ProPublica

by Ed Williams, Searchlight New Mexico, and Joel Jacobs, ProPublica

This story contains depictions of mental illness and self-harm and images of law enforcement restraining minors.

If you or someone you know needs help, here are a couple of 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

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

Near the pumps of a gas station in Las Cruces, New Mexico, a teenager in foster care sat in the back of a squad car, sobbing and gasping for air. Her hands were cuffed and her legs were bound in a “wrap restraint” to prevent her from thrashing about. A protective foam helmet covered her head.

The police had been called to find her after she ran away from a nearby youth homeless shelter, where she had been placed by the state child welfare agency.

It was at least the 16th time in six months that staff at shelters had called 911 about the girl, including five calls for suicide attempts or threats. This time, police caught up with her and another runaway foster child at the gas station.

After officers put the 16-year-old in the back of a police SUV, she became agitated and started kicking and hitting the vehicle. Officers expressed frustration about having to deal with yet another child in the custody of the state Children, Youth and Families Department.

“I don’t understand why they do that, why they bring high-risk kids here, and they can’t even handle them?” said Officer Lucy Milks, recorded by her body camera.

The girl pushed and scratched Milks when she tried to handcuff her. That’s when officers brought out the wrap restraint. Three of them held the girl on the pavement and bound her legs, her white sneakers poking out from under the dark fabric and reflective strips.

Officers tried to figure out what to do next. “This happens all the time,” one of the nine officers who responded to the call said to another. “It’s so frustrating.”

A frame from a police body camera video shows a teenage foster girl in a squad car after officers put her in a “wrap restraint” to prevent her from thrashing around. (Body camera footage obtained by ProPublica and Searchlight New Mexico)

More than 1,100 times from January 2019 through June 2022, someone at a shelter housing foster kids in New Mexico called emergency dispatchers for help with runaways, violent outbursts, disorderly conduct or mental health crises.

Many of the kids placed in these shelters by CYFD have severe mental health or behavioral problems, including PTSD and depression, but shelters don’t provide psychiatric services. Kids break down, get into fights, destroy property, threaten staff or run away. Sometimes they say they want to kill themselves or try to.

In these moments of crisis, it’s police and paramedics, not mental health professionals, who intervene.

Searchlight New Mexico and ProPublica set out to understand what happens when shelters call 911. We obtained nearly 6,000 pages of dispatch logs, dozens of call recordings and more than 120 incident reports. In addition, we reviewed 26 hours of body camera videos for 16 incidents involving foster teens who appeared repeatedly in emergency calls.

Videos show police arriving to find broken windows and doors, sobbing teens and rattled staffers. Officers know little about the kids and have trouble getting guidance from CYFD. They’re often bewildered about what to do.

“We’re trying to figure out why, like — what we’re doing here,” a Bernalillo County sheriff’s deputy told his supervisor after responding to a call at a shelter outside Albuquerque in October 2021. “We’re a little confused.”

Searchlight and ProPublica contacted every law enforcement agency involved in incidents in this story; they didn’t respond, declined to comment or didn’t take issue with our findings.

Experts say encounters like these can damage a child’s mental health for years. Virtually every foster child is dealing with extraordinary psychological damage, and many have had run-ins with police, said Tim Gardner, legal director of Disability Rights New Mexico. Dealing with law enforcement when they’re in crisis, he said, “just further traumatizes them.”

Kids like this are not supposed to be in shelters. Three years ago, the state promised to stop housing kids in shelters, offices and other places that don’t provide the mental health care that they need — except in “extraordinary circumstances” when needed to protect the child. CYFD has delivered on just a portion of those promises.

In the meantime, the referrals keep coming.

“We've had countless conversations with the department to say, hey, these are not kids that should be in shelter,” said Jennica Bustamante, a manager at My Friend’s Place, the facility in Las Cruces that the 16-year-old ran away from. “These are not kids that we can properly care for, that we can safely care for.”

Emily Martin, CYFD Protective Services Division chief, said the department exhausts every other option before placing a child at a shelter; the number of placements, according to figures provided by Martin, has dropped by about 40% since 2019. Since last fall, the department has licensed two more specialized group homes, which they say offer expanded mental health services.

Currently, she said, some 50 foster youth are cycling in and out of shelters in New Mexico. That’s a small fraction of all children in custody of CYFD’s protective services office.

In the gas station parking lot, a police officer asked the 16-year-old what she was doing in southern New Mexico when she was from Albuquerque, roughly 200 miles away. “There’s nobody that would take me in,” the teenager replied.

Officers took the girl to a hospital for a medical evaluation because they had used force on her. She was escorted through the emergency room in handcuffs. That night, she was back at the shelter.

Five days later, officers were called to find her again.

Crisis. Call. Repeat.

When foster kids run away, shelters call 911.

When kids break down or express suicidal thoughts, shelters call 911.

When kids hurt or threaten others, shelters call 911.

Shelter managers say they often have little choice. They are required to notify police about runaways so kids can be located or entered in a missing persons database. And kids in crisis often need to be taken to a hospital for a psychiatric evaluation.

Of the more than 1,100 calls regarding shelter residents, more than 460 were for physical violence, disorderly conduct or mental health crises. That includes more than 70 calls for suicidal youth. At least 650 calls were for runaways.

These records didn’t always say whether a shelter resident was in CYFD custody, but managers of shelters involved in the vast majority of calls said most of their residents are foster kids. All of the body camera videos reviewed by Searchlight and ProPublica involved foster kids, according to police records.

This frame from a deputy’s body camera video, blurred by the sheriff’s department, shows a foster child restrained on a gurney after he tried to run when deputies told him he would be taken to a hospital for a psychiatric evaluation. It was at least the fifth time in 11 days law enforcement had responded to calls about him. (Body camera footage obtained by ProPublica and Searchlight New Mexico)

After police get involved, CYFD often moves the kids to another shelter. And the cycle repeats. The girl at the gas station was one of at least 24 foster kids who were the subject of calls from three or more shelters in the period analyzed by the news outlets.

In 2021, a Bernalillo County sheriff’s deputy arrived at the Amistad Crisis Shelter in Albuquerque’s South Valley after that same girl tried to strangle herself. She was quietly telling another deputy that she was depressed.

“You look familiar. Have I talked to you before?” Deputy Adrienne Seay asked the girl, their conversation recorded on her body camera.

Seay realized she had — four months before, when she had responded to a call at Amistad after the girl had cut herself and made suicidal threats. In that short time span, the girl had bounced around among at least four shelters throughout New Mexico and had been the subject of at least eight calls to police, dispatch records show.

This time, EMTs took the girl to a hospital for a psychiatric evaluation. She asked a deputy to fetch her stuffed animal first.

Deputies responded to calls at Amistad for residents in crisis more than once a week, on average, over three and a half years, according to dispatch records. Every deputy in the Bernalillo County Sheriff’s Office, the largest in New Mexico, has responded to calls at the youth shelter, said Undersheriff Aaron Williamson.

Sometimes law enforcement must stay with kids for hours, unable to respond to other calls, as they wait for a CYFD employee to show up or tell them what to do, according to videos and interviews with law enforcement.

“So now we’re waiting. We’re waiting for somebody to show up that can make a decision about this kid’s care,” Bernalillo County Sheriff’s Office Lt. Amy Dudewicz said in an interview. “It is a frustration. And it is a huge concern for those of us that are answering those calls, like, is this the best response that we have to offer?”

CYFD gives staff three hours to respond in such cases, department spokesperson Rob Johnson said in an email. Staff are almost always working on something else and could be hours away. “That’s why the department routinely sends a nearby case manager, even if that person might not know anything about that young person,” he said.

Even CYFD staff themselves sometimes call 911 seeking help.

Over the course of 2020 and 2021, dozens of 911 calls were made from the agency’s Pine Tree office, a complex in Albuquerque where foster kids sleep when CYFD can’t find any other place for them. At least 14 calls were for violent behavior, runaways or mental health crises.

CYFD told Searchlight and ProPublica that was during the heart of the pandemic, when shelters were limited in how many kids each could accept. But they acknowledged that kids continue to sleep at the office.

One of those calls involved the same 16-year-old girl. In October 2021 she broke a window at the office building. CYFD staff called police and urged officers to arrest her, saying they planned to press charges.

“It’s not safe for staff or any of our youth right now to have her there in the state of mind she’s in,” Leticia Salinas, a CYFD regional manager, told state police officer Kevin Smith.

But the girl’s actions didn’t warrant juvenile detention, Smith replied. “It’s a nonviolent crime. They’re not going to book her,” he said.

Staff escorted her back inside for the night. She ran away the next day, and state police were called again.

Sweeping Up the Pieces

When police arrive, they see the fallout from placing foster kids with serious mental health problems in facilities that aren’t equipped to deal with them. Staffers at those facilities say they don’t always know foster kids’ backgrounds and sometimes have to handle volatile or violent incidents. Officers’ body cameras record it all.

Managers of every shelter that housed foster kids during the period analyzed by Searchlight and ProPublica said they had taken in kids without being informed of their mental health conditions or histories of aggressive or suicidal behavior. If staff had been informed, they could’ve taken steps to safeguard residents, they said.

CYFD’s Johnson disputed that contention. “That’s not what has been expressed to us by the shelters,” he told the news outlets. “​​We know that the shelters struggle sometimes, but they have the option to decline admission.”

He said shelters receive a screening form that includes information about prior arrests and any history of substance use, aggression, self-harm, suicide or psychosis. Shelter managers say it’s often not complete.

In August 2020, CYFD placed a 15-year-old at Youth Shelters & Family Services in Santa Fe shortly after he was charged with battery of a police officer and stealing a car. A shelter manager told police that CYFD didn’t disclose that the boy had a juvenile probation officer until a few days after he was placed there.

About two weeks into his stay, the boy smashed several windows and threatened to kill a staff member while wielding a broken piece of door frame, according to a police report. Employees frantically dialed 911. Police located the boy in a field, his fists bleeding from punching out windows, and charged him with aggravated assault and criminal damage to property.

“We Need People Here Now”

In August 2020, a shelter staffer in Santa Fe called 911 saying a resident was threatening staff and destroying property. The incident quickly escalated, and the sound of breaking glass can be heard in the background.

When police responded, Jennifer Reese, a shelter manager, told Officer Mariah Gonzales about the boy’s history, their conversation recorded by Gonzales’ body camera. Reese declined to comment for this story, saying she was bound by a confidentiality agreement.

“Is this a common thing you guys experience, with no one communicating with each other?” Gonzales asked as Reese swept up glass from the broken office door.

Reese said it was. “If we had known what the deal was, then we could have maybe prevented this,” she said. “But we had no idea.”

First image: A frame from a police body camera video showing damage, including a broken glass door, caused by a 15-year-old at a shelter in Santa Fe. Second image: A frame from another officer’s body camera video during the boy’s arrest in a nearby field. (Body camera footage obtained by ProPublica and Searchlight New Mexico)

Reese recounted how CYFD had placed a girl at the shelter about a month earlier without her medications and without informing staff of her medical history. Several days later, she was found in the backyard trying to cut her wrists.

CYFD later tried to place her in the same shelter but still didn’t have her medications. Reese told Gonzales the shelter wouldn’t accept her — “not because we don’t want to help her, but we can’t help her.”

CYFD should have taken care of her meds, Reese said: “She’s a little kid. I mean, it’s bad enough when it’s a grownup, but a little kid? Do your job.”

“Yeah, it’s frustrating,” Gonzales replied.

Johnson, the CYFD spokesperson, said caseworkers must hand a foster child’s medication to a shelter employee. “Why wouldn’t a youth have meds?” Maybe the prescription hasn’t been filled, he said. “Maybe the youth had meds at a foster-home placement and didn’t bring them. Maybe they’ve been on the run.”

After taking photos of the damage, Gonzales told Reese to let her know if she needed anything else.

“Hopefully I won’t see you guys for a long time,” Reese replied.

Santa Fe police would be called to the shelter 44 more times for incidents involving residents in the next 17 months.

“A Survival Response”

Experts, shelter staff and even police agree: Cops aren’t the best people to deal with these kids. The mere presence of police can be triggering to a youth in crisis. Sometimes kids fight back and get into more trouble.

In September 2021, police and EMTs responded to a shelter in Hobbs after a foster teenager destroyed property and allegedly hit a staffer. She struggled and made suicidal statements as officers tried to restrain her, drawing their stun guns three times in the process. The girl was forced onto a gurney so she could be taken for a psychiatric evaluation, screaming as she was loaded into an ambulance.

A frame from police body camera video, blurred by police, shows an officer threatening to use his stun gun on a handcuffed foster girl because she was struggling as paramedics and another officer held her down. The girl, who was not tased, was charged with several offenses including assault of an officer and destruction of property. (Body camera footage obtained by ProPublica and Searchlight New Mexico)

The next month near Albuquerque, after a teenager threatened shelter staff, an on-call CYFD employee unfamiliar with his case said the boy should go to a hospital for a psychiatric evaluation, according to police records and body camera video. When the kid tried to run, deputies handcuffed him and EMTs sedated him. Then CYFD changed course, telling emergency responders not to take the boy to the hospital. By then, he was already on a gurney.

When a police officer chased down a 17-year-old runaway in Taos at about the same time, the girl turned around and punched him in the face. It was at least her sixth runaway incident in the previous three months, according to dispatch logs.

“I’m sorry I attacked you, but I did not feel safe,” she told the officer at the station. “I've been getting hurt so many times, and that’s why I'm running away, because I don’t want to get hurt no more.”

A frame from a police body camera video showing officers detaining a 17-year-old foster girl after she attacked an officer who chased her down. She was charged with battery and interfering with a police officer. (Body camera footage obtained by ProPublica and Searchlight New Mexico)

Children older than 14 have the right to refuse placements, and it’s not a crime to run away, said Martin at CYFD. But when they do, police have to be called, in part because CYFD needs to determine the children aren’t in danger. “I’m worried about them” when they’re on the run, Martin said. “I want them to be safe.”

Scenes like the ones captured by body cameras are “extremely predictable,” said George Davis, CYFD’s former chief psychiatrist and a leader in efforts to change how the department deals with foster kids.

These kids can have extreme mood swings, Davis said, “because of the trauma they’ve already been through.” Putting them in a shelter, rather than a foster home where they can access appropriate mental health care, is almost certainly going to cause an emergency, he said.

“Reacting to police this way is a survival response for them,” he said.

In many of the videos viewed by Searchlight and ProPublica, police officers try to defuse the situation, even attempting to counsel teenagers. Sometimes they sit with a child in crisis for an hour or more, talking to them as they wait for the child to be transferred to another shelter or sent for a psychiatric evaluation.

In November 2020, a teenage girl in foster care threatened to kill herself at the DreamTree Project shelter in Taos. A team of officers stayed with her on the front porch and tried for over an hour to talk her down.

“I’ve been here at DreamTree for two months. I can’t do this anymore!” she cried to the officers. “I just want the pain to end.”

“You’re 15 years old, you’re a young lady. You have your whole future ahead of you,” Officer Gilbert Martinez said. “You don’t want to give up. I have kids. They’re already older, but if I ever heard my daughter say, ‘That was it,’ I would be devastated.”

Roughly an hour later, two CYFD employees arrived.

“She needs to go to the hospital,” one said to the other. Then they would try to find the girl a bed at another shelter. “You gotta start calling and looking around.”

by Justin Elliott, Joshua Kaplan and Alex Mierjeski

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Influential Democratic lawmakers have called for immediate investigations and vowed to create stricter ethics rules following a ProPublica report that revealed Justice Clarence Thomas has, for decades, failed to disclose luxury trips he received from a real estate magnate and conservative megadonor.

Illinois Sen. Dick Durbin, who chairs the Senate Judiciary Committee — influential for its role in vetting and confirming Supreme Court nominees — said his panel is calling for an “enforceable code of conduct” for justices. “The ProPublica report is a call to action, and the Senate Judiciary Committee will act,” Durbin said.

Lawmakers and advocates have long called for codified ethics rules that prohibit the type of behavior uncovered by ProPublica’s investigation.

For more than two decades, records and interviews show, Thomas has accepted luxury trips virtually every year from Dallas billionaire Harlan Crow without disclosing them. Thomas has vacationed on Crow’s superyacht around the globe, flown on Crow’s jet and typically spends about a week every summer at Crow’s private resort in the Adirondacks, the investigation found.

These trips appeared nowhere on Thomas’ financial disclosures. His failure to report the flights appears to violate a law passed after Watergate that requires justices and other federal officials to disclose most gifts, ethics law experts said. He also should have disclosed his trips on the yacht, these experts said.

A Supreme Court spokesperson didn’t immediately respond to a request for comment regarding the lawmakers’ calls for investigations.

Thomas has not responded to ProPublica’s questions about his travel. Crow told ProPublica that Thomas “never asked for any of this hospitality” and that his treatment of the justice was “no different from the hospitality we have extended to our many other dear friends.”

Crow said he has never discussed a pending case with Thomas. “We have never sought to influence Justice Thomas on any legal or political issue,” he said.

While justices are required by law to disclose most gifts, there are few rules on what gifts justices can accept. That’s in contrast to the other branches of government. Members of Congress are generally prohibited from taking gifts worth $50 or more and would need pre-approval from an ethics committee to take many of the trips Thomas has accepted from Crow.

On Thursday, a growing chorus of Democratic lawmakers said Thomas’ failure to disclose the luxury vacations is an example of why public trust in the Supreme Court is faltering.

Maryland Sen. Chris Van Hollen said in a statement that Americans’ confidence in the Supreme Court is “tanking because of this kind of conduct.”

“We need answers,” he said. “And the Court needs a code of ethics.”

Rhode Island Sen. Sheldon Whitehouse said in a statement that the Supreme Court has lost its ethical compass, calling for Chief Justice John Roberts to open an investigation. “It’s no wonder that the American people are losing faith in the idea that they can get a fair shake before the nation’s highest court when they see a Supreme Court justice openly flouting basic disclosure rules in order to pal around with billionaires in secret,” he said.

This year, Whitehouse and others introduced a bill that would strengthen the Supreme Court’s disclosure and recusal rules, among other reforms. In his statement, the senator called for a hearing and vote on the bill.

“The Supreme Court urgently needs an enforceable system for holding justices accountable,” he said.

Massachusetts Sen. Elizabeth Warren said Americans deserve a judiciary that is “accountable to the rule of law, not wealthy Republican donors.” ProPublica’s reporting, she added, “is a stark reminder that judges should be held to the highest ethical standards and free from conflicts of interest.”

So far, no current GOP lawmakers have addressed the revelations publicly. Sen. Lindsey Graham, ranking member for Republicans on the Senate Judiciary Committee, did not immediately respond to requests for comment. Neither did the Republican-led House Judiciary Committee.

At least two Democratic representatives have called for Thomas to be impeached or resign.

“Justice Thomas must resign immediately,” said Georgia Rep. Hank Johnson, a member of the House Judiciary Committee. Failing that, Johnson said, fellow justices should censure Thomas and the Department of Justice should investigate potential federal crimes “to determine whether Justice Thomas remains fit to retain his license to practice law.”

New York Rep. Alexandria Ocasio-Cortez said on Twitter: “This is beyond party or partisanship. This degree of corruption is shocking — almost cartoonish. Thomas must be impeached.”

Do you have any tips on the courts? Josh Kaplan can be reached by email at joshua.kaplan@propublica.org and by Signal or WhatsApp at 734-834-9383. Justin Elliott can be reached by email at justin@propublica.org or by Signal or WhatsApp at 774-826-6240.

Brett Murphy contributed reporting.

by Perla Trevizo, ProPublica and The Texas Tribune, and Suzy Khimm, NBC News

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

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

This article was also produced in partnership with NBC News.

BETHESDA, Md. — The federal government is moving forward with sweeping new regulations to make portable generators safer, citing the increasing number of deaths they cause and the failure of manufacturers to protect consumers.

On Wednesday, the Consumer Product Safety Commission voted unanimously to advance a proposal that would require portable generators to emit less carbon monoxide and to shut off automatically when the deadly gas reaches a certain level. The invisible and odorless gas emitted by the devices claims an average of 85 lives a year, making generators one of the deadliest consumer products the CPSC regulates.

If the proposal is finalized, it will be the first time that the federal government will require companies to manufacture generators that protect consumers against carbon monoxide poisoning — the most significant step that the agency has taken after decades of studying the hazard.

“This issue has been going on for too long, and too many people have been dying each year,” CPSC Chair Alexander Hoehn-Saric said shortly after Wednesday’s vote. “It’s a tremendous step forward.”

The agency’s proposal comes in the wake of an investigation by NBC News, ProPublica and The Texas Tribune that revealed the lack of safeguards underpinning the worst carbon monoxide poisoning event in U.S. history. In Texas, at least 19 residents died from carbon monoxide poisoning and more than 1,400 others were treated in emergency rooms during a winter storm that pummeled the state in 2021, the news organizations found. At least 10 of those deaths involved generators.

“The importance of safety for portable generators will only grow as demand for them grows in the face of extreme weather events,” Commissioner Mary Boyle said during Wednesday’s meeting.

The Portable Generator Manufacturers’ Association, the industry’s largest trade group, said the agency had “no legal authority” to implement the rule that it is proposing, pointing to safeguards that the industry has created.

“There is a voluntary consumer product safety standard that is effective at preventing deaths and injuries and will have substantial compliance by the industry,” Joseph Harding, the group’s technical director, said in a statement ahead of the vote. The industry group declined to comment afterward.

Under federal law, once manufacturers propose voluntary safety standards, the CPSC can only create mandatory ones if it can prove that the industry’s approach doesn’t work or that not enough manufacturers have adopted it.

Created in 2018 to ward off the federal government’s last attempt to intervene, the trade group’s safety standards are more lenient than what the agency is now proposing: They do not restrict how much carbon monoxide generators can emit and have a higher threshold for automatically shutting off the device.

In 2022, two months after the news organizations ​​detailed the deadly cost of the government’s failure to regulate portable generators, the agency concluded that the industry’s efforts were inadequate. It found that less than a third of companies embraced the voluntary safeguards and that manufacturers had not done enough to prevent carbon monoxide poisoning.

“This problem will not correct itself. In fact, we expect incidents with consumers dying or being injured will likely increase,” Janet Buyer, a CPSC engineering project manager, told the commissioners during a recent meeting, urging them to adopt more stringent safeguards.

Buyer pointed to a Louisiana incident, reported by the news organizations, following Hurricane Ida in 2021: A woman and her two children were killed by carbon monoxide from a portable generator that was placed outside, with the exhaust inches from their back door and pointing inside.

The Portable Generator Manufacturers’ Association has disputed that the device was at fault, saying the user did not appear to have followed warning label instructions. Harding later said one of the labels on the machine directed users to point “engine exhaust away from occupied structures.”

But Buyer said it is not uncommon for carbon monoxide from generators to filter into homes — a scenario that happened 63 times in the aftermath of Hurricane Ida in the New Orleans area. The generator in the case that she highlighted had an automatic shut-off sensor, but it’s unclear whether it activated. That’s why mandatory standards are necessary, Buyer said.

The Portable Generator Manufacturers’ Association also disputed the CPSC’s conclusion that few manufacturers are adopting the voluntary standards. An estimated 60% of available generators will have such safety features by the third quarter of 2023, Susan Orenga, executive director of the trade group, said in a statement.

The public has 60 days to comment on the CPSC’s proposed rule, which the agency can modify in response. The commission will vote on the final version in September.

by Joshua Kaplan, Justin Elliott and Alex Mierjeski

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

Update, April 7, 2023: Since publication, Justice Clarence Thomas has made a public statement defending his undisclosed trips.

In late June 2019, right after the U.S. Supreme Court released its final opinion of the term, Justice Clarence Thomas boarded a large private jet headed to Indonesia. He and his wife were going on vacation: nine days of island-hopping in a volcanic archipelago on a superyacht staffed by a coterie of attendants and a private chef.

If Thomas had chartered the plane and the 162-foot yacht himself, the total cost of the trip could have exceeded $500,000. Fortunately for him, that wasn’t necessary: He was on vacation with real estate magnate and Republican megadonor Harlan Crow, who owned the jet — and the yacht, too.

Clarence Thomas and his wife, Ginni, front left, with Harlan Crow, back right, and others in Flores, Indonesia, in July 2019. (via Instagram)

For more than two decades, Thomas has accepted luxury trips virtually every year from the Dallas businessman without disclosing them, documents and interviews show. A public servant who has a salary of $285,000, he has vacationed on Crow’s superyacht around the globe. He flies on Crow’s Bombardier Global 5000 jet. He has gone with Crow to the Bohemian Grove, the exclusive California all-male retreat, and to Crow’s sprawling ranch in East Texas. And Thomas typically spends about a week every summer at Crow’s private resort in the Adirondacks.

The extent and frequency of Crow’s apparent gifts to Thomas have no known precedent in the modern history of the U.S. Supreme Court.

These trips appeared nowhere on Thomas’ financial disclosures. His failure to report the flights appears to violate a law passed after Watergate that requires justices, judges, members of Congress and federal officials to disclose most gifts, two ethics law experts said. He also should have disclosed his trips on the yacht, these experts said.

Get in Touch

ProPublica plans to continue reporting on the judiciary. If you have information about Harlan Crow and Justice Clarence Thomas, travel by Supreme Court justices or anything else we should know about the judiciary, please get in touch. Josh Kaplan can be reached by email at joshua.kaplan@propublica.org and by Signal or WhatsApp at 734-834-9383. Justin Elliott can be reached by email at justin@propublica.org or by Signal or WhatsApp at 774-826-6240.

Thomas did not respond to a detailed list of questions.

In a statement, Crow acknowledged that he’d extended “hospitality” to the Thomases “over the years,” but said that Thomas never asked for any of it and it was “no different from the hospitality we have extended to our many other dear friends.”

Through his largesse, Crow has gained a unique form of access, spending days in private with one of the most powerful people in the country. By accepting the trips, Thomas has broken long-standing norms for judges’ conduct, ethics experts and four current or retired federal judges said.

“It’s incomprehensible to me that someone would do this,” said Nancy Gertner, a retired federal judge appointed by President Bill Clinton. When she was on the bench, Gertner said, she was so cautious about appearances that she wouldn’t mention her title when making dinner reservations: “It was a question of not wanting to use the office for anything other than what it was intended.”

Virginia Canter, a former government ethics lawyer who served in administrations of both parties, said Thomas “seems to have completely disregarded his higher ethical obligations.”

“When a justice’s lifestyle is being subsidized by the rich and famous, it absolutely corrodes public trust,” said Canter, now at the watchdog group CREW. “Quite frankly, it makes my heart sink.”

When a justice’s lifestyle is being subsidized by the rich and famous, it absolutely corrodes public trust. Quite frankly, it makes my heart sink.

—Virginia Canter, former government ethics lawyer

ProPublica uncovered the details of Thomas’ travel by drawing from flight records, internal documents distributed to Crow’s employees and interviews with dozens of people ranging from his superyacht’s staff to members of the secretive Bohemian Club to an Indonesian scuba diving instructor.

Federal judges sit in a unique position of public trust. They have lifetime tenure, a privilege intended to insulate them from the pressures and potential corruption of politics. A code of conduct for federal judges below the Supreme Court requires them to avoid even the “appearance of impropriety.” Members of the high court, Chief Justice John Roberts has written, “consult” that code for guidance. The Supreme Court is left almost entirely to police itself.

There are few restrictions on what gifts justices can accept. That’s in contrast to the other branches of government. Members of Congress are generally prohibited from taking gifts worth $50 or more and would need pre-approval from an ethics committee to take many of the trips Thomas has accepted from Crow.

Thomas’ approach to ethics has already attracted public attention. Last year, Thomas didn’t recuse himself from cases that touched on the involvement of his wife, Ginni, in efforts to overturn the 2020 presidential election. While his decision generated outcry, it could not be appealed.

Crow met Thomas after he became a justice. The pair have become genuine friends, according to people who know both men. Over the years, some details of Crow’s relationship with the Thomases have emerged. In 2011, The New York Times reported on Crow’s generosity toward the justice. That same year, Politico revealed that Crow had given half a million dollars to a Tea Party group founded by Ginni Thomas, which also paid her a $120,000 salary. But the full scale of Crow’s benefactions has never been revealed.

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Long an influential figure in pro-business conservative politics, Crow has spent millions on ideological efforts to shape the law and the judiciary. Crow and his firm have not had a case before the Supreme Court since Thomas joined it, though the court periodically hears major cases that directly impact the real estate industry. The details of his discussions with Thomas over the years remain unknown, and it is unclear if Crow has had any influence on the justice’s views.

In his statement, Crow said that he and his wife have never discussed a pending or lower court case with Thomas. “We have never sought to influence Justice Thomas on any legal or political issue,” he added.

In Thomas’ public appearances over the years, he has presented himself as an everyman with modest tastes.

“I don’t have any problem with going to Europe, but I prefer the United States, and I prefer seeing the regular parts of the United States,” Thomas said in a recent interview for a documentary about his life, which Crow helped finance.

“I prefer the RV parks. I prefer the Walmart parking lots to the beaches and things like that. There’s something normal to me about it,” Thomas said. “I come from regular stock, and I prefer that — I prefer being around that.”

“You Don’t Need to Worry About This — It’s All Covered”

Crow’s private lakeside resort, Camp Topridge, sits in a remote corner of the Adirondacks in upstate New York. Closed off from the public by ornate wooden gates, the 105-acre property, once the summer retreat of the same heiress who built Mar-a-Lago, features an artificial waterfall and a great hall where Crow’s guests are served meals prepared by private chefs. Inside, there’s clear evidence of Crow and Thomas’ relationship: a painting of the two men at the resort, sitting outdoors smoking cigars alongside conservative political operatives. A statue of a Native American man, arms outstretched, stands at the center of the image, which is photographic in its clarity.

A painting that hangs at Camp Topridge shows Crow, far right, and Thomas, second from right, smoking cigars at the resort. They are joined by lawyers Peter Rutledge, Leonard Leo and Mark Paoletta, from left. (Painting by Sharif Tarabay)

The painting captures a scene from around five years ago, said Sharif Tarabay, the artist who was commissioned by Crow to paint it. Thomas has been vacationing at Topridge virtually every summer for more than two decades, according to interviews with more than a dozen visitors and former resort staff, as well as records obtained by ProPublica. He has fished with a guide hired by Crow and danced at concerts put on by musicians Crow brought in. Thomas has slept at perhaps the resort’s most elegant accommodation, an opulent lodge overhanging Upper St. Regis Lake.

The mountainous area draws billionaires from across the globe. Rooms at a nearby hotel built by the Rockefellers start at $2,250 a night. Crow’s invitation-only resort is even more exclusive. Guests stay for free, enjoying Topridge’s more than 25 fireplaces, three boathouses, clay tennis court and batting cage, along with more eccentric features: a lifesize replica of the Harry Potter character Hagrid’s hut, bronze statues of gnomes and a 1950s-style soda fountain where Crow’s staff fixes milkshakes.

First image: A lodge at Topridge where Thomas has stayed. Second image: Thomas fishing in the Adirondacks. (First image: Courtesy of Carolyn Belknap. Second image: Via NYup.com.)

Crow’s access to the justice extends to anyone the businessman chooses to invite along. Thomas’ frequent vacations at Topridge have brought him into contact with corporate executives and political activists.

During just one trip in July 2017, Thomas’ fellow guests included executives at Verizon and PricewaterhouseCoopers, major Republican donors and one of the leaders of the American Enterprise Institute, a pro-business conservative think tank, according to records reviewed by ProPublica. The painting of Thomas at Topridge shows him in conversation with Leonard Leo, the Federalist Society leader regarded as an architect of the Supreme Court’s recent turn to the right.

In his statement to ProPublica, Crow said he is “unaware of any of our friends ever lobbying or seeking to influence Justice Thomas on any case, and I would never invite anyone who I believe had any intention of doing that.”

“These are gatherings of friends,” Crow said.

Crow has deep connections in conservative politics. The heir to a real estate fortune, Crow oversees his family’s business empire and recently named Marxism as his greatest fear. He was an early patron of the powerful anti-tax group Club for Growth and has been on the board of AEI for over 25 years. He also sits on the board of the Hoover Institution, another conservative think tank.

A major Republican donor for decades, Crow has given more than $10 million in publicly disclosed political contributions. He’s also given to groups that keep their donors secret — how much of this so-called dark money he’s given and to whom are not fully known. “I don’t disclose what I’m not required to disclose,” Crow once told the Times.

Crow has long supported efforts to move the judiciary to the right. He has donated to the Federalist Society and given millions of dollars to groups dedicated to tort reform and conservative jurisprudence. AEI and the Hoover Institution publish scholarship advancing conservative legal theories, and fellows at the think tanks occasionally file amicus briefs with the Supreme Court.

I prefer the RV parks. I prefer the Walmart parking lots to the beaches and things like that. There’s something normal to me about it. I come from regular stock, and I prefer that — I prefer being around that.

—Clarence Thomas Listen to Thomas speak, from the documentary “Created Equal.”

On the court since 1991, Thomas is a deeply conservative jurist known for his “originalism,” an approach that seeks to adhere to close readings of the text of the Constitution. While he has been resolute in this general approach, his views on specific matters have sometimes evolved. Recently, Thomas harshly criticized one of his own earlier opinions as he embraced a legal theory, newly popular on the right, that would limit government regulation. Small evolutions in a justice’s thinking or even select words used in an opinion can affect entire bodies of law, and shifts in Thomas’ views can be especially consequential. He’s taken unorthodox legal positions that have been adopted by the court’s majority years down the line.

Soon after Crow met Thomas three decades ago, he began lavishing the justice with gifts, including a $19,000 Bible that belonged to Frederick Douglass, which Thomas disclosed. Recently, Crow gave Thomas a portrait of the justice and his wife, according to Tarabay, who painted it. Crow’s foundation also gave $105,000 to Yale Law School, Thomas’ alma mater, for the “Justice Thomas Portrait Fund,” tax filings show.

Crow said that he and his wife have funded a number of projects that celebrate Thomas. “We believe it is important to make sure as many people as possible learn about him, remember him and understand the ideals for which he stands,” he said.

To trace Thomas’ trips around the world on Crow’s superyacht, ProPublica spoke to more than 15 former yacht workers and tour guides and obtained records documenting the ship’s travels.

On the Indonesia trip in the summer of 2019, Thomas flew to the country on Crow’s jet, according to another passenger on the plane. Clarence and Ginni Thomas were traveling with Crow and his wife, Kathy. Crow’s yacht, the Michaela Rose, decked out with motorboats and a giant inflatable rubber duck, met the travelers at a fishing town on the island of Flores.

First image: From left, Crow, Paoletta, Ginni Thomas and Clarence Thomas in Indonesia in 2019. Clarence Thomas flew to the country on Crow’s jet, according to another passenger on the plane. Second image: A worker from Crow’s yacht ferries Thomas and others on a small boat in Indonesia. (via Facebook)

Touring the Lesser Sunda Islands, the group made stops at Komodo National Park, home of the eponymous reptiles; at the volcanic lakes of Mount Kelimutu; and at Pantai Meko, a spit of pristine beach accessible only by boat. Another guest was Mark Paoletta, a friend of the Thomases then serving as the general counsel of the Office of Management and Budget in the administration of President Donald Trump.

Paoletta was bound by executive branch ethics rules at the time and told ProPublica that he discussed the trip with an ethics lawyer at his agency before accepting the Crows’ invitation. “Based on that counsel’s advice, I reimbursed Harlan for the costs,” Paoletta said in an email. He did not respond to a question about how much he paid Crow.

(Paoletta has long been a pugnacious defender of Thomas and recently testified before Congress against strengthening judicial ethics rules. “There is nothing wrong with ethics or recusals at the Supreme Court,” he said, adding, “To support any reform legislation right now would be to validate these vicious political attacks on the Supreme Court,” referring to criticism of Thomas and his wife.)

The Indonesia vacation wasn’t Thomas’ first time on the Michaela Rose. He went on a river day trip around Savannah, Georgia, and an extended cruise in New Zealand roughly a decade ago.

During a New Zealand trip on Crow’s yacht, Thomas signed a copy of his memoir and gave it to a yacht worker. (Obtained by ProPublica)

As a token of his appreciation, he gave one yacht worker a copy of his memoir. Thomas signed the book: “Thank you so much for all your hard work on our New Zealand adventure.”

Crow’s policy was that guests didn’t pay, former Michaela Rose staff said. “You don’t need to worry about this — it’s all covered,” one recalled the guests being told.

There’s evidence Thomas has taken even more trips on the superyacht. Crow often gave his guests custom polo shirts commemorating their vacations, according to staff. ProPublica found photographs of Thomas wearing at least two of those shirts. In one, he wears a blue polo shirt embroidered with the Michaela Rose’s logo and the words “March 2007” and “Greek Islands.”

Thomas didn’t report any of the trips ProPublica identified on his annual financial disclosures. Ethics experts said the law clearly requires disclosure for private jet flights and Thomas appears to have violated it.

Thomas has been photographed wearing custom polo shirts bearing the logo of Crow’s yacht, the Michaela Rose. (via Flickr, Washington Examiner)

Justices are generally required to publicly report all gifts worth more than $415, defined as “anything of value” that isn’t fully reimbursed. There are exceptions: If someone hosts a justice at their own property, free food and lodging don’t have to be disclosed. That would exempt dinner at a friend’s house. The exemption never applied to transportation, such as private jet flights, experts said, a fact that was made explicit in recently updated filing instructions for the judiciary.

Two ethics law experts told ProPublica that Thomas’ yacht cruises, a form of transportation, also required disclosure.

“If Justice Thomas received free travel on private planes and yachts, failure to report the gifts is a violation of the disclosure law,” said Kedric Payne, senior director for ethics at the nonprofit government watchdog Campaign Legal Center. (Thomas himself once reported receiving a private jet trip from Crow, on his disclosure for 1997.)

The experts said Thomas’ stays at Topridge may have required disclosure too, in part because Crow owns it not personally but through a company. Until recently, the judiciary’s ethics guidance didn’t explicitly address the ownership issue. The recent update to the filing instructions clarifies that disclosure is required for such stays.

How many times Thomas failed to disclose trips remains unclear. Flight records from the Federal Aviation Administration and FlightAware suggest he makes regular use of Crow’s plane. The jet often follows a pattern: from its home base in Dallas to Washington Dulles airport for a brief stop, then on to a destination Thomas is visiting and back again.

ProPublica identified five such trips in addition to the Indonesia vacation.

On July 7 last year, Crow’s jet made a 40-minute stop at Dulles and then flew to a small airport near Topridge, returning to Dulles six days later. Thomas was at the resort that week for his regular summer visit, according to a person who was there. Twice in recent years, the jet has followed the pattern when Thomas appeared at Crow’s properties in Dallas — once for the Jan. 4, 2018, swearing-in of Fifth Circuit Judge James Ho at Crow’s private library and again for a conservative think tank conference Crow hosted last May.

Thomas has even used the plane for a three-hour trip. On Feb. 11, 2016, the plane flew from Dallas to Dulles to New Haven, Connecticut, before flying back later that afternoon. ProPublica confirmed that Thomas was on the jet through Supreme Court security records obtained by the nonprofit Fix the Court, private jet data, a New Haven plane spotter and another person at the airport. There are no reports of Thomas making a public appearance that day, and the purpose of the trip remains unclear.

Jet charter companies told ProPublica that renting an equivalent plane for the New Haven trip could cost around $70,000.

On the weekend of Oct. 16, 2021, Crow’s jet repeated the pattern. That weekend, Thomas and Crow traveled to a Catholic cemetery in a bucolic suburb of New York City. They were there for the unveiling of a bronze statue of the justice’s beloved eighth grade teacher, a nun, according to Catholic Cemetery magazine.

Thomas attended the 2021 unveiling of a statue of his eighth grade teacher. (via Catholic Cemeteries of the Archdiocese of Newark)

As Thomas spoke from a lectern, the monument towered over him, standing 7 feet tall and weighing 1,800 pounds, its granite base inscribed with words his teacher once told him. Thomas told the nuns assembled before him, “This extraordinary statue is dedicated to you sisters.”

He also thanked the donors who paid for the statue: Harlan and Kathy Crow.

Do you have any tips on the courts? Josh Kaplan can be reached by email at joshua.kaplan@propublica.org and by Signal or WhatsApp at 734-834-9383. Justin Elliott can be reached by email at justin@propublica.org or by Signal or WhatsApp at 774-826-6240.

Matt Easton contributed reporting.

Design and development by Anna Donlan and Lena V. Groeger.

by Kathleen McGrory and Neil Bedi

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For decades, chemical companies fought attempts to ban asbestos, claiming they needed the potent carcinogen to manufacture chlorine. As recently as last April, in fact, the CEO of one of the last major companies still clinging to the toxic substance argued for it to remain legal. Acceptable alternatives “do not exist,” Olin Corp. CEO Scott Sutton told regulators.

In a dramatic turnaround, Olin said on Tuesday that it would support a federal ban on the deadly mineral.

ProPublica’s reporting changed the national conversation on asbestos, challenging a long-standing and successful industry argument that chlorine companies kept their employees safe. Late last year, ProPublica revealed that workers across the country had been exposed to the substance, including those at an Olin facility in Alabama who said they could “see it all the time” and weren’t given protective gear when they worked around it. (Olin did not return repeated calls or emails from ProPublica seeking comment on those findings.)

“I just wish they had stopped sooner,” Andy Lang, a contract pipefitter who worked at the plant in McIntosh, Alabama, told ProPublica on Wednesday. “I wish they had stopped years ago. I’m thinking about the people in my neighborhood like my sister.”

Lang’s sister, Bertha Reed, was a plant employee who worked a number of jobs and spent time around asbestos. Reed, who never smoked, died of lung cancer in 2017. It’s unclear what caused the cancer, but Lang blames the substances his sister was exposed to in the plant.

Andy Lang visits the gravesite of his sister, Bertha Reed. (Rich-Joseph Facun, special to ProPublica)

In a letter to the Environmental Protection Agency this week, Sutton said Olin would endorse a proposed ban if the companies were given seven years to phase out asbestos materials already in use. Companies apply the mineral to thick metal screens used in the production process to keep explosive chemicals from mixing. Sutton said workers would not have to apply new asbestos to screens during the last five years of the phase-out period, minimizing the potential for exposure.

“Additionally, no asbestos imports into the U.S. are required past today,” he added.

Olin did not reply to ProPublica’s questions on Wednesday.

The EPA said that it would consider Olin’s letter and other comments it has received, and that it was “moving expeditiously” to finalize its ban this year. The agency opened a new public comment period on the ban to account for new information, including ProPublica’s reports on the dangers at asbestos-dependent chlorine plants. That period ends April 17.

Olin’s letter marks a turning point in the battle over asbestos in the United States.

The U.S. has lagged behind dozens of other countries that outlaw asbestos, which is known to cause deadly cancers like mesothelioma. To this day, the U.S. continues to let chlorine companies import hundreds of tons annually.

Last year, ProPublica found that chlorine companies had spent decades lobbying against a ban. Behind the scenes, industry representatives pushed for regulatory exemptions, marshaled pro-business lawmakers to make their talking points and found support from 12 prominent attorneys general who said a ban was a “heavy and unreasonable burden.”

Supporters of a ban heralded Olin’s new position.

“We are deeply encouraged that Olin Corporation has stepped forward to publicly say they are committed to ending asbestos use in the chlor-alkali industry,” said Linda Reinstein, the co-founder of the Asbestos Disease Awareness Organization, in a statement on Wednesday.

The EPA still needs to address resistance from the rest of the chemical industry.

The American Chemistry Council, a powerful trade association that lobbies for chlorine companies, has pushed for its members to be exempted from the ban and said it would be impossible to transition to newer asbestos-free technology in less than 15 years.

In a statement provided to ProPublica on Wednesday, the group said its 15-year timeline was based on limited contractor resources, supply chain disruptions and regulatory approval cycles, among other factors.

“We continue to hold this position and therefore oppose calls to implement unrealistic timetables and deadlines,” the statement said.

OxyChem, another major producer of chlorine, did not respond to requests for comment from ProPublica. Last year, workers from its recently shuttered plant in Niagara Falls, New York, described conditions that experts called “totally unacceptable,” “fraught with danger” and “like something that maybe would happen in the 1940s or the 1950s.” At the time, OxyChem said ProPublica’s reporting on the plant was inaccurate, but it would not say what specifically was incorrect.

Hanging over the EPA is the agency’s failure to ban asbestos in 1989. Back then, the asbestos industry successfully overturned a ban by arguing in a lawsuit that it was too burdensome. Advocates and experts are now watching to see if history will repeat itself.

Last week, citing ProPublica’s reporting, lawmakers renewed efforts to write an asbestos ban into federal law, a measure that would be more difficult to challenge in court.

by Paul Kiel

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

Flying to Ireland to inhale the seaside air as you drive a golf ball into the scenic distance. Crossing the country to reach your enormous yacht, which is ready for your Hudson River pleasure cruise. Hosting a governor’s wife on your very own aircraft. These are only a few of the joys that the richest Americans have experienced in recent years through their private jets. And what made them all the sweeter is that they came with a tax write-off.

Over the past two years, ProPublica has documented the many ways that the ultrawealthy avoid taxes. The biggest or most daring maneuvers scale in the billions of dollars, and while the tax deductibility of private jets isn’t the most important feature of U.S. tax law, the fact that billionaires’ luxury rides come with millions in tax savings says a lot about how the system really works.

There are dozens of examples of wealthy Americans taking these sorts of deductions, which are premised on the notion that the planes are used mainly for business, in the massive trove of tax records that have formed the basis for ProPublica’s “Secret IRS Files” series. The ultrawealthy, however, can easily blur business and pleasure. And when they purport to make their planes available for leasing, to fulfill one definition of using the planes for business, they tend to be more adept at generating tax deductions than revenue.

Bryan Marsal (Agencja Fotograficzna Caro/Alamy Stock Photo)

Tony Alvarez and Bryan Marsal built a successful consulting firm specializing in restructuring — advising struggling or bankrupt companies on what to sell and whom to lay off. It can be a grim business: Marsal has been known to announce to prone firms that they were now a “community of pain.” But the partners, who are also close friends, own another enterprise, the Hogs Head Golf Club (“Built by Friends, for Friends, for Fun”), on the southwest coast of Ireland. It boasts views of the nearby mountains and bay.

In 2016, before opening their new course, the pair teamed up, via an LLC they named after their golf club, to buy a 2001 Gulfstream IV jet. The next year, President Donald Trump signed his big tax cut into law. It made buying a plane even more attractive: The full price of the plane could be deducted in the first year, a perk called “bonus depreciation.” Before, depreciation was typically only partially front-loaded, with the full balance spread over five years. The law also for the first time made pre-owned planes eligible for this treatment.

As a result, when Alvarez and Marsal sprang for their second plane in 2018, this one a Gulfstream V, the entire cost was deductible. That year, the pair’s two planes netted them a tax deduction of $14 million.

Tony Alvarez in 2008 (Brendan McDermid/Reuters/Alamy Stock Photo)

Last August, their Gulfstream V took off from Westchester County Airport in New York state for Ireland. About an hour later, their Gulfstream IV left for the same destination, a small airport in County Kerry near their club. Both planes can comfortably seat over a dozen passengers, but flight records don’t show who was on board. Over the coming month and a half, the two planes crisscrossed the Atlantic several times.

Were these business trips? Possibly, yes. (ProPublica’s records do not indicate whether specific trips were taken as deductions.) If so, operating expenses — including crew, fuel and other costs — from the partners’ trips to oversee the course would be fully deductible. These deductions would come in addition to depreciation.

Michael Kosnitzky, co-chair of the private client and family office group at the law firm Pillsbury Winthrop, said his wealthy clients often own a business, such as an art gallery, in the same area where they own a vacation home. If the main purpose of a flight there is to attend to that business, jet owners must take care to make that as clear as possible. “I advise my clients to go to their secondary business location first” upon landing, he said, as a way to help build the case.

Accounting for how a jet is used can get complicated. If nonbusiness guests, such as family, ride along on a business flight, it’s treated as a fringe benefit, which is taxable. (The benefit is typically attributed to the jet owner, experts said.) But that wrinkle isn’t too bad: The IRS formula used to calculate the benefit drastically undervalues the cost of riding on a private jet and is closer to the price of a first-class commercial ticket.

Last Christmas, flight records show the two Gulfstreams again leaving together, this time to St. Vincent and the Grenadines in the Caribbean. While Alvarez and Marsal’s consulting firm boasts an office in the Cayman Islands, there isn’t one on these particular islands (which are about 1,400 miles from the Caymans), making it appear this was a family trip. Operating costs from “entertainment” flights like these are not deductible under tax law. But indulging in some pleasure doesn’t necessarily imperil the key tax prize of bonus depreciation: As long as, over the course of a year, the jet is used over 50% of the time for business, the owner gets to keep that perk.

A spokesperson for Alvarez and Marsal’s firm did not respond to a request for comment.

Mori Hosseini made his fortune as a Florida homebuilder and has owned a plane since at least 2006. When Trump’s tax bill began to gain momentum in Congress in the fall of 2017, he decided it was time for a new jet.

The $19.5 million he paid for his nine-seat Bombardier Challenger 350 appeared as a deduction on his 2017 taxes, leading to almost $8 million in tax savings right off the bat. But there were more deductions to come. Even the interest on the loan he’d taken out to buy the plane was deductible, and his 2018 taxes show a $600,000 expense.

Soon, Hosseini, a longtime Republican donor and close adviser to Florida Gov. Ron DeSantis, was helping the governor and his family travel in style. In 2019, DeSantis’ wife, Casey, flew on the jet from Tallahassee to Jacksonville to attend a fundraiser held by a defense contractor. It was just one of several times that the DeSantises or the campaign have used the jet over the past few years, according to campaign finance records. Such flights are generally allowed under Florida law as long as they are disclosed as in-kind contributions. Hosseini did not respond to questions from ProPublica.

The interior of a Bombardier Challenger 350 (Paulo Whitaker/Reuters/Alamy)

On his taxes, Hosseini says the LLC that holds his plane is in the business of “aircraft leasing.” It’s a very common move among jet owners. When they are not using the plane, they rent out the plane for charter flights, usually via an independent leasing company. Not only does this defray the costs of ownership, but it has tax benefits, too. It helps them establish that they bought the aircraft for a business purpose, the business of chartering.

In theory, taxpayers aren’t allowed to deduct losses from something that has no hope of being a profitable business. In practice, though, some billionaire-owned operations that look like expensive hobbies, such as racing horses in the Kentucky Derby, rack up business deductions by the tens of millions of dollars.

ProPublica examined the tax records of over 30 wealthy Americans who owned planes, and one thing was very clear: Profits in the airplane chartering business for this set, judging from their taxes, were extremely rare. Hosseini's records show two years of profit over an eleven-year period.

Or take George Argyros, a California billionaire real estate developer who once owned the Seattle Mariners. A major GOP donor, he also was the U.S. ambassador to Spain from 2001 to 2004. Argyros, 86, has leased out his aircraft through his own chartering company for decades. From 2002 through 2019, his tax records show, his company pulled a profit just twice. Overall, he deducted over $50 million in net losses over the years.

In June 2021, Argyros’ Gulfstream landed at the small airport near Newburgh in New York’s Hudson Valley, having flown cross-country from California. Nearby, his $83 million, 248-foot yacht the Huntress awaited. Over the coming weeks, the ship would be seen cruising up and down the Hudson River, astounding locals who gawked at its six decks, helipad and hot tub.

The Huntress on the Hudson River in July 2021 (Gary Hershorn/Getty Images)

A representative for Argyros declined to comment.

Yachts are dealt with differently from airplanes in tax law. They are considered entertainment facilities, so you can’t claim deductions on the premise that you used it for business travel.

But that doesn’t mean there’s no tax savings to be had. Mike Fernandez is a capable businessman, having made a fortune starting and investing in health care companies. But the Florida-based investor seems to have abysmal luck with one of his businesses: leasing out his 180-foot yacht, the Lady Michelle, when he’s not using it. On his 2017 and 2018 tax returns, he claimed a total of $11.3 million in expenses connected with the Lady Michelle from depreciation, repairs, wages and other costs. Meanwhile, his revenue over the two years totaled $178,000. Fernandez did not respond to questions from ProPublica.

Should the IRS audit one of these businesses — itself unlikely over the past decade, due to the gutting of the agency’s budget — the IRS faces a high hurdle: proving that not only was the business not profitable, but that the business owner was not really trying to profit. The case of personal jets adds an additional difficulty for an auditor. The ultrawealthy can often argue that, even if chartering did not result in profits, they also used the plane to help conduct their main business.

Robert Bigelow made his fortune in real estate and owns Budget Suites of America, an extended-stay apartment chain. His passions, however, reach to the skies and beyond. For decades, he’s poured resources into investigating UFO sightings and paranormal phenomena. Two years ago, he announced $1 million in grants from his Bigelow Institute for Consciousness Studies for research “into contact and communication with post-mortem or discarnate consciousness.”

Robert Bigelow (NG Images/Alamy Stock Photo)

His main focus, however, has been space. He founded Bigelow Aerospace, a company focused on building expandable space habitats. The company has had some successes, winning a contract from NASA for a module for use on the International Space Station. But what it has not had is profits. Bigelow put more than $350 million into the company, “my own real black hole,” as he’s put it.

In the two decades prior to 2018, even as Forbes and The Wall Street Journal variously estimated his net worth as $700 million and $900 million, Bigelow posted negative incomes on his taxes most years, as large losses from his aerospace company wiped out his other income. His personal jet, held by Cosmos Air LLC, also played a role. From 2005 to 2018, he deducted a total of $51 million related to use of his plane. ProPublica could not find evidence that Bigelow charters his aircraft, nor did Bigelow respond to ProPublica’s requests for comment.

Of course, the deductions could also be justified on the basis that the aircraft is necessary to tend to Bigelow’s various businesses. The plane is a luxury expense, in other words, essential to help him run up millions more in tax deductions — one black hole orbiting another.

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Jeff Ernsthausen contributed reporting.

by Margaret Coker, The Current, and Mollie Simon, ProPublica

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In February, Georgia lawmaker Josh Bonner introduced a bill that he hoped would fix a thorny problem that entangles tens of thousands of state residents in debt each year.

The Republican state representative from Fayetteville, a southern Atlanta exurb, aimed to close a loophole used by title lenders, who offer short-term cash to customers in exchange for a lien on their car title. The industry can currently charge triple-digit annual interest, more than three times what state law allows other financial companies.

Bonner, a military veteran and a church deacon, was outraged by the threat posed to consumers, especially military members and their families. In late February, federal regulators fined Savannah-based TitleMax, the country’s largest title lender, $15 million for multiple violations of the federal law that protects members of the armed forces from predatory, high-interest loans.

“I wondered, ‘How can this be legal, and who wouldn’t want some common-sense reform?’” Bonner recalled.

Bonner, a past House floor leader who whipped votes for Gov. Brian Kemp, isn’t an outsider to the corridors of power at the Georgia Capitol. Yet, within a month, his bill died in the House Banks and Banking Committee — the sixth time in nearly two decades that Georgia Republicans tried and failed to erect better guardrails for the industry.

Georgia state Rep. Josh Bonner introduced a bill this year to regulate title lenders to better protect consumers. (Nicole Buchanan, special to ProPublica)

In Georgia, political observers said, the top-down nature of the legislature meant the measure had no chance without the support of top GOP statehouse leaders — whose cozy donor relationships with title lenders have stood in the way of reform.

David Ralston, the House speaker who died unexpectedly in November, never brought a reform bill to a floor vote during the 12 years he ran the lower chamber. In the upper house, while a reform bill passed the Senate Finance Committee in 2020, Senate leaders didn’t schedule a floor vote, leaving it to die. In more than four years as governor, Kemp, now the party’s most powerful state leader, hasn’t taken a position publicly on the industry, despite having voted for a reform bill earlier in his career as a state senator.

“There’s a venerable tradition here, no matter who is in charge, that change happens slowly — or until you reach the ear of a senior politician or his wife,” said Richard Griffiths, president emeritus of the Georgia First Amendment Foundation and an advocate for greater government transparency in Georgia.

Georgia is home to two of the nation’s largest title lenders: TMX Finance, the parent company of TitleMax, which posted $910 million in revenue in 2019; and Alpharetta-based Select Management Resources, which owns the brand LoanMax. The companies and their founders have spent millions of dollars trying to defeat regulation attempts both in Washington, D.C., and in state legislatures across the country.

The two companies have prioritized lobbying statehouse leaders and leadership committees over rank-and-file members, according to an analysis of campaign finance data compiled by The Current and ProPublica.

In late February, the Consumer Financial Protection Bureau imposed a $15 million fine against Savannah-based TitleMax for violating the federal law that protects military members from predatory, high-interest loans. (Malcolm Jackson for ProPublica)

State Sen. Nan Orrock, a Democratic member of the Senate Finance Committee, said the two companies promote their interests by leaning heavily into “a strong mode of thinking here that all business is good for the state.” She added, “This is an industry that pushes that pro-business sentiment all the time.”

Top GOP leaders, including Kemp, either declined to comment or did not respond to questions for this story. TMX Finance and Select Management did not respond to questions for comment.

The situation rankles the portion of state Republicans who have led the charge for more regulation of the industry since taking over both chambers of the legislature in 2005.

“Privately my colleagues all tell me that almost no one is against reform,” said state Sen. Chuck Hufstetler, who chairs the Senate Finance Committee and is in favor of reform. “But publicly we can’t get that support.”

Title lending has been around in Georgia since the 1980s, catering to people who are often written off as credit risks by traditional lending institutions. It has drawn legislative ire almost from the start.

In 1995, a state Senate panel convened hearings to investigate the industry. “They practically get to write their own rules and rates,” then-state Sen. René Kemp, who represented Hinesville — the former hometown of TMX Finance founder Tracy Young — said at the time.

The industry really took off in the middle of the next decade. In 2005, both parties introduced bills that would have increased consumer protection against title lenders by forcing them to adhere to the state usury law that caps interest rates at 60%.

In response, Select Management’s founder, Rod Aycox, told The Atlanta Journal-Constitution that he had asked the American Legislative Exchange Council, a conservative policy think tank, to draft a model title lending bill that would have removed interest rate caps altogether for the industry.

Aycox took the model legislation to then-House Rules Committee Chairman Earl Ehrhart. The powerful Republican lawmaker, who, according to the Journal-Constitution, accepted free flights on planes owned by TitleMax and Select Management, pushed Aycox’s bill forward. Ehrhart declined to comment for this story.

In the end, neither the reform bills nor the model legislation survived, preserving the status quo that benefits title lenders by allowing them to operate under pawn shop statutes, instead of banking laws, and remain exempt from oversight by the state Department of Banking and Finance and usury caps. Instead, they can continue to charge up to 187% annual interest.

Since then, title lenders have been working behind the scenes to maintain the regulatory status quo. TMX Finance, Young and his wife, Beverly, have contributed more than $1.8 million in Georgia since 2006, with approximately a third of those funds going to political action committees, such as the Georgia House Republican Trust, according to an analysis of campaign finance data by The Current and ProPublica. Aycox, his immediate family and his corporate holdings have given $1.4 million during the same period.

These contributions are relatively modest compared to other industries. The political action committees for the NRA and Planned Parenthood, for instance, spent more than $600,000 each in the state in 2022 alone.

But title lenders have given consistently to legislative leaders. Among the chief recipients of these contributions were former House speaker Ralston and his longtime confidante Jon Burns, who was elected to take over Ralston’s position this year.

The two industry executives and their companies have also given generously to other lawmakers in a position to bottleneck any reform legislation — including the Georgia House whip, who controls the GOP caucus leadership committee, and the Senate majority whip, who controls floor votes, as well as the lieutenant governor, who controls the Republican caucus in the upper house.

A top lobbyist for Select Management, Raymon White, also helped raise money for Burt Jones’ successful 2022 bid to become lieutenant governor and thus president of the Senate. Jones was among the fake Trump electors in the former president’s bid to overturn the 2020 election results in Georgia. The rest of the fake electors are being investigated by a special grand jury, but a judge exempted Jones from being questioned by the district attorney in charge of the case. Neither Burns nor Jones responded to requests for comment.

The industry’s hold on Georgia lawmakers contrasts sharply with what has taken place in other states, including South Dakota, Virginia, Illinois and New Mexico. Lawmakers in these states have passed stricter laws that capped annual interest rates at 36% on subprime financial loans. That rate cap mirrors the federal Military Lending Act that protects military members and their families from predatory loans.

Economic studies from some of those states suggest many of the arguments advanced by title lending companies — including that lower interest rates would cause lending to high-risk people to dry up — are hollow.

In South Dakota, for instance, a citizen-led referendum in 2014 led to the passage of a 36% annual interest rate cap for financial products sold in the state. Title lenders stopped doing business there, but new credit lenders stepped in, and consumers ended up with more choice and lower interest rates, according to a four-year economic study conducted by the Center for Responsible Lending. “The only group that lost in this scenario were the title lenders,” said Steve Hinkey, a South Dakota pastor who as a then-Republican lawmaker spearheaded the referendum.

Illinois reported similar findings after that state passed a 36% cap on interest rates for consumer financial products.

In 2020, Georgia Republicans tried again to rein in the industry, which issues new title pawns for about 75,000 vehicles per year in the state. State Sen. Randy Robertson, a Republican from Cataula, introduced a reform bill after hearing from a constituent who was stuck paying the high-interest debt on her stepfather’s title pawn after he moved into a nursing home.

Robertson’s bill aimed to bring title lending under the purview of the state Department of Banking and Finance and banking laws instead of pawn shop statutes, which would have capped interest rates at 60%. The bill also aimed to close another loophole: Georgia pawn shop statutes allow title lenders to keep the profits from selling cars that they repossess due to nonpayment — even if the profits from the car sale are greater than the original debt.

"Just because something is legal doesn’t mean it is moral,” Robertson, a retired police officer, told The Current and ProPublica.

The bill passed in committee, despite industry pushback, when Sen. Hufstetler, the committee chairman, broke a deadlock by voting in favor of the measure. Senate leaders, however, did not schedule a floor vote.

State Sen. Chuck Hufstetler, who chairs the Senate Finance Committee, believed a bill to reform the title lending industry would have enough support to pass a full Senate vote this year. It didn’t happen. (John Amis/AP Photo)

Two senior Republican lawmakers, speaking about private discussions among state GOP leaders on the condition that their names not be used, told The Current and ProPublica that they support a change in the title lending laws. But one of the reasons party leaders tabled reform legislation in 2022, they said, was for fear of angering deep-pocketed corporate supporters at a time when GOP incumbents were fighting tough primary battles with insurgent pro-Trump members of the state party.

With the war chests accrued from donors like TitleMax’s PAC, House and Senate Republican caucuses spent months trying to protect state leaders, such as Kemp and Attorney General Chris Carr, from GOP rivals during primary races. They also wanted to keep people like Aycox, a known Donald Trump loyalist, on the Kemp side of the party candidate list. “It was a battle royal, and we couldn’t afford any defections,” said one of the senior Republicans about the 2022 primary races.

When the 2023 legislative session commenced in January, Hufstetler told The Current and ProPublica that, if a new reform bill were introduced, he believed it would have enough support to pass a full Senate vote.

But that didn’t happen. On the evening of Jan. 26, the same day the Senate GOP caucus released its legislative priorities, Select Management held a $10,000 dinner open to the Senate’s Republicans, according to a lobbyist disclosure report filed by White. It was the most money paid by an individual corporation — rather than an association or trade group — for a lobbying event during the first two months of the legislative session, and the sixth-highest lobbying expenditure overall during the same period. Georgia campaign disclosure laws do not require any further disclosure by lobbyists about who attended the dinner or the location of the event.

Hufstetler said he did not attend the January dinner. A spokesperson for Jones said the event was not listed in his diary but could not confirm if he attended. No other Republican senator responded to questions about the dinner.

When asked whether he considered the dinner a success, White declined to comment.

Meanwhile, TitleMax sponsored a breakfast for the House majority whip’s team on the same day Bonner’s bill was scheduled for its committee hearing.

Almost immediately after introducing his reform bill, Bonner received his first baptism from the industry. Within three hours, he got a call from the TitleMax vice president of government relations — a Republican legislative veteran who lives in Bonner’s district. On this call and in meetings with lobbyists, he heard the same arguments the industry has made for nearly 20 years.

Bonner, though, wasn’t convinced by their arguments. In fact, he became more supportive of reform after he heard that the Consumer Financial Protection Bureau had found TitleMax to be in violation of the Military Lending Act. The federal regulator found that the company sold their high-interest title loans to military members and their families in multiple states, including Georgia. TitleMax has denied wrongdoing.

Bonner, who was a military intelligence officer and now chairs the Georgia House Defense & Veterans Affairs Committee, considered that behavior beyond the pale. “Frankly, if a law is good enough for our servicemen and women, it should be good enough for all Georgians,” he said.

By Bonner’s count, 11 of the 28 members of the House Banks & Banking Committee had signed their support for his bill by the time the chairman scheduled a hearing. But Rep. Noel Williams Jr., a Republican who hails from Cordele, a city of 10,000 residents and four title pawn shops, told The Current and ProPublica that he warned Bonner in advance that he wasn’t going to call a vote.

Bonner, a military veteran, was outraged by the threat that the title lending industry poses to consumers, especially military members and their families. (Nicole Buchanan, special to ProPublica)

After a marathon day of voting on the House floor, the committee hearing came to order in the late afternoon. Bonner was last on the agenda. He spent approximately five minutes speaking on behalf of the 46-page bill. “There is no state-level oversight of this industry, which often operates in underserved communities and can often trap people in a cycle of debt that can last for years,” he told the committee.

At least six industry executives and lobbyists were in the dark-paneled chamber ready to argue the other side, after a brief summary of support by the lobbyist for Georgia Watch, a consumer advocacy group.

Travis Bussey, the vice president of government relations at TMX Finance, spoke first, telling the lawmakers that the company was “not opposed to reform,” just deeply opposed to Bonner’s bill. The company’s general counsel chimed in saying the legislation was poorly written.

John McCloskey, a vice president and general counsel for Select Management, said the bill would make it impossible for title lenders to survive in Georgia.

When Republican Rep. Emory Dunahoo, who favors reform, asked McCloskey in a soft-spoken Southern drawl to explain how a financial services company would not turn a profit by charging 60% interest, McCloskey demurred.

Rep. Will Wade, a floor leader for Kemp, was one of several on the Republican side who expressed ambivalence about the bill, saying he understood the current regulatory environment made it difficult for lenders to make money.

As Williams gaveled out, he said he looked forward to working with stakeholders to advance the bill at a later time. The cluster of industry executives and lobbyists moved forward to shake his hand. Six of the industry executives and lobbyists in attendance declined to answer questions posed by The Current and ProPublica.

Later that evening, Bonner sounded vexed as he dissected his failure.

“They used the tired but time-honored excuse that they look forward to working with me in the future,” he said with a sigh. “I was hoping that future would start sooner. ”

by Kyle Hopkins, Anchorage Daily News

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

An Alaska Superior Court judge has dismissed a sex abuse case against former acting state Attorney General Clyde “Ed” Sniffen. In an order Friday, Judge Peter Ramgren sided with Sniffen’s lawyer, who argued too much time had passed for him to be charged with the alleged 1991 crime.

A grand jury indicted Sniffen in September on three counts of sexual abuse of a minor by an authority figure, based on his alleged sexual relationship with a then-17-year-old student. Sniffen was 27 at the time and a coach for the West Anchorage High School girls’ mock trial team.

While Alaska state law currently has no statute of limitations for felony sexual abuse of a minor, Ramgren dismissed the charge based on the argument that the law was different in 1991, when a five-year statute of limitations was in place.

The alleged victim, Nikki Dougherty White, learned of the dismissal Saturday morning by email. She called the ruling a “huge disappointment.”

“A huge sense of being let down by the court system,” she said.

White said that despite the dismissal, she does not regret going public with her story in January 2021, after she learned Sniffen had been appointed attorney general by Gov. Mike Dunleavy. Sniffen resigned as the Anchorage Daily News and ProPublica prepared to publish an article about the allegations.

“Because the truth is important. And because Alaska has too long been a place that favors abusers, that does not provide a safe space for victims, for women, for girls. For anybody who doesn’t fit, you know, the white male profile,” White said in a phone interview.

“The Alaska judicial system isn’t built for us and it doesn’t protect us,” she said.

Sniffen pleaded not guilty to the charges. He could not be reached for comment Saturday. His attorney, Jeffrey Robinson, was out of state Saturday for a professional obligation and had just received the judge’s order on Saturday afternoon, he wrote in an email.

“I’ve not had any time to review it,” Robinson wrote.

The special prosecutor in the case, Gregg Olson, said Saturday that no decision has been made on whether the state will appeal the order.

Another Superior Court judge, Erin Marston, presided over the case in January when Sniffen’s attorney argued it should be dismissed on the grounds that the statute of limitations had expired and that the long delay between the alleged abuse and the filing of charges violated Sniffen’s right to due process.

Marston on Jan. 26 rejected a motion to dismiss the case related to alleged due process violations. Ramgren replaced Marston as the case judge on Feb. 7 due to Marston’s retirement. Ramgren was appointed to the bench in 2019 by Dunleavy.

In his Friday order, Ramgren wrote that a five-year statute of limitations was in place for the crime of sexual abuse of a minor at the time of the alleged offense, May 1991. The Legislature reduced or removed time limits to charge people for certain crimes in 1992 and again in 2001, the judge wrote, but he concluded those changes did not apply to Sniffen’s case.

“The court finds the applicable statutes and legislative history indicate these changes cannot be applied to the alleged offenses,” Ramgren wrote. “For that reason, the statute of limitations governing Mr. Sniffen’s conduct has expired and he cannot be subject to indictment.”

Sniffen led the state Department of Law, as Alaska’s top lawyer and legal adviser to the governor, for roughly five months in 2020 to 2021. His predecessor, Kevin Clarkson, resigned as attorney general when the newsrooms reported Clarkson had sent hundreds of unwanted text messages to a junior colleague.

by Dan Schwartz and Topher Sanders, with additional reporting by Gabriel Sandoval and Danelle Morton, graphics by Haisam Hussein

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

Just before 5 a.m., Harry Shaffer’s wife called to him from across the living room, where he’d fallen asleep on the couch, exhausted from installing an aboveground pool. Did he hear that sound, that metallic screeching from up the valley? She opened the door of their double-wide trailer and walked outside as Shaffer closed his eyes.

A moment later came a thunderous crack of splintering lumber. Debris shot through the living room. Shaffer opened his eyes again to find a hulking train car steps from where he lay. It had shorn off the roof, exposing the murk of the pre-dawn sky. He jumped up and ran outside and saw the garage next door in flames.

Though it sat at the floor of a valley along a busy stretch of railroad tracks, the quiet town of Hyndman, Pennsylvania, hadn’t seen a major derailment in recent memory. Trains didn’t frighten residents like Shaffer even though 21 of them trundled through the town’s center day and night.

But unbeknownst to them, the corporations that ran those trains had recently adopted a moneymaking strategy to move cargo faster than ever, with fewer workers, on trains that are consistently longer than at any time in history. Driven by the efficiency goals of precision scheduled railroading, companies are forgoing long-held safety precautions, such as assembling trains to distribute weight and risk or taking the proper time to inspect them, ProPublica found. Instead, their rushed workers are stringing together trains that stretch for 2 or even 3 miles, sometimes without regard for the delicate physics of keeping heavy, often combustible tanker cars from jumping off the tracks.

Rail safety grabbed headlines this February after a Norfolk Southern train passed sensors designed to flag mechanical issues and catastrophically derailed in East Palestine, Ohio; Republicans and Democrats alike are now calling for tighter regulations on company operations, especially in light of precision scheduled railroading.

ProPublica’s reporting suggests they should start by looking at federal regulators’ ponderous response to the mounting warnings about the dangers of long freight trains.

Before that morning in Hyndman in August 2017, regulators had already investigated seven long-train accidents in which the length was a culprit, and the nation’s largest rail worker union had sounded alarms about a pattern of problems.

None of this caused the Federal Railroad Administration, the agency in charge of train safety, to intercede — even as more long trains crashed in the years after the Hyndman derailment, sending cars spilling into other communities.

Today, the rail administration says it lacks enough evidence that long trains pose a particular risk. But ProPublica discovered it is a quandary of the agency’s own making: It doesn’t require companies to provide certain basic information after accidents — notably, the length of the train — that would allow it to assess once and for all the extent of the danger.

“It’s one of our biggest frustrations, without question,” said Jared Cassity, the alternate national legislative director for the International Association of Sheet Metal, Air, Rail and Transportation Workers, or SMART. The union representative said the agency can track train length for accidents “and they’ve chosen not to.”

In the absence of data, the industry insists that long trains have actually helped to improve rail safety, pointing to an overall decline in derailments. The Association of American Railroads, the industry lobby, says safety is the priority when building long trains and notes that regulators have never cited length as the direct cause of an accident. The nation’s seven largest rail companies, the so-called Class 1s, echo these points, defending their safety practices and saying that PSR has led to fewer problems.

To make sense of this gap in information, ProPublica reviewed court and regulatory records of thousands of incidents involving trains of all lengths, as well as technical and investigative notes in federal files from nearly two decades of long-train incidents. We conducted more than 200 interviews, including candid conversations with rail personnel who described how companies have sidestepped best practices when building and running long trains. Then we went to Hyndman to learn what happens to a community in the aftermath of a preventable catastrophe, uncovering damage that cannot be repaired, even with millions in rail company checks.

An aerial view of the Hyndman crash (CSX Train Derailment with Hazardous Materials Release via National Transportation Safety Board)

That summer morning, the sky was burning red when Shaffer, a thin, stoic man of 50, surveyed his neighborhood. Mounds of what looked like grain had spilled from the train cars and molten sulfur, like lava, crawled across the grass. He spotted his wife standing on a neighbor’s porch, but before he could process the relief, he saw another neighbor, Kristina Sutphin, screaming from a second-story window. “Help me!” she yelled. “I can’t get out!”

Sutphin, 27, had thought it was an earthquake when her house started shaking, and she’d rolled on top of her 2-year-old daughter, Mia, to protect her. When it stopped, she hit the lights and found drywall dust everywhere. Her house, too, had been struck by a train car, knocking a wall panel studded with nails over the stairs, trapping her and her daughter as the fire outside grew.

Shaffer ran for a ladder, but the train car had demolished one side of his home, including the bedroom where, on any other night, he and his wife would have been sleeping and where his German shepherd, Diamond, had her kennel. He couldn’t see Diamond, and he wouldn’t learn until a few days later that she had been crushed to death.

By the time he got to Sutphin, her brother had run across the street and a neighbor had arrived with a ladder. Her brother climbed up and carried Mia down as Sutphin followed behind. Volunteer firefighters, fear on their faces, raced door to door, urging people to evacuate.

Kristina Sutphin and her daughter, Mia (Jamie Kelter Davis for ProPublica)

For longtime residents, it felt like another dark chapter: In 1949, a Christmas tree fire burned through dozens of businesses and homes; a flood in 1984 lapped at door frames and swamped basements; and in 1996, another flood submerged window sills in brown, swirling water.

But this disaster, thought Bobby Walls, Hyndman’s 36-year-old emergency manager, was something else. He’d grown up in Hyndman, starting a family in the green, peaceful valley. Now a flaming geyser towered over the rooftops, and Walls wondered: Was anyone dead? As he ran toward the blaze in his firefighting gear, Walls didn’t know that the tanker car at its center contained propane — enough that if it erupted and set off the six others around it, the explosion could engulf the entire town of some 900 people.

The tanker car still howled about seven hours later as Walls and a number of first responders waited in a cinderblock-walled classroom for word from a train company crew that was monitoring the fire. Then, the door flung open. The room quieted as a CSX worker hustled to the whiteboard and began to write.

The tanker car is rapidly failing.

An explosion is imminent.

We need to evacuate now.

Footage from the Hyndman derailment (Associated Press via YouTube)

For generations, railroad workers considered a 1.4-mile-long train huge.

Then Hunter Harrison came along.

Harrison was a railroading innovator with only a high school education, hired as a car oiler in a Memphis yard in 1963. By the 1980s, he had moved into the top management of Illinois Central, a carrier he viewed as bloated and fatally unprofitable. It was an era when most railroads, including his, had an operating ratio in the 90s, meaning that the company had to spend about 90 cents to make a dollar and was netting less than a dime, or 10%, in profit.

Harrison, a self-described “stern, disciplinarian taskmaster,” was obsessed with efficiency. At a time when other executives feared computers, he used them to track every boxcar and locomotive and learned which ones sat idle. “Railroads,” he once said, according to the biography “Railroader,” “only make money when cars are moving. ... So why would we lay down tracks just to have cars sit idle?”

When he became CEO in 1993, Harrison looked for even the smallest ways to cut costs, from tearing up unused tracks to eliminating document storage and overnight stays for train crews. By 1998, he had managed to drop the operating ratio to 62.3, a significant jump in profitability. But the savings were never enough. He flew around in a corporate jet with a tail number that read OR59, his aspirational operating ratio.

In the years that followed, Harrison made his mark as a senior leader at Canadian National after it acquired Illinois Central; he sold off 35% of its locomotive fleet and focused on moving cars in and out of yards at breakneck speeds. To do this, the employees had to work harder, and so did the trains. “I’m impatient,” he once told Progressive Railroading. “I’m also demanding. But I’m asking people to stretch.” By then, he was CEO.

Longer trains would become integral to the management philosophy he dubbed precision scheduled railroading. The rail industry makes its money by the weight and distance of the freight it hauls. A long train makes in one trip what a short train would make in two or three or four, and with fewer employees. There was no need to design a new breed of super trains; these behemoths could be built from more of the same components: more cars with engines spliced into midsections to help move, and stop, more weight.

By 2013, Harrison was CEO of Canadian Pacific when he wrote in its annual report: “We’re driving longer and longer trains, which means fewer train starts, faster network velocity and better service at lower cost.”

Hunter Harrison in 2015 (Chris Goodney/Bloomberg via Getty Images)

America’s largest railroads took note. They began making their trains longer and their staffing margins smaller; in 2015, companies started laying off what would become a fifth of the workforce at the largest railroads. That year, CSX bragged to its investors about its “train length initiative” and how longer trains helped to reduce staff needs. Harrison left Canadian Pacific to run CSX in 2017; that year, the company reported $249 million in “efficiency savings.” CSX told ProPublica that it “impugns the assertion that its management philosophy promotes dangerous practices.”

Harrison died nine months after taking over CSX, but he’d already secured his legacy. Many of the biggest railroad companies operating in the U.S. had adopted precision scheduled railroading. They were running long trains. The Association of American Railroads told ProPublica the industry has been safely running long trains for more than 80 years. It says they are more fuel efficient and allow companies to run fewer trains, which means fewer chances of collisions at railroad crossings.

In April 2017, the Federal Railroad Administration got a letter from the nation’s largest railroad union, SMART. Workers had been seeing troubling patterns related to these long trains, wrote John Risch, the union’s national legislative director at the time. “While I am fully aware that there are no federal regulations limiting the size of trains, running these monster trains [is] inherently unsafe and FRA has broad authority to investigate the practice and put an end to it.”

By the time Risch sent his note, the agency was well aware that the growing length of trains was creating unique issues. ProPublica’s review of more than 600 investigative reports on train accidents over almost two decades found that the FRA had known of problems for years.

The reports revealed that some long trains were too big to fit into sidings off of main tracks that were often built to accommodate trains no longer than 1.4 miles, and passing trains were crashing into their rear ends. It happened in September 2005 when a 1.5-mile-long BNSF train tried to fit into a siding in Missouri that was 1.4 miles long. The same thing happened the following year in Utah to a 1.5-mile-long Union Pacific train.

An October 2017 derailment in Atlanta (John Spink/Atlanta Journal-Constitution via AP)

The hulking trains could generate forces powerful enough to break the heavy-duty materials their cars were made of. In March 2008, the rear end of a 1.5-mile-long BNSF train ran forward as the front of the train decelerated, sandwiching the train and cracking an old repair on a tanker car. The train broke in two in Minnesota, dumping 20,000 gallons of ethylene glycol, commonly used in antifreeze, into a tributary of the Mississippi River.

And long trains that were assembled with too much weight in the rear and too little up front were hurtling out of control and jumping off of tracks. It happened in Virginia in 2006, in Wisconsin in 2015 and in Iowa in May 2017. Short trains can derail in the same way, but experts say longer trains can cause more damage when they fling dozens of cars and their contents through neighborhoods.

The companies involved in these accidents did not comment on them specifically, but Union Pacific and Norfolk Southern, in separate statements, said they spend more than $1 billion annually maintaining and improving infrastructure for safety and work closely with regulators. See what they said about their broader safety practices here. BNSF did not reply to a request for comment.

On July 31, 2017, CSX assembled Train Q38831 in a rail yard in Chicago, destined for a city outside of Hyndman. It had five locomotives at the front and 136 cars trailing behind, about half hauling hazardous material: propane, isobutane, ethyl alcohol, phosphoric acid and molten sulfur heated to 235 degrees Fahrenheit. It was a bomb train, as some workers refer to them, given its combustible cargo. When it left the yard and traveled east, the train grew. In Lordstown, Ohio, workers added 28 cars. In New Castle, Pennsylvania, they added 14. Now the train was 2 miles long.

Engineer Donald Sager, who boarded the train on the night of Aug. 1 in Connellsville, Pennsylvania, about 50 miles west of Hyndman, was uncomfortable with it. It was, he later told federal investigators, “big and heavy and ugly.” It had 38 empty cars near the front with almost all the train’s tonnage behind them, so the empty cars would be lurching around as all that weight bore down on them. He said the train would be bucking.

Sager took the train with his conductor, James Beitzel, from the Connellsville yard at 8:28 p.m. under a clouded sky and began climbing the backside of the mountain outside Hyndman. The climb was steep and the train needed a push from an extra locomotive, which coupled onto the rear. The locomotive broke off when the bulk of the train crested the mountain, passing a sign that read: “Summit of Alleghenies, Altitude 2258.”

The long, winding descent into Hyndman is one of the steepest in all of CSX territory, and the train weighed 18,252 tons, heavier than 200 fueled and loaded Boeing 737s. An engineer on a train like that has to closely watch the speed. It’s best to operate the brakes proactively, but as the train started down the mountain, Sager’s instruments were telling him the air brakes were beginning to fail. He stopped the train at 11:36 p.m. and radioed dispatchers.

“Got a problem with the train.”

Beitzel climbed down from the engine with his light and began walking in the gravel along the tracks. He had to manually set the brakes on 30% of the cars to be sure the train didn’t start moving on its own. Per company rules, he applied them on 58 cars near the front, cranking around and around a big steel wheel at the end of each car. Then Beitzel walked nearly 2 miles to the rear, where he found the problem at Car 159. A brake line had cracked and air was hissing out. That type of malfunction typically affects the brakes on all of the cars, like a chain reaction.

About two and a half hours later, when he finally got back, his shift had ended and Sager was briefing a new crew. Mechanics replaced the brake line while Ron Main, the new engineer, and Michael Bobb, the new conductor, waited. It was around 2 a.m. The train wouldn’t budge with the hand brakes on, so Bobb climbed down and walked back, knocking off brakes as he went. He released 25 and left the remaining set because the descent was steep, a practice at odds with accepted rail safety then and now, investigators and railroad workers say. Then finally, at 4:17 a.m., the train began rolling down the valley into Hyndman.

Bobb’s approach created a dangerous problem, investigators would later conclude. The 33 cars with hand brakes left on were toward the head of the train, and 13 of those were empty. There were also 25 other empty cars near the front. This meant the lightest section of the train was doing the bulk of the braking. It also meant that the heaviest section of the train — literally the rest of it — was bearing down on them. Such forces can pop empties or lightly loaded cars off the tracks, as had already happened in at least three long-train derailments investigated by the FRA.

The other part of the problem was in the hand brakes themselves. They play the same role as emergency brakes in an automobile; conductors usually put them on when they need to park a train. Applied and functioning properly, they immobilize a train car’s wheels. But driving a train with the hand brakes set can damage it, and that’s what happened to the Hyndman train. Its speed fluctuated as its locked steel wheels ground along the tracks, beginning to deform and lose purchase.

It’d be easy to blame Bobb or Main for what was about to happen. But they were only following CSX policy when they set the hand brakes on this huge, heavy train and sent it rolling down the long, steep hill. A safe and proper move would have been to break the train into two at the top of the hill and drive each section down separately, said Grady Cothen, a former FRA attorney who has written a widely cited white paper on the challenges of operating longer trains. But it would have taken more time, and the train was already delayed. CSX at the time was the only one of the seven largest train companies to allow the use of hand brakes to control the speed of a train down a hill.

It would also be easy to blame the crew in New Castle that had added eight empty and six loaded cars to the head of the train, making it longer and less stable. Or the crew before it in Lordstown that added 28 cars, all empty, to the head of the train. But these crews, too, were following a CSX policy, which dictated they could ignore a more sensible policy — don’t put so many loaded cars behind empties — if they were pressed for time. It was a risky edict considering crews are always pressed for time in the age of precision scheduled railroading.

That August morning, the train hit a speed of 29 miles an hour as it reached the bottom of the hill, passing the house where Shaffer slept on his living room couch. Main and Bobb felt a lunge in the cab. The train’s emergency brakes kicked in and it screeched to a stop.

“Hey, Alex,” Main called to the dispatcher. “We just went into emergency. ... I’m not sure what’s going on back there, but the conductor’s getting ready to get on the ground.” (Main, Bobb and Sager could not be reached, and Beitzel declined to comment. Their remarks are from transcripts in the federal investigation of the accident.)

Bobb climbed down from the cab and began walking toward the problem. Suddenly, there was an explosion and a fireball rose into the night about a half-mile back from the engines. Main, up in his locomotive, hadn’t noticed. He didn’t learn about it until a man drove up to his window and yelled the news into the cab.

Federal investigators would later learn that Car 35 — empty, hand brakes set — had jumped the tracks on a curve, and two cars ahead of it and 30 behind it had followed.

Early on the morning of Aug. 2, 2017, CSX Train Q38831 was traveling east toward Hyndman, Pennsylvania.

The train was 2 miles long and weighed over 18,000 tons.

It was loaded with innocuous cargo like paper and corn syrup as well as hazardous materials such as propane and molten sulfur.

Ninety percent of the train’s weight was behind the leading 42 cars.

Because of a previous brake failure, 33 cars had their hand brakes on as the train rolled downhill toward Hyndman.

With its wheels locked and over 16,000 tons of weight trailing it on a downhill, the 35th car was the first to derail west of Hyndman.

Thirty-two more cars derailed as the train entered Hyndman on a 1.7% downslope while rounding a curve.

The derailment caused massive destruction, and three of the loaded cars released hazardous material.

After the derailment, the National Transportation Safety Board recommended in a letter that CSX prohibit using hand brakes on empty cars to control a train’s speed down a hill. It also recommended that large blocks of empty cars be placed near the end, not the front. “We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations.”

But CSX responded more than two years later and only after ProPublica began asking recently why it had ignored the NTSB. In its response letter, CSX says the agency was wrong; the train’s makeup did not contribute to the crash. However it still reformed the policy, requiring, among other things, placing more weight near front of the train and prohibiting trains from “having more than a third of its weight in the trailing fourth of the train.” It also adopted the NTSB’s other recommendation on hand brakes, prohibiting their use on empty cars in “mountain grade territory,” a company spokesperson told ProPublica. It said the derailment was caused by “hand brakes on empty rail cars to control train speed on steep grade ... not PSR.”

By that afternoon, emergency manager Walls and the other first responders had evacuated everyone who would agree to leave Hyndman. The tanker burned for two days and yet did not explode. Though it came close: The pressure inside the car caused the steel wall of its inner hull to stretch as thin as a credit card. They’d come 1 millimeter, Walls said, from disaster.

Bobby Walls (Jamie Kelter Davis for ProPublica)

The U.S. House Transportation and Infrastructure Committee took note of the derailment and asked the Government Accountability Office to study the safety and impacts of long trains. The committee’s two ranking members hadn’t even signed the letter before CSX derailed another long train in Georgia, just two months after Hyndman.

It was 2.4 miles long, and like the Hyndman train, a bulk of its tonnage had been loaded in the rear. When the engineer began to brake, the back of the train slid forward and shoved a car ahead of it off the tracks on a curve, and 13 other cars followed. One car crashed into a home and the person inside was rushed to a hospital. The man survived. CSX did not comment on this accident but did tell ProPublica the company is committed to operating safely and is constantly evaluating its rules, specifically on train handling. See what else it said about its safety practices here.

The 2017 derailment in Atlanta that sent a person to the hospital (John Spink/Atlanta Journal-Constitution via AP)

It was only after all of this happened that the FRA, in March 2018, replied to the union officials who had expressed concerns that previous spring. In a letter, the agency said it “began looking at the length of trains as a potential contributing cause of FRA reportable accidents/incidents” in 2016. The agency still did not have “the sufficient data or evidence to justify an Emergency Order limiting the length of trains.”

In May 2019, the GAO completed its study, coming to a similar conclusion: long trains may be dangerous, but more information was needed. Its effort was partly stymied, the GAO said, because most rail companies refused to hand over enough of their private train-length data to allow investigators to make findings. The FRA also told ProPublica it has asked companies for this data but never gotten it.

On Thursday, the FRA told ProPublica it is starting the process of requiring companies to disclose the train length for every reportable accident, a move prompted by the Infrastructure Investment and Jobs Act. But there is no guarantee the regulators will succeed. The FRA said it first needs to publish a notice of the new data-collection effort and ultimately the Office of Management and Budget would need to approve the measure.

Had the FRA issued an emergency order as the union requested in 2017, a rare and extreme step, the railroads would have likely gotten a judge to block it, said Cothen, author of the white paper on longer trains. He acknowledged that most of the long trains in the country arrive at their destinations without incident, but he feels the railroads are operating with an unreasonable degree of risk. He believes the FRA has the evidence it needs to start crafting a rule to limit train lengths, a process that would include input from the industry. “My issue to this point,” Cothen said, “has been that effective action has not been taken.” The FRA says it disagrees.

Across the country, worried state lawmakers have tried to cap the lengths of trains that roll through their communities. Since 2019, in Arkansas, Iowa, Kansas, Georgia, Nebraska, Washington, Arizona and other states, lawmakers have proposed maximum lengths of 1.4 to about 1.6 miles. But every proposal has died before becoming law. Opponents, which include Class 1 railroad companies, claim that the efforts are driven by unions to create jobs and that the proposals would violate interstate commerce laws.

Georgia state Sen. Rick Williams, a Republican, attempted to work around this angst by offering a simple resolution last year that would have urged the FRA to limit train length. Even that died. “It’s frustrating,” he said, “when you see something that happens, like in East Palestine, Ohio, and you know it very easily could happen here and we could suffer the same consequences.”

Democratic Arizona state Rep. Consuelo Hernandez’s bill to limit train length was approved by two committees this session with bipartisan support. But Republicans refuse to put the bill on the floor for a general vote, and so it has stalled. ProPublica spoke with her the day after a 1.9-mile-long BNSF train derailed there. “The train companies are so powerful,” Hernandez said. “What it comes down to is public safety versus corporations.”

Many states have passed laws that would punish railroads for blocking road crossings, but that power, state courts rule every time, rests solely with the federal government.

At any moment, Congress could intervene and limit the length of trains. If it did, independent experts say, there’d be more trains, moving faster with fewer breakdowns and derailments, and customer service would improve. But the rail companies, which move 40% of the country’s cargo, have a lot of leverage. For more than a century, the industry has convinced lawmakers that the success of America is tied to the success of the rails; it’s a view that persists today, sustained by the $10 million the Association of American Railroads spends some years lobbying Congress.

So long trains have continued jumping the tracks.

In June 2019, one month after the inconclusive GAO study, a 2.2-mile-long Union Pacific train derailed in Nevada. It was so long and the terrain so mountainous that at times sections of the train climbed uphill while other sections climbed downhill, which made driving it a nightmare. Ultimately the engineer couldn’t manage it, and the train lifted a car up and dropped it on the ground. Twenty-seven cars followed.

In July, a 2.5-mile-long Union Pacific train derailed for the same reasons elsewhere in Nevada.

In August, a 1.6-mile-long Union Pacific train going 48 miles an hour derailed in Texas. The company ran computer simulations after the crash and concluded it never should have been operating the long train at that speed at that spot on the tracks.

In September, Union Pacific crashed yet another long train. It was 1.5 miles long and broke in two in Illinois. Half of the train rolled out of control away from the other half. It then slowed, stopped and began rolling back. The two halves collided and exploded. The fire spread underground through a storm drain and ignited a holding pond at a chemical plant. More than 1,000 residents and at least 1,000 schoolchildren were evacuated.

And then in October, in separate instances, Norfolk Southern derailed two long trains, both in Georgia. One was 2 miles long. The engineer had struggled to control it, and his use of the brakes caused the rear of the train to run into the front and lift a car off the tracks. The other train was 1.6 miles long. Its autopilot had the brakes applied in the front and the engine in the middle giving it gas, and as it reached the bottom of a hill the opposing forces popped 32 cars off the tracks. They ruptured a pipeline, which released nearly 2.3 million gallons of natural gas.

The following summer, in June 2020, a 2.3-mile-long Union Pacific train derailed in Idaho because it was too big, the FRA determined. It was constructed unevenly with 34 empty cars coupled near the front and loaded, heavy cars behind them. The heavy cars pushed the light cars off the tracks. The FRA also determined the engineer lacked the training necessary to operate a train of that length.

In July 2020, a 2-mile-long BNSF train derailed in Arizona for similar reasons: a long block of heavy cars coupled behind a set of empty cars squeezed them off the tracks.

The companies involved in these accidents did not comment on them specifically. See what they said about their safety practices here. BNSF did not comment at all.

First image: A 1.5-mile-long train that broke in two in Illinois. Second Image: A 2.2-mile-long train that derailed in Nevada. (First image: Derik Holtmann/Belleville News-Democrat via AP. Second image: Nevada Department of Public Safety via AP.)

Finally, in September 2020, the FRA launched a study examining the brake systems in long trains. The agency did not say why it took three years after the Hyndman derailment and the warnings from the union to begin examining the issue. It plans to complete the study this year. Also, late last year, it completed a small survey of rail workers, labor unions and railroad managers. Managers claimed long trains pose no new dangers, but government employees and labor unions said they are concerned.

The National Academies of Sciences, doing a separate assessment of trains longer than 1.4 miles at the request of Congress, must report its findings by June 2024.

Three days after the evacuation of Hyndman, Walls and his family returned home. They’d been gone only 72 hours, but it felt like a reunion with neighbors they hadn’t seen in years. He mowed his grass. It felt good doing something so pedestrian.

But Shaffer and his wife never returned to their doublewide trailer. It wasn’t safe, Shaffer recalls being told by CSX. “Pretty much had to fight with them to get my guns and stuff out of there,” he said. The company paid out a settlement the couple used to buy a big house with a big porch 7 miles out of town, far away from the railroad tracks. But even years later, the derailment haunts him, whether he is waiting uneasily in his truck at a railroad crossing or watching the news. When the East Palestine disaster appears on his TV, he has to get up and walk away. “It’s definitely still with me,” he said.

Sutphin and Mia bounced from her aunt’s house out of town to a hotel with her stepdad then to a house on Myrtle Beach, an upscale vacation town on the coast of South Carolina, and stayed there for a year. Every time an airplane flew over the house, Sutphin shook and ran to the window, afraid that something was about to crash into them. Mia rarely slept through the night. Sutphin financed their long vacation with a $50,000 check from CSX. The railroad also bought her a brand new Hyundai Santa Fe valued at $32,000.

Sutphin and Mia play on a swing set in Sutphin’s grandmother’s yard in Hyndman. (Jamie Kelter Davis for ProPublica)

After it nearly razed the town, CSX handed out a lot of money. It bought residents clothing, medicine, food, gas and hotel rooms. It reimbursed businesses for lost revenue. It paid volunteer firefighters every day about $1,000. It gave residents so-called inconvenience fee payments of about $300 a day. It gave one family $10,000 for veterinarian bills and damage to its property. It gave the fire department $190,000. A church pastor said residents welcomed the payments, but he also said they felt like “hush money,” and that’s the effect the money appears to have had on some residents. When ProPublica asked about the derailment, many said that the railroad did “all right by” them. Cleaning up and rebuilding the town and the tracks, according to the FRA, cost $9.6 million. CSX defended the money it spent around town, saying it did not ask the residents to release their legal rights in exchange for the payments. “Such actions,” a spokesperson told ProPublica, “are part of CSX’s industry-leading standard of care when incidents like the derailment in Hyndman occur.”

Walls remembers a CSX official walking up to him while he was standing on the front steps of the charter school on the morning of the derailment, a gray column of smoke from the tanker car still billowing into the sky. “I know we came in and messed your town up,” the official said, “but we’ll make it right before we leave.” Walls appreciates the money CSX spent on the town and its people. But that was the railroad’s responsibility. What would make things right, he said, is “making sure that the trains coming through here are safe.”

Hyndman (Jamie Kelter Davis for ProPublica)

Do Blocked Railroad Crossings Endanger Your Community? Tell Us More.

Correction

April 3, 2023: This story originally misstated the brand of Kristina Sutphin’s car. It is a Hyundai Santa Fe, not a Honda.

by Emily Hopkins and 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. This story was co-published with Minnesota Public Radio and KARE-TV.

Amy Morris started working at Hilltop Health Care Center in Watkins, Minnesota, in June 2021 with a clean nursing license that belied her looming troubles.

Morris, a licensed practical nurse, had been fired from a nearby nursing home seven months earlier for stealing narcotics from elderly residents. The state of Minnesota’s health department investigated and found that the accusation was substantiated, and then notified the Board of Nursing, the state agency responsible for licensing and monitoring nurses.

But even though state law requires the board to immediately suspend a nurse who presents an imminent risk of harm, it allowed Morris to keep practicing.

In September 2021, supervisors at Hilltop discovered that pain pills were disappearing during Morris’ shifts and called the sheriff. Only then did Hilltop learn of allegations of narcotic theft that had been made nearly a year earlier at the other nursing home.

“I thought, ‘How is she practicing now?’” Meeker County Sheriff Brian Cruze recalled.

In an excerpt from an October 2021 Minnesota Department of Health report, a manager for Hilltop Health Care Center said the facility didn’t know about a previous incident in which nurse Amy Morris was found to be involved in drug “diversion,” or theft. (Screenshot by ProPublica)

The answer, ProPublica found, is that the nursing board’s investigations frequently drag on for months or even years. As a result, nurses are sometimes allowed to keep practicing despite allegations of serious misconduct.

It wasn’t supposed to be this way. In the face of intense criticism eight years ago, the nursing board announced changes to improve its performance. But that progress was short-lived, ProPublica found.

Since 2018, the average time taken to resolve a complaint has more than doubled to 11 months, while hundreds of complaints have been left open for more than a year; state law generally requires complaints to be resolved in a year. Some nurses, like Morris, have gone on to jeopardize the health of more patients as the board failed to act on earlier complaints.

Some of the board’s problems stem from vexingly bureaucratic issues, ProPublica found. For example, the board had started meeting every month to resolve cases more quickly. But, for the past few years, it has gone back to meeting every other month.

Some complaints get caught in a general email inbox, where they sometimes sit for weeks or months before being forwarded to staff for investigation, according to current and former staffers.

And the board, which oversees licensing and discipline for more than 150,000 nurses, has been perennially shorthanded. By state law, the board is supposed to have 12 nurses and four members of the public. But at times, it has operated with barely enough members to make up a quorum. In March, Gov. Tim Walz made five appointments to the board, leaving one vacancy.

Other problems stem from the board’s professional staff, who investigate complaints and prepare the materials the board uses to make disciplinary decisions. Several former employees told ProPublica that the lag time in resolving discipline cases could be attributed to a dysfunctional office environment and a wave of resignations, many of them since the board’s August 2021 selection of veteran staffer Kimberly Miller as executive director.

David Jiang, who resigned from the board in August because he moved out of the state, told Walz in a letter that the board’s problems “arise because of a general lack of confidence from the staff, lack of communications to the board, and, most importantly, a general lack of oversight by the Board.”

Walz’s office did not respond to ProPublica’s requests for comment about Jiang’s concerns.

David Jiang resigned from the Minnesota Board of Nursing in August, telling Gov. Tim Walz in a letter that mismanagement by Executive Director Kimberly Miller had contributed to dysfunction at the agency. (Highlights added by ProPublica)

William Hager, a former legal analyst for the board, vented his frustrations about Miller’s leadership in an email to another employee in February 2022. “I am very concerned the Director seems to have been unaware of this ‘backlog,’” Hager, who left the board a few months later, said in the email. Miller “has chosen to not learn how to work” the case management system “or engage with software and staff to oversee our work.”

Miller, who worked for the board for more than two decades before becoming executive director, acknowledged the case backlog in an interview but said she was working to “right the boat,” including by hiring a consultant to improve board performance. Although the number of pending complaints is higher now than it was after a critical 2015 state audit, the backlog has been reduced by about a quarter since peaking last summer, according to state data.

“I think that we are on a good course at this point, and we’re making the changes that we need to, and learning to work as a team, and working out our system that I think is going to be really wonderful at some point,” Miller said in an interview. She did not respond to questions about criticism of her job performance.

Miller blamed the backlog on the transition to remote work during the height of the pandemic and on a new case management system that she said board members found difficult to use. She said some cases simply take longer than others. When a nurse won’t agree to discipline as part of a settlement, she said, the board must file the case in the state’s administrative court, where Miller said scheduling a hearing can take “at least a year.”

But a spokesperson for the administrative court said that the court was not the source of delays, and nurse discipline cases are concluded on average in four months from the time they are filed.

The state’s own data, in part, counters Miller’s assertions of progress. The board closed more complaints in fiscal years 2020 and 2021, respectively, than it did in 2022, when vaccines were widely available and many industries were returning to in-person work.

It was not clear why the board did not move quickly to suspend Morris after the substantiated report of pill theft. Miller declined to discuss individual discipline cases, citing confidentiality rules.

ProPublica contacted 10 current and seven former members of the board. None responded to requests for comment.

The nursing board finally issued a temporary suspension of Morris’ license in November 2021 — a month after prosecutors filed charges in the Hilltop case. She is facing felony theft charges for both incidents and has failed to show up in court. She has not entered a plea because she has not appeared to face the charges, and authorities have issued warrants for her arrest.

She did not return messages left on her cellphone and sent by email.

Administrators for both facilities declined to comment. Records show that one Hilltop manager was frustrated by a lack of warning about Morris. The manager complained to a state inspector that there was “nothing flagged on the background study or license verification,” according to the facility’s inspection report.

“This is not a facility system problem but a state system problem,” the manager said.

Investigations Drag On

When Christy Iverson started working for the board last year on investigations of nurse misconduct, she was surprised by the backlog of cases. Some she took on were around five years old. It was embarrassing, she said, to put her name on cases that had been on hold for so long.

Then, about four months into her tenure, she said, she was instructed to help the licensing staff with an influx of applications ahead of an anticipated nursing strike at several hospitals in the Twin Cities and Duluth areas. Iverson, who had spent over a decade working in leadership positions at an area hospital, said she largely spent her days folding letters and sorting paperwork. So she quit.

The problems she observed weren’t new. A Minneapolis Star Tribune investigation in 2013 had sparked the state audit that found serious delays at the board and led to improvements for a time.

With auditors scrutinizing it in 2014, the board began to dispose of complaints more quickly. The average age of closed cases was reduced from six months to four. But delays then climbed, eventually reaching the current average of 11 months, according to state data.

And despite a state mandate to resolve complaints within a year, the percentage of cases that go beyond that mark has soared from less than 5% in 2016 to 30% now, the state data shows.

Miller said the board is mindful of the backlog and puts a priority on “all of our more egregious cases.”

Minnesota’s Nursing Board Resolved Complaints Faster After a 2015 State Audit, But Progress Has Reversed Note: Years are the board’s fiscal year, which runs from July to June, and the chart shows complaints according to the fiscal year in which they were closed. The 2023 value is the average as of March 2023. (Source: Minnesota Board of Nursing)

An internal email provided to ProPublica described how complaints can sit for weeks or even months simply because they weren’t forwarded in a timely manner. Those delays, the employee wrote, were “unprofessional” and “inefficient.”

For example, a complaint about a nurse stealing medication sat in the main inbox for more than two months before it was forwarded to the discipline staff, according to that internal email. It was the fourth complaint the board had received about that nurse. The employee’s email describing these delays was sent to several other employees and the board’s executive director in December. Miller did not answer ProPublica’s questions about the employee’s allegations.

Some delays begin in the earliest stages of processing a complaint, according to former employees and lawyers who represent nurses in front of the board. Eric Ray, a former discipline program assistant from January 2020 until fall of 2021, said in an interview that the board didn’t always meet statutory requirements to notify nurses of a complaint within 60 days of receiving it. Ray said he saw complaints “sitting for months or a year” before the board sent a notice to the nurse.

Miller said the board “did take seriously the 60-day issue” and recently made changes to the management software so that it would remind caseworkers that a letter needed to be sent out.

The notification delays can also hurt a nurse’s ability to mount a defense, according to lawyers who defend nurses in front of the board. As complaints age, they become more difficult to investigate, evidence becomes harder to locate, nurses move on to other jobs and witnesses forget key details.

“This is your professional career on the line,” said attorney Marit Sivertson. “It makes it incredibly difficult for someone to be able to fairly defend themselves.”

The state law that requires the board to resolve complaints within a year also gives the board sweeping discretion to take longer if it determines the case can’t be resolved in that time. Still, Sivertson said that does not explain why so many cases take more than a year to resolve. She and eight other lawyers have met several times to raise these issues with Miller and assistant attorney general Hans Anderson, legal counsel to the board. In October, they presented their concerns at a board meeting. They said they are still waiting for a response.

Del Shea Perry is also still waiting. It’s been nearly five years since the death of her son, Hardel Sherrell, in the Beltrami County Jail in northern Minnesota. The incident sparked public outrage and led to reforms and consequences for some of the officials connected to his care. Sherrell died on the floor of his cell after guards and medical staff refused his pleas for help. A pathologist hired by Perry as part of a wrongful death lawsuit later ruled that he died of Guillain-Barré syndrome, a treatable neurological disorder.

Del Shea Perry, mother of Hardel Sherrell, who died in jail in 2018, founded Be Their Voices, an organization that advocates for incarcerated people and their families. (Caroline Yang, special to ProPublica)

State legislators passed a law named after Sherrell that aims to improve access to health care for jail inmates. Todd Leonard, the jail doctor who monitored Sherell’s condition via telephone, had his medical license indefinitely suspended in early 2022. And this month, Beltrami County and Leonard’s company agreed to settle Perry’s lawsuit by paying Sherrell’s family $2.6 million.

But there have been no consequences for Michelle Skroch, a nurse who worked for Leonard and was directly in charge of Sherrell’s care in the last two days of his life. According to a state administrative judge who ruled in the doctor’s licensing case, Skroch failed to provide care to Sherrell or even check his vital signs as he lay nearly lifeless on the floor of his cell wearing adult diapers soaked in his own urine.

An emergency room doctor had released Sherrell to the jail with instructions to bring him back if his symptoms worsened. Instead, Skroch instructed jail staff not to assist him because she said there was nothing medically wrong with him, according to the judge’s report.

The judge wrote that it could appear from Skroch’s notes that she had “provided some type of care or assessment” of Sherrell. “She, in fact, did not,” the judge wrote.

Video later showed she had only briefly peered into his cell twice and had missed that he was in distress: Sherrell was unconscious on the floor with a white substance coming out of his mouth.

In response to Perry’s lawsuit, Skroch testified that she was able to sufficiently assess Sherrell’s condition without touching him and that she believed his condition was improving. She also noted that emergency room doctors had diagnosed him with weakness and “malingering,” a medical term for faking illness.

In ruling that the medical board had cause to discipline Leonard, the judge also called for the nursing board to investigate Skroch’s “dereliction of duty and shocking indifference.” Noting that the doctor was both Skroch’s supervisor and her romantic partner, the judge wrote it appeared “she was unconcerned about being held accountable by the attending physician.”

Five years later, Skroch still has an unblemished license and her online professional profile identifies her as the nursing director of Leonard’s medical firm. She declined to comment.

Another nurse who provided care to Sherrell at the jail filed an official complaint about Skroch with the nursing board. But she said that after an interview with a board representative about a year after the death, she has not heard an update. The board is required to provide updates every 120 days on the status of a case.

“I have no idea what the board is doing, and it sure as hell shouldn’t take 4 years to investigate,” Perry wrote in a text message.

“A Clear Message”

When a nurse is accused of misconduct, the board can seek discipline ranging from a reprimand, which is essentially a public slap on the wrist, to a license revocation, which means the nurse can no longer work in the field. Typically, the board allows a nurse to continue working while it tries to reach an agreement or takes the complaint to the state’s administrative court.

(Matt Huynh, special to ProPublica)

But in cases when the nurse poses an immediate risk to patients, the board can use its power to issue a temporary suspension and remove the nurse from practice while it investigates.

The board rarely used that power until the state legislature changed the law in 2014. Under the revised rules, the board wasn’t just authorized to use the emergency suspension — it was required to do so in cases where there was “imminent risk of serious harm.”

As a result, the board ramped up its use of temporary suspensions, issuing 55 of them from 2014 to 2017, more than twice as many as it had in the preceding four years, according to data reported to a national database of actions taken against medical professionals.

In 2018, this increase was touted by Daphne Ponds, then a board employee. Speaking at a national seminar on nurse regulation, Ponds, who helped investigate complaints against nurses, told her peers that the Star Tribune’s stories had “made us look bad, made us look ineffective.”

She added, “The legislature had really sent the board a clear message that you have this tool of temporary suspension — you need to use it.”

But about that time, the board had reverted to its pre-audit practices. In 2018, it issued only three temporary suspensions, according to a national discipline database. And it issued only 11 over the next three years.

Miller said the board is now inclined to protect the public by pursuing a voluntary agreement to stop practicing with nurses who’ve been the subject of a complaint. She said this is because there are “more hoops” to jump through to issue a temporary suspension, while the voluntary agreements can be drafted and signed by the nurse in days.

Asked how she reconciles this with a state law requiring a temporary suspension when there is an imminent risk of serious harm, Miller said Minnesota’s attorney general had signed off on the strategy.

Hager, the former legal analyst for the board, said that while a stipulation to cease practicing may work in some cases, it doesn’t work in all of them, especially when nurses don’t want to cooperate. In one case reviewed by ProPublica, a nurse kept her license for more than a year because she refused to sign a stipulation. The board suspended her only after she was convicted of financial exploitation.

Sometimes, the delays hurt patients. In early 2018, the board received complaints about a nurse named La Vang that accused him of stealing narcotics from patients — including one allegation that was validated by the state health department.

But the board didn’t issue a temporary suspension, and Vang got a new job later that year. He stole pain medicines from another patient, LaVonne Borsheim, according to a lawsuit that Borsheim and her husband brought against Vang and the home care company that employed him.

In that lawsuit, Borsheim described pain so severe that she didn’t want to go on living. (Attempts to reach Vang for comment were unsuccessful.)

By the time the nursing board got Vang to sign an agreement to cease practicing in August 2018, the police had already arrested him on charges that he had stolen Borsheim’s drugs. Vang pleaded guilty in federal court to obtaining controlled substances by fraud. At his sentencing, Vang’s attorney said he was in treatment for drug addiction and was embarrassed that he had violated Borsheim's trust. He was sentenced to 18 months in prison.

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by Neil Bedi and Kathleen McGrory

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Citing ProPublica’s reporting, lawmakers on Thursday reintroduced a bill that would ban the use of asbestos in the United States, bringing it in line with dozens of countries that have outlawed the carcinogenic substance.

Even though asbestos is known to cause deadly diseases, the U.S. still allows companies to import hundreds of tons of the raw mineral. It is primarily used by two chemical manufacturers, OxyChem and Olin Corp., in the production of chlorine. The legislation, called the Alan Reinstein Ban Asbestos Now Act of 2023, would ban the import and use of all six types of asbestos fibers. It would give OxyChem and Olin two years to transition its asbestos-dependent chlorine plants to newer, asbestos-free technology.

The chemical industry has long argued against a ban in the U.S. by saying employees are protected by strict safety protocols. Last year, however, ProPublica found that workers were repeatedly exposed to asbestos in some of the plants. In one OxyChem plant in Niagara Falls, New York, former workers said asbestos floated in the air and accumulated in corners and on top of machines. At an Olin plant in Alabama, a longtime janitor said she was tasked with scraping up dry asbestos but wasn’t given protective gear, even while pregnant. (OxyChem said the workers’ accounts in Niagara Falls were inaccurate but would not specify which details were incorrect. Olin did not respond to multiple requests for comment.)

“ProPublica’s recent reporting on the devastating damage of this deadly substance has underscored the need for urgent action,” said Rep. Suzanne Bonamici, a Democrat from Oregon who is sponsoring the bill in the House. “There is no safe level of exposure to asbestos, and we have seen that we cannot rely on industry to put the safety of workers first.”

In a press release, Sen. Jeff Merkley, another Democrat from Oregon and the bill’s sponsor in the Senate, also cited ProPublica’s reporting as a reason the ban is necessary.

“Any expert will tell you there simply is no level of exposure to asbestos that is safe for the human body,” Merkley said in the release. “We’ve known for generations that asbestos is lethal, yet the U.S. has continued to allow some industries to value profits over people.”

The bill is named after Alan Reinstein, a man who died in 2006 from mesothelioma, a cancer caused by asbestos. His wife, Linda Reinstein, has long advocated for an asbestos ban in the U.S. and co-founded the Asbestos Disease Awareness Organization, a nonprofit that works to protect the public from the dangers of the substance.

“This long overdue legislation will protect all Americans — especially vulnerable workers, disadvantaged communities, consumers, first responders, and children — who are most at-risk from being exposed to this deadly carcinogen,” Reinstein said in a statement on Thursday.

Merkley and Bonamici have tried to pass similar legislation before, but they have not been successful. The bill they proposed last year had a hearing in a Senate subcommittee and five co-sponsors in the House, but it ultimately stalled.

At the Senate hearing, industry representatives pushed back on efforts to outlaw asbestos, saying an all-out ban would be too onerous for the chemical companies. They cautioned that a prohibition could threaten the supply of chlorine in the U.S., some of which is used to clean drinking water.

OxyChem and Olin did not respond to requests from ProPublica for comment on the latest bill. The American Chemistry Council, an industry trade group, did not respond to ProPublica, either.

The Environmental Protection Agency, meanwhile, is working on its own asbestos ban. The agency proposed a rule last year that would ban only chrysotile asbestos, the most commonly used type and the one that is used in chlorine plants. The EPA has missed some legislative deadlines to enact the ban but says it will finalize the regulation by October.

Two weeks ago, the EPA invited the public to weigh in on new information the agency received about the proposed asbestos ban, including ProPublica’s reports about workplace safety.

Some advocates worry the EPA’s ban will be further delayed or be overturned in court. They point to the EPA’s failed attempt to enact an asbestos ban in 1989, which was overturned by a federal judge after companies sued the agency.

“We can’t afford to wait any longer,” said Reinstein, who believes legislation will be the most effective way to stop asbestos use. “The cost of inaction and the lives we know will be lost is far too great of a price to pay.”

Merkley and Bonamici’s bill is also endorsed by several other public health groups, including the International Association of Fire Fighters and the American Public Health Association.

by Doug Bock Clark

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

The courtroom was packed when the North Carolina State Board of Elections convened on Tuesday to consider removing two members of the Surry County Board of Elections from their posts. At the Surry County GOP convention not long before, one board member, Tim DeHaan, had appealed for people to attend the meeting at the county courthouse. And now, dozens of supporters, one with “We the People” tattooed on his forearm and another with cowboy boots stamped with American flags, whispered tensely among themselves.

DeHaan and Jerry Forestieri were facing the state elections board because, at a November meeting to certify the county’s 2022 general election results, they had presented a co-signed letter declaring “I don’t view election law per NCSBE as legitimate or Constitutional.” Then Forestieri refused to certify the election, while DeHaan only agreed to certify it on a technicality.

This month, both Forestieri and DeHaan refused to certify a redo of a November 2022 municipal election. The new contest had been called after a poll worker allegedly made a mistake in telling voters that one of the four candidates had died, which could have swung a race decided by eight votes. (The results of the second race were the same as the first.)

Both elections were ultimately certified by the board’s three Democrats. But DeHaan’s and Forestieri’s refusals to certify, along with similar actions by conservative county election officials in Arizona, Nevada, New Mexico and Pennsylvania, exposed a weakness in the nation’s electoral system. If local officials failed to certify, the disruption could cascade and cast into dispute state and federal election outcomes, potentially allowing partisan actors to inappropriately influence them, according to election law experts. A ProPublica review of 10 such cases found that most officials have not faced formal consequences for their refusal to certify. DeHaan’s and Forestieri’s hearing was to be the first completed disciplinary process for such officials nationwide after the 2022 election.

At the trial-like state elections board meeting, Bob Hall, the former executive director of the watchdog group Democracy North Carolina whose complaint had launched the disciplinary process, argued that DeHaan and Forestieri could not be trusted to supervise elections because of their refusal to follow the law. Forestieri and DeHaan told the board that they could not be certain of the identities of voters or the validity of their ballots because they disagreed with a federal judge striking down a voter ID law for discriminating against minorities. Forestieri defended their actions as a “free speech issue.”

The lone Republican board member present, Stacy Eggers, made two motions to remove the men from office, and each motion passed unanimously, 4-0. “We cannot substitute our own opinions,” Eggers said, for “what the law actually is.”

As the motions passed, one woman exclaimed in the quiet courtroom: “The law is perverted! The law is perverted!”

Afterward, in the hall outside the courtroom, DeHaan and Forestieri were sought out by local supporters and election deniers who’d traveled to the hearing from outside the county. Talk swirled of appealing the decision in court, though Forestieri said a final decision about an appeal would be made at a later date.

“We took a stand for lawful, credible elections appropriate for the owners of this republic, we the people,” said Forestieri at the courthouse. “I cannot apologize for that.” Forestieri later wrote to ProPublica that he disagreed with his removal from office, and that the “NCSBE proved itself unwilling to recognize clear law in General Statutes” by striking down his and DeHaan’s arguments.

DeHaan declined to comment and did not respond to written questions.

Michella Huff, the elections director for Surry County, had watched the proceedings stoically. It was a year to the day since Huff had blocked the chairman of the county Republican Party from illegally accessing her voting machines to further a conspiracy theory, after which he launched a pressure campaign that included attempts to reduce her pay and raucous protests featuring nationally prominent election deniers, as ProPublica has previously reported. (The county chairman told ProPublica that he did not seek to cut her pay, though text messages and emails obtained via public records requests showed otherwise.)

Huff helps election workers on a day when all voting machines are tested to ensure each is functioning properly. (Cornell Watson for ProPublica)

As a result of the year’s travails, Angie Harrison, Huff’s deputy director, has said she will retire in June. “Here in Surry County and across the entire nation, people want to put more scrutiny on the election process, which is a good thing to help voters understand the law — our philosophy is to educate,” she said. But “we take it personally when people start attacking the job that we have been so proud to deliver accurately and without bias.”

In early 2022, a national survey from the Brennan Center for Justice found that a fifth of local elections officials reported they were unlikely to stay in their jobs for the 2024 election. “We’re in the middle of an exodus of election workers,” said Larry Norden, the senior director of the Brennan Center’s Elections and Government Program. An Arizona election official, whose county supervisors refused to certify November 2022 results until ordered to do so by a court, also recently left to “protect her health and safety” after working conditions became “intolerable,” as her lawyer wrote in a letter to the county.

Huff, however, is staying in her post. Last fall, after the state’s attorney general, Josh Stein, read ProPublica’s story about Huff, his office gave her an award for her “incredible commitment to democracy” as “she refused to buckle to those who lie about stolen elections,” Stein wrote in a statement. A year ago, she had felt overwhelmed by the new and unprecedented challenges inundating election officials, but now she felt more capable to confront them. “Not saying that it’s going to be easy” in 2024, she said, “but I’m a little more prepared now for the what-ifs.”

The election deniers departed the courthouse boisterously, talking about going out for lunch. Huff got in a van with another election worker and was driven past cornfields to her office. The November 2022 election was finally done, four and a half months late, and now it was time to get ready for the next one.

by Logan Jaffe

ProPublica is a nonprofit newsroom that investigates abuses of power. This story is part of an ongoing series investigating the return of Native American ancestral remains. Sign up for ProPublica’s Repatriation Project newsletter to get updates as they publish and learn more about our reporting.

For more than 30 years, tribal nations have been asking the state of Illinois and its state-run institutions to return the remains of their ancestors for reburial within the state. For just as long, Illinois has made that nearly impossible.

But now, legislation moving through the Illinois General Assembly would finally pave the way for the remains of thousands of Native Americans to be repatriated.

The legislation, which unanimously passed the Illinois House of Representatives this month, comes after nearly two years of consultations among the leaders of more than two dozen tribal nations, the Illinois State Museum and the state Department of Natural Resources.

In January, a ProPublica investigation revealed that institutions have not returned the remains of at least 15,461 Native Americans who were excavated from Illinois. We also revealed how the Illinois State Museum had for decades displayed open Native American graves at Dickson Mounds, a burial site that was billed as a tourist attraction and then as an “educational” exhibit before its closure in the 1990s.

“We’re grateful for the bipartisan support we’ve received from Illinois legislators who are working to right historic wrongs that have, put simply, diminished us,” said Prairie Band Potawatomi Nation Chairperson Joseph “Zeke” Rupnick. “This legislation brings respect to our history and our ancestors the way they should’ve been respected centuries ago.”

State Rep. Mark L. Walker, a Democrat who represents part of Chicago’s northwest suburbs, said he introduced the bill after leaders of the Prairie Band Potawatomi Nation brought the issue to his attention. Walker, who has a master’s degree in anthropology, said it is “atrocious” that some museums and universities still keep the human remains and funerary items of Native Americans.

“These people were buried by their people with the goods they wanted to be buried with in spaces they wanted to be buried in and [we] disturbed that,” Walker said. “Just go repair it. It’s so simple.”

He added: “I don’t know what right we have to dig up somebody’s grandmother.”

Most excavated Native American remains in Illinois are held by state universities and museums. Our investigation found that the Illinois State Museum holds the remains of at least 7,000 Native Americans, yet it has returned only 2% of them to the tribal nations who could claim them under the Native American Graves Protection and Repatriation Act, a 1990 federal law that pushed for the expeditious return of human remains and funerary items excavated from Indigenous burial sites. The museum has the country’s second-largest collection of unrepatriated Native American remains, and one of the lowest return rates.

Following ProPublica’s reporting, institutions across the U.S. have vowed to return the Native American remains held in their collections. In Illinois, the proposed legislation could signal a new era of proactive repatriation and consultation with tribal nations in a state that has favored the curation and scientific study of these remains over their return.

“Native tribes have existed since before colonization, and our land and culture are the foundation of our society,” Rupnick said. “Yet the remains of thousands of our ancestors are in the hands of governments and institutions, just as our Native lands have been for centuries.”

Cinnamon Catlin-Legutko, who until her death this year served as the director of the Illinois State Museum, previously told ProPublica that the state needed to revise its existing burial law and ensure that tribal nations have more say in how their ancestors are protected and returned. According to the minutes of a November meeting of the Illinois State Museum board of directors, Catlin-Legutko said she was working on legislation with the Department of Natural Resource’s legal team.

The museum and Department of Natural Resources declined interview requests for this story, citing policies against commenting on pending legislation.

If passed by the Senate and signed into law, the bill would create a cemetery on state land where repatriated Native American ancestors and their belongings could be reburied. The state would be responsible for protecting the cemetery, which would not be for public use, from potential looting or vandalization.

Since at least the mid-1990s, state officials have known that tribal nations with cultural and geographical connections to Illinois wished to have their ancestors reburied. ProPublica obtained records from 1995 showing that the Illinois State Museum conducted consultations with leaders from 15 tribes with ancestral ties to Illinois to discuss the cultural affiliations of human remains, as required by the federal law. In those conversations, every tribal leader told the museum that the human remains in its collection should be reburied in Illinois.

In the intervening years, the museum repatriated the remains of at least 156 Native Americans, most of them to the Peoria Tribe of Indians of Oklahoma. But Illinois did not provide land for reburial and those ancestors were reburied in Oklahoma despite the preference that tribal leaders had expressed in the 1990s.

The Peoria Tribe of Indians of Oklahoma declined to comment for this story.

In addition to the creation of a cemetery, the bill would also establish a committee of leaders from more than 30 tribal nations to review state construction or other projects that might affect burial sites and other places of religious or ceremonial importance. The group would serve as an unprecedented Native voice in state affairs.

“For me, this work really is about recentering power,” said state Sen. Cristina H. Pacione-Zayas, a Chicago Democrat who sponsored the bill. “And [it’s about] communities who have been historically harmed and where policy has explicitly taken out their humanity, taken out their agency, taken out their ability to be self-determined.”

The legislation acknowledges that the state “has not maintained meaningful consulting relationships with tribal nations” and points to the “State of Illinois’ long history of removing tribal nations.” Today, there are no tribally held lands in Illinois.

“Without meaningful relationships between the State of Illinois and tribal nations, there has been harm caused to tribal nations and trust needs to be rebuilt as the State works to correct those harmful mistakes,” the bill reads.

Walker said that describing the historical context of forced removal in the bill is significant.

“It’s part of the larger discussion: Are we going to face our history or aren’t we?” he said. “As adult human beings, I think it’s time we embraced our entire history.”

The bill would establish a Tribal Repatriation Fund, which could only be used to help return ancestors and items and for reburial and would help pay for repatriation work using money from fines and other penalties collected from individuals or organizations that knowingly disturb burial sites.

Significantly, the proposed law shifts the ownership of any Native American remains and funerary items still buried in the state or accidentally unearthed from public lands to Native American nations. The current burial law, the Illinois Human Skeletal Remains Protection Act, passed in 1989, deems most Native American remains to be property of the state.

Help Us Investigate Museums’ Failure to Return Native American Human Remains and Cultural Items

More than 30 federally recognized tribes have cultural or geographical ties to the land that is now the state of Illinois. For this story, ProPublica reached out to representatives of the Peoria Tribe of Indians of Oklahoma, the Miami Tribe of Oklahoma, the Osage Nation, the Wyandotte Nation and the Prairie Band Potawatomi Nation. If you are a representative of a tribe with ties to Illinois and would like to share comments with ProPublica, please email us at repatriation@propublica.org.

by Ziva Branstetter

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

Nine months after the Supreme Court overturned Roe v. Wade, ending nearly 50 years of federal protection of abortion rights, the impact of the landmark ruling known as Dobbs v. Jackson Women’s Health Organization continues to ripple across the nation.

In Dobbs, the Supreme Court voted 6-3 that the U.S. Constitution does not confer a right to abortion.

The ruling essentially divided the nation into two territories: states where people have access to abortion care and states where most or all people are unable to obtain an abortion, even if their lives are at risk. An estimated 23 million Americans live in states that tightly restrict access to abortion. A few states, such as Tennessee, outlaw the procedure with no exceptions, forcing doctors to choose between risking their freedom and saving a pregnant patient’s life.

Since the Dobbs ruling on June 24, ProPublica has chronicled the nationwide fallout. Our stories have explored new concerns about data privacy, battle lines between blue and red states and the increasing popularity of civil lawsuits that seek to punish people for obtaining abortions.

A recent investigation by reporter Kavitha Surana explored the complicated story of a Tennessee woman who faced a life-threatening pregnancy after doctors decided they couldn’t risk prosecution to provide an abortion. ProPublica has also explored the harm created by parental involvement laws, on the books in many states long before the Dobbs ruling.

In a series of live events, ProPublica has also interviewed the nation’s top legal and medical experts about what they are seeing on the ground following the Dobbs ruling and what they expect going forward.

Last week, ProPublica talked to two leading experts on how the battle over abortion is impacting people in the most restrictive states and how legal challenges are likely to play out across the country. More than 1,400 people signed up to hear our live discussion with law professor Mary Ziegler and Tennessee OB-GYN Dr. Nikki Zite.

Ziegler is the Martin Luther King Jr. professor of law at the University of California, Davis School of Law. She is one of the world’s leading historians of the U.S. abortion debate and the author of six books on the law, history and politics of reproduction in the United States. Zite lives in Tennessee and is professor and vice chair of education and advocacy in the department of OB-GYN at the University of Tennessee Graduate School of Medicine.

Ziegler and Zite presented their personal perspectives on this issue during our discussion, and their thoughts do not reflect the positions of their institutions. This interview was edited for length and clarity.

Wyoming recently became the latest state to outlaw medication abortion. How do you see the criminal legal landscape playing out?

Ziegler: We’ve seen a rising trend within the anti-abortion movement of people who identify themselves as abolitionists. And they essentially argue that if the movement is serious that a fetus or an unborn child is a rights-holding person, then it would be logical to punish women too. The most recent manifestation that people may have heard about was in South Carolina. There were over 20 lawmakers sponsoring a bill that would treat abortion as murder and potentially subject women to the death penalty for having abortions. So far, the mainstream consensus within the anti-abortion movement that punishing women is a bad idea politically and morally is holding up, but it’s fragile.

We have the wrongful death lawsuit in Texas, in which a man is suing three women for allegedly helping his now-ex-wife obtain an abortion. Nikki, could you tell us about your experience in Tennessee?

Zite: The way our law is written, ending any pregnancy is illegal. Immediately, several of our outpatient abortion clinics closed. That not only had the effect of making abortion more challenging to access for people who needed that care, but it also made it harder for those of us who teach abortion to the next generation of OB-GYNs. Then we had all the unintended consequences: the cases like ectopic pregnancy, the cases of inevitable but not complete miscarriage, the cases of that ambiguous “How close to death does she need to be for it to meet the standards of protecting or saving her life?” It became this complicated legal situation where physicians not only felt like they had to make medical decisions, they then had to run it by hospital legal or a criminal attorney. We’ve lost a lot of physicians, and we don’t know whether or not medical students will want to train in states where they’re going to have restrictions on the type of care that they can learn.

Watch the Full Event I guess you’d call it a brain drain of doctors in this field who are leaving states like Wyoming?

Zite: There’s only a couple of OB-GYNs in some of those states. So if they leave, you really have these OB deserts.

Mary, you’ve mentioned fetal personhood laws. Does establishing fetal personhood make a pregnant person who has an abortion a murderer under the law?

Ziegler: There are proposals emerging on the right that we need to make birth free [of charge]. Georgia has its anti-abortion law requiring certain forms of child support during pregnancy. Then on the other hand, you have people saying if equal treatment is really the name of the game, then that requires murder prosecutions for people who have abortions.

So far it’s mostly been emerging in state legislators up to a point. We’ve seen it in the wrongful death lawsuit you mentioned. One question you might have is: Why bother with a wrongful death lawsuit? They wanted to say that if you provide someone else with abortion pills, you’re an accomplice to murder or you are a murderer, and that’s a personhood argument. We’re going to see it crop up more, and eventually the end game is a case brought to the U.S. Supreme Court. Whether they lead to prosecutions of women or just to nationwide abortion bans remains to be seen.

Nikki, you’ve been part of working on a bill to modify Tennessee’s law to create clear exceptions for maternal health care. Can you tell us about that effort and where it stands now?

Zite: Not in a good place. We were sticking with the things we could all agree on. The amendment passed 8 to 2 out of committee. Immediately, the right-to-life got all their members to call legislators and started threatening the legislators with losing their “ranking.” Unfortunately, we now have a very watered-down amendment. I don’t think that physicians are going to feel that it gives them much more leeway to provide lifesaving care without being criminalized.

What are the problems with policymakers trying to determine what constitutes a medical emergency?

Zite: The idea that it has to be a medical emergency is the first problem. We should be able to prevent an emergency, not just treat an emergency. The overwhelming evidence for most of these cases is that it doesn’t improve the outcome for the pregnancy to wait. That’s why laws for abortion have been liberalized in places like Poland, South and Central America and Ireland. Women died because they were made to stay pregnant until there was no longer a heartbeat and they got infected or bled. We don’t want to go back to that in the United States. Legislators don’t seem to understand that’s the inevitable outcome of what they’re forcing us to do.

I have had a question about that as a journalist. How are we going to know whether more people are dying or suffering measurable harm in states that have banned abortion?

Zite: And how long is it going to take us to get that data? When we look at the state and maternal mortality reports, they’re not always that accurate, and these reviews usually were two or three years behind.

Mary, you recently wrote that the court does not get the final word even on the meaning of its own important decisions. Can you talk about that?

Ziegler: I think what we saw with Roe, the judges pretty clearly thought that they were settling this and that Roe was going to mean abortion was a thing between a doctor and a woman. I think the court in Dobbs is trying to say the same thing: that history and tradition, in the court’s view, would not have recognized the right to abortion in the 19th century, and that’s the end of it. We’re already seeing Dobbs emerging as a symbol of things the Supreme Court didn’t want it to be. We’ve seen a lot of poll data documenting a really precipitous decline in trust of the Supreme Court and Dobbs being the most visible symbol of that decline. I think the court often holds itself out as having the last word on these constitutional struggles when it can’t.

One of our readers asks: What can people who live in states that still protect abortion rights do to safeguard maternal health for themselves and others in states that ban abortion?

Zite: I’m feeling pretty discouraged, frankly. I think it’s going to take ballot initiatives. We don’t have that option in Tennessee, but there are other states that do. Normally you say state elections are important, but when they’ve been gerrymandered so much, I don’t see things getting better in Tennessee for decades. I’m focusing at a federal level.

Ziegler: Based on what’s going on now in the federal courts, if you’re living in a state where abortion is legal, you should not take for granted that that will remain the case. The mifepristone case we’d been talking about in Texas could, depending on how the FDA responds, make it impossible for people in a state like California to have a medication abortion. We’ve seen some voices emerging essentially saying, “Look, even if you define yourself as pro-life, do you really want to spend a lot of taxpayer money enforcing criminal abortion laws?”

There’s a notion that medical exceptions to abortion bans give people appropriate access to the medical care they need. Nikki, can you talk about that a little bit?

Zite: I think that a lot of people think, well, if we add an exception, that’s going to get access for some. But access for some is not actually helping the majority. The type of care I provide in a hospital setting is less than 1% of abortion care. Without abortion care, we’re going to see maternal mortality go up. We’re going to see people stay in abusive relationships.

Dr. Zite, how are medical schools deciding what procedures are taught, and what is their legal standing?

Zite: Currently about half of the residency training programs are in banned states. It is a requirement to graduate from a residency and become a board-certified OB-GYN to be able to perform abortion care. We’ve been struggling in Tennessee to figure out how we’re going to get that training for our residents. Will it actually make it harder to become board-certified?

So you have some doctors leaving these states, training that is difficult to access and people who will be coming to emergency rooms needing abortion care in an emergency?

Zite: That’s the situation that I think is very poorly understood. I had a resident when I first got to the University of Tennessee that had opted out of all abortion training before I arrived. About three months before she finished training, we were called down to the trauma bay and a young woman who was about 16 weeks pregnant had been in a very bad car accident. There was still a fetal heartbeat. We did the case together, and afterward the resident had this moment of realizing “I’m going to be on my own in three months.” What happens if this patient comes into my ER? I am the person who should be able to save her life. We need to be able to train doctors to do these procedures.

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

by Tony Schick, Oregon Public Broadcasting

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.

The federal government has announced plans to increase funding for the Columbia River Basin’s salmon hatcheries, the often-crumbling facilities that maintain the river’s dwindling salmon populations. But tribes and state agencies say the influx of funds is only a fraction of what is needed.

The Bonneville Power Administration, the federal agency that’s required to pay for salmon recovery using proceeds from selling power generated by hydroelectric dams, is putting an additional $50 million toward repairs at hatcheries operated by tribes and states. The agency also plans to increase annual funding for hatchery upkeep from $500,000 to $2.7 million.

In May, Oregon Public Broadcasting and ProPublica reported on how the federal government’s neglect of an old and struggling hatchery system had put tribal fishing rights in jeopardy. The news organizations’ analysis showed that the outlook for fish survival was so poor that the hatchery system was at risk of collapsing under the strain of climate change, unable to produce meaningful levels of fish. Bonneville is the primary funder of the river’s hatcheries, with additional money coming from federal appropriations and local government. In August, OPB and ProPublica reported that Bonneville had resisted tribes’ restoration efforts and constrained salmon recovery funds even while generating hundreds of millions of dollars in surplus revenue.

Many salmon habitats were destroyed or drastically altered by the repeated damming of the Columbia in the mid-20th century to create hydropower, provide irrigation and improve shipping navigation. Throughout that period, Congress authorized the dams and turned to hatcheries to compensate for the fish losses.

But hatcheries never ensured that they produced the numbers of fish that tribes were promised. Around the time salmon reached endangered status in the late 1980s and 1990s, tribes opened their own hatcheries and began reforming them from mass fish-production facilities into nurseries for wild fish that could better preserve genetic diversity and bolster existing natural populations.

Now climate change and warming ocean waters are making matters worse. In recent years, salmon from Columbia River hatcheries have had some of their lowest survival rates on record. Federal scientists estimate salmon survival could further decline by as much as 90% over the next 40 years.

Throughout this unfolding crisis, lawmakers and government agencies have left poorly maintained infrastructure in place, including burst pipes, broken water pumps and crumbling concrete in the walls of aquatic pens that can harbor bacteria and sicken fish.

The $50 million and fivefold increase in hatcheries’ annual budget will begin to address problems stemming in large part from years of limited funding. It will barely make a dent, however, in the infrastructure needs at more than 50 Columbia basin hatchery programs. According to estimates assembled by state and tribal hatchery managers in 2020, all the needed upgrades and repairs across the Columbia River Basin would total more than $1 billion. Becky Johnson, director of hatchery production for the Nez Perce Tribe in Idaho, said the cost has only grown since then.

Tribes in the Northwest have struggled for years to get the federal government to recognize the inadequacy of its funding for salmon restoration, which is done primarily through the Bonneville Power Administration, an agency torn between mandates to fund conservation work and to operate as a business.

The Affiliated Tribes of Northwest Indians, a coalition of 57 tribes across Oregon, Washington, Idaho and Montana, passed a resolution in January urging the federal government to more effectively and efficiently fund salmon recovery. It passed a similar resolution in 2021.

Yet funding for salmon has not kept pace with inflation, particularly after Bonneville adopted a strategy in 2018 to shore up its budget and reduce debt in part by limiting its fish and wildlife spending.

State agencies and tribes are asking the Biden administration to use funds from the Inflation Reduction Act and the Bipartisan Infrastructure Deal to upgrade aging hatcheries beyond what the Bonneville increases will cover.

Tribes also have gained the attention of Sen. Patty Murray, a Washington Democrat who chairs the Senate Appropriations Committee. A spokesperson for Murray confirmed she was working with tribes to identify needs and pursue additional funding.

“Salmon are foundational to Washington state and Tribes’ economy, culture, and traditions. Preserving and protecting fish populations will continue to be a top priority I fight for in the other Washington,” Murray said in a statement. “I’ll be considering every option to advance salmon recovery in Washington state and across the greater Pacific Northwest.”

Tribes and conservation groups were encouraged by commitments from the Biden administration last year to prioritize Native American rights and to find a long-term solution for the ongoing decline of Columbia River salmon.

“We heard a request to fully fund fish and wildlife restoration and to vest in Tribes and states a stronger role in managing those funds,” the White House said at the time. It went on: “We cannot continue business as usual. Doing the right thing for salmon, Tribal Nations, and communities can bring us together. It is time for effective, creative solutions.”

A year later, the Biden administration remains in negotiations with state officials, tribal governments and environmental groups over the potential for dam removal and how salmon recovery will be funded.

When the Bonneville Power Administration announced a $500 million revenue surplus this year — and its plans to use just 10% of that on fish and wildlife — those parties hoped the Biden administration would intervene. The office of then-Oregon Gov. Kate Brown implored the agency to use more of its surplus on salmon, calling 10% “simply unacceptable.”

Conservation groups and tribes agree. “BPA has sort of turned a blind eye,” Mitch Cutter of the Idaho Conservation League said. “We really looked to the administration to make the right decision happen at BPA, and we’re pretty disappointed that that didn’t happen.”

The White House Council on Environmental Quality said it is making sure portions of recent infrastructure bills go to Columbia River tribes, including up to $160 million in grants issued through the Pacific Coastal Salmon Recovery Fund. .

White House staff met to discuss Columbia River salmon last week with members of the Nez Perce Tribe, Washington’s Spokane Tribe, an adviser to Oregon Gov. Tina Kotek, and representatives from American Rivers and the National Wildlife Federation.

“The Biden-Harris Administration is making significant investments to support hatcheries and other Tribally-led salmon initiatives,” White House Council on Environmental Quality spokesperson Alyssa Roberts said in an email. “We recognize more must be done and, as President Biden noted last week, we are committed to working together to bring healthy and abundant salmon runs back to the Columbia River System.”

In response to a request for comment, Bonneville spokesperson Kevin Wingert pointed to a document the agency assembled in January addressing the tribes’ and conservation groups’ concerns. The document asserted that Bonneville was meeting its legal obligations to fish and wildlife. It also said Bonneville’s obligations to salmon aren’t tied to how well the agency is doing financially.

“Just as a lack of revenue would not decrease those obligations, an influx of revenue does not increase those obligations,” the document stated.

But even if it were to address a maintenance backlog estimated at $1 billion, the Columbia hatchery system would still be lacking the upgrades scientists say are necessary to make the facilities and the fish they breed more resilient to the effects of climate change. Those include circular tanks instead of concrete pens, more precise control of water temperature and additional ponds and feeding techniques that better simulate the natural environment.

Those changes would require additional billions of dollars.

“It’s basically a drop in the bucket,” Johnson said of the funding increase. “But a start, right?”

by Elyssa Cherney, Crain’s Chicago Business, and Steve Mills, ProPublica

The statue of Buddha that was up for sale at Christie’s auction house was, according to art experts, an early test: Would recent controversy around objects once owned by two prominent Chicago collectors hinder its sale and send a signal about how the art market views the renowned collection?

The answer came quickly. The 7 1/4-inch copper-alloy Buddha from 9th-century Nepal, which had been on loan to the Art Institute of Chicago until last year, failed to sell last week, a Christie’s spokesperson said.

It never received a bid in the estimated price range of $60,000 to $80,000.

“Nobody wants to buy trouble,” said Erin Thompson, an associate professor of art crime at John Jay College of Criminal Justice in New York who has advocated for repatriation of Nepali artifacts. “Why would you buy someone else’s stolen cultural property?”

Although the Christie’s auction was a single sale of a single object, art experts said it was telling nonetheless. The rare Buddha had been in the collection of James and Marilynn Alsdorf, whose massive art holdings focused on pieces from Nepal and other parts of South and Southeast Asia.

The Christie’s spokesperson said 63% of the auction’s 124 lots found buyers.

The Alsdorfs obtained the Buddha at a time when protocols around collecting were lax, and it was sold to them by a New York dealer who at the end of his career acknowledged engaging in questionable practices. Ethical standards for acquiring antiquities became more strict after a 1970 UNESCO convention prohibited the import of looted cultural property.

The Buddha was on loan to the Art Institute beginning in the late 1990s and was last on display in 2018 at the museum, which has galleries dedicated to the Alsdorfs’ vast Asian collection. Marilynn Alsdorf, who died in 2019, left much of the collection to the museum. James Alsdorf, who once led the museum’s board of trustees, died in 1990.

Last week, ProPublica and Crain’s Chicago Business published an investigation into Nepal’s claims that the Art Institute should return a 17th-century gilt-copper necklace that is on display in its Alsdorf Galleries, as well as questions about other objects in the couple’s collection.

The investigation identified nine pieces once owned by the Alsdorfs that have been returned to other countries based on concerns they were looted or illicitly exported, a pattern some art historians said should spur the Art Institute to take a deeper look at the approximately 500 Alsdorf objects in its collection.

The investigation also showed that the Art Institute hasn’t kept up with other museums that take a more transparent approach to these problems by publicly sharing information when an object is repatriated.

Marilynn Alsdorf’s son, Jeffrey Alsdorf, did not respond to requests for comment. He is listed as an executor of his mother’s estate and sits on the board of the Alsdorf Foundation, according to the most recent publicly available tax records. Linda Feinstein, a Chicago attorney who, according to records, has represented Marilynn Alsdorf’s trust, also did not respond to a request for comment.

The Buddha up for sale at Christie’s was taken off display at the Art Institute in 2018 when the museum reinstalled its galleries, a museum spokesperson said. After Marilynn Alsdorf’s death, all of her remaining loans to the museum were concluded in 2022, the spokesperson said.

The Art Institute has said it follows best practices for investigating and documenting ownership history, or provenance, of the objects in its collection and has added staff dedicated to that process. The museum also has said it takes all repatriation claims seriously but has noted that they’re complex and often take time to resolve.

The fate of the rare Buddha is not unlike what’s happened when other controversial objects have gone up for sale. Bronzes from the West African country of Benin that were stolen by British colonialists have failed to sell or have been pulled from bidding before auctions begin. Museums are now repatriating the objects to Nigeria.

Pieces from Italy and Greece have also recently been removed from auctions after researchers linked their provenance to known antiquities smugglers and publicized concerns about them.

In such cases, prospective buyers may be worried about the potential resale value of an object that has garnered controversy, said Patty Gerstenblith, a distinguished research professor specializing in cultural heritage law at DePaul University.

“I might say to myself, ‘Am I buying a lawsuit? Am I buying bad publicity?’” Gerstenblith said. “There’s a lot of short-term and longer-term concerns, and I do believe that once something is out there, it can influence the market.”

This isn’t the first time that bidders have been wary of an Alsdorf piece on the auction circuit. In June 2020, a Benin bronze sculpture of a fish, acquired by the Alsdorfs in 1957, failed to sell at a Christie’s auction in Paris, according to news reports.

In the most recent auction, the Buddha up for sale had been purchased by the Alsdorfs from an art dealer named William Wolff, who had acquired it by 1972, according to information from Christie’s. It isn’t clear when the Alsdorfs purchased the piece from him.

For years, Wolff had a gallery on Madison Avenue in New York City. Although he was widely considered one of the nation’s top dealers in Asian antiquities, Wolff acknowledged near the end of his career that some of his dealings had occurred under questionable circumstances.

Wolff, who died in 1991, said that in many countries where he acquired objects, their export was illegal. He said he utilized a network of “scouts” to transport the pieces, sometimes across mountain ranges.

“The fellows I bought from knew how to get it out of the country,” he told the Los Angeles Times in 1990, when he closed his gallery because of rising rent. “Otherwise they would not have been able to sell it.”

For Nepalis, the increased attention on cultural artifacts in museums and private Western collections is long overdue. Activists with the Nepal Heritage Recovery Campaign, an organization that works to repatriate stolen objects to the country, have been pressing the Art Institute to return more objects donated to the museum by the Alsdorfs, who were major financial supporters of Chicago’s arts community.

A gilt-copper necklace at the Art Institute is perhaps the strongest symbol of the questions plaguing the Alsdorf collection. The Nepali government first asked the Art Institute to return the necklace in August 2021, alleging the piece had been stolen from a secure location in Nepal and illicitly exported from the country. The necklace is said to have been offered to the Hindu goddess Taleju by a Nepali king in about 1650.

The slow pace of negotiations has frustrated Nepali activists, art historians and cultural heritage scholars following the case. New details reported by Crain’s and ProPublica showed that the Art Institute asked Nepal to provide more evidence establishing ownership of the necklace, despite the decades that have passed since the piece went missing from the country.

Following the ProPublica-Crain’s investigation, Gerstenblith said it’s unlikely those records exist. She called on the Art Institute to return the necklace if Nepal can show it came from the country and has ongoing cultural significance to its people.

“To ask a country to come up with that type of documentation is as if they’re in a court of law,” Gerstenblith said. “It’s my opinion that the point of having an ethical policy is to actually move beyond that and, if anything, to shift the burden to the Art Institute.”

by Craig Silverman and Bianca Fortis

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

Just after midnight on Sept. 13, Kristian “Murda” Murphy was watching TV at home in Boca Raton, Florida, when his phone began buzzing.

“Murda u always outside we gon see you,” read a message from an account he didn’t recognize.

Murphy is a music manager, producer and entrepreneur who has worked with high-profile rapper Tekashi 6ix9ine, among other artists. Hours before the threats began, 6ix9ine posted a message to his more than 20 million followers on Instagram that mocked the recent death of rapper PnB Rock. Taking exception to the post, people began blowing up Murphy’s phone.

“I’m sitting home by myself literally watching TV, all of a sudden I see these texts started coming in and I’m like, ‘What the fuck?’” said Murphy, in a gravelly voice that retains the accents of his native Yonkers, New York. In addition to threatening bodily harm, the anonymous messengers told Murphy they were coming for one of his most valuable assets — the @murdamurphy Instagram account. It had more than 300,000 followers and brought in thousands of dollars a month thanks to people and companies who paid Murphy to share sponsored posts.

“WE PACKING ACCOUNTS SOON 🤣🤣” read a message from a person who identified himself as OBNBrandon.

Meta suspended Kristian “Murda” Murphy’s Instagram account hours after OBN threatened to take it down. (Kendrick Brinson, special to ProPublica)

Murphy didn’t know it, but he was in the crosshairs of one of the most prolific and notorious members of a booming underground community of Instagram scammers and hackers who shut down profiles on the social network and then demand payment to reactivate them. While they also target TikTok and other platforms, takedown-for-hire scammers like OBN are proliferating on Instagram, exploiting the app’s slow and often ineffective customer support services and its easily manipulated account reporting systems. These Instascammers often target people whose accounts are vulnerable because their content verges on nudity and pornography, which Instagram and its parent company, Meta, prohibit.

A ProPublica investigation found that OBN, who also goes by OBNbrandon and Brandon, has prompted Meta to ban an array of influencers and entertainment figures. In an article he wrote for factz.com last year, OBN dubbed himself the “log-out king” because “I have deleted multiple celebrities + influencers on Meta & Instagram.”

“I made about $300k just off banning and unbanning pages,” he wrote.

OBN exploits weaknesses in Meta’s customer service. By allowing anyone to report an account for violating the company’s standards, Meta gives enormous leverage to people who are able to trick it into banning someone who relies on Instagram for income. Meta uses a mix of automated systems and human review to evaluate reports. Banners like OBN test and trade tips on how to trigger the system to falsely suspend accounts. In some cases OBN hacks into accounts to post offensive content. In others, he creates duplicate accounts in his targets’ names, then reports the original accounts as imposters so they’ll be barred for violating Meta’s ban on account impersonation. In addition, OBN has posed as a Meta employee to persuade at least one target to pay him to restore her account.

Models, businesspeople, marketers and adult performers across the United States told ProPublica that OBN had ruined their businesses and lives with spurious complaints, even causing one woman to consider suicide. More than half a dozen people with over 45 million total followers on Instagram told ProPublica they lost their accounts temporarily or permanently shortly after OBN threatened to report them. They say Meta failed to help them and to take OBN and other account manipulators seriously. One person who said she was victimized by OBN has an ongoing civil suit against Meta for lost income, while others sent the company legal letters demanding payment.

“Once you’re put on Brandon’s radar, whether someone’s paying him or not, he has this personal investment in making sure that your life is miserable and that he’ll try and get as much money out of you as he possibly can,” said Kay Jenkins, a Miami real estate agent and model. Her main Instagram account with roughly 100,000 followers has been repeatedly deactivated since 2021.

Kay Jenkins, a Miami real estate agent and model, says that OBN got her Instagram account banned and then duped her into paying him to get it back. (Kendrick Brinson, special to ProPublica)

A Meta spokesperson acknowledged that OBN has had short-term success in getting accounts removed by abusing systems intended to help enforce community standards. But the company has addressed those situations and taken down dozens of accounts linked to OBN, the spokesperson said. Most often, the spokesperson said, OBN scammed people by falsely claiming to be able to ban and restore accounts.

“We know the impact these scams can have on people which is why we continue investing to protect our users, including updating our support systems and keeping the scammers out,” said the spokesperson, who asked not to be identified due to security concerns. “This remains a highly adversarial space, with scammers constantly trying to evade detection by social media platforms.”

The story of how OBN has manipulated Meta’s systems is a cautionary tale for social media platforms. While the company is often criticized for being slow to take down misleading or offensive material, OBN was able to make a lucrative living by finding the pressure points that prompt Meta to act quickly based on false reports.

Murphy said that’s exactly what happened to him. Until OBN came along, he was earning between $15,000 and $20,000 a month from his Instagram account. It was filled with pictures of him with rappers and well-known figures from the Miami nightlife. Murphy, a stocky man with short blond hair and permanent five o’clock shadow, typically posed in black clothes, aviator sunglasses and thick diamond chains, with one or both of his middle fingers extended at the camera. He charged aspiring entrepreneurs between $2,000 and $5,000 per story to be featured in a post on his verified account.

“People pay me all the time to post promos for music, crypto,” he said. “I can make five, 10 grand by accident if I needed to. … The money’s crazy.”

Murphy had never heard of OBN until that September morning. He went to bed shortly after 3 a.m. and woke up to discover his Instagram account was disabled.

“That’s the first time I’ve ever had my account taken, ever, in my life. My heart dropped,” he said.

He was initially successful in getting Meta to reactivate it. But it’s been offline since December. Meta declined to comment on Murphy’s experience.

“I make money with that account, so it’s not fair to me that this guy has more power than Meta — it’s like a multibillion-billion-billion-dollar company,” Murphy said. “And they can’t do nothing about it.”

Online, OBN portrays himself as something of a gangster. Videos and photos he’s posted indicate he drives a white Lamborghini and wears expensive watches.

His main marketing vehicle for his services is the messaging app Telegram, where he has run a channel called @teamobn since August 2021. He posts about accounts he says he got banned, unbanned or verified. He touts software he uses to file false reports that allege an account violated Meta’s community guidelines, triggering a takedown.

He describes various strategies he uses to get accounts banned. For example, he says he can get a legitimate account suspended for violating Meta’s rule against impersonation by taking a verified Instagram account and changing its display name, profile photo and content to mirror his target’s. Then he sends Meta a report claiming that the legitimate account is impersonating the verified account.

Jilted lovers, jealous friends and business rivals use his services. OBN wrote that he also targets people for his own amusement, because they insulted a friend or client, or because they offer rival services. After banning an account, he frequently offers to reactivate it for a fee as high as $5,000, kicking off a cycle of bans and reactivations that continues until the victim runs out of money or stops paying.

Several notable people in the often-intertwined worlds of hip-hop, Miami nightlife, OnlyFans models and online influencers, including Celina Powell and Myron Gaines, have endorsed OBN. Powell is an online influencer who claims to have had sexual relationships with prominent rappers and has amassed more than 3 million followers on Instagram. Gaines co-hosts the “Fresh & Fit” podcast, a YouTube channel with more than 1 million subscribers that bills itself as providing “the TRUTH to Females, Fitness, and Finances.” Gaines, whose legal name is Amrou A. Fudl, was temporarily banned from TikTok for misogynistic comments.

On Oct. 21, 2021, Gaines paused the broadcast to offer a plug. “​Shouts out to our boy Brandon. For y’all that don’t know or follow me on Instagram on @unplugfit, I got my shit banned and then I’m back up now and my boy @obn.here was the one that got it back,” Gaines said, as an image of OBN’s Instagram account flashed on the screen. “So if you’ve got issues with Instagram, you get banned, whatever it is, this is the guy that you want to fucking contact.” Gaines didn’t respond to requests for comment. After ProPublica contacted Gaines, the video of the “Fresh & Fit” episode that featured his OBN shoutout was set to private, removing it from public view.

“Fresh & Fit” co-host Myron Gaines promoted OBN’s services and Instagram account. (Screenshot by ProPublica)

Those who said they were targeted by OBN include Adam22, the host of the popular hip-hop podcast “No Jumper,” who has 1.6 million Instagram followers, and Tommy Rodriguez, a Florida businessman with 1 million followers. OBN has said that he was responsible for banning Asian Doll, a rapper with 4.2 million followers; she did not respond to requests for comment. Meta declined to comment on all three cases.

OBN often targets women who rely on Instagram to draw people to their pages on OnlyFans, where they charge subscribers to view sexually explicit content.

“This is how I feed myself and my family,” said Danii Banks, an OnlyFans model with close to 8 million Instagram followers. She said she lost $300,000 in income when OBN induced Instagram to take down her account. He extorted thousands of dollars from her to restore her account, but it remained down, she said.

“It’s like someone lighting a fire on your business and just walking away.”

Meta declined to comment on Banks.

Banks lives in the Las Vegas area, as does OBN, according to posts, emails and public records. Banks reported him to the Las Vegas Metropolitan Police Department and the FBI for defrauding her, but she hasn’t heard back, she said. OBN, meanwhile, appears to have pursued a job with the Las Vegas police while mocking attempts by Meta and law enforcement to investigate him.

Last summer, he posted an email from the LVMPD’s Office of Human Resources that said the recipient, whose name was redacted, had met the requirements to continue the application process for becoming a police cadet. It said a written exam would be held; the date was also redacted.

“Wish me luck boys,” OBN wrote in his Telegram channel.

OBN told his followers that he’d applied to become a Las Vegas police cadet. (Screenshot by ProPublica)

The next day, he shared a video shot in the LVMPD parking lot. “It went well,” he wrote and added a thumbs-up emoji.

Roughly a month later, OBN joked about an email from Meta telling him that it had complied with a request from an unnamed law enforcement agency for data regarding one of his accounts.

“Bro instagram or meta at this point is beyond cringe lmao,” he wrote on Telegram, using the popular acronym for “laughing my ass off.”

Despite his frequent activity on Telegram and Instagram, and the shoutouts from major podcasts and influencers, OBN’s true identity — and even whether the account is run by one person or more than one — has remained a mystery.

ProPublica’s investigation led to one person who either is OBN or is closely linked to him: 20-year-old Edwin Reyes-Martinez, who lives with his mother in an apartment complex roughly 13 miles north of the Las Vegas strip.

Numerous clues connected Reyes-Martinez to OBN. Victims said OBN told them to send money to a bank account in the name of Edwin Reyes, or via an email address, ermtz030@icloud.com, that included Reyes-Martinez’s initials. That address also matched a partially redacted email, 030@icloud.com, that’s listed in the Las Vegas police letter OBN posted on Telegram.

A similar string of letters and numbers appears in a Twitter username, @ermtz030. That account bears Reyes-Martinez’s name and photo and features videos filmed inside a white Lamborghini. Although the videos don’t show the driver’s face, he is wearing a gold ring that resembles one worn by Reyes-Martinez in photos from his Facebook account. Another Facebook photo showed Reyes-Martinez posing in front of a white Lamborghini similar to the one featured in OBN’s Telegram profile.

The email address that OBN told victims to send payments to includes a string of characters that match the username on a Twitter account linked to Reyes-Martinez. (Screenshot by ProPublica)

Visited at his home in early February, Reyes-Martinez was dressed in a baggy, orange long-sleeve shirt, brown pants and brown slippers. A pair of gold and diamond studs sparkled in his ears. At first, he denied knowing who OBN is or having anything to do with him.

After being told that his own bank account had accepted more than $10,000 in payments intended for OBN in just the past few months, he changed his story. He said that someone named Brandon asked him to funnel money through his bank account to unknown recipients.

“There’s an individual that asked me if I can receive a payment,” he said. “I have no idea what that payment is for. I received them as a favor for the person.”

He pulled out his phone and showed an Instagram account called @madetoomuchmoney that he said belongs to the Brandon who contacted him. He said he didn’t know where the money went or what Brandon’s last name is. “I know a lot of Brandons.”

He said he works full time in a warehouse. “You see my hands? These are hard work hands,” he said, holding them out. “If I was OBN, I wouldn’t be working.”

ProPublica also submitted a request to the Las Vegas police for records related to any application by Reyes-Martinez to the department’s cadet program. The department declined, citing a Nevada law that allows it to withhold personnel records.

After the meeting in his apartment, Reyes-Martinez did not respond to follow-up questions. Meta sent him a cease-and-desist letter on March 17, about two weeks after ProPublica contacted the company for comment on OBN’s activities and on the evidence connecting Reyes-Martinez to OBN. A spokesperson said Meta had banned him from its platforms but declined to share the letter.

Account banning is just one of several lucrative schemes that prey on Instagram, which is uniquely important for celebrities, entrepreneurs, influencers and anyone seeking clout and status. Last year, a ProPublica investigation exposed a million-dollar operation that saw people pay $25,000 or more to fraudulently obtain verified accounts.

The verification badge, a blue tick added next to an account’s name, is applied to accounts that Instagram determines are authentic, unique, complete and notable. Verified accounts can charge more for sponsored posts, are given prominence by Instagram’s algorithms, and are seen as more difficult for people like OBN to take down. The ProPublica story prompted Meta to remove verification badges from hundreds of accounts.

OBN has said that he can take down verified accounts. “If you want someone smoked we talk 4 figures or nothing,” he wrote in his Telegram channel. In a separate post, he offered to create verified accounts for a $15,000 fee.

Meta has acknowledged that it needs to invest more in customer support. In February, founder Mark Zuckerberg announced that Meta would offer people the ability to pay for account verification and enhanced support, including “​​access to a real person for common account issues.” The Meta spokesperson said the company has invested in new account security and recovery measures, including a tool to help users who’ve been hacked. It’s also giving more users an opportunity to complain to a human agent rather than a bot.

The 1996 federal Communications Decency Act generally exempts platforms from legal liability related to the behavior of their users. However, the Federal Trade Commission has required several online platforms to bolster their security.

“If somebody is able to get into the account, the FTC doesn’t treat that company as a victim. They treat them as part of the problem,” said Eric Goldman, a professor and co-director of the High Tech Law Institute at the Santa Clara School of Law.

Meta has been under a consent decree with the FTC since 2012 because of allegations that the company, then known as Facebook, violated its privacy promises to users.

Some OBN victims have tried to hold Meta accountable. In late 2021, Tiara Johnson, a former adult performer who had more than 2.8 million Instagram followers when she lost her account, filed a breach of contract suit against Meta, which is pending in federal court. She said the company wrongly removed her account. Her suit includes screenshots of a conversation with OBN in which he says someone paid him $3,000 to ban her account. She then paid him the same amount to get it back, but he didn’t get it reactivated.

In February, Meta moved to dismiss the case, saying it has no obligation to provide an Instagram account to Johnson. The court is scheduled to consider the motion in June.

OBN can’t deactivate accounts by himself; he needs Meta to do it, either by triggering its automated systems or by getting a worker to take action. He has often boasted of bribing workers at Instagram and Meta, which recently acknowledged firing or disciplining workers who took bribes to access user accounts. ProPublica could not identify any Meta workers who accepted bribes from OBN.

But OBN did appear to have advance knowledge of a cease-and-desist letter sent on behalf of Meta to online marketer Joey Hickson.

Hickson built a business running large social media accounts like @break and @lmao, and he had four Instagram accounts with tens of millions of followers. He said he paid OBN for services such as helping people get an Instagram username they wanted or obtaining verified accounts.

After initially cooperating, OBN stopped delivering, according to Hickson. Then OBN started threatening to take Hickson’s accounts down. Last Sept. 22, OBN taunted Hickson on Instagram. “Enjoy your c&d,” he wrote, referring to the cease-and-desist letter sent by a law firm representing Meta.

Hickson immediately checked his email and saw that he had received just such a letter from Perkins Coie, a law firm that said it was writing on behalf of Meta. The letter said an investigation found that he and his company were “abusing Instagram” by offering account reactivation and verification services and by selling fake engagement such as likes and followers. It was banning Hickson and taking down his accounts.

OBN “knew before I did,” Hickson said.

OBN posted a message in his Telegram channel to celebrate that Hickson’s personal Instagram account, @joey, had been deactivated. He accused Hickson of stealing $20,000 from him and said, “enjoy the c&d my brother.”

When Meta sent marketer Joey Hickson a cease-and-desist letter, OBN bragged about it on Telegram. (Screenshot by ProPublica)

OBN then tried to convince Hickson to pay him $15,000 to reverse the ban. He said he could get Meta and its law firm to withdraw the sanction because he was responsible for it. He said another hacker had created several Instagram accounts with fabricated accusations against Hickson and then sent the complaints to a Perkins Coie attorney. Referring to the lawyer as “my people,” he said he’d tell her that the accounts were “falsely made” to frame Hickson.

“Buddy I’m the one who did it who do you think she [the lawyer] gon listen to lmao I bring her clients everyday,” OBN wrote.

OBN asked Hickson to pay him through an intermediary: Dan Folger, a former photographer for rap star Wiz Khalifa who has over 300,000 Instagram followers and a Telegram channel where he sells Instagram services such as account reactivation. OBN has posted screenshots in his Telegram channel that show crypto payments from Folger to OBN. OBN has also shared video security footage, presumably supplied by Folger, of a ProPublica reporter visiting Folger’s Nevada home. In a Telegram chat, Folger denied working with OBN. He did not respond to detailed questions sent via his attorney.

Hickson rejected OBN’s offer, saying he wasn’t aware of anyone who had gotten a cease-and-desist retracted. He denies that he broke Meta’s rules. “I’ve spent a decade of my life building what I built only to have someone come in and tarnish that. I’m just trying to get my accounts back and my life back.”

Meta said Hickson’s accounts were appropriately taken down for violating Instagram’s terms of service. Perkins Coie and the attorney mentioned by OBN did not respond to requests for comment.

Before the bans and the victims, before the white Lambo, OBN was just a teenager with a PlayStation. “We used to just play games online,” Syenrai said in a telephone interview. Syenrai is the internet handle of a young man who was once prominent in the Instagram banning community. He requested that his real name not be used. Syenrai knew OBN as Brandon when they met online around 2018. They have never met face-to-face. He said he believes that Reyes-Martinez is at least partially responsible for the online activities carried out under the OBN handle, but that more than one person may be involved.

Syenrai said that Brandon earned money by selling a how-to guide to scamming. “The guides were easily found online for free, but OBN sold them for $45 a pop,” he said.

Brandon used the OBN moniker specifically for scamming, Syenrai said. Asked what the acronym stands for, Syenrai said he was told it was “only bands” — a reference to the paper band that holds a stack of bills together — followed by the version of the N-word that ends in “a.”

Everything changed for Brandon and Syenrai in the middle of 2020. A mutual friend named Abu “learned how to ban and showed it to me and Brandon,” Syenrai said. Syenrai caught on so well that he earned a measure of fame in 2021 by “memorializing” the account of Instagram head Adam Mosseri. When an account owner dies, Instagram can enable a memorial setting that locks the account and informs viewers that the person is dead. Mosseri’s memorializing only lasted an hour, but it embarrassed the company.

“It was a wild transition for us guys, from playing games to taking down celeb pages,” Syenrai said.

That kind of high-profile takedown is a way for a banner to gain clout, a flexing of skills to showcase Instagram’s vulnerability and make fellow banners jealous — like OBN, who also took credit for memorializing Mosseri.

It was also a quick route to a stern warning.

Syenrai received a cease-and-desist notice from Meta in November 2021. He said he stopped banning and working with OBN.

Kay Jenkins’ Instagram popularity helped her earn between $15,000 and $20,000 a month from sponsorships and OnlyFans subscriptions. But after she moved to Miami from her native Utah in March 2021, both her main Instagram account and her secondary accounts for her real estate and personal coaching businesses were repeatedly suspended. Months later, she learned by chance what had happened. In November 2021, she was a guest on “Fresh & Fit,” along with Celina Powell. Powell, who rose to fame by claiming to have slept with rappers and discussing the alleged affairs on hip-hop podcasts such as “No Jumper,” had recently given a shoutout to OBN.

“I’m telling you right now if you need any Instagram services, you need your account back, whatever the fuck you need, you have to go to my boy @obn.here,” Powell had said in an Instagram video that OBN shared in his channel.

Instagram influencer Celina Powell gave at least two shoutouts to OBN. (Obtained by ProPublica)

After the broadcast, Powell and Jenkins rode the elevator from the studio up to Jenkins’ apartment. Powell called someone she referred to as Brandon and started talking about banning accounts.

“Who is this guy?” Jenkins asked her. “Can he bring my account back?”

“Yeah, he can bring it back if I tell him to,” Powell said. “Because he’s the one who shut it down.”

Powell explained that she had OBN ban Jenkins. Powell was upset after seeing a video of her then-boyfriend dancing with Jenkins at a Miami club, Jenkins said.

Jenkins hid her anger. “I was so hopeful that like, OK, if she’s the source that brought it down, she’s probably my only hope to fucking get it back,” Jenkins said.

Powell agreed to get OBN to restore Jenkins’ accounts. And soon they were reactivated. On Dec. 5, less than a week after the “Fresh & Fit” appearance, Powell posted another shoutout for OBN.

Still furious at Powell, Jenkins ended their friendship. Her main account promptly went down again.

Jenkins finished 2021 with her main Instagram account suspended and no indication from Meta about if or when it might come back.

“I had the worst Christmas of my life, I contemplated slitting my wrists, I didn’t feel like living anymore,” Jenkins said.

Powell was imprisoned in June 2022 for violating parole on a 2015 conviction for driving a getaway car in a theft. Powell, who was recently released, declined to comment. Around the time of Powell’s re-arrest, Jenkins’ Instagram account was restored. But the reprieve was short-lived. On Sept. 23, OBN messaged Jenkins. He offered to get her account verified for a fee. She declined and told him not to contact her again.

“Dumb ass b!tch,” read a private Instagram message sent to her the next day from an account linked to OBN. “I’m going to ruin you.”

Two days later, Meta suspended Jenkins’ account.

Jenkins says that OBN scammed her out of more than $10,000. (Kendrick Brinson, special to ProPublica)

Jenkins decided the only way to protect her account and income was to make peace with OBN. It proved to be an expensive decision.

OBN assured Jenkins that he would be happy to work with her. He told her that he had a senior-level Instagram contact in Europe who could help unban and verify her account. He shared a screenshot of a conversation with the contact but, in an apparent oversight, failed to fully redact the name, according to Jenkins.

Seeing no alternative, Jenkins paid OBN $5,000, receipts show. Her account briefly came back online but was soon taken down by Meta. Then OBN blocked her on Telegram and deleted their conversation, according to Jenkins. She decided she had one more option: go directly to OBN’s high-level connection at Instagram. She found the employee’s Telegram account, which had the same username, photo and bio as his verified Instagram account. She messaged the account to say that she’d been working with OBN but he failed to deliver the services promised.

The response was sympathetic: “We made insane money no clue what went wrong.” They struck an agreement to reactivate and verify Jenkins’ account for $4,000. She sent the money, and her account was unlocked on Nov. 18, but it was suspended again four days later; the contact demanded another $4,000 to fix it. Again, Jenkins sent the money.

An excerpt from a Telegram chat between Jenkins and someone she thought was a Meta employee about getting her account restored (Obtained by ProPublica)

On the morning of Nov. 24, she woke up and immediately checked Instagram to see if her account was back. It wasn’t. And she had a new Telegram message from OBN.

“Haha ur talking to my rep such a slut 🤣 he won’t help you for shit anymore I’ll make sure of that,” OBN wrote.

Jenkins’ account never came back. She hired a lawyer and sent Meta a demand letter for $25,000 in damages for the repeated loss of her main Instagram account. Meta hasn’t replied. In reality, Jenkins was paying OBN all along. In an elaborate scam, he had posed on Telegram as the Meta employee. The cryptocurrency wallet to which Jenkins sent payments matched a wallet that OBN has used for other transactions.

ProPublica also traced the IP address of the server that the alleged Meta employee used to access the internet. It wasn’t in Europe. It was used by a cellphone in Las Vegas.

Meta acknowledged that its employee was impersonated. As a result, the employee and his family have faced threats and harassment for years. The employee reported the account to Telegram. After being contacted by ProPublica, Telegram removed the account, which a spokesperson described as “fraudulent.”

Following Reyes-Martinez’s conversation with a ProPublica reporter in his North Las Vegas apartment, the @madetoomuchmoney Instagram account he said belonged to “Brandon” was deactivated. OBN blocked the reporter from his Twitter account and Telegram channel and announced he would no longer offer account banning as a service.

“I’m done with banning if you mention anything about bans I’ll block you,” OBN wrote to his followers.

But he wanted people to know he was still in business.

“Only doing instagram claims & verification, and C&Ds only for high paying nothing less let’s work 🙏.”

by Patrick Rucker, Maya Miller and David Armstrong

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When a stubborn pain in Nick van Terheyden’s bones would not subside, his doctor had a hunch what was wrong.

Without enough vitamin D in the blood, the body will pull that vital nutrient from the bones. Left untreated, a vitamin D deficiency can lead to osteoporosis.

A blood test in the fall of 2021 confirmed the doctor’s diagnosis, and van Terheyden expected his company’s insurance plan, managed by Cigna, to cover the cost of the bloodwork. Instead, Cigna sent van Terheyden a letter explaining that it would not pay for the $350 test because it was not “medically necessary.”

The letter was signed by one of Cigna’s medical directors, a doctor employed by the company to review insurance claims.

Something about the denial letter did not sit well with van Terheyden, a 58-year-old Maryland resident. “This was a clinical decision being second-guessed by someone with no knowledge of me,” said van Terheyden, a physician himself and a specialist who had worked in emergency care in the United Kingdom.

Nick van Terheyden (Jared Soares for ProPublica)

The vague wording made van Terheyden suspect that Dr. Cheryl Dopke, the medical director who signed it, had not taken much care with his case.

Van Terheyden was right to be suspicious. His claim was just one of roughly 60,000 that Dopke denied in a single month last year, according to internal Cigna records reviewed by ProPublica and The Capitol Forum.

The rejection of van Terheyden’s claim was typical for Cigna, one of the country’s largest insurers. The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for 18 million people.

Before health insurers reject claims for medical reasons, company doctors must review them, according to insurance laws and regulations in many states. Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials.

But the Cigna review system that blocked van Terheyden’s claim bypasses those steps. Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.

“We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”

Not all claims are processed through this review system. For those that are, it is unclear how many are approved and how many are funneled to doctors for automatic denial.

Insurance experts questioned Cigna’s review system.

Patients expect insurers to treat them fairly and meaningfully review each claim, said Dave Jones, California’s former insurance commissioner. Under California regulations, insurers must consider patient claims using a “thorough, fair and objective investigation.”

“It’s hard to imagine that spending only seconds to review medical records complies with the California law,” said Jones. “At a minimum, I believe it warrants an investigation.”

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

Within Cigna, some executives questioned whether rendering such speedy denials satisfied the law, according to one former executive who spoke on condition of anonymity because he still works with insurers.

“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.”

Cigna adopted its review system more than a decade ago, but insurance executives say similar systems have existed in various forms throughout the industry.

In a written response, Cigna said the reporting by ProPublica and The Capitol Forum was “biased and incomplete.”

Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,” Cigna wrote. “This allows us to automatically approve claims when they are submitted with correct diagnosis codes.”

When asked if its review process, known as PXDX, lets Cigna doctors reject claims without examining them, the company said that description was “incorrect.” It repeatedly declined to answer further questions or provide additional details. (ProPublica employees’ health insurance is provided by Cigna.)

Former Cigna doctors confirmed that the review system was used to quickly reject claims. An internal corporate spreadsheet, viewed by the news organizations, lists names of Cigna’s medical directors and the number of cases each handled in a column headlined “PxDx.” The former doctors said the figures represent total denials. Cigna did not respond to detailed questions about the numbers.

Cigna's explanation that its review system was designed to approve claims didn’t make sense to one former company executive. “They were paying all these claims before. Then they weren’t,” said Ron Howrigon, who now runs a company that helps private doctors in disputes with insurance companies. “You’re talking about a system built to deny claims.”

Cigna emphasized that its system does not prevent a patient from receiving care — it only decides when the insurer won’t pay. “Reviews occur after the service has been provided to the patient and does not result in any denials of care,” the statement said.

"Our company is committed to improving health outcomes, driving value for our clients and customers, and supporting our team of highly-skilled Medical Directors,” the company said.

PXDX

Cigna’s review system was developed more than a decade ago by a former pediatrician.

After leaving his practice, Dr. Alan Muney spent the next several decades advising insurers and private equity firms on how to wring savings out of health plans.

In 2010, Muney was managing health insurance for companies owned by Blackstone, the private equity firm, when Cigna tapped him to help spot savings in its operation, he said.

Insurers have wide authority to reject claims for care, but processing those denials can cost a few hundred dollars each, former executives said. Typically, claims are entered into the insurance system, screened by a nurse and reviewed by a medical director.

For lower-dollar claims, it was cheaper for Cigna to simply pay the bill, Muney said.

“They don’t want to spend money to review a whole bunch of stuff that costs more to review than it does to just pay for it,” Muney said.

Muney and his team had solved the problem once before. At UnitedHealthcare, where Muney was an executive, he said his group built a similar system to let its doctors quickly deny claims in bulk.

In response to questions, UnitedHealthcare said it uses technology that allows it to make “fast, efficient and streamlined coverage decisions based on members benefit plans and clinical criteria in compliance with state and federal laws.” The company did not directly address whether it uses a system similar to Cigna.

At Cigna, Muney and his team created a list of tests and procedures approved for use with certain illnesses. The system would automatically turn down payment for a treatment that didn’t match one of the conditions on the list. Denials were then sent to medical directors, who would reject these claims with no review of the patient file.

Cigna eventually designated the list “PXDX” — corporate shorthand for procedure-to-diagnosis. The list saved money in two ways. It allowed Cigna to begin turning down claims that it had once paid. And it made it cheaper to turn down claims, because the company’s doctors never had to open a file or conduct any in-depth review. They simply denied the claims in bulk with an electronic signature.

“The PXDX stuff is not reviewed by a doc or nurse or anything like that,” Muney said.

The review system was designed to prevent claims for care that Cigna considered unneeded or even harmful to the patient, Muney said. The policy simply allowed Cigna to cheaply identify claims that it had a right to deny.

Muney said that it would be an “administrative hassle” to require company doctors to manually review each claim rejection. And it would mean hiring many more medical directors.

“That adds administrative expense to medicine,” he said. “It’s not efficient.”

But two former Cigna doctors, who did not want to be identified by name for fear of breaking confidentiality agreements with Cigna, said the system was unfair to patients. They said the claims automatically routed for denial lacked such basic information as race and gender.

“It was very frustrating,” one doctor said.

Some state regulators questioned Cigna’s PXDX system.

In Maryland, where van Terheyden lives, state insurance officials said the PXDX system as described by a reporter raises “some red flags.”

The state’s law regulating group health plans purchased by employers requires that insurance company doctors be objective and flexible when they sit down to evaluate each case.

If medical directors are “truly rubber-stamping the output of the matching software without any additional review, it would be difficult for the medical director to comply with these requirements,” the Maryland Insurance Administration wrote in response to questions.

Medicare and Medicaid have a system that automatically prevents improper payment of claims that are wrongly coded. It does not reject payment on medical grounds.

Within the world of private insurance, Muney is certain that the PXDX formula has boosted the corporate bottom line. “It has undoubtedly saved billions of dollars,” he said.

Insurers benefit from the savings, but everyone stands to gain when health care costs are lowered and unneeded care is denied, he said.

Speedy Reviews

Cigna carefully tracks how many patient claims its medical directors handle each month. Twelve times a year, medical directors receive a scorecard in the form of a spreadsheet that shows just how fast they have cleared PXDX cases.

Dopke, the doctor who turned down van Terheyden, rejected 121,000 claims in the first two months of 2022, according to the scorecard.

Van Terheyden’s denial letter from Cigna (highlights and redactions added by ProPublica)

Dr. Richard Capek, another Cigna medical director, handled more than 80,000 instant denials in the same time span, the spreadsheet showed.

Dr. Paul Rossi has been a medical director at Cigna for over 30 years. Early last year, the physician denied more than 63,000 PXDX claims in two months.

Rossi, Dopke and Capek did not respond to attempts to contact them.

Howrigon, the former Cigna executive, said that although he was not involved in developing PXDX, he can understand the economics behind it.

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”

Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection, according to Howrigon and other former employees of the company. The PXDX list is focused on tests and treatments that typically cost a few hundred dollars each, said former Cigna employees.

“Insurers are very good at knowing when they can deny a claim and patients will grumble but still write a check,” Howrigon said.

Muney and other former Cigna executives emphasized that the PXDX system does leave room for the patient and their doctor to appeal a medical director’s decision to deny a claim.

But Cigna does not expect many appeals. In one corporate document, Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review.

“A Negative Customer Experience”

In 2014, Cigna considered adding a new procedure to the PXDX list to be flagged for automatic denials.

Autonomic nervous system testing can help tell if an ailing patient is suffering from nerve damage caused by diabetes or a variety of autoimmune diseases. It’s not a very involved procedure — taking about an hour — and it costs a few hundred dollars per test.

The test is versatile and noninvasive, requiring no needles. The patient goes through a handful of checks of heart rate, sweat response, equilibrium and other basic body functions.

At the time, Cigna was paying for every claim for the nerve test without bothering to look at the patient file, according to a corporate presentation. Cigna officials were weighing the cost and benefits of adding the procedure to the list. “What is happening now?” the presentation asked. “Pay for all conditions without review.”

By adding the nerve test to the PXDX list, Cigna officials estimated, the insurer would turn down more than 17,800 claims a year that it had once covered. It would pay for the test for certain conditions, but deny payment for others.

These denials would “create a negative customer experience” and a “potential for increased out of pocket costs," the company presentation acknowledged.

But they would save roughly $2.4 million a year in medical costs, the presentation said.

Cigna added the test to the list.

“It’s Not Good Medicine”

By the time van Terheyden received his first denial notice from Cigna early last year, he had some answers about his diagnosis. The blood test that Cigna had deemed “not medically necessary” had confirmed a vitamin D deficiency. His doctor had been right, and recommended supplements to boost van Terheyden’s vitamin level.

Van Terheyden (Jared Soares for ProPublica)

Still, van Terheyden kept pushing his appeal with Cigna in a process that grew more baffling. First, a different Cigna doctor reviewed the case and stood by the original denial. The blood test was unnecessary, Cigna insisted, because van Terheyden had never before been found to lack sufficient vitamin D.

“Records did not show you had a previously documented Vitamin D deficiency,” stated a denial letter issued by Cigna in April. How was van Terheyden supposed to document a vitamin D deficiency without a test? The letter was signed by a Cigna medical director named Barry Brenner.

Brenner did not respond to requests for comment.

Then, as allowed by his plan, van Terheyden took Cigna’s rejection to an external review by an independent reviewer.

In late June — seven months after the blood test — an outside doctor not working for Cigna reviewed van Terheyden’s medical record and determined the test was justified.

The blood test in question “confirms the diagnosis of Vit-D deficiency,” read the report from MCMC, a company that provides independent medical reviews. Cigna eventually paid van Terheyden’s bill. “This patient is at risk of bone fracture without proper supplementations,” MCMC’s reviewer wrote. “Testing was medically necessary and appropriate.”

Van Terheyden had known nothing about the vagaries of the PXDX denial system before he received the $350 bill. But he did sense that very few patients pushed as hard as he had done in his appeals.

As a physician, van Terheyden said, he’s dumbfounded by the company’s policies.

“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?” he said.

“Intellectually, I can understand it. As a physician, I can’t. To me, it feels wrong.”

Doris Burke contributed research.

Clarification, March 27, 2023: This article was updated to clarify that a response from the Maryland Insurance Administration referred to medical directors in general.

by Kathleen McGrory and Neil Bedi

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The Environmental Protection Agency took an unusual step last week: It opened a new period in which the public can comment on its proposed asbestos ban. The agency had gotten new information, officials said, including a series of ProPublica reports on dangerous working conditions in factories that use asbestos to make chlorine.

Asbestos has been long known to cause deadly cancers and other serious illnesses. While dozens of countries have outlawed the substance, the U.S. still imports hundreds of tons each year, mostly for use in chlorine manufacturing.

Last spring, the EPA proposed a ban on chrysotile, or white asbestos, the most common type. People had until July to submit comments. More than 150 did, the EPA said.

In their comments, the chlorine companies said that workers in their plants had handled asbestos safely for decades and that requiring manufacturers to quickly transition to newer, asbestos-free technology could cause a shortage of the chlorine used to disinfect drinking water.

Then, in October, ProPublica revealed that workers in a Niagara Falls, New York, plant were regularly exposed to asbestos until the facility closed in 2021 for unrelated reasons. Experts called the conditions described by workers “unacceptable” and “fraught with danger.” The company that ran the plant, OxyChem, said the workers’ accounts were not accurate but would not specify what information was incorrect. ProPublica’s report also detailed how chlorine companies have quietly fought against a ban for decades, even though they use modern, asbestos-free technology in some of their plants.

ProPublica later reported that workers at four other plants had observed unsafe practices involving asbestos at their facilities, too. One longtime janitor at an Alabama plant run by Olin Corp. said she was given no personal protective equipment, even while pregnant, as she scraped dried asbestos from bathroom floors. Olin did not return repeated calls or emails from ProPublica.

Last Friday, the EPA announced it was publishing additional information it had obtained from chlorine companies and the nonprofit Asbestos Disease Awareness Organization during meetings that took place in recent months. The agency also said it was publishing written comments submitted during that time.

ProPublica’s reports were among the subjects of the meetings and comments, the EPA said.

The submissions from the chlorine companies focused largely on the EPA’s proposed two-year timeline to comply with a ban, records show. The companies said that shortages of rare metals and other factors would make it difficult to transition to different technology that quickly. They also pushed back on an alternative plan that would give them five years if they complied with requirements for monitoring worker exposure to asbestos, saying that option was not technically feasible. They want at least 15 years to transition away from the toxic mineral.

Asbestos Disease Awareness Organization president Linda Reinstein was critical of the information from the chlorine companies and industry groups, some of which had been previously submitted to the EPA. “This ‘new information’ from industry is another desperate attempt to delay transitioning their archaic plants to modern technology,” she said in a statement.

OxyChem and Olin did not return emails from ProPublica.

The American Chemistry Council, a trade organization for the chlorine producers, told ProPublica that the companies had provided “data and information that outlines the multiple steps required for large manufacturing operations to begin conversion, including engineering design, permitting and regulatory approvals, delivery of critical components, construction and startup.” The group added: “Conversion to another technology is extremely capital intensive and will take many years to complete.”

Members of the public have until April 17 to comment on the material. The EPA has specifically requested feedback on its proposed timeline for implementing a ban, on the suggested exposure monitoring requirements and on the safety issues raised in ProPublica’s reports.

The agency — which was recently the subject of a Government Accountability Office report that found it consistently missed deadlines relating to chemical regulation — told ProPublica this week that it was still on track to finalize the rule in the fall.

Reinstein, in her statement, urged the agency to “move forward with a transition plan that puts people over profits.”

She and her organization are also continuing their push to get an even tougher asbestos ban through Congress. In years past, lawmakers have filed a bill named for Reinstein’s husband, Alan, who died from mesothelioma, a cancer caused by asbestos exposure. Sen. Jeff Merkley and Rep. Suzanne Bonamici, both Oregon Democrats, said they plan to reintroduce the bill soon.

by Duaa Eldeib

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Federal officials have released a bleak assessment of the country’s progress in understanding and preventing stillbirths, calling the rate “unacceptably high” and issuing a series of recommendations to reduce it through research and prevention.

The National Institutes of Health report, titled “Working to Address the Tragedy of Stillbirth,” mirrored findings of an investigation by ProPublica last year into the U.S. stillbirth crisis, in which more than 20,000 pregnancies every year are lost at 20 weeks or more and the expected baby is born dead.

ProPublica’s reporting found that a number of factors contributed to the nation’s failure to bring down the stillbirth rate: medical professionals dismissing the concerns of their pregnant patients, a lack of research and data, and too few autopsies being performed. Additionally, alarming racial disparities in stillbirth rates have compounded the crisis.

“The extent of the problem is massive,” said Dr. Lucky Jain, who served as co-chair of the Stillbirth Working Group of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Council, which issued the report last week. “All of my life, I have maintained that what I cannot measure, I cannot improve. And so if I don’t have proper data, records, autopsy findings, genetics, the background information of why a fully formed baby died suddenly, how do I even begin improving things as a scientist?”

The working group concluded that barriers to lowering the stillbirth rate could not be traced to one federal agency or a single state health department or local hospital, Jain said, but to problems “at every level.”

“The report has reinforced what you all have already been saying,” said Jain, who is chair of pediatrics at Emory University School of Medicine and pediatrician-in-chief at Children’s Healthcare of Atlanta. “ProPublica has emphasized the need for an autopsy, has emphasized the need for reporting stillbirths. There’s plenty of overlap and the same type of concern that ProPublica has expressed around stillbirths.”

ProPublica found that federal health agencies had not prioritized stillbirth-focused research, data collection or analysis, and that those agencies, along with state health departments, hospitals and medical providers, had done a poor job of raising awareness about stillbirth risk and prevention.

Although many people, including some medical providers, believe that stillbirths are inevitable, research shows that as many as 1 in 4 may be preventable.

The newly released report, which called stillbirth “a major public health concern,” was the result of a congressional mandate that required the Department of Health and Human Services to develop a stillbirth task force. The working group was charged with examining health disparities and communities that face a higher risk of stillbirth; barriers to collecting data; the psychological impact of and treatment received after a stillbirth; and known risk factors.

Dr. Diana W. Bianchi, director of the National Institute of Child Health and Human Development, the branch of the National Institutes of Health that led the working group, said in an email that one of the agency’s goals is to advance efforts to “better understand and ultimately prevent” stillbirths. Among its priorities, Bianchi said, is moving forward on the working group’s recommendation to create a research agenda to “develop specific, actionable approaches to prevent stillbirth.”

Work to implement the report’s recommendations, she said, will begin this spring and summer.

In total, the working group issued 12 recommendations, the majority of which were aimed at the NIH and the Centers for Disease Control and Prevention. A CDC spokesperson said the agency is investigating risk factors and health disparities and is considering which existing CDC projects could be used for stillbirth research, such as those that already collect data on birth defects and pregnancy risks.

“Findings on factors associated with stillbirths will inform CDC’s next steps, including further research and potential prevention efforts,” the spokesperson said.

Several of the working group’s recommendations were related to improving the quality of stillbirth data at the local, state and national levels. Specific changes included standardizing definitions, enhancing training for employees who collect data for fetal death certificates, and making it easier to amend that data when needed.

One of the reasons stillbirth data often is incomplete or inaccurate is that autopsies, placental exams and genetic testing are not uniformly performed. And even if one or more of those exams are carried out and do reveal a cause of death, that critical piece of information is typically not updated in state or federal databases.

ProPublica found that in 2020, placental exams were performed or planned in only 65% of stillbirth cases and autopsies were conducted or planned in less than 20% of cases. The federal report identified several of the same barriers that ProPublica had spotlighted.

“Many parents report that hospital staff discouraged them from requesting an autopsy of their stillborn baby because of cost, because it might be inconclusive, or because it would disfigure the baby,” the working group concluded. “Doctors may also be worried about liability.”

The report noted that while Medicaid covers a large portion of pregnancies and births, it does not cover the cost of an autopsy. Experts previously told ProPublica that they believed an autopsy after a stillbirth should be covered as a continuation of maternal care.

A spokesperson for the Centers for Medicare & Medicaid Services said autopsies are not covered because they do not fall “within the definition of medical assistance established by Congress.”

The working group also suggested that states could model their policies for stillbirth autopsies after policies relating to sudden infant death syndrome. Many states, which have designated SIDS as a “public health emergency,” pay for autopsies if a baby is suspected to have died of SIDS. In 2020, the number of stillbirths was 15 times the number of SIDS deaths.

The report also addressed the devastating psychological effects of a stillbirth. Many parents withdraw from the world and are at a higher risk of depression, post-traumatic stress disorder and anxiety, the working group found. Those feelings may be compounded if patients are dismissed or blamed for the stillbirth.

“It is not uncommon for individuals of color, in particular, to speak of healthcare providers who treated them with a dismissive attitude or who feel that there is no point in speaking up about certain concerns because they will not be heard and it will not make a difference,” the report said.

Black women are more than twice as likely — and in some states close to three times as likely — as white women to have a stillbirth, according to 2020 CDC data. The national stillbirth rate for Black women that year was 10.3 per 1,000 births, and for white women it was 4.7. But it’s not just Black babies who are dying at a disproportionate rate. So are their mothers.

The same week that the NIH stillbirth report was released, the CDC issued a separate report on maternal mortality that found that the rate of mothers dying while pregnant or shortly after birth increased in 2021, while the rate of maternal mortality in Black women was more than double that of white women.

Sen. Jeff Merkley, a Democrat from Oregon, said the stillbirth report, coupled with ProPublica’s reporting and the most recent CDC data on maternal mortality, “underscores the fact that stillbirths and maternal mortality are shockingly high in the United States compared with other similarly developed nations, and that Black women are paying the highest price.”

Merkley, who last year had co-sponsored a stillbirth bill that did not ultimately pass, called for change and said one way to “stem the tide of these horrific outcomes” is to ensure that states use federal maternal health funding to implement stillbirth interventions, as he proposed doing in his legislation.

The American College of Obstetricians and Gynecologists, the nation’s leading organization of OB-GYNs, supports the report’s findings, particularly the need for additional research, said Dr. Christopher Zahn, ACOG’s chief of clinical practice and health equity and quality. Many stillbirths, he said, remain unexplained.

Members of PUSH for Empowered Pregnancy, a New York-based nonprofit that works to prevent stillbirths, emerged as vocal advocates during the working group sessions. Samantha Banerjee, executive director of PUSH, said the organization forwarded ProPublica’s reporting to the working group and pressed for families who’ve experienced a stillbirth to be included in the process. After a rocky start in the early sessions, she said, she and her team witnessed a shift in the way the group approached the issue.

Banerjee, whose email signature includes “Mom to Alana, born still in 2013,” said the final report exceeded her expectations.

“This is the first time in over a decade that we have seen the U.S. take a substantial step in the right direction when it comes to ending preventable stillbirths,” she said. “The dire landscape of stillbirth prevention is accurately described, and there are clear calls to action for systemic change intended to prevent stillbirths.”