalist payee and a socialist payer.” Seven out of 10 of the largest hospices in the U.S. have been sued at least once by former employees under the federal False Claims Act. The law includes a “qui tam” provision — the term derives from a Latin phrase that translates as “he who sues on behalf of the King as well as himself ” — that deputizes private citizens to bring lawsuits that accuse government contractors of fraud and lets them share in any money recovered. Qui-tam complaints, like Farmer and Richardson’s, are initially filed secretly, under seal, to give the Justice Department a chance to investigate a target without exposing the tipster. If the government decides to proceed, it takes over the litigation. In 2021 alone, the government recovered more than $1.6 billion from qui-tam lawsuits, and the total amount awarded to whistleblowers was $237 million.

In the two years after Farmer and Richardson filed their complaint, both slept poorly. But their covert undertaking also felt cathartic — mental indemnification against a job that troubled their consciences. Farmer continued to bring in patients at AseraCare while passing company documents to Barger, including spreadsheets analyzing admissions quotas and a training PowerPoint used by the company’s national medical adviser, Dr. James Avery. A pulmonologist who was fond of citing Seneca, Tolstoy and Primo Levi in his slides, Avery urged nurses to “be a detective” and to “look for clues” if a patient didn’t initially appear to fit a common hospice diagnosis. (Avery said that he never encouraged employees to admit ineligible patients.) He sometimes concluded his lectures with a spin on an idea from Goethe’s “Faust”: “Perpetual striving that has no goal but only progress or increase is a horror.”

Barger was impressed by the records that Farmer collected and even more so by her candor about her involvement in AseraCare’s schemes. She and Richardson reminded him of friends he’d had growing up: smart, always finishing each other’s sentences and not, he said, “trying to be heroes.” Nor, as it turned out, were they the only AseraCare employees raising questions about company ethics. The year before, three nurses in the Milwaukee office had filed a qui-tam complaint outlining similar corporate practices. The False Claims Act has a “first to file” rule, so the Wisconsin nurses could have tried to block Farmer and Richardson from proceeding with their case. Instead, the nurses decided to team up with their Alabama colleagues, even if it meant that they’d each receive a smaller share of the potential recovery. Also joining the crew was Dr. Joseph Micca, a former medical director at an AseraCare hospice in Atlanta. Every hospice is required to hire or contract with a doctor to sign forms certifying a patient’s eligibility for the program, and Micca accused the company of both ineligible enrollments and lapses in patient care. In his deposition, he described one patient who was given morphine against his orders and was kept in hospice care for months after she’d recovered from a heart attack. The woman, who was eventually discharged, lived several more years.

Whistleblower lawyer James Barger (Kate Medley for ProPublica)

Among the most critical pieces of evidence to emerge in the discovery process was an audit that echoed many of the allegations made by the whistleblowers. In 2007 and 2008, AseraCare had hired the Corridor Group, a consulting firm, to visit nine of its agencies across the country, including the Monroeville office that Farmer oversaw. The Corridor auditors observed a “lack of focus” on patient care and “little discussion of eligibility” at regular patient-certification meetings. Clinical staff were undertrained, with a “high potential for care delivery failures,” and appeared reluctant to discharge inappropriate patients out of fear of being fired. Emails showed that the problems raised by the audit were much discussed among AseraCare’s top leadership, including its vice president of clinical operations, Angie Hollis-Sells.

One morning in the spring of 2011, Hollis-Sells strode into the old bank building that housed the Monroeville office, her expression uncommonly stern. Farmer knew at once that her role in the case had been exposed. She was sent home on paid leave, and that evening half a dozen colleagues showed up at her clapboard house in the center of town. Some felt betrayed. Their manager had kept from them a secret that might upend their livelihoods; worse, her accusations seemed to condemn them for work she’d asked them to do. But shortly afterward, when Farmer took a job as the executive director of a new hospice company in Monroeville, Richardson and several other former co-workers joined her.

Less than a year later, the Justice Department, after conducting its own investigation, intervened in the whistleblowers’ complaint, eventually seeking from AseraCare a record $200 million in fines and damages. As Barger informed his clients, the company was likely to settle. Most False Claims Act cases never reach a jury, in part because trials can cost more than fines and carry with them the threat of exclusion from the Medicare program — an outcome tantamount to bankruptcy for many medical providers. In 2014, Farmer traveled to Birmingham for her deposition, imagining that the case would soon end. But, in the first of a series of unexpected events, AseraCare decided to fight.

United States v. AseraCare, which began on Aug. 10, 2015, in a federal courthouse in Birmingham, was one of the most bizarre trials in the history of the False Claims Act. To build its case against AseraCare, the government had identified some 2,100 of the company’s patients who had been in hospice for at least a year between 2007 and 2011. From that pool, a palliative care expert, Dr. Solomon Liao, of the University of California, Irvine, reviewed the records of a random sample of 233 patients. He found that around half of the patients in the sample were ineligible for some or all of the hospice care they’d received. He also concluded that ineligible AseraCare patients who had treatable or reversible issues at the root of their decline were unable to get the care they needed, and that being in hospice “worsened or impeded the opportunity to improve their quality of life.”

Before the trial started, the judge in the case, Karon O. Bowdre, disclosed that she’d had good experiences with hospice. Her mother, who had an ALS diagnosis, had spent a year and a half on the service, and her father-in-law had died in hospice shortly before the trial. Principals in the case disagree about whether she disclosed that the firm handling AseraCare’s defense, Bradley Arant, had just hired her son as a summer associate.

The defense team had petitioned Bowdre to separate the proceedings into two parts: the first phase limited to evidence about the “falsity” of the 123 claims in question, and the second part examining, among other things, the company’s “knowledge of falsity.” The Justice Department objected to this “arbitrary hurdle,” arguing that the purpose of the False Claims Act was to combat intentional fraud, not accidental mistakes. “The fact that AseraCare knowingly carried out a scheme to submit false claims is highly relevant evidence that the claims were, in fact, false,” the government wrote. Nonetheless, in an unprecedented legal move, Bowdre granted AseraCare’s request.

Trial lawyers are expected to squabble over the relevance of the opposing party’s evidence — and, in the private sector, they are compensated handsomely for doing so. But the government lawyers seemed genuinely confused about what the judge would and wouldn’t allow into the courtroom during the trial’s “falsity” phase. In long sidebar discussions, during which jurors languished and white noise was piped in through the speakers, Bowdre berated the prosecution for its efforts to “poison the well” with “all this extraneous stuff that the government wants to stir up to play on the emotions of the jury.” Much of her vexation was directed at Jeffrey Wertkin, one of the Justice Department’s top picks for difficult fraud assignments. A prosecutor in his late 30s, he had a harried, caffeinated air about him and had helped bring about settlements in more than a dozen cases. This was only his second trial, however, and Bowdre was reprimanding him like a schoolboy. “It made me sick to watch her treatment of him,” Henry Frohsin, one of Barger’s partners, recalled. “At some point, I couldn’t watch it, so I just got up and left.”

The judge’s prohibition on “knowledge” during the trial’s first phase constrained testimony in sometimes puzzling ways. Richardson, for instance, could talk about admitting patients, but she couldn’t allude to the pressure she was under to do so. The audit by the Corridor Group that corroborated whistleblower claims was forbidden because it wasn’t directly tied to the specific patients in the government’s sample. Micca, the former medical director from Atlanta, was not allowed to testify for the same reason. Nonetheless, over several days, the government’s witnesses managed to paint a picture of AseraCare’s cavalier attitude toward patient eligibility. Its medical directors were part time, as is common in the industry, and workers testified that they’d presented these doctors with misleading patient records to secure admissions. One said that a director had pre-signed blank admissions forms. “Ask yourself: How could a doctor be exercising their clinical judgment,” Wertkin told the jury at one point, “if he’s signing a blank form?”

When Farmer took the stand, Wertkin asked if she was nervous. “A lot nervous today,” she replied. She thought the jurors might judge her for trolling for wheelchair ramps or other recruitment tactics. She needn’t have worried. Bowdre’s restrictions prevented Farmer from testifying about much of anything. “I felt like the judge did not want to know the truth,” she said. “The whole time that I was on the stand, I kept thinking, Why would you not listen to the story?”

The bulk of phase one was dominated by doctors: Liao, the government’s expert, read selections from thousands of pages of medical files to explain why he’d concluded that patients were ineligible, and AseraCare’s medical experts took the stand and disagreed with most of his conclusions. However, the crux of AseraCare’s defense was that the entire debate about eligibility was essentially moot because, although death is certain, its timing is not. A medical director who signed a hospice certification form would have had no way of anticipating whether a patient’s illness would deviate from the expected trajectory of decline. Even Medicare, the defense team emphasized, has noted that predicting life expectancy is “not an exact science.”

After nearly two months of testimony, the jurors deliberated for nine days on phase one. On Oct. 15, 2015, they found 86% of the patient sample ineligible for some period of hospice care. Elated, Barger rushed out of the courtroom to call Farmer and tell her that the jury had come back overwhelmingly in the government’s favor. The next part of the trial will be icing on the cake, she remembers thinking.

The next part never happened. A few days later, Bowdre made a startling announcement: She had messed up. The instructions that she’d given the jury had been incomplete, she said, and because of this “major reversible error” she was overturning the jury’s findings and granting a request by AseraCare for a new trial. She invited the government to submit evidence other than Liao’s opinion to prove that the claims were false; the government replied that the record presented ample evidence of falsity. Five months later, in March 2016, Bowdre granted summary judgment to AseraCare.

It’s unusual for a judge to overturn a jury’s findings, order a new trial and then declare summary judgment on her own accord, Zack Buck, a legal scholar at the University of Tennessee who studies health care fraud, told me. The case, he said, “just kept getting weirder.” Wertkin, who had expected to return to Washington, D.C., with that rare article — a jury verdict in a False Claims Act case — later said he felt as though the “rug had been ripped out from under me.”

In a widely circulated opinion, Bowdre wrote that clinical disagreement among doctors was not enough on its own to render a claim false. Otherwise, hospice providers would be subject to liability “any time the Government could find a medical expert who disagreed” with their physician, and “the court refuses to go down that road.” The Justice Department appealed Bowdre’s ruling, but many in the hospice industry celebrated the opinion. “There are huge implications,” Buck said. “So much of our system is based on a doctor’s discretion, and if you can’t say the doctor is wrong you’ve really hamstrung the government’s ability to bring these kinds of cases.” In op-eds and on the lecture circuit, defense lawyers for health care companies hailed the beginning of a post-AseraCare era.

Family practitioner Scott Nelson (Edmund Fountain for ProPublica)

That year, Dr. Scott Nelson, a family practitioner in Cleveland, Mississippi, was wrapping up a lucrative tour of duty in the hospice trade. Since 2005, Nelson had referred approximately 763 patients to 25 hospices, 14 of which employed him as the medical director, according to a special agent in the Department of Health and Human Services’ Office of Inspector General. Some of Nelson’s patients, however, didn’t know that they were dying and a decade or more later remained stubbornly alive.

In the course of roughly six years, by the doctor’s own account, he received around $400,000 for moonlighting as the medical director at eight of the companies. Meanwhile, those hospice owners, some of whom were related to one another, received a total of more than $15 million from Medicare for the patients he’d certified. In a scheme that the special agent, Mike Loggins, later testified was spreading across the Mississippi Delta “like cancer,” hospices bused in vans of people to Nelson’s clinic. The owner of Word of Deliverance Hospice — one small-town provider that briefly put Nelson on its payroll — bought a $300,000 Rolls-Royce that was later confiscated by the government. Nelson, who was convicted earlier this year of seven counts of health care fraud, told me that he’d fallen victim to greedy hospice entrepreneurs who had done hundreds of “third-grader-level forgeries” of his signature when racking up illegal enrollments, and that he’d assumed other forms he’d signed were truthful. Nelson awaits sentencing and has filed a motion challenging the verdict.

The Mississippi Delta has an acute shortage of primary-care providers — a problem that contributes to the region’s poor health outcomes. When I visited some of the fraud victims in the case, all of whom were Black, they told me that the experience of being duped had deepened their mistrust of a health care system that already seemed out of reach. Some of the patients Nelson had approved for hospice were in their 40s and 50s. One had cognitive disabilities, and another couldn’t read. Marjorie and Jimmie Brown, former high school sweethearts in their 70s, found out that they had been enrolled in Lion Hospice only in 2017, when Loggins knocked on the front door of their yellow brick bungalow. A worker for Lion had tricked the Browns into trading away their right to curative care, and Nelson — whom they’d never heard of, let alone seen — was one of two doctors whose names were on the paperwork.

Losing access to care is hardly the only thing that can go wrong for patients inappropriately assigned to hospice. In May 2016, Lyman Marble found his wife, Patricia, unresponsive and lying face down in their bed. At a hospital near their home in Whitman, Massachusetts, doctors were shocked by the high doses of opiates she’d been prescribed. An addiction specialist later observed that she was ingesting the equivalent of dozens of Percocet pills a day. Only after Lyman told the doctors to “flush her out like Elvis” did her family come to suspect that her health crisis was caused by hospice care itself.

The Marbles, who had been married for more than 50 years, worked together in a variety of jobs, among them operating an outer-space-themed carnival ride. Five years earlier, Patricia had been admitted to a hospice owned by Amedisys, the third-largest provider in the country. The diagnosis was end-stage chronic obstructive pulmonary disease.

She was 70 years old and had health troubles: She used a wheelchair and supplemental oxygen, and had diabetes, hypertension and a benign tumor that caused her pain. That pain had been treated by a fentanyl patch, but once she was in hospice the medical director, Dr. Peter Roos, prescribed morphine, Vicodin, Ativan and gabapentin, too. Over the next five years, he kept prescribing narcotics, recertifying her for hospice 30 times. (Roos, who said in a deposition that he prescribed morphine to ease Marble’s respiratory distress, did not respond to requests for comment.) Court documents later revealed that cash bonuses were a reward for good enrollment numbers at that branch of Amedisys, and that nurses had resigned after being pressured to admit and recertify patients who they didn’t think were dying.

Patricia Marble and her husband, Lyman (Melissa Lyttle for ProPublica)

While under the care of Amedisys, Patricia sometimes couldn’t remember who or where she was. “I felt like I was dead,” she later said. “It just made me feel like ‘That’s right, I’m in the right place because I’m going to die.’” But after Lyman learned that he could “fire hospice,” as he put it, and Patricia was slowly weaned from narcotics, her memory began to return and her breathing improved. Lyman, who had thought that he might lose his wife at any moment (at one point, Amedisys had asked if he was making funeral arrangements), was stunned by her transformation. Today, more than a decade after first enrolling in hospice, Patricia remains opioid-free and has described her lost years as like being on “the moon or someplace.” For that misadventure, the company billed Medicare almost half a million dollars. Last year, Amedisys settled a suit brought by the Marbles for $7.75 million. The company declined to comment, stating that the settlement was confidential.

Because pinpointing what constitutes a “good death” is nearly as difficult as determining what makes a good life, families may not always realize when hospice is failing them — even when they work in the industry. In November 2014, Carl Evans, a 77-year-old former janitor from Orange County, took a fall and, when hospitalized, was tentatively diagnosed as having end-stage thymus cancer. Soon after, he was discharged to a nursing home and enrolled in a hospice run by Vitas, one of the largest providers of end-of-life care in the United States. Andrea Crawford, one of his daughters, was a hospice nurse and had worked for the company early in her career. When she visited her father in his private room, which had a sofa and a flat-screen TV, he told her that he was being treated “like a king.”

Evans had been living independently, with his longtime girlfriend, before his fall. And, unlike many hospice patients, he remained mobile and gregarious, with a big appetite much noted in his charts. Early in the morning of Nov. 22, in search of a non-institutional meal, he climbed out a window and got on a bus to his girlfriend’s house. (His preferred ride, a lovingly maintained burgundy Trans Am, was unavailable.) A family friend eventually located him, 30 miles away.

On Evans’ return, Dr. Thomas Bui, a medical director at Vitas, placed an urgent order for him to receive phenobarbital, a barbiturate that is sometimes prescribed for agitation and can cause extreme drowsiness. A few days later, Vitas records show, Bui added Keppra, an anti-seizure medication that also has sedative properties, to the mix. Evans had no known history of seizures, and Crawford later suspected that the two drugs had been prescribed to subdue him for the convenience of the staff. After the addition of Keppra, his chart shows, Evans became wobbly on his feet and then so lethargic that he couldn’t get out of bed — though he remained alert enough to be terrified at his sudden decline. Crawford, concerned, attributed the change to the drugs he was taking, as did a Vitas employee, according to medical records. On Dec. 6, Evans died.

A photo of Carl Evans held by his daughter Andrea Crawford (Philip Salata for ProPublica)

The official cause of death was cancer (hospice patients are not typically given autopsies), but Evans’ family filed a suit against Vitas and Bui. The lawsuit was settled, and Vitas denies allegations of wrongdoing. Bui, who said in a deposition that he medicated Evans to soothe his agitation, didn’t respond to requests for comment. The California medical board disciplined him for his handling of the case. He was placed on a three-year probation, during which he was prohibited from practicing alone, and was ordered to take a course on safe prescribing.

Malpractice cases against hospices are rare. As Reza Sobati, an elder-abuse lawyer who represented Evans’ family, told me: “The defense we often get in a nursing home case is that they were going to die anyway from their issues. That’s even harder to overcome with hospice, since a doctor has literally certified it will happen.”

Afterward, as Crawford reviewed medical charts and tried to understand what had happened to her father, she came across some notes that surprised her. When Evans entered hospice, Vitas had certified him for a heightened level of care intended for patients with uncontrolled pain or severe and demanding symptoms, which Evans didn’t have. As a hospice nurse, Crawford knew that such coding allowed Vitas to bill Medicare more — roughly four times more — per day than the rate for a routine patient. (Vitas denies inappropriate billing.)

In 2016, not long after Judge Bowdre dismissed the AseraCare case, someone began to anonymously contact companies that were the subjects of sealed qui-tam complaints. Those sealed complaints named the whistleblowers and the details of their accusations — information that the accused companies could use to get ahead of government investigators and their subpoenas or possibly to intimidate informers into silence. When a general counsel at a tech firm returned the mysterious voicemail, the insider, who called himself Dan, offered to share a complaint that named the company in exchange for a “consulting fee” of $300,000, preferably paid in bitcoin.

The lawyer alerted the FBI and began recording his conversations with Dan, including one arranging the handoff of the documents in Silicon Valley. On the morning of Jan. 31, 2017, Dan texted an FBI agent posing as one of the tech company’s employees the address of a hotel in Cupertino and instructed him to sit in the lobby on “a chair with a newspaper on it” just past “the water station.” Moments after the undercover agent sat down, Dan approached him with a copy of the complaint and was arrested. It turned out that Dan, who the FBI said was disguised in a wig, was the former government prosecutor Jeffrey Wertkin.

By then, Wertkin had left the Department of Justice to become a partner at the elite law firm Akin Gump, a job that paid $450,000 a year. His bio on the company’s website noted that, after leading more than 20 fraud cases, he had “first-hand knowledge of the legal and practical considerations that shape government investigations.” As part of a plot that his former Justice Department colleagues termed “the most serious and egregious example of public corruption by a DOJ attorney in recent memory,” Wertkin had, on his way out the door, taken at least 40 sealed qui-tam complaints belonging to the Civil Fraud Section.

He later ascribed his short-lived criminal spree, which his defense team compared to “a scene out of a B-grade action movie,” to what had occurred in Judge Bowdre’s courtroom. Wertkin’s wife said in a letter to the court that he had returned home from the AseraCare trial a “shell of a man” who drank heavily and spent several days watching movies on his phone in bed. Wertkin, who pleaded guilty in 2017 and was sentenced to two and a half years in prison, wrote in a statement that the government’s reversal of fortune in the case had led him “to question things I never doubted before. Does the system even work?” At his sentencing hearing, a prosecutor argued that the False Claims Act itself was one of Wertkin’s victims. “The False Claims Act is incapable of deterring fraud if the Department of Justice can’t be trusted by whistleblowers,” she said. “We have no way of measuring what chilling impact there might be on whistleblowers based on what the defendant did in compromising their secrecy.”

On Sept. 9, 2019, the False Claims Act took a second hit when the U.S. Court of Appeals for the Eleventh Circuit published a long-anticipated ruling on the AseraCare case. The judges concurred with Bowdre that the government needed more than the testimony of an outside expert to prove a claim was false. However, they vacated Bowdre’s summary judgment, saying that the prosecution should have been able to present all its evidence, including AseraCare’s alleged “knowledge of falsity,” and sent the case back to her courtroom for a retrial. “When the goalpost gets moved in the final seconds of a game,” the judges wrote, “the team with the ball should, at the least, have one more opportunity to punch it into the endzone.”

The government did not appear enthusiastic about trying the AseraCare case for a second time before Bowdre, though. Wertkin had been disbarred and was serving his sentence, and some of his former colleagues had left for the private sector. In February, 2020, 11 years after Farmer and Richardson filed their complaint, the government reached a settlement with AseraCare for a million dollars. As in most such settlements, AseraCare paid the sum, admitted no wrongdoing and was allowed to keep billing Medicare. Jack Selden, a partner at Bradley Arant who worked on the defense team, told the trade journal Law360, “When a case settles for $1 million where the claims have been for over $200 million, I think that speaks for itself.”

From a certain point of view, Wertkin’s attempts to shake down government contractors made manifest the transactional logic that governs the False Claims Act. Even to some of their biggest beneficiaries, these qui-tam settlements have come to resemble a mutual-protection racket: Executives keep their jobs and their companies keep billing Medicare; whistleblowers and their lawyers get a cut; and Justice Department attorneys can cash in on their tough-on-fraud reputations by heading to white-shoe law firms to defend the companies they once prosecuted.

In 2020, not long after AseraCare settled with the government, the company was bought for $235 million by Amedisys, which was facing qui-tam troubles of its own. A nurse from an Amedisys office in South Carolina had filed a lawsuit accusing the corporation of admitting ineligible patients, falsifying paperwork and handing out bonuses to staff to entice new recruits. (Amedisys denies the allegations.) This time, the government has declined to join the nurse’s case.

Earlier this year, when I visited Farmer at her home in Alabama, boxes were piled in the living room. She was preparing for an upcoming move to Missouri, where her husband had taken a job with a nonprofit hospice and home health company. Farmer had remained close with Richardson, who told me: “I have a whole different view of justice in America now. It’s definitely powered by the dollar bill.” But the women no longer talked about the trial. “Nobody really cared,” Farmer said. “The government didn’t care, the judge didn’t care, and all of these people’s money was wasted.” Sitting in a plush reclining chair, Farmer let out a short, sharp cough as she spoke. In December, she had been diagnosed as having an aggressive form of breast cancer, and the chemotherapy had left her vulnerable to lingering infections.

The hospice benefit imposes a dichotomy between caring for the living and caring for the dying, when, in truth, the categories are often indistinguishable. Most older people will face a chronic disability or a disease in the last years of their life and will need extra care to remain safely at home. That help is rarely available, and Americans often end up in a social-welfare purgatory, forced to spend down their savings to become eligible for a government-funded aide or a nursing home bed. “We all think it’s not going to affect us, but if you have a stroke and go bankrupt you’re not just going to go out and shoot yourself in the desert,” Dr. Joanne Lynn, an elder-care advocate and a former medical officer at the Centers for Medicare and Medicaid Services, told me. Once you cross over into the kingdom of the sick, she said, it’s easier to see that some problems classified as hospice fraud are really problems of the inadequate long-term-care system in this country.

In the 1970s, Lynn worked at one of the first hospices in the United States. At the time, most of the patients had cancer and died within weeks; the six-month guidance was originally designed around their needs. Today, the majority of hospice patients have chronic illnesses, including heart disease and dementia. And some of them — regardless of whether they have six months or six years to live — depend on hospice for in-home support and holistic services that would otherwise be unavailable. Yet under the current system, as the number of patients with ambiguous prognoses rises, providers (including ethical ones) are under financial pressure to abandon those who don’t die quickly enough. It’s a typically American failure of imagination that people with dire but unpredictable declines are all but left for dead.

Elisabeth Kübler-Ross thought she understood why societies isolate the old and the dying: They remind the rest of us of our own mortality. This aversion might partly explain why decades of warnings about hospice care — including a full quarter century of pointed alerts from the inspector general’s office at the Department of Health and Human Services — have gone largely unheeded. Recently, though, some of the reports were so disturbing (maggots circling feeding tubes, crater-like bedsores) that members of Congress have called for reforms, and the Centers for Medicare and Medicaid Services is enacting a few. The agency has just begun making available to the public a greater range of data on hospice providers, including the average number of visits that nurses and social workers make in the last days of a person’s life. More significantly, the agency now has the power to impose fines on problem providers, should it choose to use it. (Previously, the agency’s only consequential penalty for bad hospices was to boot them from the Medicare program, an option it seldom exercised.)

Some state lawmakers, too, are asking deeper questions about end-of-life care. This year, in the wake of a Los Angeles Times investigation, California placed a moratorium on new hospices, and state auditors raised alarms about a raft of tiny new hospices, some with fictional patients and medical staff, that were engaged in “a large-scale, targeted effort to defraud Medicare.” In Los Angeles County alone, there are more than a thousand hospices, 99% of them for-profit. By comparison, Florida, which, unlike California, requires new providers to prove a need for their services, has 51 hospices.

But when regulators close a door they sometimes open a window. Licensing data I’ve reviewed suggests that, as scrutiny of end-of-life-care providers intensified in California, the hospice boom traveled eastward. In Clark County, which contains Las Vegas, the number of new hospices has more than doubled in the past two years, and in Harris County, which encompasses Houston, the number has grown almost as quickly. Sheila Clark, the president of the California Hospice and Palliative Care Association, attributed some of the surge in new licenses to a scheme called “churn and burn.”

“Providers open up a hospice and bill, bill, bill,” she said. Once that hospice is audited or reaches the Medicare-reimbursement limit, it shuts down, keeps the money, buys a pristine license that comes with a new Medicare billing number, transfers its patients over and rakes in the dollars again. The directors of two nonprofit hospices in the Southwest told me that they had been accepting patients who were fleeing such new providers. Some patients switched because while they were with the startup hospices they hadn’t seen a nurse in two weeks, and no one was answering the phone.

An office building in Phoenix that is home to dozens of new hospices (Lara Cerri for ProPublica)

On a rainy morning in November, I found myself in a vast, sand-colored commercial plaza on the outskirts of Phoenix. The complex was designed in the style of a Spanish hacienda, with a central courtyard, a stone fountain and a stately bell tower. Maricopa County was another place where the number of hospices had doubled in two years; 33 new ones, licensing data indicated, had appeared at this single address. There was no building directory, but eventually I realized that most of the hospices were clustered together on the basement level. All the hospices listed the same phone number for inspectors to call, and some had taped the same apology to their door: “Sorry we missed you! We’ll be back in 45 mins, if you need immediate assistance pls call us.” Each time I called the listed number, I got an answering machine whose mailbox was full.

When I buzzed the Ring video doorbell of B-116, which housed at least nine hospices, I was told by the man who answered that the manager was currently on the other side of the building. When I walked to the other side and rang B-117, the same man picked up. Sensing my confusion, he said, “I’m just the voice at the door.” His name was Ted Garcia, and he had been hired to monitor the hospices from his laptop at home. I told him that I was searching for a registered nurse named Svetik Harutyunyan, who was listed as the CEO of multiple hospices in the neighborhood, among them Ruby, Sapphire and Garnet, which were within the complex, as well as Platinum, Bright Star and First Light, down the road. I told Garcia that I particularly wanted to ask Harutyunyan about Ruby Hospice, which I’d seen listed for sale in an online ad for a quarter of a million dollars.

The day before, I’d searched for her at a squat building in Los Angeles that had drawn auditors’ attention. That address holds, according to state records, 129 hospices — a tenth of the city’s supply. When I knocked on the door of a hospice that the licensing data had linked to Harutyunyan, a worker told me that no one by that name was involved. Later, when Harutyunyan and I spoke by phone, she acknowledged owning hospices in California and Arizona and said that the arrangement was legal. She had wanted every member of her family to have one, she said.

Garcia told me through the doorbell that, as far as he understood, the hospices he monitored weren’t seeing actual patients; instead, the offices were a kind of “holding pen” to keep the licenses viable with requisite physical addresses until demand could be drummed up. The remote work was dull, he allowed. Apart from inspectors occasionally stopping by and transient people defecating outside the doors at night, my visit was the most action he’d seen in months. As the rain let up and I sat in the deserted courtyard trying to decide which of Harutyunyan’s holdings to visit next, it occurred to me that this world of paper hospices — empty of patients, valued at six figures, watched over by virtual guards — might be the clearest expression of the industry’s untamed frontier that I was going to encounter.

Later that afternoon, Garcia told me that he’d begun to research whether he could open a hospice himself. The market was bigger and more lucrative than he’d realized. People in Montana and Texas and Tennessee, he said, were posting ads online for “turnkey-ready hospices” for as much as half a million dollars. He called an ex-cop he knew to see if he wanted in. “We can turn a profit and split it,” he said.

How We Reported the Story

For this investigation, Ava Kofman drew on medical records; state and federal licenses; inspection and complaint surveys; government watchdog reports; thousands of pages of court documents; and interviews with more than a hundred families, hospice employees, elder care experts, attorneys and government officials.

Doris Burke contributed research.

by Mike Reicher and Lulu Ramadan, The Seattle Times

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

For years, the complaints languished with Washington state education officials.

A therapist emailed about a teenage boy with severe autism, who had wailed for hours inside a locked room in her school, pleading to be let out. A local education official saw a teacher shove her foot in a student’s face as he lay on the ground and threaten to step on him. A special education director observed uncertified teachers struggling with no curriculum and urged the state to step in to protect “these extremely high-risk students.”

The alarming reports cataloged a failure to serve kids with disabilities at the Northwest School of Innovative Learning, a private school designed to cater to Washington’s most vulnerable students.

Despite the complaints, the state took no action to force changes at Northwest SOIL. Instead, it allowed the school to stay open and tap a pipeline of taxpayer money. In the five school years ending in 2021, Northwest SOIL collected at least $38 million and took in hundreds of public school students.

Northwest SOIL operated for years with few trained teachers, and its staff relied heavily on restraint and isolation. Some of the students made no academic progress and even regressed, as their parents were shut out of information that would be available at any public school.

The lack of state oversight has allowed Northwest SOIL to essentially warehouse kids with complex developmental and behavioral disabilities, according to a Seattle Times and ProPublica review of more than 17,000 pages of documents from 45 school districts, three police departments and the state education department.

“Northwest SOIL is an example of turning back the clock 50 years on kids” to an era when people with disabilities were denied access to education, said Vanessa Tucker, a Pacific Lutheran University professor who serves on the state’s Special Education Advisory Council. “It should not continue.”

A Northwest SOIL teacher threatened to step on a boy with autism, according to a complaint by an Orting School District staffer. The student cried and said, “Please don’t step on me.” (Gabriel Campanario/The Seattle Times)

While most of the roughly 140,000 students in special education in Washington attend classes within their public schools, Northwest SOIL is the biggest player in an obscure but vital corner of the state’s special education system. It’s one of a set of private schools, known as nonpublic agencies, that serve about 500 public school students with the most serious disabilities.

Since the 1980s, states across the country have reduced their reliance on separate schools for special education students and moved to integrate such students with their peers. Washington, which has the nation’s second-highest dropout rate for special education students, has recently made strides by increasing the amount of time students spend in regular classrooms.

But for those with the highest needs, the state has been heading in the opposite direction, sending more students out of traditional public schools.

That led to the state and school districts pouring at least $173 million into outsourcing special education to Northwest SOIL and other schools over the five school years ending in 2021. While a full accounting is not available, state spending on these programs more than doubled during that time.

The state knows little about the more than 60 campuses that serve the students. Some of these private schools have decent reputations, but the state doesn’t track how many kids in private schools successfully return to their community schools — a key goal for many of the programs. It doesn’t know how many are restrained or locked in isolation rooms. Until two years ago, it couldn’t even count how many public school students attended these schools.

Northwest SOIL’s Tacoma campus building, left, on the grounds of a white-domed megachurch (Ken Lambert/The Seattle Times)

Those gaps are the result of a fundamental flaw in Washington’s oversight system, which places responsibility for monitoring the private schools not on the state but on individual school districts. State education officials said districts are expected to spot and correct problems, as they’re the ones contracting with the schools to educate students.

But because more than 40 districts at a time send students to Northwest SOIL’s three campuses, and each district only receives information about its own students, no single school district or agency has a complete picture of what’s going on there.

So serious incidents — one district learned that a Northwest SOIL staffer kicked a fourth-grader, another heard that a teacher dragged a 9-year-old boy with autism by his thigh — might appear to be isolated rather than signs of systemic problems. Pieced together, reports from parents, teachers, visitors and police paint a troubling picture the state has failed to address.

In 2019, a 9-year-old boy with autism told police that his teacher at Northwest SOIL grabbed him by the thigh and dragged him across a classroom because he wouldn’t run laps. (Tacoma Police Department report obtained, annotated by The Seattle Times and ProPublica)

“There is probably a sentiment that those kids are bad kids,” said Carrie Basas, the former director of the Washington State Governor’s Office of the Education Ombuds. “It’s just students that we have already written off, that teachers or school leaders may perceive as threatening, and we just send them somewhere.” She added, “There has to be somebody in charge.”

Even Northwest SOIL’s top administrator in 2021, Donna Green, complained to the school’s owner, Fairfax Hospital, that the company had crossed ethical boundaries. In a resignation letter, Green said she struggled to make changes as the hospital’s parent company, Universal Health Services, a Fortune 500 health care corporation, cut staff hours and skimped on basic resources to increase profits.

The state “needs to be more hands-on to ensure that these kids are getting a proper education and not just feeding a money horse for UHS,” Green said in an interview.

Leaders of Northwest SOIL and Fairfax, the largest private psychiatric facility in Washington, declined to be interviewed for this story. They defended the program in a statement to the Times and ProPublica, saying administrators take seriously the responsibility of addressing students’ complex needs. The school said it has recently purchased a new English and math curriculum, along with computers for teachers and students.

“We are proud of our overall academic and clinical performance and earned reputation for accepting the most difficult referrals in the area,” the school said. UHS said it had no comment beyond the school’s statement.

Chris Reykdal, who heads the state Office of Superintendent of Public Instruction, said in an interview that his office doesn’t have clear investigative authority or enough people to monitor private schools. But he said his staff looked into complaints about Northwest SOIL four years ago, and he stands by the agency’s decision to not crack down on the school.

Superintendent of Public Instruction Chris Reykdal at the OSPI building in Olympia, Washington, in 2020 (Ellen M. Banner/The Seattle Times)

“I do think that the response was there,” Reykdal said. “It’s just that people might disagree that we should have done more — which is a fair criticism.”

With no one responsible for scrutinizing the schools, even the most serious warning signs fell through the cracks, with devastating consequences.

“I Am Not OK to Be Here”

Northwest SOIL’s website paints a serene picture, splashed with stock photos of smiling kids. The Tacoma campus advertises hiking trails, pet therapy and 11 separate staff specialties — from speech language pathologists to licensed mental health counselors.

In reality, the building sits in the vast asphalt parking lot of a megachurch. The closest thing to a hiking path is a 200-foot-long walkway that cuts through a patch of greenery between sections of pavement.

Former employees and records from the state and districts describe more of an institution than a school: A staffer wands students with a metal detector as they arrive. Kids bang on the locked doors from inside “quiet rooms,” whose walls are sometimes smeared with feces or blood. At times, children wander the school or aides sleep in chairs.

The Times interviewed 23 former staffers, many of whom described chronic shortages of classroom assistants, inadequate training, a lack of licensed therapists and high-school-educated aides running classes. Amid high turnover, some positions sat vacant for months.

(Lauren Frohne/The Seattle Times and Ramon Dompor/The Seattle Times) (Lauren Frohne/The Seattle Times and Ramon Dompor/The Seattle Times)

"My role was to be the school therapist, but it rarely worked out that way because they were so understaffed,” said Kingsley Simpson, who worked at the Tumwater campus from 2016 until this March. “I covered as an educational assistant or a teacher or at the front desk. I rarely got the opportunity to do therapy."

Northwest SOIL said its hiring practices ensure that “only appropriate and qualified candidates are hired.” It added, “As in many areas of healthcare in Washington (and other states), staffing shortages are a challenge. Nonetheless, we meet appropriate staffing levels that satisfy our student needs.”

Former employees say — and documents back up — that Northwest SOIL staffers were stretched thin managing students and often resorted to restraint or isolation. But the state doesn’t track how often restraints are used.

“They don’t treat you like people; they just grab you,” said Christopher, 16, who attended Northwest SOIL in Tacoma. (Gabriel Campanario/The Seattle Times)

Among the few reports state regulators do require are annual staffing lists. But even then, OSPI doesn’t consistently check them to see if staff are qualified to teach.

Jimmy Fioretti worked at Northwest SOIL for five years. The school repeatedly listed Fioretti as a special education teacher even though he lacked that certification and at times was only approved to be a substitute.

In 2017 and 2019, police investigated after two separate allegations that Fioretti had choked students at Northwest SOIL. Each time, he told the police he never violated school restraint policy. Prosecutors declined to pursue charges, citing insufficient evidence or a law that broadly permits student discipline.

Fioretti — who has been convicted of assault and felony drug possession — was also accused in July 2020 of choking a housemate while living at a drug and alcohol rehabilitation home, according to a police report. He pleaded guilty to misdemeanor assault and served five days in jail.

Fioretti did not respond to phone calls or emailed questions.

State law requires nonpublic agencies to “promptly notify” the state and school districts of “any complaints it receives regarding services to students.” But the law doesn’t define what constitutes a complaint. There is no indication that Northwest SOIL notified state education officials of any police investigations.

Scott Raub, OSPI’s administrator for these private schools, said in an interview that abuse allegations would likely count as a complaint, but “just because you notified us, it doesn’t result in anything specific.”

Scott Raub, an OSPI administrator for private special education schools (Ken Lambert/The Seattle Times)

While the law is unclear about who’s responsible for investigating problems, the state has powerful enforcement tools. Officials can force these private schools to comply with specific conditions or prohibit them from accepting public school students if they don't. That could have shut down Northwest SOIL. But the state never took those steps.

One day in late 2020, Fioretti wrapped his arm around a 13-year-old boy’s neck and hauled him across the classroom, as the teenager grasped at Fioretti’s forearm.

A school counselor reported the “chokehold” to Child Protective Services and the police, describing how Fioretti had instigated the confrontation and how the boy couldn’t breathe, his eyes bulging for half a minute until Fioretti released him. Almost immediately, the boy vomited in a trash can. The chokehold was caught on surveillance video reviewed by Tacoma police.

But, once again, neither the state nor the school district would know the severity.

In the more sanitized narrative that Northwest SOIL reported to the boy’s parents and his home district, Tacoma Public Schools, Fioretti wrote that staff “restrained” the student without injury and “attempted to deescalate” the situation, then “escorted him to the hallway.”

Shortly after the incident, the school director sat down at Fioretti’s desk. Fioretti said the boy was “running his lips,” according to an internal company email. Fioretti “then got teary eyed,” the director wrote, “and said, ‘I can’t do this. I love my job and you guys but I am not OK to be here.’”

Nine days later, Northwest SOIL fired him for misconduct.

Northwest SOIL administrators declined to comment on specific allegations of abuse but said “use of restraints and seclusion are always used as a last response when a student is at imminent risk of hurting themselves or others.” The school said any allegation is promptly investigated. “Since even one unintended outcome is one too many, we take the time to determine what lessons can be learned from the regrettable incident,” the statement said.

A review of more than 1,000 pages of restraint reports show that Northwest SOIL regularly sends districts vague summaries of events.

One teenage boy with autism couldn’t tell his parents what happened at Northwest SOIL. He only knows a few words and mostly doesn’t speak. So every day when he returned home, his parents would strip off his clothes and check his body for bruises. They found them often, said his father, who asked that neither he nor his son be named to protect the privacy of his family.

A father described his son’s injuries to Northwest SOIL administrators. (Federal Way School District emails obtained, annotated by The Seattle Times and ProPublica)

One summer afternoon in 2020, Northwest SOIL reported to the boy’s school district and his parents that he was shoving staff. They tried to “redirect” him to his desk, and he “tripped over a chair, falling backwards,” the report says, his arm smashing through a glass window. The boy, then 16, went to the hospital and received three stitches.

His father questioned how his son could fall backward, arm first, into a glass window. The report didn’t say where the window was or how the incident started.

Before the fall, the boy was marked as “safe, responsible & respectable - Holding a Book” at 9:38 a.m. Then he tried to “elope” — or wander away, a common occurrence among children with autism — 11 times, the report says. That was just 10 minutes later.

“It doesn’t make any sense,” his father said.

State Didn’t Intervene

As far back as 2014, Northwest SOIL was already drawing scrutiny from the state’s biggest school district.

Two special education officials from Seattle Public Schools visited the Redmond campus and reported that what they saw left them “literally speechless.” They said kids roamed freely around campus without supervision, and education was virtually nonexistent. They implored the district to withdraw all its students immediately.

Seattle Public Schools staffers visited Northwest SOIL’s Redmond campus and recommended that the district remove all its students immediately. (Seattle Public Schools letter obtained, annotated by The Seattle Times and ProPublica)

Records show the district continued to send students each year but monitored Northwest SOIL more closely. After conditions seemed to improve, the school board voted in 2016 to keep using the school.

Seattle was focused on its own students. But administrators from other districts were also fielding alarming reports about Northwest SOIL.

In October 2017, the head of special education at the Orting School District, Chris Willis, emailed the state about the Tacoma teacher who had threatened to step on a boy. The incident happened in front of an Orting official and parent who were touring the campus, and Willis said he worried problems at the school were “more systemic.” But OSPI had no record of investigating.

Resources for parents navigating nonpublic agencies in Washington

Then, in May 2018, Rochester School District’s special education director visited Northwest SOIL’s Tumwater campus to check on a student and wrote to Glenna Gallo, then OSPI’s assistant superintendent of special education, that “the elementary student did nothing during the time I was in the class and no one interacted with him.”

During one visit, the Rochester director observed the boy opening YouTube on a computer and watching a game of “a man going to different places with a large machine gun shooting at everything in front of him.” When Rochester pulled him out of Northwest SOIL and brought him back into a district school, it found “little to no growth academically in the two years’ time that he was at NW Soil,” the director wrote.

A Rochester School District official reported to the state seeing a student watching a YouTube video of a game involving “a man going to different places with a large machine gun shooting at everything in front of him.” (Gabriel Campanario/The Seattle Times)

A month after Rochester schools’ visits, Cecilia McCormick, a McCleary School District director, reported to OSPI that her district’s student had no special education teacher supervising his instruction. “This is a violation of both federal and state law,” McCormick wrote. The fourth grade boy, who had a history of harming himself, was told by a staffer he’s a “bad boy,” she wrote.

In the summer of 2018, the Tumwater campus was up for its annual review by the state. By that point in the year, OSPI had received at least five serious complaints about Northwest SOIL from district administrators and a parent. Gallo and Raub scheduled a meeting with Northwest SOIL’s leaders.

“We said that this is not acceptable. You have to follow the expectations,” Raub said. “And we got all the assurances that we wanted to hear.”

After the meeting, more complaints poured into Raub’s inbox. The Tumwater School District reported its student did puzzles while his aide — whom the district paid for — slept in the classroom. The school also didn’t provide speech language services for months despite telling the district it had hired a specialist, Tumwater added.

A Tumwater School District official, who visited Northwest SOIL, complained to the state that he saw an aide sleeping while a student “was just doing puzzles.” (Gabriel Campanario/The Seattle Times)

Northwest SOIL didn’t respond to questions about the specific district complaints but said it “strongly refutes claims regarding the intentional billing of services not provided.”

Gallo approved the school’s 2018 annual renewal. She has since left the agency and has been nominated to be the U.S. Department of Education’s assistant secretary for special education.

Gallo did not respond to multiple requests for comment, but in a 2021 interview with The Times she said the state expects school districts to address problems at private schools.

A complaint to state education officials in 2018 describes an elementary school student’s encounter with staff at Northwest SOIL. (Office of the Superintendent of Public Instruction document obtained, annotated by The Seattle Times and ProPublica)

Raub, who was new to the private schools role in 2018, said he would approach the complaints differently now that he has more experience. He pointed to a 2020 case in which OSPI received abuse allegations at another private school and conducted a detailed review of student restraint and isolation files, school policies and staff qualifications.

But the department continued to be hands-off when presented with concerns about Northwest SOIL, including an April 2021 allegation of emotional and physical abuse against an Everett student by a Northwest SOIL staffer.

Raub instructed the district to investigate and said he would be there for “continued support” if it “uncovers a broader, more systemic issue.” OSPI said the district and family never followed up. Everett said it investigated but “did not conclusively find evidence to report back” to OSPI.

This month, the agency said it was investigating a complaint about Northwest SOIL’s Redmond campus after a parent reported inadequate staffing and their student coming home with injuries — the same sort of allegation that has flowed to the state for years.

Because of the diffuse oversight system, many complaints never made it to OSPI. Less than four months after the Everett allegation, Green, Northwest SOIL’s top administrator across all campuses, detailed a series of complaints in her resignation letter, ranging from a lack of training to cutting assistants’ hours that school districts had already paid for. She also sent it to Tacoma Public Schools.

But with no requirement to forward Green’s letter to OSPI, Tacoma never did so, and neither did Northwest SOIL, leaving the state missing a critical piece of the puzzle.

Other States Have Stricter Standards

In many ways, Washington’s special education funding system has exacerbated oversight problems at private schools like Northwest SOIL.

The state reformed its funding model in 1995, realizing that school districts needed more money to educate students with disabilities. It developed a safety net fund to help districts pay for special education services.

But the program prohibits those funds from being used to train teachers in public schools. And while a 2012 state Supreme Court ruling on school financing, known as the McCleary decision, resulted in the Legislature sending billions of state dollars to public schools, lawmakers sidestepped special education.

With limited options, the districts came to rely on the private schools.

The safety net model “made it easier for districts to say, ‘Let’s place the student at Northwest SOIL,’” said Tucker, the Pacific Lutheran professor.

But, unlike in other states, Washington lawmakers have not adopted key oversight and transparency regulations to protect students and taxpayers.

Northwest SOIL’s Tumwater campus building (Steve Ringman/The Seattle Times)

In Massachusetts, similar private schools are required to report all instances of restraint and isolation directly to the state, allowing central oversight.

This isn’t true in Washington. While the state tracks isolation and restraint incidents in public schools with a goal of reducing their use, it doesn’t at private schools that receive public money.

The only institution with the complete picture is the private school itself, but Northwest SOIL claims it doesn’t have to disclose the restraint and isolation reports because it’s a private company. The Times filed a public records lawsuit against Northwest SOIL’s parent company after the school denied a request for those reports and other records typically available from public schools. The lawsuit is pending.

Without information from either the state or the school, the Times and ProPublica requested copies of restraint and isolation records inside Northwest SOIL from 34 school districts. Only 27 districts provided reports, and many documents were missing.

The Bethel School District, for instance, destroyed a year's worth of reports “in error,” an official said, and had to retrieve paper copies of others from a warehouse. A district that sent dozens of students to Northwest SOIL turned over fewer restraint reports than a district that sent only one.

Raub said the department is working to improve data collection and acknowledged it “would be very useful” to track restraint and isolation.

Washington also doesn’t demand state inspections and has vague staffing obligations. It requires an unspecified number of certified teachers and only one special education teacher per school. A representative from a district has to visit every three years.

In contrast, California requires periodic state inspections, a teacher with special education credentials in every classroom and a specific ratio of students per teacher, typically 14-to-1.

Stricter standards allowed former students and staff in California to build a whistleblower case when similar problems cropped up at Universal Health Services schools there. The company shut down the last of those campuses in 2013 shortly after settling the case, without any admission of wrongdoing.

Reykdal, the Washington state superintendent, said stricter staff qualifications could improve the quality of education and reduce staff turnover at private schools.

“I think it's likely that our Legislature has to say, ‘When it comes to basic ed, we're not going to have different expectations for the private sector than we do for the public sector,’” he said. “And they should up their game on that.”

“It Was Hell”

Christopher, who has autism, talks about attending a Northwest SOIL school while his mother Sarah Snyder listens, in Puyallup, Washington. (Erika Schultz/The Seattle Times)

For parents like Sarah Snyder, the lax oversight of these specialty schools can turn finding the right education environment for their children into a terrifying ordeal.

Snyder knew her son Christopher needed a special school. He has autism and learning disabilities and finds it difficult at times to express his frustrations in words. Occasionally, he breaks furniture, hits his parents or punches walls.

Students like Christopher, now 16, can benefit from specialized care that private schools promise. But his mother said his stay at Northwest SOIL left him traumatized.

From his bedroom in Puyallup, his shelves brimming with Lego models, Christopher recounted his time at Northwest SOIL with extraordinary detail.

“They don’t treat you like people; they just grab you,” said Christopher, curled up on his Star Wars sheets, holding his knees to his chest. He spoke about being shoved into a seclusion room.

A picture drawn by Christopher of the room where he was isolated at Northwest SOIL (Erika Schultz/The Seattle Times)

“It was hell —” Christopher said, glancing at his mom in the bedroom doorway. “Can I say that?” She nodded. “It was hell,” Christopher repeated.

In June 2017, a few days after starting at Northwest SOIL, Christopher came home with a disturbing story. He had watched as a boy was strapped to a chair by a belt around his stomach. Another boy erupted in an outburst, competing for attention.

Scared, Christopher, then 11 years old, wanted to call the police. “I don’t feel safe here,” he thought. “I don’t feel safe here.”

He darted across the classroom toward a phone on a filing cabinet and started to dial. A staff member grabbed his arm and twisted it behind his back, yanking him away from the phone. (The staffer later threatened to break his arm, Christopher said.)

For seven months, Snyder struggled to get information about what her son had reported. She sought help from Christopher’s home district, Bethel School District, and its school board, as well as the local PTA and nonprofit advocates. She even emailed talk show host Dr. Phil.

“I was desperate,” she said. “I was begging, ‘Please, someone, help my family.’”

Christopher plays basketball outside his home. (Erika Schultz/The Seattle Times)

Snyder got Christopher out of the school within a month. But she kept complaining to officials for months after. In one letter to OSPI she wrote that it appeared “no one is responsible” for the actions of private schools like Northwest SOIL. Bethel said it cooperated with the state’s investigation.

The state found that Northwest SOIL had violated state laws, including improperly restraining Christopher and withholding the staffer’s name.

It concluded with a reminder that the state has the power to revoke Northwest SOIL’s status.

Five months later, OSPI approved the school’s renewal without any conditions.

Taylor Blatchford and Manuel Villa of The Seattle Times contributed reporting, and Alex Mierjeski of ProPublica contributed research.

by Rob Perez, Honolulu Star-Advertiser

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

For the better part of two years, Liliu Ross had lived in a one-room tin-roofed shack in the rural outer reaches of Hawaii’s Big Island. It had no running water and no electricity. But it provided shelter for Ross as she raised sheep and grew crops on land that her Native Hawaiian ancestors once called home. From the open fields and gentle slopes of her five-acre farm lot, she marveled at the stunning views of nearby Mauna Kea, one of the world’s tallest island mountains. Still, there were challenges to living under such conditions. At night she read by candlelight, and during the day she bathed outside with water she warmed in a pot over a fire.

So, in 2014, Ross secured a loan under a special program funded by the U.S. Department of Housing and Urban Development to help Native Hawaiians build or purchase homes on Native lands. An architect created drawings for a two-bedroom, one-bathroom house, complete with energy-efficient appliances and a covered lanai. And she even picked the location for the new home.

Within months, though, her plan collapsed. Ross learned in a phone call from her builder that HUD had imposed a freeze on federal housing funds throughout the region. As it turned out, her property had been part of the Waikoloa Maneuver Area, a 185,000-acre site that was used by the U.S. military for live-fire training in the 1940s. Troops had fired an unknown number of grenades, mortars and other munitions that failed to explode, and many of the potentially deadly weapons remained, hidden beneath years of soil and vegetation buildup. Federal authorities wanted to ensure the land was safe to use.

But the funding freeze had sweeping consequences. Other prospective borrowers on Native lands soon found they could no longer obtain government-insured mortgages, the only type available on such properties. The freeze also meant that local and state governments could not tap the main sources of federal funding to develop affordable housing in the region — a critical need in a state with one of the most expensive housing markets in the nation. The action effectively thwarted a century-old promise by the federal government to return Native Hawaiians to their ancestral lands.

Money would flow again, HUD decided, after the military removed any unexploded ordnance, or UXO, and state regulators vouched for the land’s safety.

Eight years later, though, Ross is still waiting. The now-64-year-old farmer continues to live in the same shack. She is one of hundreds of Native Hawaiians who are unable to secure housing on lands that the government set aside for them in a trust. Many have already waited years — and sometimes decades — for the opportunity to build homes, farms and ranches.

Liliu Ross stands among wood pallets she erected to protect saplings from strong winds that often sweep over her Big Island farm lot. Her home is in the background. (Cindy Ellen Russell/Honolulu Star-Advertiser)

“People are getting old, people are dying,” said Mary Maxine Kahaulelio, a prominent Native Hawaiian activist who lives near the UXO zone. “This is another form of delay for Hawaiians.”

No one can say for sure when relief will arrive. In one area, the state initially projected that the construction of 400-plus homes would be completed by next year. It paved streets, poured sidewalks, erected street lights and installed fire hydrants and road signs. But in 2015 it halted construction amid the federal funding freeze; not a single home has been built. Today, weeds and other vegetation are slowly overtaking the empty lots.

The U.S. Army Corps of Engineers, which is leading the remediation effort, has been plagued by shoddy work and multiple regulatory disputes, according to an investigation by the Honolulu Star-Advertiser and ProPublica. In one case, after state regulators raised concerns, the Corps rebid a contract to assess the UXO risk on the largest Native parcel in the region, prolonging a process that is years behind schedule.

The previously unreported details, laid bare in interviews and hundreds of pages of documents obtained through public records requests, provide further evidence of how government agencies have bungled the timely return of Native Hawaiians to their ancestral lands. The Star-Advertiser and ProPublica reported in 2020 and 2021 how the state was largely bypassing low-income and homeless Hawaiians because of the pricey homes it developed and how the federal government effectively circumvented a reparations law, depriving the program of prime properties suitable for housing. Today, more than 28,000 beneficiaries — the term for people who are at least 50% Hawaiian — are currently waiting for lots statewide, including nearly 6,000 seeking housing on the Big Island.

For its part, Army Corps officials said they are committed to clearing the Native lands as soon as possible. “Keep in mind we’re trying to help,” said Loren Zulick, who until recently served as the Corps’ program manager for Waikoloa, in an interview. But, he added, “our driving factor is to clean up contamination and protect human health and the environment.” In a written response to the news organizations’ findings, the Corps said it is “committed to getting the remediation done right to ensure these areas are safe” and that every acre that goes through the process “is a success toward restoration of lands.”

Hawaii Island firefighters attend a U.S. Army Corps of Engineers briefing about the ongoing remediation work at the former Waikoloa Maneuver Area. (Cindy Ellen Russell/Honolulu Star-Advertiser)

HUD also defended its Waikoloa policy, saying in a statement that it was developed “to ensure the safety of all occupants of HUD housing, including Native Hawaiians.”

Local leaders, however, say the government needs to move faster to fulfill its obligations to Hawaii’s indigenous people.

“It’s just common sense, common courtesy, basic values everyone is taught as children: If you break it, fix it,” said Robin Danner, chair of the Sovereign Council of Hawaiian Homestead Associations, the largest beneficiary group in the state. “We have the most powerful military on the planet. It’s just unacceptable that the UXO debacle is still ongoing, truly hurting families, keeping them from using our land.”

A Deadly History

Technicians use state-of-the-art equipment to look for buried munitions in a field next to a Waimea school. (Cindy Ellen Russell/Honolulu Star-Advertiser)

After World War II broke out, the U.S. used large swaths of undeveloped land in the Waikoloa region for so-called live-fire exercises, in which Marines trained in battle-like conditions with artillery shells, rockets, grenades, tank rounds and other arms. It was one of several places in Hawaii that the military used for such training. Officials estimated that about 10% of the munitions failed to detonate during the Waikoloa maneuvers, so before leaving in 1946, the military conducted a cleanup operation. Technicians methodically walked the grounds looking for unexploded arms and debris, which were then destroyed or hauled away.

But over the years, there have been a handful of accidents. In 1954, two ranch workers were killed and three colleagues injured when an old mortar shell exploded near them. The accident prompted another round of cleanup, but that effort failed to catch many remaining munitions too: In 1983, two more people, soldiers involved in a military exercise, were injured when an old shell exploded.

Despite the risks, development marched forward throughout the region. The UXO status of the lands was hazy in those early decades, before the Corps took on a formal role. Many property owners assumed that the prior cleanups made their land safe to develop, and those who were unsure hired UXO experts to guide construction. Coastal resorts, shopping centers, residential subdivisions, parks and other developments gradually popped up.

Among the developers was the Department of Hawaiian Home Lands, which manages nearly 12,000 acres within the UXO zone as part of the land trust. It was set up in 1921 by Congress to help a people then headed toward extinction. The state took over management in 1959 as a condition of statehood. Under the program, anyone who is at least 50% Native Hawaiian is entitled to lease land for $1 a year and either build or buy a home on it. Over the years, scores of beneficiaries did so within Waikoloa. Both the state and federal governments, as overseers of the trust, are legally bound to ensure the program’s success.

Government remediation efforts picked up again in the 1990s, after federal legislation resulted in the Army Corps being given responsibility for clearing former defense sites such as Waikoloa. And building continued without controversy until 2014, when a Native Hawaiian beneficiary in Puukapu, the same community where Ross lives, applied for a home loan to renovate his residence, as others had before him. This time, though, the lender rejected his application, largely because an appraiser noted that the property was in a UXO zone.

The loan denial alarmed local HUD officials, whose agency had provided millions of dollars each year to DHHL for lot development and housing assistance, including loans to eligible Hawaiians to purchase or build homes on trust land. Federal officials told the Star-Advertiser and ProPublica that they were previously unaware of the unexploded ordnance issue, which local and state environmental reviews had not adequately addressed. DHHL said it conducted such a review before starting construction on a nearby subdivision in 2012, but that it didn’t uncover any UXO. Nevertheless, once HUD learned of the potential contamination problem in the region, it imposed a freeze on funding and HUD-backed mortgages until safety concerns were addressed.

To comply with the policy, DHHL began putting UXO disclosure provisions in the new land leases it awarded to Native Hawaiian beneficiaries. The designation prevented those leaseholders from obtaining government-insured mortgages until the UXO problem in their specific community was resolved. In fact, some lenders had already stopped lending on Native lands in the Waikoloa area.

Regulators Raise Red Flags

Hundreds of Native Hawaiians looked to the Army Corps to step up its work so the freeze could be lifted. Months, however, turned into years. “My balloon is deflated,” said Leolani Kini, 65, whose plans to build a home on the Big Island are on hold. “It’s heartbreaking for me every day.”

Kini and other Hawaiians were counting on the Army Corps to review two key areas.

One was Puukapu, the mostly rural area where Ross lives and Kini wants to move. It’s the largest trust parcel in the UXO zone and includes nearly 450 lots leased by beneficiaries. The other area was Lalamilo, the location of the unfinished 400-home subdivision.

Given the limitations of technology and other factors, all parties acknowledge, it’s impossible to remove all munitions from the UXO zone. Hawaii’s rugged terrain and high iron levels, for instance, interfere with the digital equipment used to search for buried bombs. Instead, the cleanup goal is to reduce the UXO risk to “negligible.” But over the past several years, state health department documents reveal its regulators have raised significant questions about how the Corps performed its assessments in both areas.

In Puukapu, the department issued a scathing response to an initial Corps report, saying “there appears to be intentional efforts to omit and obscure relevant data.” Regulators also objected to the Corps’ finding in the 2018 report that the UXO risk was acceptable and no further action was needed.

“They basically were saying, ‘Hey, we’re done,’” said Sven Lindstrom, the health department regulator who oversees the Corps’ remediation work. “And we were like, ‘Whoa, whoa, whoa. No, we need to talk about this more. You need to allay our concerns that there might still be hundreds of munitions items at this site.’”

The Corps took two years to respond, and after that it had to hire another contractor to help complete the report, which still isn’t finished.

In Lalamilo, regulators questioned the effectiveness of new technology the Corps is using to detect munitions, as well as the reliability of its past sweeps of the area. The skepticism was driven by a series of discoveries by workers in other parts of the UXO zone that the federal agency had previously designated as clear. In 2018, for example, they discovered large fragments on the ground and a foot-long projectile just steps away from a low-income apartment complex. The old shell, which still had the potential to explode, was buried just three inches below the surface.

Weeds overtake the sidewalks at the Lalamilo Housing development in Waimea on July 15, after construction stalled due to concerns about unexploded ordnance. (Cindy Ellen Russell/Honolulu Star-Advertiser)

To allay concerns, the Corps analyzed nine past sweeps of the area that includes Lalamilo. The results, however, were far from reassuring. As it did in Puukapu, the agency backed away from its initial assessment, telling the state it had low confidence in the effectiveness of its prior work. The Corps is now doing a new, more comprehensive sweep of Lalamilo, using state-of-the-art equipment, and is discussing the data with regulators as the work progresses. The technology dispute, however, remains unresolved.

Meanwhile, Native Hawaiian beneficiaries regularly drive by the subdivision site, just off the main road into Waimea. About a dozen told the Star-Advertiser and ProPublica that they often wonder when the project will get back on track. The site’s 2012 groundbreaking sign, which is still standing, touts the name of Gov. Neil Abercrombie. He left office eight years ago.

In response to questions from the news organizations, the Corps acknowledged that the remediation process is time-consuming. But the agency won’t sacrifice quality for speed, according to Lt. Col. Ryan Pevey, who heads the Corps’ Hawaii operations. “At the end of the day, it’s about the safety of the people of Hawaii and the environment,” he said in an interview. The Corps said it is highly confident that the Puukapu assessment, once completed, will allay the state’s concerns and show that hundreds of UXO will not be left in the ground.

The trust lands have been getting special attention in recent years, officials added. “It is a priority for us to try to help the Department of Hawaiian Home Lands with their needs for people who are trying to get loans on their properties,” said Zulick, the former Waikoloa program manager.

The Corps said Lalamilo is currently ranked No. 1 among its Waikoloa priorities and Puukapu is third, designations that direct resources to expedite the UXO work. Just a few years ago Puukapu was No. 22 — a reflection of the fact that the area had not been used as intensively for live-fire training as other sectors, according to the Corps. Some beneficiaries believe no remedy is needed in Puukapu. They say people have worked the land there for decades without incident, and many express frustration that the Corps is taking so long to assess a site they believe is safe.

William J. Aila Jr., who oversees DHHL and the 203,000-acre land trust, reflected on the balance that must be struck to successfully resolve the UXO problem. “Obviously, we would like to see this effort proceed faster, but we understand the Army Corps has a process, and we want them to do a thorough job,” Aila said in a statement.

Native Hawaiians Pay the Price

Native Hawaiians are paying the price for the delays — sometimes, quite literally.

Shirley Gambill-De Rego, a Big Island mortgage manager, recalled the case of a man who, after learning of the UXO delay, paid a private company $25,000 to sweep his mother’s land in Puukapu so he could get a loan to replace her aging home. Given that his mother was elderly, the man concluded that he couldn’t afford to wait for years for the Army Corps to do its job, said Gambill-De Rego, who ultimately helped the family get financing for construction. The new home was completed about seven years ago. The mother has since died.

Others have also had to dip into their own pockets.

Rocky and Kamala Cashman moved to Puukapu with designs for a new home in 2014. The retirees, who were in their 70s at the time, set up shop in a temporary trailer, expecting to live there for a year at most while workers constructed their new prefabricated home. But just before building began, their bank canceled the loan because it was no longer insurable due to the UXO problem. Other lenders subsequently turned them down as well. As a result, the trailer became their home for the next five years.

Kamala Cashman, 81, is thrilled to be in her new Puukapu home after spending five years living in a cramped trailer on the property because she and her husband were unable to obtain financing due to the UXO problem. (Cindy Ellen Russell/Honolulu Star-Advertiser)

The rented camper, which measured 240 square feet, had just enough room for a king-sized bed, a bathroom and a small refrigerator. The couple made meals with a toaster oven, microwave, electric frying pan and rice cooker. While the living situation was cramped, Kamala Cashman said, it was offset, in part, by the natural beauty of their five-acre lot, which featured expansive mountain views. “We made it work,” she said.

The financial cost, though, was significant. On top of renting the trailer, the Cashmans paid to lease two shipping containers to hold their household belongings and a third to store the wood and other materials for their new home. Their total five-year rental tab came to about $60,000.

Then, in 2019, the Council for Native Hawaiian Advancement, an advocacy organization for Hawaii’s indigenous people, stepped in. The group agreed to lend the Cashmans $300,000 through a program designed to assist Hawaiians unable to get more conventional financing. The council approved the loan even though the UXO assessment in Puukapu was still ongoing.

“I knew if we didn’t step in and help, this family would still be in the trailer,” said Kuhio Lewis, the council’s chief executive officer.

The Cashmans moved into their new home in 2020. The three-bedroom, three-and-a-half-bath cedar-and-redwood residence spans about 2,500 square feet of living space — more than 10 times the size of their rented trailer — and features a dome-shaped great room and a wraparound balcony facing Mauna Kea.

“It’s sad that it took five years for us to move into something that should’ve happened in a few months,” said Kamala Cashman, who is now 81.

“That shouldn’t be happening at their age,” added Noe Aiu, Cashman’s daughter.

Rocky Cashman, 81, with his daughter, Noe Aiu, 60, at their Pu'ukapu homestead. (Cindy Ellen Russell/Honolulu Star-Advertiser)

The HUD freeze is impacting Native Hawaiians in other ways too.

Those who have wanted to sell their homes in the region have had to look for all-cash buyers because of the unavailability of financing. And some have been unable to refinance existing mortgages, which prevented the homeowners from taking advantage of record-low interest rates in 2021. Rates have since rebounded to two-decade highs.

The result, advocates say, has been that Native Hawaiians have been deprived of building financial equity during a period in which Hawaii real estate values have soared. If any other group were denied such an opportunity, government officials would “move mountains to turn that faucet back on,” said Rolina Faagai, vice chair of Hawaiian Lending & Investments, a beneficiary-run organization that helps Hawaiians obtain mortgages on trust lands. “Not for our community. Why is that?”

A Plea for Help

Given how long beneficiaries have suffered under the freeze, Native Hawaiians and their advocates are now calling for the Corps and the state’s congressional delegation to expedite remediation.

“They’ve got to prioritize this,” said Lewis, head of the Native Hawaiian advocacy council, citing the state and federal governments’ long-standing legal duty to beneficiaries as overseers of the land trust. “This is a trust obligation to Native Hawaiians, an obligation that is being unfulfilled, unmet.”

The Star-Advertiser and ProPublica reached out to Hawaii’s four members in Congress about the Waikoloa cleanup process. Just two responded: U.S. Sens. Mazie Hirono and Brian Schatz.

Hirono did not answer the news organizations’ questions but issued a general statement saying more needs to be done to ensure the governments’ trust obligations are fulfilled.

Schatz was more specific. In written responses, he said he would push for more funding to speed up the cleanup effort to help ensure no one waits longer than needed. “It’s a dangerous job that understandably takes time,” he said of the remediation work. “But for beneficiaries, every delay in the process has a real impact.”

In recent years, Congress has approved additional monies for Waikoloa, according to Schatz, who sits on the Senate’s appropriations committee. A decade ago, the project was getting about $10 million annually. This year, the total hit more than $18 million, a record, Schatz said. Much more, however, is needed. The Corps estimates $375 million will be required to finish the job.

Danner, the beneficiary leader, urged DHHL to help supplement the remediation effort. “If the lots were good enough to issue to our families, then they are good enough for DHHL to spend resources to clear the lands for safety,” she said. But the department, which received a record $600 million from the state this year to boost the Native Hawaiian homesteading program, said the federal government is obligated to pick up the tab and should.

For now, Ross continues to wait. Several years ago, she added a second room to her shack and now has running water and a power generator. But she is losing hope that she’ll ever see an actual house.

“There’s a lack of concern for the Hawaiian people,” she said. “So we’ll just continue to be successful on our trust land.”

Liliu Ross tends to the flock of sheep she raises on her Puukapu farm. (Cindy Ellen Russell/Honolulu Star-Advertiser)

by Molly Parker, Lee Enterprises Midwest

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

It was the last Friday in October, and barges filled with mounds of glistening coal sat parked in the Ohio River below Lee Esther Logan’s high-rise public housing apartment complex in Cairo, Illinois. Wispy white clouds streaked a baby blue sky. The panoramic waterfront view is one that normally gives Logan peace as she takes it in from the brown recliner on her balcony.

But on the day I visited her, Logan wasn’t at peace. She was anxious.

Two days prior, officials from the U.S. Department of Housing and Urban Development had called Logan and about 60 of her fellow public housing residents to a meeting. An engineering assessment has found that the Connell F. Smith Sr. Building may not be structurally sound enough to withstand an earthquake. The federal government plans to raze their home, and they have to move out by early next year, the federal housing officials told them.

The building mostly houses seniors and people with disabilities and is also home to a small number of children and their parents. Officials told the residents they’d get vouchers and moving assistance. But that’s of little comfort to the many residents who want to stay in Cairo.

Lee Esther Logan has lived her whole life in Cairo. (Julia Rendleman for ProPublica)

Since its population peaked at 15,000 residents in the 1920s, Cairo has faced decades of population and economic decline. It’s now one of the poorest cities in Illinois, and its population has dropped to about 1,600. There’s no grocery store or gas station — and most critically for the high-rise residents facing eviction, there’s an extreme shortage of safe rental options. That means that under HUD’s plan, most residents will have to move at least 30 miles away to find available units in other towns’ public housing complexes or private-market rentals.

The decision sent residents reeling. Logan’s close-knit, majority-Black town sits at the confluence of the Mississippi and Ohio rivers, where the borders of Illinois, Kentucky and Missouri meet.

When newcomers visit, they’re often struck by the blight of a hollowed-out city: streets lined with boarded-up homes, vacant buildings and empty lots. The Smith building itself holds a lot of history — not all of it good. Constructed in 1968, it’s named for a former housing authority board member who, the decade before, had affixed a flashing neon arrow to his garage roof; it pointed at the home of an attorney who was working to integrate Cairo’s public schools alongside Thurgood Marshall. In an essay, Langston Hughes described it as a 4-foot “red arrow of bigotry.”

But for residents, a strong sense of community remains. Cairo is known regionally for its historic churches — some of which still gather a spirited crowd on Sundays — ties to American history, music festivals, acclaimed barbecue and standout high school basketball teams over the years. It’s one of the few small towns in southern Illinois to offer a children’s orchestra and ballet lessons.

A public housing high-rise, planned for demolition, sits on the banks of the Ohio River. (Julia Rendleman for ProPublica)

For many of the seniors and people with disabilities who live at the Smith building, the prospect of heading out of town — for some, the only place they’ve ever lived — is daunting.

“A lot of people are scared. I’m scared,” said Logan, 55, a disabled woman who has spent her entire life here. “I don’t want to leave Cairo.” I heard many neighbors echo her concerns as I knocked on doors that afternoon. “I don’t know where I’m gonna go. I’m 83 years old,” said Harry “Mack” McDowell Jr., a retired car salesman who is still grieving the death of his wife in July and who is dreading having to apartment shop and move during the holidays.

Few federal agencies have a mission so squarely aligned with what Cairo needs: to uplift disadvantaged people and places and, as HUD describes it on its website, “to deliver on America’s dreams.”

But HUD has let generations of Cairo residents down time and again. And although HUD could oversee the building of new apartments in the city, it has no plans to do so.

Cairo was once a thriving city. Now, its streets are home to boarded-up buildings and vacant lots. (Julia Rendleman for ProPublica)

Cairo isn’t just another Midwestern river town befallen by hard economic luck.

The storied epicenter of a region colloquially known as “Little Egypt,” Cairo holds a central place in the American story. The town, the most southern point in a northern state, was a key station on the Underground Railroad and a Midwestern staging area for Gen. Ulysses S. Grant’s Union armies along the Mississippi artery.

It had been a mostly white city until thousands of formerly enslaved Black Americans fled on steamers headed north along the Mississippi River during the height of the war. The federal government sent them to Cairo and housed them in what were called “contraband camps,” shanty tents set up near the riverbanks where people had little to eat and disease ran rampant.

At the war’s end, the camps disbanded and many people left. But at least 3,000 Black Americans stayed in Cairo and established a vibrant, though largely segregated, community of churches, schools and businesses. By the early 1900s, nearly 40% of the population was Black, and the strongly organized community leveraged its political power to win elected seats in town.

Despite those gains, white supremacists maintained the balance of power and ensured that Cairo’s Black population remained locked out of the best jobs and public schools. Jim Crow-era policies that followed Reconstruction remained firmly rooted in Cairo well after they’d begun to unravel elsewhere.

Housing discrimination was a common thread.

In the 1940s, the town built two large family housing complexes: one for Black families using cheap wood materials at the site of the old “contraband camp” and one for white families built of brick.

In 1972, the U.S. Civil Rights Commission held hearings in the town. Numerous Black citizens testified about being forced to live in the segregated and dilapidated public housing complex; they were terrorized by rodents and white vigilantes who, for months, fired into the apartment complex from the Mississippi levee, shattering windows and streets lights, to intimidate a Black civil rights leader and his followers who lived there. The commission concluded that federal housing officials had known about the town’s defiance of federal fair housing laws for years but done little.

More than 40 years later, I, along with several colleagues from The Southern Illinoisan, documented unsafe conditions in the same buildings cited in the federal report. They had fallen into even worse disrepair. There were severe foundational issues. Homes were overrun with mice and roaches. Doctors expressed alarm at the number of mothers bringing in children with asthma and other breathing problems from mold. The heating system was so poor that many families used their gas ovens to stay warm in the winter. Similar to the commission’s findings, our reporting revealed that HUD had known about problems and done little. In 2016, on the heels of our investigative series, HUD exercised its rarely utilized authority to remove the housing authority based in Cairo from local control and place it into federal receivership.

Images of riverboats hang in a hallway of the high-rise building that HUD plans to demolish. (Julia Rendleman for ProPublica)

A year later, under President Donald Trump and his HUD secretary, Ben Carson, the federal agency announced the closure of two family housing complexes in Cairo, and 10 months after that, two more in nearby Thebes. The buildings were home to about 500 people, and most of them ended up leaving the area to find housing. The community was livid — not at HUD’s decisions to tear down buildings long past their prime but at the fact that HUD would not commit to replacing even a small fraction of what had been lost.

At the time, federal officials promised they would do what they could to maintain the public housing that remained in Cairo, including the high-rise where Logan lives. At least 14 families forced out of the demolished homes moved into the Smith building. And residents were hopeful that President Joe Biden’s administration might take a different approach.

But to residents in Cairo, last month’s announcement is another broken promise in a long line.

“Here we go again,” a frustrated Thomas Simpson, Cairo’s mayor, quipped on his way out the door of the meeting with HUD officials. He’s working with other community leaders to open a co-op grocery store. And he’s hopeful that plans to build a new inland river port in town — a development that Gov. J.B. Pritzker has committed $40 million in state funds toward — will boost the region’s economy.

Cairo’s mayor, Thomas Simpson, would like HUD to come up with a plan to keep residents of the agency’s buildings in Cairo. (Julia Rendleman for ProPublica)

But HUD’s continued gutting of his community makes it hard to stay a step ahead, he said. After more than seven years under HUD control, the local housing authority has not managed to replace a single unit in his town. The mayor believes HUD has overstated the urgent need for people to move. (HUD does not typically assess seismic risk; it ordered an architectural assessment after an agency official noticed cracks in the building in 2021. The study identified problems but did not make any recommendations, and there’s no HUD policy that dictates what is an acceptable seismic risk for a public housing property). He’d like to see the agency slow down and come up with an alternative solution.

One is already on the table.

A developer with extensive affordable housing experience has offered HUD a plan to build a 40-unit housing community in Cairo at the site of one of the previously demolished homes. The roughly $5 million needed for the project already exists in the housing authority’s coffers. And the developer who pitched the solution, Nashville, Tennessee-based U.S. Management Services, is already under contract with HUD to develop a long-term plan for the housing authority and its tenants in Cairo. The owner of the development company told HUD he could complete the Cairo project in six months by shipping in manufactured homes.

But while a HUD official later told me that the project hasn’t been rejected outright, he said that the deal is more complicated than meets the eye. More detailed questions, he said, would have to be directed to HUD’s spokesperson. Christina Wilkes, HUD’s press secretary, did not specifically respond to my questions about the proposed development. In an emailed response, she said the agency is “committed to partnering with the Mayor and community leaders to develop a plan for the future, based upon the Mayor’s vision.”

The mayor, however, said HUD only notified him of its plan to demolish the Smith building a few hours before notifying the residents, even though the agency first noticed problems with the building more than a year ago. He wants the agency to pursue all viable options to keep people in Cairo. And if the agency goes ahead with the plan to move people out of the high-rise, those residents will take their vouchers with them, leaving insufficient funding for the new units.

On the afternoon that HUD broke the news, the residents and other community leaders packed into the meeting room shoulder to shoulder. People spilled into the hallways. A few residents shed tears; others begged HUD officials to come up with another solution. Community leaders admonished the agency for the pain it has caused the town.

Phillip Matthews, a pastor and community activist, stood up, stared the officials down and told them to deliver this message to their superiors in Washington on behalf of the town: “It’s not happening this time.”

“This was not an easy decision,” a defensive HUD official fired back. “If you think it was, you’re sorely mistaken.”

At the meeting, a HUD official promised to share the town residents’ concerns with higher-ups in Washington. But the agency has not backed off of its plans to move people from the building in Cairo, located in Alexander County. “The safety of the HUD assisted residents is our top priority and moving them to safe housing as soon as possible is our focus at this time. If there is any future ACHA housing, it would allow former ACHA residents the first priority to return,” Wilkes, the HUD spokesperson said, referring to the Alexander County Housing Authority that is in receivership.

In the days that followed that tense meeting, residents and community leaders have fought back. The state’s attorney filed a lawsuit challenging that HUD had not followed its own requirements for when a public housing property is slated to be demolished. That resulted in a county judge issuing a temporary restraining order, which has since expired; the case was then transferred to federal court, where it is pending. (HUD has maintained that it hasn’t violated any laws or regulations with its announcement.) Political leaders wrote letters to HUD advocating for the town. And residents say they plan to flood a housing authority board meeting next week, where HUD officials are expected to officially vote on the plan.

Kaneesha Mallory, who lives in the building slated for demolition with her 2-year-old daughter Bre’Chelle, is holding out hope that HUD will have a change of heart. She’s lived in other places but never felt the same sense of belonging.

“This is home. My roots are here in Cairo,” she said. “If you move anywhere else, you won’t find nowhere else like Cairo.”

Kaneesha Mallory and her 2-year-old daughter live in the building slated for demolition. (Julia Rendleman for ProPublica)

by Heather Vogell

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

The Department of Justice’s Antitrust Division has opened an investigation into whether rent-setting software made by a Texas-based real estate tech company is facilitating collusion among landlords, according to a source with knowledge of the matter.

The inquiry is being launched as questions have arisen about a 2017 merger between RealPage and its largest pricing competitor. The source told ProPublica some DOJ staff raised concerns about the merger but were overridden by political appointees of former President Donald Trump.

Congressional leaders have pushed for an investigation into RealPage in three letters to the DOJ and the Federal Trade Commission, which were sent after a ProPublica report on the software’s use in mid-October.

The letters raised concerns that RealPage’s pricing software could be pushing rents above competitive levels and allowing big landlords to coordinate their pricing in violation of federal antitrust laws.

“We are concerned that the use of this rate setting software essentially amounts to a cartel to artificially inflate rental rates in multifamily residential buildings,” three senators said in a letter in early November. They included Sen. Amy Klobuchar, the Minnesota Democrat who chairs the Senate Subcommittee on Competition Policy, Antitrust and Consumer Rights.

The Capital Forum first reported the existence of the investigation and some details on Tuesday.

RealPage’s software works by collecting information from property managers who are the company’s clients, including what rents they are able to charge tenants. That information is fed into an algorithm that then recommends prices daily for each available apartment.

Though RealPage says the information is aggregated and anonymized, some experts have said using private data from competitors to set rents could run afoul of antitrust laws, allowing property managers to illegally coordinate their pricing.

ProPublica found the software is widely used in some markets: In one downtown Seattle ZIP code, 70% of more than 9,000 apartments were controlled by just 10 property managers — every one of which used RealPage’s pricing software in at least some of its buildings.

RealPage did not immediately respond to a request for comment.

The company has said RealPage “uses aggregated market data from a variety of sources in a legally compliant manner.” The company said its software prioritizes a property’s own internal supply and demand dynamics over external factors like competitors’ rents. The company also said its software helps reduce the risk of collusion that would occur if landlords relied on phone surveys of competitors to manually price their units.

The DOJ’s investigation represents the second time the federal law enforcement agency has looked into RealPage’s rent-setting software. In 2017, the DOJ flagged a proposed merger in which RealPage sought to buy its biggest competitor, a company called Rainmaker Group, which made rent-setting software known as LRO, or Lease Rent Options.

RealPage’s then-CEO, Steve Winn, said the $300 million purchase would allow RealPage to double the number of apartments it was pricing, from 1.5 to 3 million units.

After the acquisition was announced in early 2017, the DOJ requested additional information from the companies involved. Federal regulators scrutinize mergers above a certain size — right now, it is transactions valued at $101 million — and typically allow them to proceed after only a preliminary review.

But the government can request more information from companies and even seek to block the merger in court if it believes it could substantially harm competition.

A paralegal specialist who worked on the original DOJ probe into RealPage said it was narrowly focused on the impact on competitors who made software with a similar purpose. The paralegal said she was unaware of any complaints by those companies about the proposed merger.

Merger review guidelines used by both the DOJ and FTC say the agencies “normally evaluate mergers based on their impact on customers,” which include both direct customers and final consumers. But the paralegal said the investigation did not involve talking to tenant advocates or renters.

“The focus of the investigation was ‘talk to competitors, talk to large rental companies,’” said the paralegal, who did not want to be named because she was not authorized to speak about the investigation. “That was the limited focus.”

ProPublica found that in the Seattle ZIP code it examined, some of the 10 largest property managers used RealPage’s original pricing software and others were clients of the competitor it acquired.

Though some career DOJ staff members were concerned about the merger, political appointees leading the agency at the time under Trump chose not to challenge it in court, according to the source with knowledge of the matter.

The investigation fell at a time when the DOJ’s Antitrust Division was preparing to sue to block a proposed merger between AT&T and Time Warner, which promised to take up a lot of the division’s resources. “It was a resource constraint issue he was trying to balance,” the source said of Makan Delrahim, the former assistant attorney general charged with overseeing the division at the time. In addition, RealPage did not have the same reach then as it does today, the source said.

Delrahim declined to comment on Tuesday about the first RealPage investigation, saying he was bound by government ethics restrictions from discussing nonpublic aspects of the case and referring questions to the current administration.

He said that given that it had been almost five years, his “memory is fuzzy at best.” But he added that in general, “as evident from my past record, I was not shy about greenlighting cases that I felt were meritorious even if difficult or unprecedented.”

Antitrust prosecutions by the division fell to historic lows under Trump.

The DOJ declined to comment on Tuesday.

Klobuchar’s recent letter to the DOJ mentioned the 2017 merger, saying that such consolidation can make markets “more susceptible” to collusion and encouraging the department to consider looking at RealPage’s past behavior to see if any of it was anticompetitive.

RealPage says its customer base across all its products — which also include other types of software, such as accounting — has exceeded 31,700 clients.

Marketing materials dated 2021 on the company’s website said its so-called revenue management products, formerly called Yieldstar and LRO, are “trusted by over 4 million units.”

ProPublica also detailed how RealPage’s User Group, a forum that includes landlords who adopt the company’s software, has grown to more than 1,000 members, who meet in private at an annual conference and take part in quarterly phone calls. Klobuchar’s letter raised specific questions about the group, saying the senators were “concerned about potential anticompetitive coordination” occurring through it.

In addition to the letters from congressional lawmakers, renters have filed three lawsuits in federal court in Seattle and San Diego since mid-October, alleging RealPage and a slew of large landlords are engaging in anticompetitive behavior through the company’s software.

After the San Diego lawsuit was filed, a RealPage representative said the company “strongly denies the allegations and will vigorously defend against the lawsuit.” It has not responded to requests for comment on the other two lawsuits.

A property manager named in one of the Seattle lawsuits, Campus Advantage, said in a statement that it “strongly disagrees with the unsubstantiated allegations in the lawsuit and intends to vigorously defend against the claims. Campus Advantage is proud of its track record creating successful communities.”

Other property management firms named in the three lawsuits either did not respond to requests for comment or declined to comment. One could not be reached.

by Tony Schick, Oregon Public Broadcasting, and Maya Miller, ProPublica

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

Salmon heads, fins and tails filled baking trays in the kitchen where Lottie Sam prepped for her tribe’s spring feast.

The sacred ceremony, held each year on the Yakama reservation in south-central Washington, honors the first returning salmon and the first gathered roots and berries of the new year.

“The only thing we don’t eat is the bones and the teeth, but everything else is sucked clean,” Sam said, laughing.

Her mother and grandmother taught her that salmon is a gift from the creator, a source of strength and medicine that is first among all foods on the table. They don’t waste it.

“The skin, the brain, the head, the jaw, everything of the salmon,” she said. “Everybody’s gonna have the opportunity to consume that, even if it’s the eyeball.”

Sam is a member of the Confederated Tribes and Bands of the Yakama Nation. They are among several tribes with a deep connection to salmon in the Columbia River Basin, a region that drains parts of the Rocky Mountains of British Columbia, Canada, southward through seven U.S. states into the West’s largest river.

It’s also a region contaminated by more than a century of industrial and agricultural pollution, leaving Sam and others to weigh unknown health risks against sacred practices.

“We just know that if we overconsume a certain amount of it that it might have possible risks,” Sam said as she gutted salmon in the bustling kitchen. “It’s our food. We don’t see it any other way.”

But while tribes have pushed the government to pay closer attention to contamination, that hasn’t happened. Regulators have done so little testing for toxic chemicals in fish that even public health and environmental agencies admit they don’t have enough information to prioritize cleanup efforts or to fully inform the public about human health risks.

So Oregon Public Broadcasting and ProPublica did our own testing, and we found what public health agencies have not: Native tribes in the Columbia River Basin face a disproportionate risk of toxic exposure through their most important food.

OPB and ProPublica purchased 50 salmon from Native fishermen along the Columbia River and paid to have them tested at a certified lab for 13 metals and two classes of chemicals known to be present in the Columbia. We then showed the results to two state health departments, U.S. Environmental Protection Agency officials and tribal fisheries scientists.

A laboratory analyst processes salmon filets for testing at a lab in Washington. (Kristyna Wentz-Graff/OPB)

The testing showed concentrations of two chemicals in the salmon that the EPA and both Oregon and Washington’s health agencies deem unsafe at the levels consumed by many of the 68,000-plus Native people who are members of tribes living in the Columbia River Basin today. Those chemicals are mercury and polychlorinated biphenyls, or PCBs, which after prolonged exposure can damage the immune and reproductive systems and lead to neurodevelopmental disorders.

The general population eats so little fish that agencies do not consider it at risk, which means that government protocols are mostly failing to protect tribal health. In fact, the contaminants pose an unacceptable health risk if salmon is consumed even at just over half the rate commonly reported by tribal members today, according to guidelines from the EPA and Washington Department of Health.

Contaminants in Fish Put Tribal Members at Risk (Source: Data obtained by Oregon Public Broadcasting and ProPublica. Average diet figures from EPA surveys of the Nez Perce Tribe and the general population, and fish advisory guidance from the EPA. Additional information can be found in the methodology section below. Illustration by Irena Hwang/ProPublica.)

The potential for exposure extends along the West Coast, where hundreds of thousands of people face increased risks of cancer and other health problems just by adhering to the salmon-rich diet their cultures were built upon.

Chinook salmon, like the ones OPB and ProPublica sampled, migrate to sea over the course of their lives, where they pick up contaminants that Northwest waters like the Columbia and other rivers deposit in the ocean. EPA documents obtained under the Freedom of Information Act show that even with minimal data available, agency staff members have flagged the potential for exposure to chemicals in salmon caught not just in the Columbia but also Washington’s Puget Sound, British Columbia’s Skeena and Fraser rivers, and California’s Sacramento and San Joaquin rivers.

The Columbia River faces many pollution threats, including from mining. Two reports have found that a tailings dam at British Columbia’s Copper Mountain, 25 miles north of the Washington border, has a probability of failing and flooding communities and tributaries of the Columbia with poisonous sludge. (Kristyna Wentz-Graff/OPB)

Tribes entered into treaties with the U.S. government in the mid-1850s, ceding millions of acres but preserving their perpetual right to their “usual and accustomed” fishing areas; the Supreme Court later likened this right to being as important to Native people as the air they breathe.

But time and again, the U.S. has not upheld those treaties. Damming the Columbia River destroyed tribal fishing grounds and, along with habitat loss and overfishing, drove many salmon populations to near extinction, wiping some out entirely. Previous reporting has shown how the federal government failed in its promises to compensate tribes for those losses and in some cases worked against tribes’ efforts to restore salmon populations. In addition, the EPA has allowed cleanups to languish, and state regulators have been slow to rein in industrial pollution. That toxic pollution impairs the ability of salmon to swim, feed and reproduce.

Continually poor and declining salmon numbers have prompted the White House to acknowledge an environmental justice crisis in the Columbia River Basin.

The results of our testing for toxic chemicals point to yet another failure.

Salmon, first image, is prepped for a variety of tests, including evaluating for the presence of mercury, second image. (Kristyna Wentz-Graff/OPB) A Toxic Mystery

Questions over fish safety go back generations in some tribal families, predating government concerns by decades.

Karlen Yallup remembers tribal elders telling her the water had been clean enough to drink at Celilo Falls, their primary fishing site on the Columbia River. Yallup’s great-great-grandparents, members of the Warm Springs tribe, lived near the falls and would fish there every day.

Karlen Yallup

CONFEDERATED TRIBES OF WARM SPRINGS

On her relationship with salmon: “My grandma’s grandma … fished all day – gave thanks, treated the salmon with respect. … Then, [the area where they fished] was flooded. It was very devastating to the tribes. … Salmon would face some of the hardest times they would ever face. When the salmon is gone, we are gone.”

How she likes to prepare salmon: “So you first start by finely mashing the salmon up, and then you add the beaten eggs into the salmon, and then you salt and pepper it through the whole thing, then you shape the patties and put it in flour, make sure it’s fully covered and put it on the pan.”

As the industrial revolution boomed, farming, industry and urban sprawl grew throughout the basin. In 1957, the falls were submerged by water that pooled behind The Dalles Dam — one of 18 built on the Columbia and its main tributary, the Snake River, to turn the river into a shipping channel, irrigate farmland and generate hydroelectricity. By then, pollution from those new industries had dirtied the water.

Tribal elders told Yallup they knew the water was no longer clean enough to drink when they could see changes and hear differences in the way it ran. They also worried about the health impacts of Hanford, a sprawling nuclear weapons production complex dozens of miles upstream. Hanford became one of dozens of heavily polluted sites across the Columbia basin, considered one of the largest and most expensive toxic cleanups in the world.

Yallup said her elders began to suspect that whatever was getting into the water was getting into the fish. They became “very worried about the salmon getting the family sick,” she said.

It wasn’t until the 1990s, however, that the government and the broader public drew attention to the risk to people eating those fish.

In 1992, despite two decades of improving water quality under the Clean Water Act, an EPA study found chemicals embedded in carp from the Columbia River. The results alarmed the region’s tribes, which responded by working with the agency to test more fish and survey members about their fish consumption rates.

Those efforts revealed that tribal people, on average, eat six to 11 times more fish than non-tribal members. They also detected more than 92 different contaminants in the fish, some at levels high enough to harm human health.

In the years that followed, EPA staff expressed concerns over toxic contamination in report after report, but little happened in response. The issue officially became an agency priority during the administration of President George W. Bush, but the EPA repeatedly fell short of its goals to clean up toxic sites as responsible parties fought over how much it would cost, who would pay and how quickly it needed to be done.

Tracy Selam

YAKAMA NATION

On his relationship with salmon: “My father and mother taught me how to do this. Same with my grandparents. A long time ago, we cooked on alderwood. We get a stick or something and poke through the salmon, and then we’ll cook it on top of, right next to, a fire.”

How he likes to prepare salmon: “Usually I like it when they make dumplings … and then make ’em kind of like soup. How I make dumplings usually just get a pot, you can put it like halfway or fill it up all the way with water and once that boils, then you can get canned salmon or smoked salmon and break it up in there. Then you can either put a can of corn or dried corn. … Then once that boils down a little bit, then that’s when I would try to be done with the dough, which is just flour and water. Then you break off pieces into the pot.”

The agency also never had the money to fulfill its plans for continuous monitoring, said Mary Lou Soscia, the Columbia River coordinator for the EPA, leaving the agency unable to determine whether the river was getting cleaner.

“Nobody wanted to pay attention to toxics,” said Soscia, who has been working on river cleanup since the late 1990s. “But there are small amounts of studies that give us like those yellow blinking lights. And when tribal people eat so much fish, it’s something we have to be really, really concerned about.”

Finally, Oregon delivered in 2011 what was hailed as a breakthrough moment: It adopted new water-quality standards to protect tribal people’s health. The state vowed to restrict the amount of chemicals released by industrial facilities and wastewater plants so that people could eat over a third of a pound of fish per day without increasing their risk of health problems. That amount of fish was based on a survey of tribal members done in the 1990s.

Other states that share the Columbia River or its tributaries were slow to follow suit. Washington waited a decade to adopt equally protective standards; Idaho and Montana still have not.

But while Oregon was ahead of its neighbors, state regulators took few steps to ensure polluters actually met the state’s new limits. For as many as half the contaminants at issue, the state said it didn’t have the technology to measure whether polluters met the new stricter criteria.

The Oregon Department of Environmental Quality also said it didn’t have the staff to keep pollution permits updated. It let more than 80% of polluters operate with expired permits, meaning they weren’t even being held to new standards.

When asked in September for evidence of how the state’s highly touted standard has actually improved water quality, the DEQ said it “does not have significant amounts of data on the concentration of bioaccumulative pollutants in the Columbia River, and therefore does not have any trend information.”

Jennifer Wigal, DEQ’s water quality administrator, said the standards were implemented not because of pollution but to ensure that tribal diets were represented.

Lottie Sam

YAKAMA NATION

On her relationship with salmon: “I don’t think we would be here without this food. … Our parents or grandparents just taught us this way, you know, as we were growing up. … So now it’s a habitual thing. … It’s a delicacy, it has nutrients, it has medicine … and so, even today, in 2022, we’re still going to consume it.”

How she likes to prepare salmon: “Canning, I’ve been doing it for a long time so it’s simple to me. … Start with fresh salmon, then I add a little bit of salt and pepper. … It’s best to use a pressure canner. … You cut the salmon to fit in the jars, add the salt and pepper, clean the rim of the jar and make sure there are no cracks or anything, and you have to seal the lid.”

Wigal also said that when companies release harmful contaminants into the river, most are at such low concentrations that they are below the agency’s ability to detect them. Additionally, most of the contamination affecting fish, the DEQ said, comes not from those polluters but from runoff and erosion from industries like agriculture and logging.

But the DEQ also has yet to curtail that source of pollution. Along the Willamette River, which flows through Oregon’s most populated areas and feeds into the Columbia, the EPA determined last year that the state needed to cut mercury pollution from these sources by at least 88% if it was going to meet its standards for protecting human health.

Congress tried to take matters into its own hands, but it fell into the same pattern of bold plans and delayed action. In 2016 it amended the Clean Water Act, the seminal law governing water pollution nationwide, to require the EPA to establish a program dedicated to restoring the Columbia. It took four years and a nudge from the Government Accountability Office for the program to actually begin. That same year, in 2020, an EPA regional staffer found that broad swaths of the river were polluted with toxic chemicals and were below the standards of the Clean Water Act.

In an emailed response to questions, the EPA repeatedly said Congress gave the agency orders to clean up the Columbia but failed to provide the agency with funding to carry out the work. Even after the agency designated the Columbia an EPA priority, finally elevating the river to the same status as other major ecosystems like the Great Lakes and the Gulf of Mexico, it received no additional funding and staff for cleanup or long-term monitoring.

“That needs to happen,” Soscia, the agency’s Columbia River coordinator, said. “It hasn’t happened.”

A Disproportionate Risk

Had the government followed through on its plans for monitoring, it might have found what OPB and ProPublica’s testing revealed: that contamination was high enough that it would warrant at least one of the state health agencies to recommend eating no more than eight 8-ounce servings of salmon in a month.

For non-tribal people, who on average eat less than those eight monthly servings, the risk is minute. But surveys show members of some tribes in the Columbia River Basin on average eat twice as much fish as the agency’s recommended eight monthly servings.

The testing also revealed the potential for increased cancer risks from PCBs and another class of chemicals known as dioxins. Given an average Columbia River tribal diet, according to recent surveys commissioned by the EPA, the risk is as much as five times higher than what the EPA considers sufficiently protective of public health. This means that, based on the news organizations’ samples, roughly 1 of every 20,000 people would be diagnosed with cancer as a result of eating the average tribal diet — about 16 servings of fish each month — over the course of a lifetime.

The harm goes beyond the raw numbers. That’s because the risk is compounded by exposure from other fish and other toxic chemicals, such as pesticides and flame retardants in those same waters, that weren’t included in OPB and ProPublica’s testing because of cost constraints. Those chemicals are known to accumulate in fish. Beyond fish contamination, tribal populations already experience disproportionately high rates of certain cancers.

Public health officials caution that any cancer risks must be weighed against the many health benefits of eating fish, including the potential to lower the risk of heart disease. The Oregon and Washington health departments, like those of many states, do not assess cancer risk when setting public health advisories.

We showed the result of our testing to public health officials in both Washington and Oregon. Both groups said they would be taking further steps to assess salmon and the exposure risk to tribes.

Emerson Christie, a toxicologist with the Washington Department of Health who analyzed the results, said the department will consider whether to issue an official public health advisory based on the news organizations’ findings. “These results do indicate that there’s a potential for a fish advisory,” Christie said.

David Farrer, an Oregon Health Authority toxicologist who also reviewed the results, said the agency would coordinate with state environmental regulators and the Columbia River Inter-Tribal Fish Commission about additional testing or potential advisories.

Public health advisories and cooking guidance are a last-resort attempt to protect people when larger cleanup efforts fall short or don’t happen at all.

These advisories can also be plagued with delays. When tribes collected and tested tissue from the Pacific lamprey back in 2009, they found that the culturally important eel-like fish contained dangerous levels of mercury and PCBs. The Oregon Health Authority responded by issuing a consumption warning in October — but the process took 13 years.

And while advisories put constraints on tribes’ traditional diets, they don’t help with the larger issue: that the waters from which they are eating fish are still contaminated — with no plan to clean them up.

“The long-term solution to this problem isn’t keeping people from eating contaminated fish — it’s keeping fish from being contaminated in the first place,” Aja DeCoteau, executive director of the Columbia River Inter-Tribal Fish Commission, said when the lamprey advisory was issued.

Members of the Yakama Nation scale the slippery rocks in the Willamette River near Oregon City, Ore., during the annual lamprey harvest in 2017. (Ian McCluskey/OPB)

Wilbur Slockish Jr. is a longtime fisherman who serves on the inter-tribal fish commission.

It is wrong, Slockish said, for the government to allow pollution and then, instead of cleaning it up, decide it can tell people not to eat the fish they always have.

“That’s on the back of our people’s health, the health of the land, the health of the water,” he said. “We’re not disposable.”

A Fight Too Big to Ignore

Slockish eats a lot of fish.

He relies on stockpiles of jarred, dried or smoked salmon to get him through the winter. He said it’s not uncommon for him to eat more than a pound of salmon or lamprey in one sitting, sometimes multiple times per day.

He’s a direct descendant of the Klickitat tribe’s Chief Sla-kish, who signed the Yakama Treaty of 1855, guaranteeing his people’s right to the fish. At that time, studies estimate that, on average, Native people in the region ate five to 10 times more fish than they do today. Slockish is not going to stop eating fish because of warnings about chemical contamination.

He doesn’t see the alternatives as any better. Many in his family have struggled with heart disease, diabetes and cancer. He connects it to their being forced away from the river and made to eat government-issued commodity foods full of preservatives.

“All of our foods were medicine,” he said. “Because there were no chemicals.”

Research across the globe has connected the loss of traditional diets with spikes in health problems for Indigenous populations. In one West Coast tribe, the Karuk of Northern California, researchers found a direct link between families’ loss of access to salmon and increased prevalence of diabetes and heart disease.

Public health experts agree that wild salmon, wherever it’s caught, remains one of the healthiest sources of protein available, and that chemicals can also contaminate other foods beyond just fish.

A member of the Confederated Tribes of Warm Springs prepares wind-dried salmon the traditional way, inside a drying shack, in September 2021. After she removes the heads and bones, the salmon is sliced into strips, salted and hung to dry for several days. (Arya Surowidjojo/OPB)

Tribal leaders also worry more about their members getting too little fish than too much of it. And because salmon are a primary income source for many tribal fishers, they worry that fears over fish safety will drive away customers.

But for Columbia River tribes, fish are also a cultural fixture, present at every ceremony. They are shared as customary gifts. Babies teethe on lamprey tails. Salmon heads and backbones are boiled into medicinal broths for the sick and elderly.

Tribes up and down the river continue to fight for their right to a traditional diet and to clean fish.

Yallup, from the Warm Springs tribe, decided to become an advocate for salmon after hearing from her grandmothers how much more limited their traditions had become.

She’s on track to graduate in December from Portland’s Lewis & Clark Law School. Yallup chose the law profession to fight for salmon, she said, and to change laws to protect the river from pollution.

“If I had a choice, I would just be a fisherman. I felt the responsibility to have to leave the reservation and have to go to law school,” Yallup said. “It’s such a big fight now. It’s kind of impossible to ignore.”

Earlier this year, tribes successfully lobbied for one of their Columbia River fishing sites just east of Portland, known as Bradford Island, to be added to the list of polluted places eligible for cleanup money from the federal Superfund program.

The east end of Bradford Island, where the U.S. Army Corps of Engineers dumped toxic materials into the Columbia River. The island was added to the list of polluted places eligible for cleanup money from the federal Superfund program. (Monica Samayoa/OPB)

In August, the EPA received $79 million to reduce toxic pollution in the Columbia River as part of President Joe Biden’s Bipartisan Infrastructure Law. It is the most money ever dedicated to reducing Columbia River contamination. It’s also a fraction of what tribes and advocates say is needed.

The Yakama Nation is using some of that EPA money to lead a pilot study into the kind of long-term monitoring that has been a recognized need for decades.

Laura Klasner Shira, an environmental engineer for Yakama Nation Fisheries, said the tribe put together four federal grants to pay for its pilot study, which is limited to the area around Bonneville Dam, east of Portland. They hope someday it could grow to span nearly the entire length of the Columbia, up to the Canadian border. But it took 10 years to get as far as they are now.

“It’s disappointing that the tribes have to take on this work,” she said, noting that government agencies not only have treaty and legal responsibilities but better funding. “The tribes have been the strongest advocates with the least resources.”

They will sample resident fish, young salmon on their way to the ocean, and adult salmon after they’ve returned.

They have two years to finish the work. After that, funding for their monitoring becomes a question mark.

Methodology

Oregon Public Broadcasting and ProPublica reporters conducted interviews and listening sessions with tribal leaders, toxicologists and public health experts, many of whom became informal advisers throughout the project. Tribal leaders expressed support and interest in additional fish testing. Based on these conversations, the reporters developed a preliminary methodology to test salmon for toxics in a stretch of the Columbia River. The reporters sent this methodology to the same informal advisers for review.

A reporter purchased 50 salmon from tribal fishers upriver of the Bonneville Dam, in the zone of the river reserved for tribal treaty fishing. The majority of the fish were fall Chinook salmon, with two coho salmon and one steelhead. The fish were caught in late September 2021. With the salmon in hand, a reporter gutted the fish, removed the heads and cut them into pieces so they would fit into five coolers. The fish were placed on ice in five different coolers, with 10 fish of roughly the same size placed in each cooler.

Testing of fish can be done on the whole body of the fish, on a fillet with the skin on or on a fillet with the skin removed. Although many people, particularly in tribal communities, consume the head of the fish, reporters asked the laboratory to test fillets with skin because it was determined to capture the best approximation of what’s most often consumed in tribal diets.

A reporter sent the fish samples to ALS, a certified laboratory, and followed ALS protocols for the collection and delivery of samples. The laboratory combined fish to create five new composite samples, each one with 10 fish. (Creating composite samples enables more fish to be tested without raising laboratory costs.) Then, ALS technicians conducted testing to assess levels of 13 metals and two classes of chemicals in each of the five fish samples. In March 2022, ALS sent OPB and ProPublica an analytical report that included the case narrative, chain of custody and testing results, which we again shared with experts and public health officials as we developed a plan to analyze the results.

As a first step, the reporters conducted quality assurance checks on the testing and processed the data. While doing so, the reporters encountered testing limitations that prompted them to make two choices that are standard in both national and international approaches to fish toxics testing:

1. ALS tested for general mercury, yet methylmercury is the form that is most concerning to public health. The EPA and European Food Safety Authority assume 100% of mercury sampled in fish tissue is methylmercury. The reporters adopted the same approach.
2. ALS tested for arsenic, yet inorganic arsenic is the form that is most concerning to public health. The reporters found that there isn’t as much of a cohesive approach toward identifying the proportion of arsenic that is inorganic without directly testing for it. The Idaho Department of Environmental Quality recently launched a sampling effort where researchers found that, on average, about 4% of the arsenic in fish is inorganic. The department’s study is one of the most robust examinations of inorganic arsenic concentrations near the Columbia River. The Oregon Health Authority takes a different approach. David Farrer, a toxicologist with the agency, said they would initially assume 10% of arsenic is inorganic and, if the results signaled the levels could harm human health, they would then reanalyze any leftover sample specifically for inorganic arsenic. If that were not possible, the health department would not use the data at all. Given these uncertainties, OPB and ProPublica chose not to move forward with assessing cancer risk of inorganic arsenic since the news organizations did not specifically test for it.

The reporters then calculated the average concentration of chemicals across each of the wet weight samples. They then assessed how these results compared to EPA, Oregon Health Authority and Washington Department of Health standards.

Of the 13 metals and two classes of chemicals tested, three contaminants surpassed federal and local standards at varying levels of fish consumption: mercury, or methylmercury; polychlorinated biphenyls, or PCBs; and dioxins/furans.

The reporters shared their methodology and findings with experts for review. Toxicologists with the Oregon Health Authority and the Washington Department of Health, as well as former and current EPA scientists, reviewed the results and, in some cases, conducted their own calculations to assess how the testing findings compared to their respective standards. The reporters then met with each of these individuals to talk through the findings, ask and answer questions, and ultimately update their own findings to incorporate feedback. The experts’ feedback was consistent with one another. This process led to the finding that concentrations of mercury (methylmercury) and PCBs would warrant the EPA and at least one state health agency to recommend eating no more than eight 8-ounce servings of salmon in a month. The equation used for these calculations can be found in this Oregon Health Authority report (Page 4) and this Washington Department of Health report (Page 35).

Simultaneously, OPB and ProPublica calculated the estimated cancer risk from consuming salmon with the contaminant levels found through our testing. For each contaminant, a reporter calculated the levels of exposure for multiple scenarios based on how different populations eat, including general population consumption and average and high rates for Columbia River tribes, which were based on consumption surveys. The amount of contamination assumed in this calculation was taken from the 95% upper confidence limit of the test results. Current and former EPA scientists reviewed the methodology and calculations.

To calculate lifetime cancer risk, the dose of a probable carcinogen must be multiplied by a cancer potency factor, which estimates toxicity. Cancer potency factors, also known as slope factors, were sourced from this EPA report. Former and current EPA officials, as well as an epidemiologist, reviewed the calculations and results.

We also factored in the following consideration: Under EPA guidance, when calculating safe levels of exposure to different chemicals, the agency calculates monthly limits to the exact number of meals a person should eat. But it then rounds that down to the nearest multiple of four in an effort to make risk communication easier to follow. For example, if one were to find that the levels of dioxins would warrant that someone only eat five fish per month to avoid excess cancer risks, that would be rounded down to the four fish per month.

Ultimately, this led to the finding that, based on the levels of dioxins in our samples, anything above four 8-ounce servings of these tested fish each month would create an excess cancer risk beyond the EPA’s benchmark of 1 in 100,000. That means of 100,000 people exposed to these levels of contaminants, one of them would develop cancer as a result of the exposure.

Help Us Understand Pacific Northwest Salmon and Treaty Rights

by Jessica Lussenhop, ProPublica, and Joey Peters, Sahan Journal, with data analysis by Haru Coryne, ProPublica

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

This story was produced in collaboration with Sahan Journal, a nonprofit newsroom dedicated to covering Minnesota's immigrants and communities of color. Sign up for Sahan’s free newsletter to receive stories in your inbox.

For many Somali families in Minnesota, the barriers to home ownership have long seemed insurmountable: reluctant lenders, low incomes, short work histories, little credit.

Members of the East African Muslim community encounter an additional, unique challenge: Because of the principles of their faith, many avoid paying or profiting from interest. This means they typically won’t apply for traditional mortgages. As a result, the conventional path to buying a house — and the accompanying hope of building generational wealth — has been nearly impossible.

Roughly three years ago, a handful of lending firms began offering an “interest free” way to buy a home. Word spread fast in Minnesota’s Somali community, which numbers about 80,000 people. Families began moving out of their cramped apartments and government-subsidized housing and into homes in the suburbs with expansive lawns and enough bedrooms for their large, multigenerational families.

The seeming solution came in the form of a short document with three boldfaced words at the top: “Contract For Deed.” An alternative way to purchase a house, a contract for deed is, at its simplest, a financial agreement in which a buyer pays the seller directly in installments. No mortgage. No bank.

But seller financing, as it is also known, lacks key protections for the buyer. Until the final payment is made, the seller holds the ownership papers to the property, and the contract can be canceled by the seller if the buyer falls behind on their monthly payments. If that happens, the buyer forfeits all the money they’ve put into the purchase, including the down payment. The seller could then evict the buyer after as little as 60 days.

Many buyers mistakenly believe if they make the monthly payment stipulated in their contracts, they will successfully pay off the home by the end of the contract term. But those payments may only add up to a portion of the price of the home, and the buyer is expected to make up the difference with a lump-sum payment, known as a balloon, or by refinancing the loan. The lenders almost have an incentive for contracts to fail. They get the home and pocket the payments.

To prospective Somali buyers desperate for extra space, safer neighborhoods with better schools and the chance to pass a home on to their children, any deal was better than no deal.

One of those buyers was a long-haul truck driver who for years had rented an apartment in a Minneapolis suburb. The apartment was too small for his wife and their growing family; their children had to double and triple up in the bedrooms. Buying a house had always been the couple’s goal, but the husband believed his credit score was too low.

Still, he couldn’t help himself from perusing listings on real-estate websites and attending the occasional open house. One day, he took two of his children with him.

“‘Hey, Dad, this house has more bedrooms. This house has a playground.’ They’ve never seen their own yard,” said the trucker, who spoke to ProPublica and Sahan Journal on the condition he not be named. “They were really excited. That’s when I say: ‘OK, I can do it. If my kids are happy like this, I can do it.’”

The trucker, a quiet, nattily dressed man in his mid-30s, contacted a friend who recently had bought a house and asked how he did it. The answer: a contract for deed. Following the same steps as his friend, this summer the trucker purchased a spacious home in an outer-ring suburb south of Minneapolis.

But just two months later, he said, the contract had already become unmanageable. His family is at risk of losing not only the house, but about $100,000 they have paid, including a hefty down payment. He said he never understood the disadvantages and quirks of the contract for deed.

Now, it’s too late to get out of it.

“It’s really scary,” he said. “To be honest, you’re sleeping right there and you can’t think of it as if it’s your house.”

(Imran Hussein, special to ProPublica)

Fartun Weli, the CEO of Isuroon, a nonprofit that advocates for Somali women and girls, said her housing team has been trying to gauge the scope of the problem in the Twin Cities, where affordable housing is scarce.

She estimates at least 100 Somali families had purchased homes with contracts for deed but believes there could be many more. Last year, more than 1,800 contracts for deed were signed in Minnesota’s 11 most populous counties — all of which have more than 100,000 residents and which include Minneapolis and St. Paul, as well as cities such as St. Cloud, Rochester and Duluth. (Neither the state nor counties track these sales by race or ethnicity.)

Many of those contracts were for newly constructed, multibedroom homes that sold in the mid to high six figures; some sold for close to $1 million. According to the contracts, buyers could lose hundreds of thousands of dollars if they default, as well as the house itself.

Sahan Journal and ProPublica spoke to five Somali homebuyers who said they signed contracts they did not understand, though none would agree to be identified. Weli said she is alarmed that so many Somali families are entering into precarious real estate transactions believing they have found a “shortcut” to homeownership.

“It’s so delicious, the bait. Well, you don’t really know when you swallow there’s a sourness, a small piece of cyanide that’s getting to you,” Weli said. “Contract for deed is really an amazing trap for our community.”

There is nothing illegal about contract-for-deed agreements. Defenders say they offer an alternate path to home ownership for people whose financial circumstances don’t fit the standards set by conventional mortgage lenders.

“There are buyers out there who don’t necessarily have pristine credit. That’s the purpose of a contract for deed,” said Larry Wertheim, a real estate attorney in Minneapolis who has worked with these kinds of agreements for decades. “They do serve a purpose. But, you know, they can be abused, too.”

But Wertheim and other housing advocates say the market needs stronger consumer protections.

In the wake of the 2008 housing crisis, the number of contract-for-deed agreements spiked, sparking a wave of defaults.

“Most of those contracts for deed were designed to fail,” said Luke Grundman, litigation director at Mid-Minnesota Legal Aid. “They may have sunk tens of thousands of dollars into the down payment and monthly payments. And then it’s not just the actual money but the false hope of homeownership.”

Since 2012, the number of contracts in Minnesota’s 11 most populous counties declined, from a high of about 2,500 that year to a low of about 1,500 in 2020. But that downward trend ended last year. As the number of contracts has rebounded, a growing market has emerged: Somali homebuyers seeking interest-free financing.

“Don’t you want your own property ... a house your whole family can fit in?” says the website for C4D LLC, one of the largest contract-for-deed providers in Minnesota and whose site is in Somali and English. “Buying a house in the States normally asks you to pay interest. Or to have a good credit score. But you don’t have to if you choose a contract-for-deed agreement.”

Steven Legatt, a partner at C4D, said his business grew out of an existing market for car loans serving the Somali community. His company offers both interest-free and conventional contracts for deed, and he described his customer base as mostly Somali, including first-time homebuyers.

“They’re generally large families, and a lot of them are bumping their heads in their rentals,” Legatt said. “They wanted to put their money towards purchasing a house, not just renting.”

The company purchases homes using mortgages from a conventional lender. Then, it sells the houses — often on the same day and at a higher price — to buyers through a contract for deed. It is one of several companies that Sahan Journal and ProPublica identified that flip homes in this way.

Jeff Scislow is a real estate agent who began advertising his contract-for-deed services on a Facebook page called “My Somali Home,” since renamed “My Interest Free Home.” While Scislow said he screens potential buyers and writes contracts with clear payment schedules, he knows other sellers don’t.

He called the market in the Twin Cities “the Wild West.”

In the background of all this: For decades, Minneapolis and St. Paul have recorded some of the biggest racial homeownership gaps among the nation’s metro areas. According to the Urban Institute, a nonprofit research organization, 21% of all Black families in the Twin Cities own their homes, compared with 70% of white families. Research by the Amherst H. Wilder Foundation, a nonprofit community organization in St. Paul, estimates that only 10% of Minnesota Somali families own their home.

In 2013, Minnesota lawmakers, responding to a Star Tribune investigation, passed a law to curb the excesses of contracts for deed. The statute requires sellers who write more than four agreements a year to provide buyers with a notice spelling out the transaction’s disadvantages. But the notice is just a list of recommendations and warnings; no state agency is tasked with enforcing it, and buyers have to sue the seller to trigger any potential penalties. The law also does not require sellers to verify buyers’ ability to repay their debts.

Legatt said he typically attends closings to answer buyers’ questions and tries to make sure the contracts are in his buyers’ best interest. But, he said, he generally doesn’t have a uniform process for screening buyers and doesn’t verify buyers’ incomes with documentation like paystubs, which is standard practice when getting a mortgage from a bank.

At a recent closing, he said, he had to explain to a potential buyer that they would not actually own the house until the contract was satisfied. He said that he provides an interpreter when needed.

“We have built our business the right way,” he added in an email.

Under a contract for deed, buyers assume many of the risks and responsibilities of a traditional owner, and yet they can face terms that are harsher than mortgages.

Unlike a mortgage from a bank, which typically needs to be paid off in 15 or 30 years, contracts for deed often come due in five or 10 years; some contracts reviewed by ProPublica and Sahan Journal were even shorter. An assessment of the value of the house, known as an appraisal, is not required to determine the selling price. The buyer is responsible for all repairs and renovations, as well as insurance costs on the property.

“All the obligations of ownership come to you without really any of the benefits of ownership,” said Ron Elwood, supervising attorney at the Legal Services Advocacy Project, the policy advocacy arm of Legal Aid in Minnesota.

The amount of the lump-sum, or balloon, payments, which can be tens or even hundreds of thousands of dollars, may not be spelled out in the contract terms; the payment dates may also be unclear. And sellers may expect these buyers to pay off the contract by obtaining a conventional mortgage for the remainder of the balance.

Some Somali contract buyers told Sahan Journal and ProPublica that they signed documents without reading them, relying instead on verbal explanations from people they thought were trustworthy.

Some of the lawmakers behind the 2013 legislation agreed that more needs to be done to protect homebuyers.

“We got the ball somewhat down in the field, to borrow a football analogy,” said State Rep. Jim Davnie, a Democrat from south Minneapolis who sponsored the legislation. “Was it everything that was needed at the time? Probably not.”

States like Arizona and Florida have laws affording buyers more protection, like a requirement that canceled contracts be handled through the foreclosure process. This gives the buyer more time to pay the overdue balance or at least some options to recoup their money.

“We need to think very hard about following some of these other states’ leads and providing more protections and more balance in the statute to make it so that if the deal fails, it’s not a total washout,” Elwood said.

Some critics say Minnesota should take an even tougher stand against contracts for deed.

“It should not be legal, not this way, in Minnesota,” said Shirwa Adan, the executive director of the Central Minnesota Community Empowerment Organization, a nonprofit serving the Somali community in St. Cloud. “It’s targeting our community.”

Wafiq Fannoun, the owner of a Minneapolis-based Islamic financial consulting business called Reba Free LLC, said Islam allows flexibility when a family is facing dire circumstances or when there are no alternatives. A handful of lenders in Minnesota offer Islamic or halal financing: loans that buyers can pay off through interest-free installments.

But some prospective buyers still can’t qualify for those loans, which leaves contract for deed as one of their last options.

“Those people really need to make sure that in the process they are not being used or abused,” Fannon said.

Once the truck driver and his wife decided to buy, they visited the same real estate agent his friend had used. The agent, Ismail Harun, showed them a newly constructed home and explained the terms of a five-year contract.

In the Somali community, business deals are sometimes struck verbally and reputation matters. The trucker liked what he heard. The real estate agent connected the trucker with the principal of an investment company called Banken Holdings LLC.

Chad Banken, of Banken Holdings LLC, is listed as the officer of at least four other companies that sell homes through contracts for deed. Taken together, his companies have sold at least 100 properties since 2019, according to property records, making him one of the largest contract sellers in the state.

Banken has been a figure in Minnesota real estate for more than a decade. In the 2000s, he was a defendant in two federal lawsuits filed by homeowners attempting to save their homes from foreclosure. According to the lawsuits, Banken’s companies arranged to buy the homes and then resold them at a higher price to their former owners.

In both cases, the buyers fell into default but alleged they’d been misled — one of the cases was covered in 2006 by Minnesota Public Radio as an example of “mortgage foreclosure rescue” services gone bad. Banken denied misleading anyone and the lawsuits were settled. Banken did not return calls or respond to a detailed list of questions for this story.

Banken promotes his current contract-for-deed program on websites with names like “A Good Deed” and “Slow Flip LLC,” which call contracts for deed a “forgotten tool.” The sites say buyers must have 10% of the house price or $30,000 — whichever amount is larger — for a down payment; a “reasonable” income; and an “exit strategy” to pay off the contract at the end of its five- to 10-year term.

“Typically refinancing with a mortgage is the plan, but some exit strategies involve selling the property or making large periodic payments. Having a reasonable plan is critical to success with A Good Deed contract for deed,” one site reads. “A relief for many buyers is that YOUR CREDIT SCORE IS NOT A FACTOR.”

The truck driver bought his home according to Banken’s script: On the day of the sale, Banken’s company purchased the house using a conventional mortgage and then sold it to the trucker at a markup. The trucker and his wife put 10% down and agreed to monthly installments that were more than triple what they had been paying in rent.

The trucker said he believed that, if he worked longer hours and his wife got a job, they could swing the monthly payment, as well as make an additional $50,000 payment at the end of each year. But almost as soon as the family moved in, inflation hit the trucker’s bottom line. The cost of diesel went up and the loads he was carrying got smaller, making the monthly payments a struggle. After the trucker read the terms of his contract again, he realized his debt was even steeper; he wouldn’t be able to pay off the contract.

What’s more, the contract included interest at a rate of about 6% — which defeated the main reason to use a contract for deed. After five years, he would still be more than $500,000 in debt, which would come due all at once.

At that point, if the family couldn’t pay the balance or refinance, they could lose their home and have to walk away from nearly $300,000 in payments.

(Imran Hussein, special to ProPublica)

Since then, the trucker has been looking for help to get out of the deal. This summer, he and his wife walked into the Bloomington offices of Sakan Community Resource, a nonprofit that provides financial counseling and homebuying classes to the Muslim immigrant community. The trucker gave Executive Director Johanna Osman a copy of the contract he’d signed.

Although she’d heard from friends and colleagues that more and more Somali families were buying homes this way, it was the first contract Osman had seen with her own eyes.

“While I was reading, I was getting really angry,” she said. “Oh, it was insidious.”

The trucker also spoke to one of the banks in Minnesota that offer Islamic financing. But he said it turned him down because the price he’d agreed to pay for his house exceeded the appraised value.

“The problem is that the markup is just kind of a made-up number,” said Wertheim, the attorney who specializes in contracts for deed. “The real disconnect is [the buyers] think: ‘All right, I’ve done this deal. At the end, I will own it.’ No, they won’t. You’ve got a balloon. That’s the problem, and it’s made more difficult by the fact that you overpaid.”

The trucker said his real estate agent, Harun, misled him about how the contract could be paid off in five years. Harun, who has sold multiple homes with Banken-backed contracts for deed, denied misinforming his clients and said he warns buyers that some contracts are overpriced and include interest. He connected Sahan Journal and ProPublica with a client who said that Harun explained the terms clearly.

“I can advise them, but I cannot force them. And I’m not here to make decisions on their behalf,” Harun said. “Whoever’s doing the loan, that’s the person who has to explain to them what the terms are, what the down payments are, what the rates are, how they pay and all that stuff.”

Osman said she is trying to work with families to bring complaints about predatory practices to the attorney general’s office. Weli, of Isuroon, said her organization is building a legal team to help families who have bought through contracts for deed. But she added that many buyers are ashamed and afraid.

“These families are not talking. They’re not talking. They’re just disappearing,” she said. “So then there’s a lack of accountability.”

On a visit this summer, the trucker stood in his finished basement gazing out onto the verdant backyard that he’d wanted so much for his children. The room was almost empty. He’d been so worried about losing their home that he stopped trying to furnish it.

Signing the contract, he said, was the biggest mistake of his life.

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by Brett Murphy

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This story contains detailed descriptions of the death of a child.

Detective Eric Matthews decided Jessica Logan probably killed her baby before he talked to a single eyewitness or collected almost any evidence. At that point, on Oct. 9, 2019, the coroner hadn’t yet announced a cause of death. What Matthews did have was a recording of Logan’s 911 call from two days earlier.

The detective scribbled notes as he listened.

“Jessica,” the 911 dispatcher said at one point, “take a deep breath for me, OK?”

“I can’t,” Logan replied, inhaling sharply to force the words out. “That’s my baby.”

“I know. I know.”

“I need my baby.”

The call had come in just after 3 a.m. from a duplex in the heart of Decatur, Illinois. On the tape, Logan struggled to gain her composure as the dispatcher asked what had happened.

“I came in my son room to try to give him a breathing treatment because he needs breathing treatments,” Logan said as she sobbed. “And he’s not breathing.”

She had found her 19-month-old son Jayden tangled up in his bed sheets, face down and stiff, one arm bent above his head and white foam spilling out of his mouth.

“He’s so cold and hard,” Logan said.

“What?”

“He’s so cold and hard.”

Rigor mortis had already begun to set in by the time Jayden’s grandmother and her husband rushed into the apartment. For the final two minutes of the call, Logan could no longer speak. There were only screams.

All of this, the detective concluded after the recording stopped, was an act: The 25-year-old mother of two had likely staged the scene to cover up a murder. He had the evidence right there on tape, and now he was going to build his case against her. Matthews, a veteran on the Decatur police force with buzzed hair and an even temperament, didn’t reach this revelation by applying some tried-and-true police method or proven science.

Logan and her sons in May, 2018. Jayden, the younger son, died nearly 17 months later. (Photo by Hope Bradford.)

Five months earlier, he had taken a two-day law enforcement training course called “911 homicide: Is the caller the killer?” that was held at a nearby community college. The instructor, who is the chief architect of the discipline, promises those who attend his classes they’ll leave with the power to solve murders by listening to a 911 call.

For more than a decade, the training program and its methods have spread across the country and burrowed deep into the justice system, largely without notice. Pitched exclusively to law enforcement, others in the justice system, including defense lawyers and judges, often learn police have used the technique for the first time in the courtroom.

Today there are hundreds of police officers, prosecutors, coroners and dispatchers nationwide who have taken the course and could now present themselves as experts, able to divine truth and deception — and guilt and innocence — from the word choice, cadence and even grammar of people reporting emergencies.

For Matthews, Logan presented a textbook case on which to apply his newly minted skills. She did not explain precisely what had happened until almost a minute into the 911 call, and she never explicitly asked for an ambulance for Jayden. These, the detective noted in a report, are “indicators of guilt.”

She gave information in an inappropriate order. Some answers were too short. She equivocated. She repeated herself several times with “attempts to convince” the dispatcher of Jayden’s breathing problems. She was more focused on herself than her son: I need my baby instead of I need help for my baby. And when asked if Jayden was beyond any help, Logan said, “I think he’s gone.” She had “already accepted that Jayden was deceased,” Matthews noted in his report.

According to the detective, almost everything Logan said — and didn’t say — was evidence of her guilt.

He documented his findings and then got to work sharing them. His interpretation of her 911 call that day would come to play a profound role at almost every turn of the case that followed, while Logan’s family, already shattered by one unspeakable loss, reckoned with the possibility of another.

Listen to critical moments in Jessica Logan’s 911 call and read the lead detective’s analysis.

Here’s How Police Used Dubious “911 Call Analysis” to Determine Jessica Logan Was Lying

The lead detective heard her 911 call and concluded it was full of “indicators of guilt.” His analysis played a crucial role throughout the case.

(Interactive by Jeff Frankl and Lucas Waldron)

Matthews did not respond to multiple interview requests, and the chief of the Decatur Police Department declined to comment or make any of his staff available for an interview. Neither replied to a list of detailed questions.

In the coming weeks, ProPublica will reveal the origins of 911 call analysis and the local, state and federal agencies that foster it, despite a consensus among experts that its application is scientifically baseless. Police and prosecutors continue to leverage this method against unwitting defendants across the country, ProPublica found, in some cases slipping it past judges to present it to jurors.

Listen to more of Jessica Logan’s 911 call

The case against Jessica Logan — reconstructed here from dozens of interviews, videos and audio recordings, as well as more than 1,000 pages of internal emails, text messages, police reports, court filings and other records — illustrates the fragility of long-established legal protections meant to guard against junk science and its impact on families.

Hope Bradford, a mother of three with eyes that smile before her mouth can catch up, took in Logan, her son’s then-girlfriend, when she was 17. It was an unofficial adoption after Logan’s biological mother died of cancer. She’s called Bradford “Mom” ever since. To Bradford, Logan is “Butterball.” Only Jessica if she’s in trouble: Jessica when she cut class; Jessica when she was arrested for shoplifting as a teenager; Jessica when she got caught joyriding her father's Chevy and showed up at Bradford’s doorstep.

Bradford at home (Mauricio Rodríguez Pons and Nadia Sussman /ProPublica)

Watch video ➜

Bradford’s tone, normally buoyant, drops low and icy when she’s meting out discipline to her kids and grandkids. “You’ve got to get your shit together,” she told Logan one time after her new daughter backslid. Like most do when Bradford gives orders, Logan obeyed.

Bradford’s son, Shawneen Comage — father to Logan’s two boys — did not. In October 2018, he was arrested for punching Logan in the face six or seven times, just feet from where Jayden slept, child services records show. He was convicted of domestic battery. Comage had abused her before over the years, his fits of rage memorialized by holes pockmarked in the drywall around his bedroom. In an interview, he said he regrets that part of his past and that he’s come a long way since.

After the episode in 2018, a state child services investigator noted that Logan seemed “somewhat complacent” about Comage’s violence. It’s not far from how friends and family describe her: gentle and guileless, with a placid affect that can be difficult to read. Her narrow green eyes often stare vacantly. As a child, she was diagnosed with a learning disability so severe that she qualified for government benefits after graduating high school. She needed the questions on her final exams read to her.

Family photos of Logan as a teenager (Mauricio Rodríguez Pons/ProPublica)

When Logan speaks, she takes long pauses to think over an answer, and the words fall out of her mouth slowly. She drags vowels. She repeats herself often. “It’s like she’d be in a daze about certain things,” one relative observed. “I don’t want to say Jess is slow,” another said affectionately before trailing off.

Logan turned 22 and moved into her own apartment, the first that felt like a real home after brief stints in two other places. It was a Section 8 duplex with white vinyl siding minutes away from Bradford. Logan loved the clean carpets and playground right outside where she could snap pictures of Jayden and her older son Je’Shawn playing together. She recorded hundreds of such moments — the mundane and the milestones: first steps, spaghetti dinners, birthday parties, even trips to the doctor.

Logan felt independent. She started to plan a future for her family, maybe somewhere down south. She researched U-Haul prices and affordable housing options. “My goal,” she said later, “was to have three kids and own my own house before the age of 30.”

Logan documented her life with her children in hundreds of cell phone pictures and videos. (Jessica Logan)

But the bills piled up quickly. She tried to keep her head above water with odd jobs and babysitting gigs, relying largely on food stamps and whatever she could borrow from family and payday loan companies. More than once, she overdrafted her checking account to buy gas and diapers. Bradford, a certified nursing assistant, eventually helped her land a full-time job in the kitchen at a nearby long-term care facility.

On the afternoon of Oct. 6, 2019, Bradford picked up Logan and the boys and drove to Walmart. Jayden — who had grown thickset, with curly black hair and a pigeon-toed waddle — needed new socks and sippy cups. Just socks for Je’Shawn. Logan had $20 in her pocket and nothing in the bank as she pushed Jayden in the shopping cart.

Bradford told Logan, “You need to get some new underwear, Butterball,” something she had discovered after finding tattered panties in the laundry. But the $20 was just enough to cover the boys. At checkout, Bradford paid for the underwear and then dropped all three back home.

Hours later, just after 3 a.m., Bradford’s phone rang. On the other end, Logan wailed. Jayden or Je’Shawn — Bradford couldn’t make out which one — wasn’t breathing. She told Logan to hang up and call 911.

Bradford and her then-husband, Clint Taylor, sped to the duplex, through red lights, in less than two minutes. Taylor jumped out before the car stopped rolling and bolted inside, where he found Logan talking to the 911 dispatcher and cradling Jayden’s body.

Photos of Jayden's bed and Paw Patrol sheets (Obtained by ProPublica from the Decatur Police Department)

When Bradford came into the living room, both women began to scream. Taylor scooped Je’Shawn up and carried him outside toward the flashing lights that had arrived on the scene. Firefighters rushed in, but it was too late.

When the coroner took Jayden’s body away, “I observed Jessica to be very upset and crying,” a patrol officer wrote in his report. “After giving her time to calm down, I conducted an interview.”

When a child dies, families are tormented by what they don’t know. Sometimes babies and toddlers just stop breathing in their sleep, from accidental asphyxiation, illness or a maddeningly unclear combination. In 2019, at least 125 children Jayden’s age died of “undetermined causes” in the U.S., according to government estimates, a phenomenon known as Sudden Unexplained Death in Childhood. More than 200 were killed in homicides.

The cemetery where Jayden Comage is buried (Mauricio Rodríguez Pons and Nadia Sussman /ProPublica)

Watch video ➜

There often appears to be little way of distinguishing between the two explanations. Absent definitive physical evidence, police may try to fill the gap with circumstantial clues, assigning meaning to how family members behaved before and after. The grieving parent becomes a suspect.

Once they decide a death is a homicide, detectives have an array of tools at their disposal. For decades, law enforcement has repeatedly embraced the latest evidence to fall under the banner of “forensics.” Bite marks, hair follicles, roadside drug tests, written statements, polygraphs and blood spatter have all been analyzed with techniques that were later called into question.

Still, some prosecutors have accepted this evidence as fact before they leverage it in plea deals or judges allow them to present it to juries. At least 416 people nationwide have been exonerated since 2012 after they were convicted with faulty forensics or misleading expert testimony, according to data from the National Registry of Exonerations, a project from three universities.

Similarly, 911 call analysis is a measure of law enforcement’s credulity, favored in cases with few witnesses or other evidence to differentiate an accident from a murder. Use of this method is still a well-kept secret among police and prosecutors, who almost never share their analyses publicly. In emails with one another, however, they extol its value in solving murders and frequently consult with the program’s chief architect, a retired deputy police chief from suburban Ohio named Tracy Harpster.

Emergency 911 calls are, without doubt, critical pieces of information for investigators. They often establish a raw first-hand account and timeline that can later be checked against other evidence. But Harpster preaches they are also much more: The recordings are ciphers that can be decoded to help solve murders, if, and only if, you take his training course. He gets paid up to $3,500 to teach an eight-hour class.

Tracy Harpster, chief architect of the 911 call analysis training program, and a sample of “guilty indicators” from his model (Photo illustration by Mauricio Rodríguez Pons/ProPublica. Sources: Macon County State's Attorney's Office and Toledo Police Department website.​​)

One in three callers reporting a death, Harpster claims, betray their true involvement with unconscious word choices, omissions and patterns of speech — what the program calls “indicators of guilt.” For instance, “Huh?” in response to a dispatcher’s question is a guilty indicator. So is an isolated “please.” Other indicators are more subtle and subjective: Did the caller provide “extraneous information”? Was there too little urgency in their tone? Too many Freudian slips or other “mental miscues”?

Those who take the training are given a simple checklist to track how many of these errors a caller commits. Harpster first began developing the list as a criminal justice graduate student. For his master's thesis in 2006, he listened to 100 recordings and claimed that certain indicators correlate with a caller's guilt, and others with innocence.

Today, Harpster tells students they can use the model — which he and two coauthors later expanded on in a peer-reviewed exploratory study — to predict a 911 caller’s role and h​​elp solve murders. If there are enough guilty indicators, he often says, then the call is “dirty."

Twenty researchers from seven federal government agencies, universities and advocacy groups have tested Harpster’s model against other samples of 911 calls to see if the guilty indicators he had identified did, in fact, correlate with guilt. They’ve consistently found no such relationship for most of the indicators. In two separate studies, experts at the FBI’s Behavioral Analysis Unit warned law enforcement officials to exercise caution when using 911 call analysis because their results contradicted so many of Harpster’s claims.

Given the popularity of the training course, one researcher told ProPublica, “we had to make sure it could be replicated — and it couldn’t.”

Patrick Markey, a psychologist at Villanova University who has been studying 911 calls, added that he’d find it “very disturbing” if Harpster’s method were being used to help convict people. “We don’t know if it’s valid or not,” Markey said.

In an interview last summer, Harpster defended his program and noted that he has also helped defense attorneys argue for suspects’ innocence. He maintained that critics don’t understand the research or how to appropriately use it, a position he has repeated in correspondence with law enforcement officials for years. “The research is designed to find the truth wherever it goes,” Harpster said. “I’m pro-police but I’m not pro-bullshit.”

He would not allow ProPublica to sit in on one of his training sessions and declined subsequent interview requests. He also did not respond to a detailed list of questions about his method’s role in Logan’s case.

Susan Adams, a retired FBI agent and one of Harpster’s coauthors, said in an email that they analyzed 300 calls for their study and a book on the subject. They’ve also volunteered their time to help police and prosecutors on many other cases. (Harpster claims he has directly assisted in more than 1,000 homicide investigations.) No single indicator can be used to determine the likelihood of innocence or guilt, Adams said. “Instead, our study examined indicators in combination, just as 911 call analysis should be used in combination with case facts to uncover the truth.”

Matthews checked off a list of indicators of guilt that he claimed to have identified in Logan’s 911 call. (Obtained by ProPublica from the Macon County State's Attorney's Office)

Psychologists and criminal justice experts say applying the model in the real world is dangerous because those indicators can indicate very little; that such judgments often amount to reading tea leaves; that it’s extremely difficult to decide what someone should or shouldn’t say in an emergency because everyone reacts differently; and that parents holding their dead children may very well speak irrationally.

“You might as well flip a coin,” said Maria Hartwig, a psychologist and professor at John Jay College of Criminal Justice with expertise in deception detection. Hartwig and others said that a commercial operation selling 911 call analysis should be met with skepticism instead of credence.

Decatur, Illinois (Mauricio Rodríguez Pons and Nadia Sussman /ProPublica)

Watch video ➜

This did not happen when Matthews took the course in Decatur. Records show that local and state officials readily certified and funded Harpster’s program with taxpayer dollars.

Matthews’ class was held at Richland Community College, a low brick complex on the far side of Decatur, an agroindustrial city in the center of Illinois. Decatur is scarred by train tracks and surrounded by corn and soybean fields. On a typical day, student drivers in a tractor-trailer navigate orange cones in the school’s parking lot.

Over the years, the Illinois Law Enforcement Training and Standards Board has approved Harpster’s program for credits toward a lead homicide investigator’s certificate, often funding the class with state grants. As the name suggests, the board is supposed to set statewide training standards.

When approached by ProPublica, the board could provide no record that it had scrutinized the research behind the curriculum. John Keigher, the board’s chief legal counsel, said he was unsure how the previous training manager had vetted Harpster’s application. “Maybe he did his own research and Googled stuff,” Keigher said.

Excerpts from two advertisements for trainings by Harpster, from the websites of Wilmington University and the Southern Illinois Criminal Justice Training Program (Photo Illustration by Mauricio Rodriguez Pons/ProPublica)

Keigher had no misgivings about the program and said that local training agencies, which are partly funded by the board, get to choose who they host.

In Decatur, that entity is called the Law Enforcement Training Advisory Commission, which also provided no record of evaluating the validity of the course before offering it to local police and prosecutors.

Approval from these outside agencies lent Harpster’s class unqualified legitimacy. To small departments that may be less equipped to judge new techniques on their own, the method appears groundbreaking. Or, as one former attendee wrote in the commission’s course evaluation form: “One of the best if not the best course I’ve taken in 21 years of law enforcement.”

Five months after he took the 911 call analysis training, Matthews put his new skills to the test on Logan’s call the day he was assigned the case. Emails indicate that he asked Harpster for a consultation on the case. It was at that moment that Logan became a suspect.

First image: Decatur police detective Eric Matthews asks Logan to sign a consent form for a search of her home on Oct. 17, 2019. Second image: Matthews interrogates Logan at the Decatur Police Department on Oct. 23, 2019. (From video provided by the Macon County State's Attorney's Office)

After he analyzed the call, Matthews spoke with the patrol officer who had first interviewed Logan at the scene. That officer then filed a new report “in light of recent discoveries.”

In the second report, he wrote that Logan’s emotions were insincere; there were no actual tears in her eyes; and she was silent sometimes but hysterical at others. “I originally believed this was possibly due to the shocking and traumatic experience,” the officer said, “but the crying somehow did not seem genuine and felt forced.” (He later explained in court that he normally chooses to report only facts to preserve the integrity of the investigation, but after learning the new information from Matthews, the officer wanted to put his opinion about Logan’s demeanor into the record as well.)

Matthews also testified at the coroner’s inquest — a hearing separate from criminal proceedings where the coroner presents an autopsy report and other evidence to a panel of jurors, who then determine the official manner of death. Matthews told the jurors he was trained in basic and advanced 911 call analysis and said he found “mostly all guilty indicators” in Logan’s recording.

At one point early in the investigation, Matthews told a child services investigator that he had identified red flags in the case, according to meeting notes of the conversation. The detective explained that Logan “had failed the 911 stress test,” citing the fact that she repeated several times that Jayden suffered from breathing problems, as if to establish an alibi.

Jayden Comage in the hospital in August 2018. He was treated for viral pneumonia and bronchiolitis. (Jessica Logan)

Jayden did have a history of respiratory illness. Medical records show his mother took him to the hospital or doctor’s office more than two dozen times after he was born, the final time a month before he died, when he had a fever, cough and rash. “I just be so paranoid and scared,” Logan told Matthews once. Jayden had been diagnosed with respiratory syncytial virus, or RSV, and treated for bronchiolitis and viral pneumonia at different points in 2018. He was admitted at least four times. Doctors prescribed him breathing medication to be administered through a nebulizer. He was sick, it seemed, more than he wasn’t.

At Jayden’s funeral, Je’Shawn, who turned 4 that same week, looked inside the casket, touched his little brother’s face and asked his mother to fill Jayden’s sippy cup. Jayden was buried next to three cousins, each of whom had been born months premature before dying in the hospital. All four names are tattooed on Bradford’s wrists.

The names of four of Bradford’s grandchildren who died young are tattooed on her wrists. (Mauricio Rodríguez Pons/ProPublica)

For days, condolence messages poured in from friends and relatives checking on Logan. She deactivated her Facebook profile and ignored many of the texts, replying only in quick bursts to others:

Trying to keep it together

Can’t stop crying

I haven't slept or really ate in 2 days

Just trying stay strong for Je’Shawn

He keep asking for his brother.

The coroner hired Dr. Scott Denton, a forensic pathologist, to perform the autopsy and determine a cause of death. After his preliminary review, Denton asked Matthews to enlist Logan for a video reenactment of the night Jayden died. Logan said she didn’t feel like she had a choice and returned to the duplex with Bradford, but without a lawyer, on Oct. 17. Matthews told Bradford to wait outside.

With the camera rolling, Logan stood in Jayden’s bedroom and held a Jayden-sized mannequin. She placed it on top of the Paw Patrol bed sheets, which were still where she’d left them weeks earlier, and gave her account of the crucial hours between Walmart and the 911 call.

Logan holds a toddler-sized mannequin during a police reenactment on Oct. 17, 2019. (Excerpt of video provided by the Macon County State's Attorney's Office)

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Logan said she had followed the nightly routine: baths at 7:30, playtime and television for an hour and then off to bed. She put Jayden down in the bottom bunk. “I gave him a kiss good night and told him I loved him,” she said. Je’Shawn slept in her bed.

Before she climbed in next to Je’Shawn around 10:30, she peeked at Jayden, who had been fighting a cold, and then set two phone alarms, one for midnight and one for 3 a.m., to administer the breathing medication. She slept through the first alarm. (Days before, she had Googled “what does it mean when you sleep really heavy and can’t hear nothing,” according to her search history.) Then, she said, she woke at 3 a.m. before padding across the hall into Jayden’s room.

Logan found him face down with the fitted sheet wrapped around his head. His bare back was cold and his arms stiff. Just like her biological mother had felt to her on her deathbed 10 years earlier. “I knew,” Logan told Matthews, “that he was already gone.”

In his report, Matthews echoed several of his observations from the 911 call analysis: “Jessica did not appear to be upset or troubled when manipulating the mannequin and illustrating how she discovered her deceased son in his bed.” Before leaving the house, the detective asked for Logan’s cell phone. She handed it over.

A week later, Matthews invited Logan to the police station to talk again. A relative drove her downtown. Je’Shawn, his cousin and another friend rode in the back seat. “I’ll be right back,” Logan told them. The detective led her into a small, white room, where a white chair was waiting for each of them.

Matthews pushed his chair back from a desk and turned to face Logan, their knees inches apart. “I’m running into a lot of problems with this, your account of what happened,” he said. “I’m finding problems from the moment you called 911 until today.”

Matthews, who has been a juvenile detective for years, spoke obliquely at first. Her story didn’t add up, he said, and the professionals agreed with him; she wasn’t a monster, but a young, desperate mother at the end of her rope. As his words rushed at her, Logan hardly moved. Matthews alluded to something incriminating on her phone but didn’t elaborate. (Records show police had discovered evidence of a Google search, apparently from the day before Jayden died, for the phrase “How do you suffocate.”)

“There’s irrefutable proof that something happened to this kid and that you did something to him. OK?” Matthews said. “You killed Jayden.” At that, she shook her head back and forth: “No, I did not. No, I did not.”

Matthews interrogates Logan at the Decatur Police Department. (Excerpt of video provided by the Macon County State's Attorney's Office)

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“I’m going to be able to prove it,” the detective said. He told her that during one of their earlier interactions she “had no emotion at all.” In his report later, Matthews wrote that Logan remained “generally emotionless,” with her hands in her pockets and little visible reaction. That inscrutable countenance again.

“Everybody shows their emotions different,” she told him.

When Logan asked for a lawyer, the detective said she was going to be arrested for murdering Jayden and stood to leave. For almost an hour, she waited in the white room alone, hardly moving except for a tapping right foot. She was so still, the motion-sensitive lights turned off. She sat in darkness.

In the parking lot outside, Je’Shawn played in the back seat of the car. His entire immediate family had now vanished — both parents behind bars and his only brother dead.

Je'Shawn and his cousin Aniya Phipps talk about the future. (Mauricio Rodríguez Pons and Nadia Sussman/ProPublica)

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Almost two weeks later, Je’Shawn climbed on top of a large leather chair in a child services center in downtown Decatur. He sat across from a female staffer. Between them was an easel. She said she wanted to ask him some questions about his family while they drew pictures together.

“Who all do you live with?” the woman, cross-legged on the floor, asked gently. Je’Shawn fidgeted with toys and explored the room. He said he lived with his grandma now. She drew a house with two smiley faces inside.

“My brother not there,” Je’Shawn offered.

“How come your brother’s not there?”

“Because he’s in heaven.”

A child services worker interviews Je’Shawn on Nov. 5, 2019. (Excerpt of video provided by the Macon County State's Attorney's Office)

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The staffer tried to get details about the night Jayden died and what Je’Shawn may have seen. He mentioned a cover over his brother’s face but little else that tracked. (“I farted,” he confessed at one point.)

After a few more rounds, she left Je’Shawn in the room by himself for a moment. He picked up a toy cellphone and flipped it open. “Hi, Mama,” he whispered into the receiver. “I’ll draw you a picture.”

He pressed the marker against a new sheet of paper and drew his brother.

After Logan was arrested, Denton submitted his final report. Cause of death, the pathologist wrote, was asphyxia by “smothering and compression of the neck.” The coroner’s inquest made it official: homicide.

ProPublica consulted with three forensic pathologists who had no prior knowledge of Jayden’s case to review the coroner’s files, including the autopsy report, photographs, medical records and reenactment video. None of them accepted Denton’s conclusion of smothering, which, they said, is tantamount to declaring homicide. They noted that deaths by asphyxia are often accidents or due to illness. (Denton did not respond to multiple interview requests, and the coroner who had hired him declined to comment for this article. Neither replied to a detailed list of questions.)

Dr. Shaku Teas, a forensic pathologist who performed more than 600 autopsies on children during her nearly two decades at medical examiners’ and coroners’ offices across Illinois, said she could see no trauma to Jayden’s body. “There’s going to be some trauma when you suffocate a 19-month-old,” she said, because of their size coupled with an instinct to resist. “I don’t know where he came up with a homicide.”

Jayden Comage’s autopsy report (Mauricio Rodríguez Pons/ProPublica)

In the autopsy report, Denton identified light blanching on the tip of Jayden’s nose and tiny dots on his eyelids, cheeks and elsewhere — burst blood vessels called petechiae. Teas and the other pathologists said Denton’s interpretation of the dots was overstated. Much of it looked like it could be a rash, they said.

Two preeminent pathology experts wrote in a 2000 paper that petechiae dots around the face and eyes, by themselves, “point to no particular cause of death” because they can also appear during moments of physical exertion like coughing, sneezing or respiratory distress. Misattributing these dots, the authors wrote, can lay “false grounds for conviction.”

Dr. Jane Turner, a private consultant and former medical examiner in St. Louis, told ProPublica the petechiae and blanching on Jayden could be explained by accidentally suffocating face down or a seizure. She said Denton didn't seem to test for respiratory viruses or test Jayden’s cerebral spinal fluid — grave errors given his medical history. “The cause of death and manner of death should have been undetermined,” Turner said. “There were gaps in the investigation with respect to the autopsy and some questionable conclusions.”

After Bradford attended the inquest and learned the results of Denton’s autopsy report, she realized Logan’s case would likely go to trial. Logan called her that day from jail. They cried as they spoke. “I’m sick to my stomach right now,” Bradford said. “I just cannot believe this.” Je’Shawn played in the background.

Logan told Bradford she was feeling so depressed that she planned to see a mental health counselor. “J.J. was a sweet innocent boy,” she said, using Jayden’s nickname.

“I would never,” Logan added, her voice catching.

“I know you wouldn’t,” Bradford said before it was time to hang up. “I love you, Butterball."

Logan’s trial took three days in June 2021. Nineteen months had passed since she was arrested. She sat in court, hands laced together, next to Christopher Amero, a local lawyer and military veteran with a thick, red beard. Logan’s family pooled their money to pay him $10,000.

Macon County Courthouse in downtown Decatur (Mauricio Rodríguez Pons and Nadia Sussman/ProPublica)

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The state’s lead prosecutor laid out his narrative to the jury several times: Logan was drowning in debt, so she murdered Jayden to cash out his $25,000 life insurance policy. Police found no vials of the breathing treatments, he said, evidence that she never intended to give them to Jayden. The jury heard a barrage of voicemails from debt collectors and prison phone conversations. In some of the recordings, Logan snapped at Je’Shawn for misbehaving. In others, she told her children's father how far behind she’d fallen on the bills.

Logan’s plan, the prosecutor said during his opening statement, was to smother Jayden in the middle of the night and call 911 a few hours later with a manufactured story about breathing problems. “That plan betrayed her,” he added. “Forensic science betrayed her.”

He played the six-minute 911 recording before calling Matthews to testify. The prosecutors had been wary of introducing Matthews as an expert in 911 call analysis, emails indicate, and resolved to instead incorporate the guilty indicators subtly during closing arguments. It’s a common legal tactic to circumvent courts’ standards for expert testimony.

“She’s 45 seconds into the 911 phone call before she even says, ‘My child’s not breathing, and I need help,’” the prosecutor told the jury. “A mother telling you that there was no reason to try to see if her 18-month-old could be saved. Does that sound right to you?” The Macon County prosecutors who tried the case did not respond to interview requests or a list of questions about how they used 911 call analysis.

But Amero served the prosecution an unexpected boon during cross examination: He asked Matthews specifically about the “multiple indicators of guilt,” which the detective had detailed in a sworn statement, along with other observations about Logan’s suspicious demeanor. Matthews seized on the moment, explaining the research and how he had first determined that Logan was a suspect.

“In this training,” he said, “we use a chart that will allow you to determine whether the person was being honest on the call or not.” Matthews testified that Logan never once explicitly asked for help during the 911 call and a full minute had elapsed before she explained what was going on.

Amero later told ProPublica he thought that the combination of the 911 recording and Matthews’ analysis was a turning point in the trial.

The prosecution’s most important piece of evidence against Logan was Denton’s testimony about his autopsy. Amero did not call another pathologist to puncture Denton’s conclusions. The jury was left to believe that the only way Jayden could have the tiny marks and light blanching on his face was if he’d been smothered.

Another critical piece of evidence was an item that police had discovered on Logan’s phone: a Google search for the phrase How do you suffocate. The police report is unclear, and an officer wrote that he found the search in some of the phone records but not others. In court, that officer testified the search took place 19 hours before Jayden died, which he had verified with a subpoena to Google. This, prosecutors said, was proof she had planned to kill Jayden. ProPublica reviewed a search history file from Google but was unable to independently verify the police department’s analysis of the data extraction.

The family disputes the timeline. After Jayden died, relatives gathered at Bradford’s house to grieve. Bradford’s biological daughter asked if Jayden could have suffocated. According to Logan and Bradford, that’s when Logan searched for How do you suffocate. (Bradford’s daughter and Taylor said they saw Logan on her phone at that moment but did not see what she typed.)

Then there was the life insurance agent who said Logan had called the day after Jayden died to inquire about his policy. The agent found the call suspicious enough to tell police. The family maintains this is also a misunderstanding. The morning after Jayden died, those at Bradford’s house discussed paying for the funeral and travel for Jayden’s father to attend.

A family friend came over with sandwiches. She overheard the conversation and suggested calling the insurance company to ask about Jayden’s policy. Then Logan made the call, according to Bradford, Logan and Taylor. “That was my fault,” the family friend told ProPublica. “That was all me.” Logan never cashed out the policy. The package the insurance company sent sat unopened atop her dresser until after she was arrested.

Police never interviewed the family friend, and Amero didn’t call her to testify. He didn’t call any character witnesses besides Bradford — a decision that incensed the family as the trial wore on. Logan’s father, Joey Logan, and her sister Brittany Phipps sat next to one another in the gallery. Phipps said the judge threw her out of the courtroom for groaning and glowering. Bradford didn’t trust herself not to do much the same and sat alone in an anteroom for most of the trial.

After an initial interview with ProPublica, Amero did not respond to requests for comment or questions about his strategy at trial.

Joey Logan looks at family photos (Mauricio Rodríguez Pons and Nadia Sussman/ProPublica)

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Joey Logan, a sandblaster with a bum eye who keeps a pack of Marlboro menthols stationed in his front shirt pocket, never got the chance to tell the jury how much his daughter doted over her sons.

“Jess would do anything for them boys,” Logan said in a recent interview. “She did everything for them boys.”

On the last day of the trial, Jessica Logan took the stand. Tattooed on her left hand, in bold letters, was the word “honesty.” She described her relationship with her boys’ father; her earlier miscarriages; the learning disabilities that slowed her down in school; her unsuccessful attempt to earn a degree from the community college; one of her jobs, at a takeout chicken restaurant in town; the two dozen doctors’ visits for Jayden. And she told her version of what happened the night he died.

Logan said she was proud of the fact that she was paying for Jayden’s life insurance and seemed confused when asked why she never cashed out the policy. “It wasn’t going to bring my son back,” she said.

In his closing arguments, the lead prosecutor warned the jury not to infantilize Logan or excuse what she’d done because she’s “not very bright.” The trial, he said, was about Jayden, “a boy who wasn’t able to protect himself from the world.” He said that was Logan’s job, “and she was the person who killed him.”

Amero pointed out that Matthews never tested the bedding for Jayden’s lung fluid. “Why was it never done? Because Detective Matthews listened to the 911 call, on the same day that he got assigned the case,” Amero said. “Because she wasn’t being emotional enough.”

The Macon County Law Enforcement Training Center and jail (Mauricio Rodríguez Pons and Nadia Sussman/ProPublica)

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In a breathless rebuttal, Amero pleaded with the jury to reconcile the 911 recording they heard, the analysis offered by Matthews and their own common sense. “It almost took a minute before she was able to get anything out to the dispatcher,” he said. “Why did it take her almost a minute? Because she couldn’t gather herself. Okay. That’s why it took a minute.”

“Every one of you heard the 911 call,” Amero continued. “If that call was not a plea for help, then I cannot explain to you what is. That entire call was a plea for help. But because she didn’t, specifically, say, ‘Please come help me,’ we’re going to use that as an indicator of her guilt. Is that justice? Is that logical? It’s not.”

The jurors deliberated for less than two hours before announcing their decision: guilty of first-degree murder. Logan’s chest got heavy, as she put it later, and the dam burst. She sobbed. A local television news reporter covering the trial criticized her for being conspicuously impassive throughout the trial. “But when that guilty verdict came down,” the reporter said, “tears started to stream down her face.”

At the sentencing in July, Logan asked the judge for leniency. “It hurt me to know people think I — think I did this based off of my emotions,” she told him. “Everyone grieve different.” The judge sentenced her to 33 years.

Logan’s former home and neighborhood (Mauricio Rodríguez Pons and Nadia Sussman/ProPublica)

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Connie Moon, a retired schoolteacher with lightning white hair, was one of the jurors at the trial. In a recent interview, she said she was persuaded by the financial motive laid out by the prosecutors. “It’s one of those sad stories about poor, desperate people,” Moon said. “But I do stand by my verdict.”

A second juror, who asked to remain anonymous so she could speak freely, told ProPublica she found Logan’s 911 call odd, an opinion validated by Matthews’ testimony at trial. But, more than anything, she was convinced by the autopsy report and Denton’s description of the findings. Because that testimony went unchallenged, the juror was under the mistaken impression that those small dots and blanching were proof positive of smothering. ProPublica shared with her the conclusions from the outside pathologists.

“I’m part of the group that put her away for 33 years. And that’s a heavy weight. I don’t take that lightly,” the juror said, in tears. “I don’t want her to suffer because we didn’t have the right information. And, I don’t know, maybe we made a mistake in our judgment. I don’t know. I felt at peace at the time. I can’t say I do right now.”

Another juror, who also requested anonymity, went much further. She put little stock into the 911 call analysis because, she said, there are too many differences in the way people speak for anyone to claim an expertise. But she believes now and she believed then: Jayden’s death was an accident, perhaps because Logan tried to settle him in too tightly in the bed.

“They kept saying it was intentional,” the juror told ProPublica, “but I honestly don’t think it was intentional.” The judge explicitly instructed the jurors that they should only vote to convict if they believed that the state proved both that Logan killed Jayden and she had intended to do it or, at the least, meant to cause him great bodily harm.

Still, the juror voted to convict Logan of first-degree murder, which is a deliberate act. She seemed to misunderstand the judge’s instructions. “She didn't murder him. That's the wrong word,” the juror said. “But what do I know?”

The night the jury’s guilty verdict was read, Matthews finished the case where it had started. He wrote an email to Harpster, the chief architect of 911 call analysis. “Just wanted to reach out to you and thank you for your help in my 2019 murder case,” he wrote, including a link to the television news story. Matthews said that he noticed the jury seemed compelled by his testimony and stared intently while nodding their heads. “I strongly believe,” Matthews finished, “that the 911 call analysis was a tremendous benefit to both my investigation and the trial.”

It was just before 6 a.m. on a Wednesday in late August when Bradford walked out of a retirement community center in navy scrubs after her shift ended. The sky over Decatur went from black to blue as she drove across town to the babysitter’s house to pick up her grandson. On Bradford’s mind was a court hearing slated for the afternoon. After more than a year, Logan’s appeal had entered its final stage, and lawyers for both sides would make arguments in front of a panel of judges.

Je’Shawn and Bradford wait for the school bus on August 24. (Mauricio Rodríguez Pons and Nadia Sussman/ProPublica)

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For weeks, Bradford, a devout Baptist, had been anxious about the date and prayed on it nightly. But, as she drove, she felt at peace with whatever the outcome: an immediate ruling from the judges or more months of uncertainty. “I’m leaving it up to God,” she said, turning into the sitter’s driveway.

Two honks of the horn and Je’Shawn bounded outside, a Jurassic World backpack strapped around his shoulders and some loose jelly beans in his pocket. Bradford is in the process of formally adopting Je’Shawn, who has been in her custody as a foster son since his mother was arrested. “He knows that I’m still grandma and he knows who his mom is,” Bradford said once. “He’s never going to forget that.”

Back at the house, as his grandmother clipped his fingernails, Je’Shawn pointed out some of her gray hairs and asked where they came from. “You gave them to me,” Bradford responded with a smile. In the years since Je’Shawn’s brother died, doctors diagnosed him with an anxiety disorder and ADHD. He sees a counselor weekly. He chews his T-shirt collars until they fall apart. He frequently grimaces and blinks with his whole face. He likes Bradford to hold his hand until he falls asleep.

At 7 a.m., after breakfast, Je’Shawn boarded the school bus. Next came Bradford’s daily ritual, an hour of near silence she steals each morning. She sat in a lawn chair on the front porch, next to Je’Shawn’s bike, while the sun rose over the train tracks, through the trees, and splashed her face.

Later that same morning, 45 minutes away past miles of farmland, Logan shuffled into a recreation room at the state’s largest women’s prison. She carried with her sketches of Je’Shawn and Jayden, artwork gifted by another inmate.

It would be Je’Shawn’s seventh birthday soon, and she would get to choose a gift from a prison catalog to mail him. They would eat ice cream and play board games together in the prison’s visitation room.

That also meant it was the anniversary of Jayden’s death. The family would visit his grave without her. Logan has been diagnosed with depression, and she’s been in and out of protective custody because of issues with other inmates, including being the target of frequent bullying. Some call her “baby killer.”

Jessica Logan in prison (Brett Murphy/ProPublica)

In the rec room, she talked about her case, the appeal hearing later that afternoon and her two sons. She twice retold the story of the night Jayden died. Her eyes welled up, and her voice broke. She blamed herself for not waking up for the first alarm at midnight to administer Jayden’s breathing treatment. That, she said, could have saved him.

Logan has been inconsistent about whether she had preloaded the nebulizer before she went to bed or if she planned to load it after waking up Jayden. There is no mention in the police or court record of any officers checking the actual machine for the medicine, and they didn’t find full or empty vials elsewhere in the house. Logan has also waffled on whether she gave Jayden CPR the night he died.

As she spoke, Logan often stammered and took several beats to connect thoughts. “I have a learning disability,” she explained. “So I can’t really, I don’t really understand a lot of things.” Unlike Bradford, who keeps her frustration close to the surface, Logan said she tends to bury painful emotions. She’s more like her father that way.

Jessica Logan’s hands (Brett Murphy/ProPublica)

“You shouldn’t feel like somebody’s guilty just because the way their emotions is. Everybody react and have emotions different than everybody else,” she said, a refrain she’s repeated since she was first arrested. “I mean there really nothing I could have said differently or did differently. I shouldn't had to reword stuff to make it, I guess, to make Detective Matthews — I feel like I did nothing wrong on the 911 call.”

An hour later, Bradford settled in front of her computer to watch the appeal hearing on a video conference — the fate of her family decided by strangers on the screen. She hunched forward, looking over the top of her glasses to text updates to family. As usual, most of the curtains were drawn, and the house dim. Bradford likes privacy.

Logan’s state-appointed appeals lawyer told the panel of judges that his client deserved a new trial because the first one was unfair for a number of crucial reasons. First, he argued, the reenactment video should never have been admitted into evidence because Logan was not read her rights before she took part in it; and the video inappropriately influenced the pathologist who prepared the autopsy report. An appellate prosecutor responded that the reenactment’s significance was being overblown.

Bradford watches Logan’s attorney conduct an oral argument in her appeal. (Mauricio Rodríguez Pons and Nadia Sussman/ProPublica)

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Logan’s appellate attorney said another critical problem with the trial was that Amero had chosen to elicit testimony about the 911 call analysis from Matthews. It was a “grossly unreasonable” gambit, the attorney said, one that allowed the detective to interpret Logan’s credibility. “And that’s the province of the jury.”

Then the hearing ended without ceremony. Everyone’s screens went black, and Bradford stared for a moment. She thought prosecutors continued to dismiss crucial facts in their portrait of Logan, treatment she considered especially glib given the circumstances. “They don’t realize it’s this girl’s life they’re playing with,” Bradford said.

A month later, Bradford got word while waiting in the hallway during one of Je’Shawn’s therapy appointments: Logan lost the appeal. Her attorney has asked the Supreme Court of Illinois to take the case. If the court agrees, it could take another year or longer of briefs and arguments. In the meantime, Bradford plans to move to Texas to be closer to her biological daughter and grandchildren. Je’Shawn will go with her.

A memorial candle holder for Jayden sits in Bradford’s house. (Mauricio Rodríguez Pons and Nadia Sussman/ProPublica)

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After the appointment, Bradford drove back to the house in the heart of Decatur, still her family’s home for now. Inside, on almost every flat surface, are candles, more than 200 of them. She collects the classic fresh linen and vanilla scents, along with the more exotic: names like pumpkin pecan waffles and clementine sherbet. At least one is always burning, giving the house a different sweet smell every day.

In the corner of the living room, propping up a card of inscriptions and prayers from the staff at Jayden’s daycare, is a memorial candle for Jayden, encased in plastic with his picture on all four sides.

Je’Shawn often asks Bradford to light it.

No, she tells him, not this one. “I don’t want it to melt away.”

To get part 2 of this story, text STORY to 917-905-1223. Standard messaging rates apply.

Kirsten Berg, Nadia Sussman and Mauricio Rodríguez Pons contributed reporting. Additional design and development by Lena V. Groeger.

by Madison Hopkins, The Kansas City Beacon

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

Earlier this week, we published a story about sheltered workshops in Missouri — facilities where it’s legal to pay employees less than the minimum wage because they have intellectual, developmental or physical disabilities. More than 5,000 disabled adults work in Missouri’s sheltered workshops, some earning less than $1 per hour.

Across the country, disability rights advocates have lamented these facilities and their low wages, calling them discriminatory and exploitative. At least 14 states have banned subminimum wages, and advocates are ramping up pressure on the federal government to repeal the more than 80-year-old law authorizing them nationwide.

So when my reporting for this story got underway in April — part of a yearlong collaboration between The Kansas City Beacon and ProPublica — I expected to hear similar sentiments in Missouri.

Instead, one of my early findings surprised me: Disabled adults and their families in Missouri seemed to strongly support sheltered workshops. They didn’t focus on the low pay or the dearth of other opportunities. Most said they were simply grateful for the jobs that the facilities offered.

This led my editors and me to wonder: Do we even have a story to tell here, if sheltered workshop employees themselves did not see any problems with their situation?

Instead of turning away from the story, we decided to dive deeper. We began an outreach effort to connect with as many sheltered workshop employees and their families as possible, so we could better understand their sentiments and find out if they saw any downsides to working with such low pay.

To do this well, we needed to make our outreach accessible to a community with diverse abilities. We knew that some sheltered workshop employees might not have access to computers and that others could be visually impaired or have difficulty understanding our questions.

I worked with ProPublica engagement reporter Maryam Jameel to come up with a few solutions. The first was to consult a plain-language translator — an expert in writing clear and concise messages for audiences with intellectual or developmental disabilities — and have her develop a plain-language version of our outreach questions. (We also published a plain-language version of our resulting story.)

Next, we talked to several advocates, some of whom are disabled themselves, about additional ways to spread the word. To connect with people who are visually impaired or otherwise unable to read our questions, we included an option for people to call and leave voicemails with their thoughts. As a no-tech option, we crafted a much smaller printout version of our questions. I handed the copies out to sheltered workshop employees as I visited these facilities and asked my sources to share them among their networks.

The responses came flowing in. We heard from more than 90 people, most of them sheltered workshop employees and their families. And their responses dovetailed with what I had heard back in April: strong support of sheltered workshops.

The respondents told me that they would be devastated if their sheltered workshops were forced to shut down. Some family members even bypassed our outreach questions and instead sent in letters expressing opposition to any changes to the federal subminimum wage law or requesting that sheltered workshops remain open in the state. A few respondents later told me that they were encouraged to respond by their sheltered workshop managers. One sheltered workshop employee said she and her coworkers were given time at work to answer our questions online.

“This job has given people with disabilities a chance to work instead of being stuck at home,” one parent of a sheltered workshop employee wrote.

As I kept following up with the respondents, I recognized a common thread: Many felt that their choice wasn’t between sheltered workshops and regular jobs, but rather between sheltered workshops and nothing at all.

Some said sheltered workshops provided a safe place for their family members to spend their days with peers and find a sense of purpose. Others said their loved ones had previously held a regular job or could handle the demands of one, but hurdles like workplace discrimination ultimately led them to believe sheltered workshops were the only realistic option.

“There’s lots of things that can be potential barriers for people working in regular competitive employment,” said Robin Prado, the mother of a sheltered workshop employee. She said her daughter had previously spent a couple of weeks working at a local library but was fired when she didn’t pick up on her training quickly enough — a problem she believes could have been solved with a little additional help.

“I didn’t really feel like we had a lot of support,” Prado said.

A current sheltered workshop employee expressed similar feelings, saying she was “afraid of going back” to a regular job. “I’ve tried jobs on the outside, and this is the first job where I feel really supported by people,” she said.

It was clear to me that the respondents saw no real alternatives in Missouri — but it doesn’t have to be this way. I talked with several experts and advocates, including Steven Schwartz, legal director for the Center for Public Representation, who told me that many other states have proven that disabled adults can successfully move into the regular workforce. To help them with the transition, these states have been directing more funding toward breaking down the kinds of barriers that Missouri’s sheltered workshop employees and their families spoke to me about.

Missouri, however, does little to help sheltered workshop employees make that move — even though getting disabled workers ready for the regular workforce is the goal behind the federal law authorizing subminimum wages. What’s more, state officials told me that they would be unconcerned if sheltered workshop employees in Missouri do not “graduate” to the regular workforce for years, or even decades, because they view the state’s sheltered workshops as employment programs rather than stepping stones to regular jobs.

Ultimately, we decided that there was a story to tell about sheltered workshops in Missouri: The seemingly widespread support among sheltered workshop employees and their families masked the failure of the state to provide them with meaningful employment options.

You can read more about what we found in the full story. We will continue reporting on sheltered workshops in Missouri, so please share our outreach questions, our phone number and the plain-language story with anyone you think would like to get in touch with us.

Help Us Learn About Sheltered Workshops in Missouri

Maryam Jameel contributed reporting.

by Kartikay Mehrotra, ProPublica, and Matti Gellman, The Kansas City Star

This story discusses suicide.

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This story was co-published with the Kansas City Star.

On the last day of Rezwan Kohistani’s life, he ate lunch alone.

Three other boys were at his table in the high school cafeteria, two of their trays touching Rezwan’s, surveillance video shows. They laughed among themselves, seemingly oblivious to their classmate, even after one of the boys accidentally knocked over Rezwan’s milk carton.

Rezwan, a tall and handsome freshman, had arrived at the school four months earlier, after fleeing Afghanistan with his family. He sat at the table for a few more minutes, at one point covering his face in apparent distress. Then he got up and made his way through the halls, past a bulletin board announcing, “You belong.”

Rezwan pushed open the school door, walked out into the rain and sent his mother a text in his native language, Dari, saying “goodbye.”

Months earlier, the Kohistanis had been among the lucky ones. The eight members of the Kohistani family had fled Kabul as it fell to the Taliban in August 2021, catching an overcrowded evacuation flight arranged as part of President Joe Biden’s pledge to rescue Afghan allies. Rezwan’s father, Lemar, had spent years risking his life to distribute fuel to the Americans.

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The Kohistanis, especially 14-year-old Rezwan, saw their arrival in America as an opportunity. But the family found itself isolated in a new home that made little sense to them: Oronogo, a sleepy town of 2,500 in southwest Missouri where almost all of the residents are white.

There were no other Afghans for miles. A few other Afghan refugees were scattered across the surrounding Joplin metropolitan area. That part of Missouri has a history with the Ku Klux Klan and lynchings, and today it has few immigrants of any nationality. About a decade ago, the area’s only mosque was shot at and then set ablaze.

Rezwan’s school had never enrolled a newly arrived refugee, according to administrators. Without Dari interpreters on staff, Rezwan used Google Translate to try to engage with his teachers and classmates. He sometimes came home crying, telling his family that he’d been mocked for things like fasting during Ramadan. His teacher, noticing him struggle with attendance and grades, sent repeated pleas for help to his resettlement agency, to no avail.

“We’d been left alone,” said Lemar. “We tried to leave. But what do I know about how this system works?”

How did the Kohistanis wind up so cut off from other Afghans? And how did Rezwan end up at a school that didn’t know what to do with him? The answer lies in a cascading series of failures that stretched from a tiny Missouri nonprofit to the White House, which was ill-prepared to handle the human fallout of America’s longest war.

Lemar Kohistani and one of his sons often go to the local park and feed the fish. (September Dawn Bottoms, special to ProPublica)

The United States has a long and fraught history when it comes to welcoming refugees. For decades, the resettlement system has been chronically underfunded, with the government outsourcing the work to a network of often-overstretched nonprofits that are supposed to help refugees navigate their new and deeply foreign worlds.

The system was further gutted when President Donald Trump slashed the number of refugees that the U.S. would accept each year by 80%. Hundreds of nonprofits, which relied on a small payment for each refugee they handled, had to cut their staff or simply close.

As a candidate, Biden had promised to reverse Trump’s cuts and “reassert America’s commitment to asylum-seekers and refugees.” Once he became president, experts, advocates and members of Congress also urged him specifically to do more to evacuate Afghan allies before U.S. troops withdrew.

But the administration let in only a trickle of Afghans. And Biden wavered on his pledge to cancel Trump’s historically low cap on refugees. The White House said it needed to assess the damage done by the previous administration. After pressure from advocates in the spring of 2021, Biden agreed to let in more refugees, but even then he raised the cap to only three-quarters of the pre-Trump numbers.

By August, when Kabul fell, most resettlement nonprofits that relied on federal payments were only just beginning to rebuild. Suddenly, they were forced to handle the U.S.’s biggest refugee influx in decades.

“They brought in numbers that were close to the amount we would resettle as a nation in a year, but they did it in a month,” said Ann O’Brien, an official at a Connecticut resettlement organization that remained open after Trump’s cuts by relying on volunteers.

O’Brien and others said their groups initially had to pay out of their own pockets to care for the incoming Afghans, as Biden and Congress took nearly two months to allocate emergency funds.

“All the resettlement agencies were welcoming families with no federal funds coming through,” O’Brien said. “We were fronting the federal government cash to take care of these families.”

Reports that Afghans were not getting the help they needed began piling up across the country. The refugees were being left without food and found themselves facing eviction and unable to get in contact with the nonprofits tasked with helping them.

When the Kohistanis arrived in the U.S., they were among tens of thousands of Afghans packed into military bases. They waited for a placement for four months in Fort Dix in New Jersey.

By many accounts, the Russian-doll-like resettlement system buckled under the strain. The government relies on nine federally designated nonprofit organizations, which, in turn, often outsource the critical work of resettlement to subcontractors who are tasked with finding homes, jobs, medical care and schools for refugee families. In exchange, the government pays $2,275 per refugee.

Every Wednesday, the U.S. Department of State hosts a Zoom call with resettlement groups, who then select refugees to take.

Lemar had initially asked to be resettled near cousins in Los Angeles, but as a second choice, he offered St. Louis, where an aunt lives. During a December call, one of the nonprofits, the U.S. Committee for Refugees and Immigrants, selected the Kohistani file.

Soon after, Lemar’s aunt, Marina Kohistani, received a call from a resettlement official to verify the relationship. Marina vowed to support the family. She had fled Afghanistan nearly two decades before and knew the family would need extra help.

“I told them the kids need special support,” Marina recalled. “Life here is different in so many ways.”

Rezwan’s younger brother outside the family’s home in southwestern Missouri. (September Dawn Bottoms, special to ProPublica)

Lemar said he was soon told that his case had been assigned to a resettlement subcontractor, the International Institute of St. Louis.

St. Louis had been ranked highly by the State Department as a relocation spot for Afghan refugees because of its relative affordability and the availability of jobs, housing and services. It has a school dedicated to students new to the U.S., complete with Dari and Pashto interpreters, along with teachers trained to recognize early signs of stress.

But in August of 2021, the International Institute was only just beginning to rebuild after Trump’s cuts. It had nearly two dozen job openings, including for caseworkers, job placement coordinators and school program managers.

“There wasn’t enough time to hire and train staff, plus no money to do so,” said Anna Crosslin, who served as the organization’s director for many years but left in the spring of last year, before the Kohistanis arrived.

Paul Costigan, who helps run the International Institute’s refugee program (and who also oversees Missouri’s resettlement program as the state refugee coordinator), said he hadn’t known the family wanted to go to St. Louis. “I think if we knew they wanted St. Louis, that would have been approved,” he said.

Instead, the International Institute assigned the Kohistanis and other families to their branch 200 miles away, the International Institute of Southwest Missouri.

“We’re a small office,” said Rebekah Thomas, director of the southwest Missouri branch. “We were quickly overwhelmed."

So her office further outsourced some of the cases it had received. It made an informal agreement to hand the Kohistanis and six other families to an even smaller organization: Refugee And Immigrant Services & Education, or RAISE, a small nonprofit based near the Arkansas-Missouri-Oklahoma border.

There was no contract in place. Nor had RAISE ever resettled refugees before. Founded in 2017, its staff of four had taught English and helped Somali refugees get jobs at a local chicken plant. RAISE had never before sought housing or enrolled kids in school.

Michael Newman, RAISE’s executive director, said the organization saw a chance to grow by filling in some of the gaps left by the Trump-era cuts. “This was our opportunity to start that process,” said Newman.

Newman, who joined RAISE in 2018, had previously worked in insurance and for a company that sells adjustable beds. He had no previous experience with refugees.

“This is like my third career,” he said. Asked what factors had gone into choosing a location for the Kohistanis, Newman said his faith guided him to help find “nice homes” for refugees.

The Kohistanis, including an uncle who fled with them, landed at Springfield-Branson National Airport on Dec. 28. They were met by a RAISE staffer and volunteers, who drove them more than an hour west. They passed the area’s largest town, Joplin, then the smaller Webb City, and wound up traveling down a rural single-lane highway into Oronogo, Missouri.“I wanted to say, ‘Where are we going?’ but the translator was in the other car,” recalled Lemar, who’s 39 and broad chested with jet-black hair. “We were coming from a city, but there was nothing around us on the road except farms.” They finally drove down a dead-end gravel road to their three-bedroom townhouse. There was an elementary school nearby, but little else. Around the corner was a shuttered fireworks store and a car wash. Half a mile down the road in one direction was a Dollar General; in the other direction, a gas station. Groceries were 7 miles away.

Like many refugees, the Kohistanis initially had no car.

“There are more cows and sheep here than people,” Lemar recalls Rezwan saying when he first surveyed the landscape around the house. “This isn’t a city, this is a village. Why are we here?”

In exchange for his risky fuel-delivery job in Afghanistan, Lemar’s salary had offered his family comforts in Kabul. They owned a bungalow in a bustling, middle-class neighborhood and the kids all went to private school. The family would pile into their Toyota Highlander for holidays and drive into the mountains to visit their grandparents.

Lemar and his wife, Muzhda Kohistani, said they did not expect the United States to replicate their old lifestyle. But they were at least hoping for familiar faces who could help them navigate the basics of life in the U.S.: How to pay for lunch. Where to get wifi access. How to get health care.

Lemar and a son buy groceries at the local Walmart in Joplin, Missouri. (September Dawn Bottoms, special to ProPublica)

As it was preparing to host Afghans, RAISE announced a partnership with a church to gather volunteers and hold cultural orientations ahead of the refugees’ arrival. The volunteers stocked the Kohistanis’ pantry with Afghan groceries, but they knew little about Afghan culture or customs. “We received cultural sensitivity training,” said one of the church volunteers. “But the idea that we could be trained and deployed in specific ways” like recognizing signs of depression or finding Rezwan a doctor, “is preposterous.”

While RAISE worked with a local church, the refugee group said it didn’t create a similar arrangement with the mosque in the area. Leaders of the small Muslim community in nearby Joplin said they were contacted by RAISE only once last year before the Kohistanis and other refugees arrived.

Navid Zaidi, the treasurer of the local Islamic Society of Joplin, shared a text exchange in which a RAISE official asked if Shiite and Sunni Muslims could be placed in the same community. But Zaidi said they were never asked to support the resettlement process. “We were approached to answer questions like: ‘Is there a mosque in the region?’” he recalled. “That’s it.”

RAISE placed a few Afghan families in Joplin. But some of them felt isolated too. “For us, we wanted a community of Afghan brothers and sisters,” said Nasirullah Safi. The Safis moved to Houston with the help of a cousin who worked for a refugee resettlement group. “We have family here in Houston, which made it better for my wife and children to grow. We call this place home.”

Zaidi said placing the Kohistanis in the smaller, more rural Oronogo was “not appropriate.”

The Kohistanis were the only Afghan family settled there.

“We were all glad to be safe, but nothing about this place felt like home,” said Lemar. “Rezwan was the most upset, and he was determined to get out as soon as we arrived.”

On a crisp January morning, Rezwan started his freshman year at Webb City High School, 3 miles south of the family’s home. Rezwan wore clothes that had been donated by a local church: sweatpants that were too short, a T-shirt that was too big and sneakers that were worn out.

That morning, he met English language teacher Sally Lee.

Rezwan smiled and nodded as Lee introduced him to some of her other students who were nonnative speakers of English. No one else spoke Dari. Over the last three years, Lee had taught Webb City’s few migrant students from Mexico and Central America, often sacrificing her summers to give them extra assistance.

When Lee learned that her remote Missouri town might be hosting Afghans, she had reached out to RAISE to request training “to help [Webb City] be prepared to meet the needs of these children and their families,” as she wrote in a Nov. 16, 2021, email. No one responded.

State money was available to pay for interpreters to help refugees adjust, but the school didn’t apply.

In an early assessment, Lee wrote that Rezwan’s English was better than she expected, but he was still worried for family members who had been left behind in Afghanistan. “We are just trying to get them familiarized with our language and culture,” she wrote on Jan. 29, 2022. “He is in survival mode, but seems very grateful to be here.”

On his second day of school, a classmate noticed Rezwan was missing from class. She wrote to him over Instagram.

Instagram direct messages between Rezwan and a classmate (Obtained by ProPublica and the Kansas City Star)

The classmate, who asked not to be identified, asked Rezwan: “Do you live close to the school, because maybe my mom could take you.”

“Yes, but your mom will be bothered,” he wrote back. “Unless your mother is merciful.”

The classmate and her mother drove Rezwan to school the next day. They hummed along to the radio and helped Rezwan practice English. “I can understand you,” he’d tease when she and her mother tried to break down a new phrase for him.

Rezwan and his classmate continued to message each other regularly the first few weeks he was at Webb City. But his attempts to connect with her often seemed to miss the mark.

(Obtained by ProPublica and the Kansas City Star)

When she asked Rezwan whether he had made any new friends, he said no.

(Obtained by ProPublica and the Kansas City Star)

One student who did befriend Rezwan was Judah Beard. They met during a school pickleball lesson. Judah was a senior, three grades above Rezwan. But they were around the same height, both athletic and fans of soccer. They bonded over fashion and their similar sense of style. “He used to ask me all sorts of questions: how I got my hair so soft, where to buy jeans, what I thought about America’s wars.”

Beard tried to introduce his senior classmates to Rezwan. But they found little in common with the Afghan teen.

Back home, Rezwan had amassed a following on TikTok, where he would flirt with the camera while lip syncing Bollywood ballads and dramatic Afghan song lyrics about life, love and sometimes death. At his new school, Rezwan would share TikToks of people falling down or farting that the other kids found childish. Some videos were in Dari, which the other teens couldn’t understand.

Watch video ➜

Sometimes kids would ask Rezwan a question and he’d turn to his phone for a translation. Beard recalled that the resulting exchanges often didn’t make sense, and kids started to feel as though they were talking to a computer.

“He’d try to ask a question. I wouldn’t understand and he’d get frustrated and stop trying,” Beard said. “Most of the kids didn’t know his name. When he had no one to talk to, he’d go on FaceTime,” talking to friends and family back home.

Rezwan tried to get noticed. He started wearing tight pants and satiny shirts, leaving the top three buttons undone, hoping to look like soccer star Cristiano Ronaldo. When he wore chunky sneakers, classmates mocked him for “knockoff Yeezys.”

Beard remembers that students in gym class made a point of walking on the opposite side of the basketball court from Rezwan.

“It’s not natural to see,” said Beard. “I’d see him over to the side, walking at the same pace as everyone, and there would be no one near him.”

His English teacher, Lee, tried to help Rezwan. She emailed RAISE on Feb. 22 asking again for cultural training. Three weeks later, RAISE’s newly hired school enrollment coordinator, Madeline Bridgford, wrote back asking how school was going for the Kohistani family.

By late March, Rezwan was struggling to make it through the school day, either leaving early or arriving midday, attendance records show. Lee wrote in an email at the time that she tried to reach out to Rezwan’s parents, but they didn’t respond. Lemar said he was out of town visiting family.

When RAISE’s Bridgford responded to Lee, the coordinator said none of the teacher’s problems were unique. Other schools and Afghan families were also requesting additional resources from RAISE. “I actually just found out today that school in Afghanistan is ½ day,” she wrote. “I’m only part-time and it’s actually insane how just an incredible amount of things need attention every day!!” (Bridgford did not respond to requests for comment.)

On March 28, Rezwan told Lee that he was moving in with his uncle in nearby Joplin and transferring to Joplin High School, where a few Afghan kids were enrolled. But that move never happened. He missed 16 classes that week, according to attendance records.

“I don’t know what’s going on with him, he seems to think he can make his own rules,” Lee wrote to a Joplin teacher over email.

His parents said that after their evacuation, they weren’t always focused on Rezwan. He was the eldest of their six kids, and they expected him to help the family navigate life in the United States.

But when Ramadan started in April, Rezwan told his mother and younger brother Emran that others made fun of him for not eating during lunch.

Muzhda said she wasn’t sure what to do. “I told him that if it doesn’t get better, that I’d talk to his teachers at school,” but she never did, she recalled. She said she didn’t know how to support Rezwan when he was wrestling with a system and culture so foreign to her.

She said that she wasn’t used to seeing her oldest son struggle. In Kabul, Muzhda recalled, Rezwan was happy and had no mental health issues. “He was a good student and a good brother to his siblings.”

Lemar and the family’s surviving children at their home in Missouri (September Dawn Bottoms, special to ProPublica)

But Rezwan’s problems in Missouri were getting worse. “He has 3 Fs right now,” Lee wrote to RAISE’s Bridgford on April 28.

Despite Lee’s effort to flag Rezwan’s troubles, Webb City schools Superintendent Anthony Rossetti said “other than an initial visit … there were no other visits with the counseling team.” Nor did the school set up an alternative learning plan, despite the district allowing students to take half days or attend virtual classes. Although the school did not schedule any follow-up meetings with Rezwan’s parents, it did send them automated calls every time Rezwan was not in class.

The same week that Lee sent an email about Rezwan’s grades, RAISE gave Lemar a questionnaire to assess how the family was doing.

It was a survey from the U.S. Committee for Refugees and Immigrants, the group that had first taken the family’s resettlement case and then subcontracted it. The form had multiple-choice questions that asked whether the family had proper housing and access to food. One of the questions was about mental health, offering a rating of 0 to 3. Lemar circled “1,” which he explained later was a reference to his own mental health struggles.

RAISE arranged a virtual appointment for Lemar to meet with a Dari-speaking therapist. The therapist recommended that the family move, Lemar recalled.

Rezwan had been begging to move since they arrived in Oronogo. He’d set his sights on Dallas, Texas, where the Kohistanis had relatives and a larger Afghan community that had expressed a willingness to support the family. In mid-April, Rezwan and Lemar had driven to Dallas to assess their future home. The trip was a success and the Kohistanis had made plans to move.

But when Lemar told RAISE about the planned move, Newman, the group’s executive director, visited the Kohistanis at home and encouraged them to stay until the end of the school year. “Their Welcome Team is trying to encourage them to stay,” Bridgford wrote on April 28 to Lee, Rezwan’s teacher. The “Welcome Team” were church volunteers organized to help the family.

Rezwan’s father agreed to hold off.

The family had planned to move on May 4. Instead, Rezwan arrived at school and confronted Lee to demand a new path to graduation. He insisted he was 17 years old and couldn’t spend four more years at school.

Later that day, Rezwan ate alone and texted his mother goodbye. Rezwan’s parents were not worried. They assumed he had gone to spend the night with his uncle in Joplin. Rezwan had done that a few times before.

Early the next morning, police received a 911 call. A student had been found dead near the high school baseball field.

The preliminary autopsy report declared Rezwan’s death a suicide, though the final report stopped short of making a definitive determination because police have yet to complete their investigation.

If you or someone you know needs help, here are a few resources:

Call the National Suicide Prevention Lifeline: 988

Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741

Rezwan was buried on May 6 after a service in the mosque outside Joplin. Dr. Tabassum Saba, a leader of the area’s small Muslim community, started a fundraiser for the family. “Not everyone here is a hatemonger. Not everybody is KKK.

But putting families in rural areas is going to be traumatic,” said Saba, who is a psychiatrist. “They would have been better off in many other places.”

Saba remembers seeing Rezwan's 5-year-old sister comforting Muzhda, and students from Webb City consoling Lemar.

The few students who’d befriended Rezwan grieved. A former classmate ran out of her classroom in tears when she saw his seat empty the next morning. “I think this whole thing could have been avoided if there were other Afghan kids and he had a group to be in instead of being alone,” his friend Beard recalled.

Others were callous. One student expressed surprise that Rezwan hadn’t died trying to “blow up the school,” multiple classmates recalled. The boys who had sat at Rezwan’s lunch table before he disappeared were asked about him by investigators. None recognized him. One said, “What’s a Rezwan?”

Webb City High School (September Dawn Bottoms, special to ProPublica)

Rossetti, the superintendent, said he’s still unsure exactly what happened to Rezwan, but he feels responsible. “We’re doing a lot of reflective soul-searching.”

He also said the school district hadn’t been given the guidance it needed. “We didn’t even know what the right questions to ask were. We didn’t know what support or approaches we may need. We didn’t even know if we were going to get one student or 50.”

The district has since hired a diversity coordinator and a counselor to monitor migrant students for trauma, and it’s hosting a suicide and bullying prevention workshop. Each change is a product of the district’s experience with Rezwan, Rossetti said.

Lee, Rezwan’s former teacher who had tried to get help for him, did not want to speak about what happened.

“I can’t think about it. I don’t think I can even talk about it. I’m trying to put it away so I can move on and try to heal,” Lee said. “It was the hardest thing I’ve ever been through in my entire career.”

When asked whether she and the school had enough support, Lee responded, “I don’t know if I want to answer that.”

Each entity that was tasked with taking care of the Kohistanis offered similar sentiments: They expressed sympathy for the family’s loss but took no responsibility for the difficulties the family faced.

The head of RAISE said Rezwan’s death is a tragedy, but he remains committed to the group’s expansion into refugee resettlement. “I’m very proud of what we’ve done. We’re very proud of Joplin. It’s risen up,” Newman said. He and RAISE declined to answer a lengthy set of questions from ProPublica and The Kansas City Star about the group’s resettlement work.

The International Institute of St. Louis, whose Springfield branch passed off the Kohistanis to RAISE, was the on-the-ground entity responsible for the family. It had to follow federal guidelines for the resettlement of refugees, including regular performing check-ins.

The International Institute did not respond to detailed questions about how it handled the Kohistanis’ case and why it handed families off to an organization with no resettlement experience.

In earlier communications, the organization said it had properly handled the Kohistanis’ placement. “We made the best decision with the information and resources we had,” the Institute’s Costigan said in an interview. “RAISE said they had the housing to support large families, and that’s what this family needed.”

The nonprofit originally tasked with resettling the Kohistanis, the U.S. Committee for Refugees and Immigrants, also declined to address questions about its handling of the Kohistanis’ case.

“We will not speculate on the circumstances of this tragic event to prevent further damage and pain to the Kohistani family,” it said in a statement. The organization noted that while “the resettlement system had been decimated,” Afghans were only placed in communities after “careful consideration and assessments involving housing, employment, transportation, school enrollment, and more.”

The federal government typically requires its main refugee partner organizations, including the U.S. Committee for Refugees and Immigrants, to audit their resettlement subcontractors and ensure that refugees have been properly cared for.

“USCRI continues to adhere to the goal of auditing all our service providers at least every three years, and we continue to achieve that aim,” said Kevin Sturtevant, a spokesperson for the organization. He declined to comment on plans to audit the International Institute.

Responsibility for resettling America’s Afghan allies ultimately falls on the Biden administration.

The State Department, which oversees the placement of refugees, said in a statement:

“We grieve with the Kohistani family, as well as the community in Missouri who opened their arms to welcome them.” It went on to point to “a staffing shortage at many refugee resettlement agencies” and said that the government “worked closely with the resettlement agencies to address these challenges.”

The investigation into Rezwan’s death remains open. Webb City police have been waiting since May for law enforcement in Joplin to unlock Rezwan’s phone, which was found near his body. (Joplin police declined to comment.) Investigators still hope to check the phone for any potential evidence.

“This is new territory for us,” said Webb City Police Chief Don Melton, who could not remember a time when his department was responsible for possible evidence on a locked mobile phone or had a case go on for more than five months. Even Rezwan’s age remains a mystery to investigators. While Rezwan’s parents and passport say he was 14, the police report noted “his real date of birth is unknown.”

The Kohistanis stayed in Missouri through the summer, awaiting word on the investigation.

On Aug. 15, 2022, a year to the day after Kabul fell to the Taliban, they finally moved to Dallas.

Lemar and family spend the morning packing up their U-Haul and getting rid of odds and ends before setting off for Texas. (September Dawn Bottoms, special to ProPublica)

The Kohistanis now have cousins and an extended community of other Afghans to rely on for meals, child care and guidance. And the kids are starting afresh at a school dedicated to immigrants and English language learners.

Lemar has had severe back pain since Rezwan’s death. He was planning to get his trucking license, but he hasn’t. He has also been putting off his plans to be an Uber driver.

Instead, Lemar spends much of his time mulling over his son’s death. Suicide is a sin in Islam, and Lemar remains convinced that Rezwan wasn’t capable of it.

“To survive war then come to America to be buried?” Lemar said, his voice trailing off. “What else is there to say? We are lost.”

Lemar prays on the balcony of his home the night before he left with his family for Texas. (September Dawn Bottoms, special to ProPublica)

About This Story

This story, a partnership between ProPublica and The Kansas City Star, is based on dozens of hours of interviews with the Kohistanis, other newly arrived Afghans, the local Islamic community, church volunteers, Rezwan’s classmates, school officials, law enforcement officers, employees at the International Institute and RAISE, and federal resettlement officials and experts. We also relied on a variety of records obtained through public records requests, including subcontracting agreements, school emails, Rezwan’s final autopsy report and video documenting his last days.

We reviewed death records, scene photos, police reports, surveillance footage from inside Webb City High School, Rezwan’s social media posts and his mobile phone data usage.

We published photos and texts from Rezwan with the consent of the Kohistani family.

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by Caleb Bedillion, Northeast Mississippi Daily Journal

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

The Mississippi head of a legal advocacy organization has filed a formal complaint with the state judicial commission against a municipal judge whose no-knock search warrants have been challenged in court.

Cliff Johnson of the Mississippi office of the MacArthur Justice Center said he filed the complaint with the state Commission on Judicial Performance to push the state Supreme Court to clarify that judges must hand all search warrants they sign over to local court clerks.

Greenville Municipal Judge Michael Prewitt signed a number of no-knock search warrants that have been challenged in court. Those warrants allow police to barge into someone’s home unannounced. Rather than turn search warrants that he signs over to the clerk, he keeps them. Key legal figures in the state say that violates court rules.

In a statement released before he filed the complaint on Tuesday, Johnson said Prewitt’s handling of search warrants violates Mississippi’s rules of criminal procedure, thwarts public scrutiny and prevents people charged with crimes from defending themselves during the early phase of proceedings.

“It is our hope that the filing of this Judicial Performance complaint will result in the Mississippi Supreme Court sending an explicit reminder to Judge Prewitt and other judges across the state that they are responsible for making sure court files are complete,” Johnson said in the statement.

The complaint follows an investigation by the Northeast Mississippi Daily Journal and ProPublica, which reported that search warrants, including no-knock warrants, are missing from some of the state’s largest municipal courts and many county-level justice courts.

The Daily Journal and ProPublica found that about a third of the state’s 82 county-level justice courts are breaking rules that require them to keep all search warrant records. So are municipal courts in at least five of the state’s 10 largest cities, including Greenville and Jackson, the capital.

Even if the commission substantiates Johnson’s complaint, it could choose to admonish Prewitt privately. Sanctions beyond that, including a suspension, fines or a public reprimand, would require action by the Mississippi Supreme Court.

Hundreds of complaints are filed each year. Since 2010, the Mississippi Supreme Court has sanctioned judges about 50 times following a commission investigation. Many other complaints have resulted in private action.

Johnson declined to provide a copy of the complaint because of confidentiality rules governing complaints before the commission.

Prewitt said Tuesday that he had not yet been notified of a complaint against him. “I’ll be happy to review it and respond to it and go from there,” he said.

In a criminal appeal pending before the 5th U.S. Circuit Court of Appeals, public defender Merrill Nordstrom argues that Prewitt improperly authorized a no-knock search warrant in 2019 after a police informant purchased less than a gram of marijuana from a Greenville man named Antoine Bryant.

Police burst into Bryant’s home early one morning while his children slept. Bryant’s girlfriend alleged that she received a minor injury during the raid.

Nordstrom argues that the evidence seized in the raid should be thrown out because Prewitt had a pattern of approving no-knock search warrants that failed to pass legal muster. However, she wasn’t able to find most of the search warrants Prewitt had signed because they weren’t at the courthouse.

Her motion to suppress the evidence was denied by a federal judge, as were other challenges to Prewitt’s search warrants that were reviewed by the news organizations.

Prewitt told the Daily Journal and ProPublica this year that he keeps search warrants at his law office. Municipal Court Clerk Priscilla Bush said at the time she was unaware he had them.

On Tuesday, Prewitt said he still doesn’t give warrants to the clerk. Citing the complaint now pending against him, he wouldn’t discuss whether he plans to change that.

The news organizations found that 15 justice courts have no search warrants and 16 have only some.

Some justice and municipal courts fail to require law enforcement to return search warrants and related documents, including inventories of what they seized. Others keep search warrant records but won’t let the public see them, defying well-established jurisprudence about the availability of court records.

Exactly how many warrants are missing from clerks’ offices is unknown because they often don’t know when judges sign warrants or when they are executed.

Experts say the failure to allow access to court records prevents oversight of no-knock raids, which have faced increased scrutiny since Louisville, Kentucky, police shot and killed Breonna Taylor in a 2020 no-knock raid.

In previous comments to the Daily Journal and ProPublica, Prewitt argued that his handling of search warrants complies with the rules of criminal procedure, and if not, the Mississippi Supreme Court should clarify its rules.

Johnson’s complaint against Prewitt argues otherwise, and he wants a definitive statement saying so. Johnson has won key legal victories in Mississippi that prevented cities and counties from jailing poor people for their inability to pay fines and fees.

Mississippi’s rules of criminal procedure, set down by the state Supreme Court, require that search warrants and some other related documents be returned to the court. Those rules don’t specify who should receive the documents. But they do say the court clerk is custodian of all court records, and they require that judges turn over to the clerk any documents filed with them.

Several key legal figures who were involved in the drafting of Mississippi’s rules of criminal procedure agreed that judges should provide executed search warrants to the clerk and the court.

“The judge can’t keep it,” said William Waller Jr., a retired state Supreme Court justice. “That’s what the clerk is there for.”

by Sarah Alvarez, Outlier Media, and Emily Hopkins, ProPublica

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

Update, Nov. 18, 2022: The Michigan Public Service Commission voted on Friday to approve a rate increase totaling $30.56 million in revenue annually, less than 10% of the $388 million DTE Energy originally requested. Residential bills will increase by less than 1% as a result. The total represents the smallest increase approved for DTE in an electric rate case in at least a decade. The commission also directed DTE to provide it with more details about the impact of its low-income assistance program.

At the same time it pushed for a steep rate hike this year, DTE Energy was shutting off Michigan customers’ electricity for nonpayment at its fastest clip in at least nine years.

DTE, which serves the Detroit area, disconnected electric accounts 176,923 times from January through September of this year, more than in the first nine months of any year since at least 2013, an analysis by Outlier Media and ProPublica found. During the same period Consumers Energy, Michigan’s second-largest utility, disconnected accounts 63,982 times, less than half as often as DTE when adjusted for the number of customers.

In March, a first-of-its-kind analysis by Outlier and ProPublica showed that DTE’s shut-off rate during the COVID-19 pandemic outpaced all other Michigan utilities owned by private investors and regulated by the state.

The news organizations have since revealed how DTE — alone among Michigan utilities — sold customers’ debt to a private company, which sued in court, forced thousands of Detroiters into default judgments and led to garnished wages. The series has shed light on a regulatory system, common across the country, that can prioritize the financial needs of utility companies over affordability and consumer protection.

As it has in the past, DTE stressed that it tries to help customers avoid shut-offs. “We continue to work aggressively and proactively to get help to customers as soon as they experience difficulty with bills,” DTE spokesperson Christopher Lamphear said in a written response to questions.

He said that the company has “a range of safeguards that help prevent service interruptions” and that DTE has helped to secure financial aid for some customers struggling to pay their bills. Lamphear added that most people whose accounts are shut off have their homes reconnected “within one or two days.”

DTE is currently seeking approval from the Michigan Public Service Commission for a rate increase that would bring in an additional $388 million in annual revenue. The company has said it needs the extra money to fund infrastructure improvements that would prevent power outages and improve worker safety. It has not had a rate increase since before the pandemic.

As part of the review process, an administrative law judge made an initial recommendation in September to limit the DTE revenue increase to $145.7 million. The judge did not address either shut-offs for nonpayment or customer debt.

The state commission in recent years has typically approved requests from utilities to raise rates but for smaller sums than requested. Officials have stressed that Michigan law leaves the commission unable to consider the affordability of rates or the impact on customers, instead saying it can only evaluate if DTE’s proposed prices are “reasonable and prudent” for the utility to provide reliable service and satisfy investors.

“There’s not sort of a clear place in Michigan law where it gets to ‘And also can customers afford to pay for it?’” commission chairman Dan Scripps told Outlier and ProPublica this year.

Wayne Metro Community Action Agency, which provides energy assistance to low-income households, has noticed an uptick in requests for help recently. Executive Director Shama Mounzer attributes this, in part, to how inflation is squeezing budgets, the end of temporary pandemic related relief programs and “high bills.”

“Since Oct. 1, we have received over 3,200 requests for energy and gas assistance,” she said. “Around this time last year, we had 1,600 requests.”

As DTE seeks a rate increase, residents, community groups and politicians have voiced concerns about the impact on consumers. And some members of the Detroit City Council have criticized DTE for its debt collection and shut-off policies.

“Putting impoverished people in more economic anxiety right now is bad faith and bad practice for a provider that calls Detroit home,” said Ramses Dukes, legislative director for City Council member Angela Whitfield-Calloway. Dukes said DTE is scheduled to come before the council in January to face questions about how it treats customers unable to pay their bills.

This latest increase in shut-offs comes as a new report on debt collection lawsuits of all types in Michigan provides greater detail on what can happen after a utility disconnection. Some customers are pushed into the hands of debt buyers, including one that has purchased old DTE debt, which then flood the state’s court systems with cases where debtors are at a disadvantage.

For example, nearly 7 out of 10 debtors who were notified about their lawsuit lose by default. And defendants are also almost always legally outmatched by the plaintiffs: About 96% of creditors are represented by a lawyer, compared with fewer than 1% of debtors.

The report, issued by the Justice For All Commission, created by the Michigan Supreme Court to improve access to the civil courts, found that Jefferson Capital Systems was one of the most prolific companies filing debt collection lawsuits in the state.

Jefferson, which both purchases and collects debt, filed a disproportionate number of cases against people living in majority Black neighborhoods, the report said. DTE has sold its customers’ debt to Jefferson in the past — a tactic that was disclosed in an Outlier-ProPublica story. Jefferson has not responded to requests for comment.

Many of the commission’s recommendations focus on giving consumers more information as they navigate the court system. Its report calls for expanding the ways debtors are notified of lawsuits so they’re aware of the claims against them and increasing the evidence creditors must produce in order to file the lawsuit.

The latter would be a “game changer” for Michigan, according to Erika Rickard, project director of the civil legal system modernization project at Pew Charitable Trusts, which partnered on the report. The report recommends that creditors should have to provide proof of the amount of the debt owed and how the debt came into their possession. January Advisors, a data firm, also partnered on the report.

Angela Tripp, vice co-chair of the commission, said in a press briefing this week that her group would begin meeting with local courts and other members of the Michigan justice system in the coming months to begin implementing these recommendations.

Other efforts aimed at helping consumers, such as freezing utility rates or reducing shut-offs, have gained minimal traction.

Environmental justice advocacy groups that have intervened in DTE’s current rate case have asked the Michigan Public Service Commission to explicitly begin holding utilities accountable for their performance on affordability and clean energy offerings by opening up a separate case on these issues. The commission has not done so, however. Asked for comment, the commission said it could not comment on matters currently under review.

Right now the public service commission only has a voluntary work group called the Energy Affordability and Accessibility Collaborative. It includes advocates and meets regularly but has no power beyond issuing nonbinding recommendations.

The effort to get DTE to come before the Detroit City Council to discuss debt collection and shut-offs, meanwhile, has moved slowly. Members first pushed for such a meeting in April.

“We look forward to having a productive discussion with the Detroit City Council,” Lamphear said.

Agnel Philip contributed data reporting.

by Heather Vogell

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

The senator tasked with overseeing federal antitrust enforcement is urging the U.S. Department of Justice to investigate whether a Texas-based company’s price-setting software is undermining competition and pushing up rents.

Amy Klobuchar, the Minnesota Democrat who chairs the Senate Subcommittee on Competition Policy, Antitrust and Consumer Rights, sent a letter to the DOJ’s Antitrust Division this month. It was also signed by two other Democrats, Sen. Richard Durbin of Illinois and Sen. Cory Booker of New Jersey.

“We are concerned that the use of this rate setting software essentially amounts to a cartel to artificially inflate rental rates in multifamily residential buildings,” the letter said. It encouraged the DOJ to “take appropriate action to protect renters and competition in the residential rental markets.”

In mid-October, a ProPublica investigation documented how real estate tech company RealPage’s price-setting software uses nearby competitors’ nonpublic rent data to feed an algorithm that suggests what landlords should charge for available apartments each day. Legal experts said the algorithm may be enabling violations of antitrust laws.

ProPublica detailed how RealPage’s User Group, a forum that includes landlords who adopt the company’s software, had grown to more than 1,000 members, who meet in private at an annual conference and take part in quarterly phone calls. The senators raised specific questions about the group, saying, “We are concerned about potential anticompetitive coordination taking place through the RealPage User Group.”

RealPage did not immediately respond to a request for comment.

RealPage has said that the company “uses aggregated market data from a variety of sources in a legally compliant manner” and that its software prioritizes a property’s own internal supply and demand dynamics over external factors such as competitors’ rents. The company has said its software helps reduce the risk of collusion that would occur if landlords relied on phone surveys of competitors to manually price their units.

The DOJ declined to comment on the letter.

The department five years ago reviewed RealPage’s plan to acquire its biggest competitor in pricing software, but federal prosecutors declined to seek to block the merger, which doubled the number of apartments RealPage was pricing.

The senators noted that transaction, saying RealPage has made more than 10 acquisitions since 2016. They said in data-intensive industries, “the ability to acquire more data can result in the algorithms suggesting higher prices and can also increase the barriers to entry” for other competitors. The lawmakers encouraged the department “to consider looking back at RealPage’s past behavior to determine whether any of it was anticompetitive.”

The letter follows two others sent by lawmakers urging the DOJ or Federal Trade Commission to investigate RealPage. Since ProPublica’s investigation was published, three lawsuits have been filed on behalf of renters alleging that the software is artificially inflating rents and facilitating collusion. RealPage has denied allegations in a lawsuit filed in San Diego, and it has not responded to calls for comment about the other two legal actions, filed in federal district court in Seattle.