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

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

On a chilly November morning in 2019, Lutrice Williams, a patient at a state-run mental health center in southern Illinois, was surprised by a visit from a sheriff’s deputy. He served Williams a summons ordering her to report to criminal court on a felony battery charge.

Williams has been diagnosed with an intellectual disability, bipolar disorder and post-traumatic stress disorder, and her personal story consists of one upheaval after another. At age 23, in a state of crisis, Williams had sought help at Choate Mental Health and Developmental Center. She’d never been charged with a crime before. But four months before the deputy showed up, a Choate employee who claimed Williams had forcefully shoved her asked her employer to pursue charges against the patient.

“You have a job to deal with people with mental health problems,” Williams said she thought at the time. “Why are you charging me?”

Williams, records show, is far from the only patient to have faced criminal charges.

By scouring courthouse and police records, reporters with Lee Enterprises Midwest, Capitol News Illinois and ProPublica discovered at least 40 felony charges filed against 29 patients since 2015 in two of the four downstate counties where the state operates a residential facility. (Reporters did not identify any charges at two of the four facilities.)

Of the 29 patients charged, 22 were receiving care at Choate. The facility, which treats people with intellectual and developmental disabilities and mental illnesses, has been the subject of a monthslong investigation by the news organizations.

The charges against patients contrast sharply with the way the facility and police agencies have handled employees who are accused of mistreating and abusing patients. In some of those cases, staff who faced serious abuse allegations experienced few consequences because colleagues refused to cooperate in investigations — or actively worked to derail them.

“Everybody [at Choate] was always fighting everybody. Residents, staff, everybody.”

—Lutrice Williams, Choate patient who was charge with aggravated battery

At the same time, the institution and its employees sought charges against patients even as watchdogs say it failed to provide legally required services, such as individualized therapy for people with traumatic histories and poor coping mechanisms. What’s more, Choate carried out its own investigations against patients under its care, and prosecutors used those investigations to press charges even in cases when the patients denied the allegations against them and there were no other witnesses.

The charges in all but one of the 40 cases were elevated from misdemeanors to felonies based on legal technicalities allowed under Illinois law — that the altercations happened at a “public place” or that the victim was a medical professional — rather than the seriousness of the acts.

The accusations included hitting, pushing, hair pulling and, in one case, throwing soiled underwear at an employee. Some patients faced multiple charges over several years. Many of the patients who were charged had legal guardians, meaning that a court had previously found them unable to handle their own affairs. Among this group was one patient whose mental function was at the level of a preschooler, court records show. Some of the young adults who faced charges had experienced physical or sexual abuse as children and had only recently aged out of the foster care system, court records show.

Reporters spoke with seven legal experts and advocates for people with developmental disabilities and mental illness who said they were alarmed that so many patients had been charged at a single facility, especially one set up to help people with complex needs and behavioral issues. Except in extreme cases, they said, patients in crisis should not be charged.

Leigh Ann Davis, who oversees the National Center on Criminal Justice and Disability at The Arc, one of the nation’s largest advocacy organizations for people with disabilities, said she’d never heard of such a large number of patients at a single facility facing charges in her 26 years in the field. Although there’s a dearth of data on the subject, she said, the numbers are “deeply concerning.”

“This is such an invisible population in the criminal justice system and this situation really showcases that,” she said.

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

The Illinois Department of Human Services does not track patient arrests at its facilities. During an interview with reporters, one senior official said she hadn’t been aware of the volume of patients who had faced charges at Choate.

She also said she didn’t know the facility security staff had been conducting investigations and determining whether patients had committed felonies that were then referred to the state’s attorney. She called the practice “highly inappropriate.” In a statement, an IDHS spokesperson said that upon learning about this, the agency “acted immediately to ensure that this practice has stopped.” The statement said that Choate itself “does not pursue criminal charges against residents and instead works to provide them with the appropriate treatment.”

The statement also said that staff members who are injured on the job by a patient do have the right to pursue charges on their own by filing a complaint with a law enforcement agency or the state’s attorney and “IDHS cannot infringe on that right,” the statement said. “When staff chooses to exercise that right, it is then the decision of the local state’s attorney and law enforcement as to how investigations proceed and whether to pursue charges and IDHS fully cooperates in all cases.”

Tyler Edmonds, who was the state’s attorney when most of the patients were charged, is no longer in that role. He declined comment to a reporter, saying it would violate judicial ethics because he’s now a judge in Union County, where the courthouse continues to hear cases about Choate. Tyler Tripp, who was the defense attorney for many of the charged patients, including Williams, and who took over as state’s attorney in 2020, said that each charging decision he makes is dependent upon the unique facts of the case and strength of available evidence. With regards to Choate patients accused of crimes, Tripp said he does take into consideration the fact that individuals are already in a facility receiving treatment and how this could impact their criminal intent, among other considerations. Court records show he has filed charges against two patients.

Patients Untreated for Years

For many patients, Choate is an option of last resort when family or supervised community homes are no longer able to provide the level of care they need.

That’s how it was for Williams, who grew up on Chicago’s South Side. She was born with fetal alcohol syndrome; her father was seldom in the picture, and her mother lost custody of her when she was a baby. Her adopted mom died unexpectedly when Williams was 16.

Overwhelmed by the loss, she began acting out and skipping school. She tried living with other family members, but they found her behaviors too difficult to manage. Then she reentered the foster care system, according to medical records she provided to a reporter.

After she aged out, Williams spent five years at a supervised community home for adults with intellectual and developmental disabilities in Chicago. She wanted nothing more than to live a normal life, and she experienced some successes. She graduated from high school at 21 and held an office job, answering phones, filing paperwork and cleaning.

Williams, who recently turned 30, has kind eyes that turn up at the edges when she smiles, and she can be exceedingly sweet. But her feelings, she said, are like a layer of raw skin — and the slightest bump against it can send her flying into fits of rage.

Lutrice Williams (Courtesy of Lutrice Williams)

“It’s like I black out until I calm down again,” she said.

In the year before she arrived at Choate, she’d been hospitalized for psychiatric treatment on four occasions for aggression and homicidal threats to staff at her community home. She had refused to take her medications and attempted to run away on multiple occasions, her medical records show.

After an incident in November 2015, staff said she couldn’t return. She spent nearly four months at the hospital while her treatment team looked for places for her to live.

Eventually, they suggested she try Choate — located at the opposite end of the state in rural southern Illinois. Williams was skeptical, but when she spoke with Choate staff by phone, they sounded nice and told her she’d get the help she needed there, Williams recalled.

She arrived on the grounds of the wooded campus in March 2016, having traveled some 350 miles in the back of an ambulance.

“When I got there, it was a whole different story,” she said.

Williams said she felt she didn’t receive the level of talk therapy she needed to address the trauma she’d endured in her life. She said some staff members were dismissive and rude, and that she was physically abused.

She is named as the victim in a felony case against an employee accused of whipping her with a belt in 2020, court records show; two colleagues reported the alleged abuse to authorities. The employee, whose employment with Choate ended after he was charged, has pleaded not guilty, and his jury trial is scheduled for early next year.

Williams said there wasn’t much to do at Choate, and residents spent much of their days watching TV.

“It’s a lot of downtime,” she said. “That’s where I think a lot of the behaviors came from. Everybody was always fighting everybody. Residents, staff, everybody.”

Williams’ criticisms of the institution’s shortcomings are echoed by oversight entities and advocacy organizations. In a 2009 report, the U.S. Department of Justice’s Civil Rights Division found “many instances where individuals were receiving inappropriate or insufficient behavioral interventions” at Choate.

These shortcomings, the report concluded, led to an overreliance on the use of restraints by Choate staff to control patients, contributed to an unsafe environment and ultimately resulted in patients staying at Choate far longer than they should have, in violation of their constitutional rights.

More than a decade later, staff with a legal advocacy organization, Equip for Equality, conducted a review of programming at Choate and again found the facility falling short. Numerous residents at Choate and other similar state-run institutions “have significant trauma histories that do not appear to be adequately addressed,” the organization wrote in a September 2021 report to the Illinois Department of Human Services obtained under the Freedom of Information Act.

Stacey Aschemann, an Equip for Equality vice president, said in an interview that Choate residents aren’t offered the individualized therapy many of them need. And monitors with the organization have observed residents sitting around for much of the day with little to do. Aschemann said that this lack of effective treatment “negatively impacts an individual’s progress and personal safety” and that it contributes to a “chaotic and sometimes unsafe environment.”

Heidi Dalenberg, an attorney with the American Civil Liberties Union of Illinois, said Choate and its staff have responded to the “consequences of its own failure of care” by arresting patients in need of help. “The end result is the person went in as someone with an illness needing treatment and exits as a ‘criminal,’” she said. “That is an abusive system.”

In previous reporting, IDHS acknowledged ongoing problems at Choate in patient care and safety and said that the shortcomings are the result of “longstanding, entrenched issues dating back decades.” The department said that the current administration, under Gov. JB Pritzker, has taken aggressive measures to resolve these issues. In a new statement, the department said its focus at Choate is on “providing quality care to residents and keeping staff and residents safe,” which includes working individually with residents to ensure they receive the appropriate treatment.

“The person went in as someone with an illness needing treatment and exits as a ‘criminal.’ That is an abusive system.”

—Heidi Dalenberg, attorney with the American Civil Liberties Union of Illinois

By the time Williams was charged, she had been a patient at Choate for more than three years. Displays of impulsive behavior were part of her history.

When she arrived, an evaluation of Williams identified verbal and physical aggression and the provoking of others as “areas of primary concern.” Her medical records stated she was admitted to Choate specifically to receive treatment to “stabilize her behavior” and moods.

The IDHS spokesperson said the agency could not disclose individual treatment plans, but said that both one-on-one and group therapy are available to Choate residents. Therapy needs, IDHS said, are “determined on a case-by-case basis.”

Other residents who faced charges while at Choate also had sought treatment because of their traumatic pasts or behaviors that stemmed from their disabilities. In March 2019, an employee accused a patient of pulling out a chunk of her hair when she told the patient that she couldn’t attend activities due to “staff shortages.” Nine months later, the patient was charged with felony battery. In a court-ordered fitness evaluation, an IDHS social worker wrote that the resident’s “maladaptive behavior” was driven by elements of her intellectual disability, including poor coping skills, lack of impulse control and low tolerance for frustration.

Another young woman who was charged while receiving care at Choate had been hospitalized dozens of times for unstable moods and psychosis while growing up in the foster care system. In November 2016, the patient told a nurse she didn’t feel well. When the nurse told her to wait to be seen while the nurse finished other work, the patient attacked her, though she wasn’t seriously injured, internal records obtained by reporters show. In August 2017, the patient pleaded guilty to felony aggravated battery.

A year later, staff found the patient dead in her room. An autopsy determined that she died by suicide while in Choate’s care, according to a coroner’s report obtained under the Freedem of Information Act.

Facility Staff Handle Investigations

Decisions on whether to pursue charges against patients for misconduct during the course of their treatment are largely left up to local officials. Reporters examined how these decisions were handled at four state-run facilities in southern Illinois.

Chester Mental Health Center, a maximum-security, state-run psychiatric hospital located about 55 miles northwest of Choate, serves the largest number of patients of the four — about 450 people annually. It primarily houses men with mental illnesses who were ordered by a court to receive treatment, including some who were accused of violent crimes. Reporters did not find any felony charges filed against patients since 2015 in Randolph County, where Chester is located.

Jeremy Walker, who was the state’s attorney in that county until late last year when he became a judge, said he didn’t pursue charges because patients would most likely be found unfit to stand trial. With a few exceptions, he said in an interview in October, it would be a “waste of time and resources” to bring them into criminal court when they were already confined to a secure facility for mental health treatment.

Alton Mental Health Center, located outside of St. Louis, serves a similar population to the one at Chester, but the smaller, medium-security hospital mostly houses women. Since 2015, prosecutors have filed 11 felony charges against seven patients at Alton. Most of these charges were filed in the past three years, though court hearings have been suspended so that patients’ treatment at Alton isn’t interrupted, a spokesperson for Madison County State’s Attorney Tom Haine said. IDHS, which also runs Alton, said the facility did not conduct the investigations against the patients there.

Chester Mental Health Center (Illinois Department of Human Services)

Reporters found no felony charges against patients at Murray Developmental Center, which serves patients with developmental disabilities. (The state’s attorney in Clinton County, where Murray is located in south-central Illinois, declined an interview).

But at Choate, it wasn’t only the number of residents taken to criminal court that alarmed advocates. The facility’s handling of residents’ alleged misconduct may have violated their civil rights, experts said.

When employees at Choate faced abuse allegations, Illinois State Police investigators were called to the scene. They notified the accused workers of their Miranda rights as well as their Garrity rights, which prohibit public employees from being compelled to incriminate themselves during an investigation by their employer.

When patients were accused, on the other hand, Choate handled the investigations internally. A Choate security officer questioned the patient and any witnesses. The accused patients were not read Miranda warnings and their guardians were not contacted.

In an interview, Steve Hartline, the longtime security chief at Choate who retired at the end of 2019, said his staff didn’t need to read Miranda warnings to patients because Choate’s security officers are civilian employees — not sworn law enforcement officers. The staff’s role, he said, was to conduct a “neutral” investigation and forward the interview reports to the state’s attorney’s office.

“We had no control over who was charged or who wasn’t charged,” Hartline said. “Everything was sent to the state’s attorney, and the state’s attorney made his discretionary call.” Hartline, who is also the longtime mayor of Anna, the town where Choate is located, stressed that he was not acting as a police officer, a job he held prior to coming to Choate. “We are not a criminal law enforcement entity. We don’t recommend any criminal charges or anything.”

But internal investigative records show that, in some cases, security officers’ reports sent to the state’s attorney’s office included their conclusions that the patients had committed felony battery. That’s what happened in Williams’ case.

“This isn’t right. Why isn’t law enforcement doing these investigations?”

—Barry Smoot, former head of security at Choate

Natalie Barnes, the employee who said she was assaulted, returned to work about two weeks after the incident and filed a statement with Choate security. She said Williams had caused a “cervical strain” in her neck that had to be treated in an emergency room. “This writer would like Chief Hartline to move forward and press charges against Lutrice Williams,” she wrote.

The next day, a security officer visited Williams’ unit and questioned her about the incident, though the officer didn’t tell her it was because an employee wanted her to be charged. Williams told the security officer that Barnes had gotten into her personal space and ordered her to stop knocking on a fellow patient’s door, so she put her hand on Barnes’ chest and pushed her backwards.

Both Barnes and Williams told the security staff that no one else was present during the altercation.

Security ultimately sent the report, complete with Williams’ statements, to the state’s attorney with a finding that she had committed aggravated battery. Four months later, Williams was charged with that crime, which carries a possible sentence of up to five years in prison and a $25,000 fine. Barnes declined comment.

Williams was one of seven patients charged at Choate in 2019. In other years, from 2015 to the present, between one and eight patients were charged per year. The last patient was charged in early 2022.

When Barry Smoot took over as security chief in early 2020, he said he was surprised to learn that patients were being charged with felonies for what he said were relatively minor assaults on staff.

He was further alarmed to discover that Choate had been taking statements from patients that became the basis for criminal charges against them.

“This isn’t right. Why isn’t law enforcement doing these investigations?” Smoot recalled thinking at the time. “We shouldn’t be interviewing people when we are providing them with services. We shouldn’t be taking those cases for charges.”

Smoot, who has since retired, initiated a change in policy that now dictates that an employee who wants to press charges must take their case to a law enforcement agency, rather than internal Choate security staff.

Consequences of Being Charged

Most of the Choate patients who faced charges were initially found unfit to stand trial because they were unable to articulate the basics of court proceedings or participate in their own defense, which are minimal competency requirements under the law. They were ordered to undergo treatment to ready them to stand trial. But in numerous cases, IDHS mental health professionals determined that they were unlikely to gain fitness because of the severity of their disabilities.

That doesn’t mean the charges didn’t come with consequences.

Through a variety of legal mechanisms, patients were ordered into the custody of IDHS for treatment in a state facility, where some remained for years, even when the criminal charges against them were dismissed.

“This ain’t right and they shouldn’t be doing this. … I’d be more educated” and wouldn't accept the plea deal if she could do things over.

—Lutrice Williams, Choate patient who was charge with aggravated battery

Among those who were able to meet the fitness benchmark to face the charges against them, two were found not guilty by reason of insanity.

Findings of unfitness or not guilty by reason of insanity usually meant a transfer to a more secure hospital. Female patients at Choate with this status were typically transferred to Alton Mental Health’s forensic treatment program, located about 140 miles northwest of Choate. One of the patients who was charged with a felony at Choate was transferred to Alton, where she later faced four additional felony charges. The patient, according to court records, had a history of physical and sexual abuse as a child.

Williams, whose intellectual disability is in the mild range, was also initially found unfit to stand trial.

She was ordered into the state’s care at Choate, where she was already a patient. “They wanted to get rid of me,” she said; Williams would have gone to Alton, but transfers were halted during the pandemic, records show. Williams said she was given printouts to read about court terminology and tested again. Eventually, she was found fit to stand trial and her defense attorney urged her to accept a plea deal for misdemeanor battery.

Tripp, who was then Williams’ defense attorney and is now the state’s attorney, said he did raise questions about the investigation when he was arguing to reduce the charge against her. Tripp said that it is typical to see defendants plead to a lower-level offense to avoid the risk of felony conviction. “There’s an additional built-in credibility hurdle to clear in most cases that rely heavily on statements by those with mental health concerns,” Tripp said, which may make a jury less apt to believe a defendant’s version of events.

In August 2020, she was sentenced to 12 months of conditional discharge, which is a less restrictive alternative to court supervision.

She’s among four patients who were convicted. Three others received felony convictions.

Of all of the problems she said she faced at Choate, Williams is most frustrated by the fact that she was charged. If she could go back, Williams said, she wouldn’t accept the plea deal.

“This ain’t right and they shouldn’t be doing this,” Williams said. “At first, I didn’t know. I’d be more educated.”

Williams was discharged from Choate in November 2020 and is trying to stabilize her life. She has enrolled in college classes and is applying for jobs. But with every application she sends out, she worries that her criminal record will give the hiring manager pause.

And in some cases, it has. She provided the news organizations with a rejection letter from a temporary hiring agency showing she’d been disqualified for jobs because of the misdemeanor battery conviction. “Based on the enclosed background report,” said the letter from PeopleReady, “we have reservations about hiring you for the initial position offered.” The letter cited her Union County conviction from her time at Choate.

Williams said she called the clerk in Union County asking if she could get help having the conviction removed from her record. Expunging or sealing a case would require her to hire a private lawyer, Williams said they told her.

“I can’t afford a lawyer,” she said.

Gabriel Sandoval contributed research.

by Abrahm Lustgarten

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On a crisp day this fall I drove southeast from Grand Junction, Colorado, into the Uncompahgre Valley, a rich basin of row crops and hayfields. A snow line hung like a bowl cut around the upper cliffs of the Grand Mesa, while in the valley some farmers were taking their last deliveries of water, sowing winter wheat and onions. I turned south at the farm town of Delta onto Route 348, a shoulder-less two-lane road lined with irrigation ditches and dent corn still hanging crisp on their browned stalks. The road crossed the Uncompahgre River, and it was thin, nearly dry.

The Uncompahgre Valley, stretching 34 miles from Delta through the town of Montrose, is, and always has been, an arid place. Most of the water comes from the Gunnison River, a major tributary of the Colorado, which courses out of the peaks of the Elk Range through the cavernous and sun-starved depths of the Black Canyon, one rocky and inaccessible valley to the east. In 1903, the federal government backed a plan hatched by Uncompahgre farmers to breach the ridge with an enormous tunnel and then in the 1960s to build one of Colorado’s largest reservoirs above the Black Canyon called Blue Mesa. Now that tunnel feeds a neural system of water: 782 miles worth of successively smaller canals and then dirt ditches, laterals and drains that turn 83,000 Western Colorado acres into farmland. Today, the farm association in this valley is one of the largest single users of Colorado River water outside of California.

I came to this place because the Colorado River system is in a state of collapse. It is a collapse hastened by climate change but also a crisis of management. In 1922, the seven states in the river basin signed a compact splitting the Colorado equally between its upper and lower halves; later, they promised additional water to Mexico, too. Near the middle, they put Lake Powell, a reserve for the northern states, and Lake Mead, a storage node for the south. Over time, as an overheating environment has collided with overuse, the lower half — primarily Arizona and California — has taken its water as if everything were normal, straining both the logic and the legal interpretations of the compact. They have also drawn extra releases from Lake Powell, effectively borrowing straight out of whatever meager reserves the Upper Basin has managed to save there.

This much has become a matter of great, vitriolic dispute. What is undeniable is that the river flows as a much-diminished version of its historical might. When the original compact gave each half the rights to 7.5 million acre-feet of water, the river is estimated to have flowed with as much as 18 million acre-feet each year. Over the 20th century, it averaged closer to 15. Over the past two decades, the flow has dropped to a little more than 12. In recent years, it has trickled at times with as little as 8.5. All the while the Lower Basin deliveries have remained roughly the same. And those reservoirs? They are fast becoming obsolete. Now the states must finally face the consequential question of which regions will make their sacrifice first. There are few places that reveal how difficult it will be to arrive at an answer than the Western Slope of Colorado.

In Montrose, I found the manager of the Uncompahgre Valley Water Users Association, Steve Pope, in his office atop the squeaky stairs of the same Foursquare that the group had built at the turn of the last century. Pope, bald, with a trimmed white beard, sat amid stacks of plat maps and paper diagrams of the canals, surrounded by LCD screens with spreadsheets marking volumes of water and their destinations. On the wall, a historic map showed the farms, wedged between the Uncompahgre River and where it joins the Gunnison in Delta, before descending to their confluence with the Colorado in Grand Junction. “I’m sorry for the mess,” he said, plowing loose papers aside.

What Pope wanted to impress upon me most despite the enormousness of the infrastructure all around the valley was that in the Upper Basin of the Colorado River system, there are no mammoth dams that can simply be opened to meter out a steady release of water. Here, only natural precipitation and temperature dictate how much is available. Conservation isn’t a management decision, he said. It was forced upon them by the hydrological conditions of the moment. The average amount of water flowing in the system has dropped by nearly 20%. The snowpack melts and evaporates faster than it used to, and the rainfall is unpredictable. In fact, the Colorado River District, an influential water conservancy for the western part of the state, had described its negotiating position with the Lower Basin states by claiming Colorado has already conserved about 28% of its water by making do with the recent conditions brought by drought.

You get what you get, Pope tells me, and for 15 of the past 20 years, unlike the farmers in California and Arizona, the people in this valley have gotten less than what they are due. “We don’t have that luxury of just making a phone call and having water show up,” he said, not veiling his contempt for the Lower Basin states’ reliance on lakes Mead and Powell. “We’ve not been insulated from this climate change by having a big reservoir above our heads.”

He didn’t have to point further back than the previous winter. In 2021, the rain and snow fell heavily across the Rocky Mountains and the plateau of the Grand Mesa, almost as if it were normal times. Precipitation was 80% of average — not bad in the midst of an epochal drought. But little made it into the Colorado River. Instead, soils parched by the lack of rain and rising temperatures soaked up every ounce of moisture. By the time water reached the rivers around Montrose and then the gauges above Lake Powell, the flow was less than 30% of normal. The Upper Basin states used just 3.5 million acre-feet last year, less than half their legal right under the 1922 compact. The Lower Basin states took nearly their full amount, 7 million acre-feet.

All of this matters now not just because the river, an unwieldy network of human-controlled plumbing, is approaching a threshold where it could become inoperable, but because much of the recent legal basis for the system is about to dissolve. In 2026, the Interim Guidelines the states rely on, a Drought Contingency Plan and agreements with Mexico will all expire. At the very least, this will require new agreements. It also demands a new way of thinking that matches the reality of the heating climate and the scale of human need. But before that can happen, the states will need to restore something that has become even more scarce than the water: trust.

The northern states see California and Arizona reveling in profligate use, made possible by the anachronistic rules of the compact that effectively promise them water when others have none. It’s enabled by the mechanistic controls at the Hoover Dam, which releases the same steady flow no matter how little snow falls across the Rocky Mountains. California flood-irrigates alfalfa crops destined for cattle markets in the Middle East, while Arizona takes water it does not need and pumps it underground to build up its own reserves. In 2018, an Arizona water agency admitted it was gaming the timing of its orders to avoid rations from the river (though it characterized the moves as smart use of the rules). In 2021, in a sign of the growing wariness, at least one Colorado water official alleged California was repeating the scheme. California water officials say this is a misunderstanding. Yet to this day, because California holds the most senior legal rights on the river, the state has avoided having a single gallon of reductions imposed on it.

By this spring, Lake Powell shrank to 24% of its capacity, its lowest levels since the reservoir filled in the 1960s. Cathedral-like sandstone canyons were resurrected, and sunlight reached the silt-clogged floors for the first time in generations. The Glen Canyon Dam itself towered more than 150 feet above the waterline. The water was just a few dozen feet above the last intake pipe that feeds the hydropower generators. If it dropped much lower, the system would no longer be able to produce the power it distributes across six states. After that, it would approach the point where no water at all could flow into the Grand Canyon and further downstream. All the savings that the Upper Basin states had banked there were as good as gone.

In Western Colorado, meanwhile, people have been suffering. South of the Uncompahgre Valley, the Ute Mountain Ute tribe subsists off agriculture, but over the past 12 months it has seen its water deliveries cut by 90%; the tribe laid off half of its farmworkers. McPhee Reservoir, near the town of Cortez, has teetered on failure, and other communities in Southwestern Colorado that also depend on it have been rationed to 10% of their normal water.

Across the Upper Basin, the small reservoirs that provide the region’s only buffer against bad years are also emptying out. Flaming Gorge, on the Wyoming-Utah border, is the largest, and it is 68% full. The second largest, Navajo Reservoir in New Mexico, is at 50% of its capacity. Blue Mesa Reservoir, on the Gunnison, is just 34% full. Each represents savings accounts that have been slowly pilfered to supplement Lake Powell as it declines, preserving the federal government’s ability to generate power there and obscuring the scope of the losses. Last summer, facing the latest emergency at the Glen Canyon Dam, the Department of Interior ordered huge releases from Flaming Gorge, Blue Mesa and other Upper Basin reservoirs. At Blue Mesa, the water levels dropped 8 feet in a matter of days, and boaters there were given a little more than a week to get their equipment off the water. Soon after, the reservoir’s marinas, which are vital to that part of Colorado’s summer economy, closed. They did not reopen in 2022.

Blue Mesa is one of Colorado’s largest reservoirs. (Susan Vineyard/Alamy)

As the Blue Mesa Reservoir was being emptied last fall, Steve Pope kept the Gunnison Tunnel open at its full capacity, diverting as much water as he possibly could. He says this was legal, well within his water rights and normal practice, and the state’s chief engineer agrees. Pope’s water is accounted for out of another reservoir higher in the system. But in the twin takings, it’s hard not to see the bare-knuckled competition between urgent needs. Over the past few years, as water has become scarcer and conservation more important, Uncompahgre Valley water diversions from the Gunnison River have remained steady and at times even increased. The growing season has gotten longer and the alternative sources, including the Uncompahgre River, less reliable. And Pope leans more than ever on the Gunnison to maintain his 3,500 shareholders’ supply. “Oh, we are taking it,” he told me, “and there’s still just not enough.”

On June 14, Camille Touton, the commissioner of the U.S. Bureau of Reclamation, the Department of Interior division that runs Western water infrastructure, testified before the Senate Committee on Energy and Natural Resources and delivered a stunning ultimatum: Western states had 60 days to figure out how to conserve as much as 4 million acre-feet of “additional” water from the Colorado River or the federal government would, acting unilaterally, do it for them. The West’s system of water rights, which guarantees the greatest amount of water to the settlers who arrived in the West and claimed it first, has been a sacrosanct pillar of law and states’ rights both — and so her statement came as a shock.

Would the department impose restrictions “without regard to river priority?” Mark Kelly,, the Democratic senator from Arizona, asked her.

“Yes,” Touton responded.

For Colorado, this was tantamount to a declaration of war. “The feds have no ability to restrict our state decree and privately owned ditches,” the general manager of the Colorado River District, Andy Mueller, told me. “They can’t go after that.” Mueller watches over much of the state.Pope faces different stakes. His system depends on the tunnel, a federal project, and his water rights are technically leased from the Bureau of Reclamation, too. Touton’s threat raised the possibility that she could shut the Uncompahgre Valley’s water off. Even if it was legal, the demands seemed fundamentally unfair to Pope. “The first steps need to come in the Lower Basin,” he insisted.

Each state retreated to its corners, where they remain. The 60-day deadline came and went, with no commitments toward any specific reductions in water use and no consequences. The Bureau of Reclamation has since set a new deadline: Jan. 31. Touton, who has publicly said little since her testimony to Congress, declined to be interviewed for this story. In October, California finally offered a plan to surrender roughly 9% of the water it used, albeit with expensive conditions. Some Colorado officials dismissed the gesture as a non-starter. Ever since, Colorado has become more defiant, enacting policies that seem aimed at defending the water the state already has — perhaps even its right to use more.

For one, Colorado has long had to contend with the inefficiencies that come with a “use it or lose it” culture. State water law threatens to confiscate water rights that don’t get utilized, so landowners have long maximized the water they put on their fields just to prove up their long-term standing in the system. This same reflexive instinct is now evident among policymakers and water managers across the state, as they seek to establish the baseline for where negotiated cuts might begin. Would cuts be imposed by the federal government based on Pope’s full allocation of water or on the lesser amount with which he’s been forced to make do? Would the proportion be adjusted down in a year with no snow? “We don’t have a starting point,” he told me. And so the higher the use now, the more affordable the conservation later.

Colorado and other Upper Basin states have also long hid behind the complexity of accurately accounting for their water among infinite tributaries and interconnected soils. The state’s ranchers like to say their water is recycled five times over, because water poured over fields in one place invariably seeps underground down to the next. In the Uncompahgre Valley, it can take months for the land at its tail to dry out after ditches that flood the head of the valley are turned off. The measure of what’s been consumed and what has transpired from plants or been absorbed by soils is frustratingly elusive. That, too, leaves the final number open to argument and interpretation.

A houseboat on Lake Powell in Arizona. By this spring, the lake shrank to 24% of its capacity, its lowest levels since the reservoir filled in the 1960s. (Rick Wilking/Reuters)

All the while, the Upper Basin states are all attempting to store more water within their boundaries. Colorado has at least 10 new dams and reservoirs either being built or planned. Across the Upper Basin, an additional 15 projects are being considered, including Utah’s audacious $2.4 billion plan to run a new pipeline from Lake Powell, which would allow it to transport something closer to its full legal right to Colorado River water to its growing southern cities. Some of these projects are aimed at securing existing water and making its timing more predictable. But they are also part of the Upper Colorado River Commission’s vision to expand the Upper Basin states’ Colorado River usage to 5.4 million acre-feet a year by 2060.

It is fair to say few people in the state are trying hard to send more of their water downstream. In our conversation, Mueller would not offer any specific conservation savings Colorado might make. The state’s chief engineer and director of its Division of Water Resources, Kevin Rein, who oversees water rights, made a similar sentiment clear to the Colorado River District board last July. “There’s nothing telling me that I should encourage people to conserve,” Rein said. “It’s a public resource. It’s a property right. It’s part of our economy.”

In November, Democratic Gov. Jared Polis proposed the creation of a new state task force that would help him capture every drop of water it can before it crosses the state line. It would direct money and staff to make Colorado’s water governance more sophisticated, defensive and influential.

I called Polis’ chief water confidante, Rebecca Mitchell, who is also the director of the Colorado Water Conservation Board and the state’s representative on the Upper Colorado River Commission. If the mood was set by the idea that California was taking too much from the river, Mitchell thought that it had shifted now to a more personal grievance — they are taking from us.

Last month, Mitchell flew to California for a tour of its large irrigation districts. She stood beside a wide canal brimming with more water than ever flows through the Uncompahgre River, and the executive of the farming company beside her explained that he uses whatever he wants because he holds the highest priority rights to the water. She thought about the Ute Mountain Ute communities and the ranchers of Cortez: “It was like: ‘Wouldn’t we love to be able to count on something? Wouldn’t we love to be feel so entitled that no matter what, we get what we get?’” she told me.

What if Touton followed through, curtailing Colorado’s water? I asked. Mitchell’s voice steadied, and then she essentially leveled a threat. “We would be very responsive. I’m not saying that in a positive way,” she said. “I think everybody that’s about to go through pain wants others to feel pain also.”

Here’s the terrible truth: There is no such thing as a return to normal on the Colorado River, or to anything that resembles the volumes of water its users are accustomed to taking from it. With each degree Celsius of warming to come, modelers estimate that the river’s flow will decrease further, by an additional 9%. At current rates of global warming, the basin is likely to sustain at least an additional 18% drop in its water supplies over the next several decades, if not far more. Pain, as Mitchell puts it, is inevitable.

The thing about 4 million acre-feet of cuts is that it’s merely the amount already gone, an adjustment that should have been made 20 years ago. Colorado’s argument makes sense on paper and perhaps through the lens of fairness. But the motivation behind the decades of delay was to protect against the very argument that is unfolding now — that the reductions should be split equally, and that they may one day be imposed against the Upper Basin’s will. It was to preserve the northern states’ inalienable birthright to growth, the promise made to them 100 years ago. At some point, though, circumstances change, and a century-old promise, unfulfilled, might no longer be worth much at all. Meanwhile, the politics of holding out are colliding with climate change in a terrifying crash, because while the parties fight, the supply continues to dwindle.

Recently, Brad Udall, a leading and longtime analyst of the Colorado River and now a senior water and climate scientist at Colorado State University, teamed with colleagues to game out what they thought it would take to bring the river and the twin reservoirs of Mead and Powell into balance. Their findings, published in July in the journal Science, show that stability could be within reach but will require sacrifice.

If the Upper Basin states limited their claim to 4 million acre-feet, or 53% of their due under the original compact, and the Lower Basin states and Mexico increased their maximum emergency cuts by an additional 45%, the two big reservoirs will stay at roughly their current levels for the next several decades. If the basins could commit to massive reductions below even 2021 levels for the Upper Basin and to more than doubling the most ambitious conservation goals for the south, the reservoirs could once again begin to grow, providing the emergency buffer and the promise of economic stability for 40 million Americans that was originally intended. Still, by 2060, they would only be approximately 45% full.

Any of the scenarios involve cuts that would slice to the bone. Plus, there’s still the enormous challenge of how to incorporate Native tribes, which also hold huge water rights but continue to be largely left out of negotiations. What to do next? Israel provides one compelling example. After decades of fighting over the meager trickles of the Jordan River and the oversubscription of a pipeline from the Sea of Galilee, Israel went back to the drawing board on its irrigated crops. It made drip irrigation standard, built desalination plants to supply water for its industry and cities, and reused that water again and again; today, 86% of the country’s municipal wastewater is recycled, and Israel and its farmers have an adequate supply. That would cost a lot across the scale and reach of a region like the Western United States. But to save the infrastructure and culture that produces 80% of this country’s winter vegetables and is a hub of the nation’s food system for 333 million people? It might be worth it.

A different course was charted by Australia, which recoiled against a devastating millennium drought that ended 13 years ago. It jettisoned its coveted system of water rights, breaking free of history and prior appropriation similar to the system of first-come-first-served the American West relies on. That left it with a large pool of free water and political room to invent a new method of allocating it that better matched the needs in a modern, more populous and more urban Australia and better matched the reality of the environment.

In America, too, prior appropriation, as legally and culturally revered as it is, may have become more cumbersome and obstructive than it needs to be. Western water rights, according to Newsha Ajami, a leading expert at Lawrence Berkeley National Laboratory and the former director of the urban water policy program at Stanford University, were set up by people measuring with sticks and buckets, long before anyone had ever even considered climate change. Today, they largely serve powerful legacy interests and, because they must be used to be maintained, tend to dissuade conservation. “It’s kind of very archaic,” she said. “The water rights system would be the first thing I would just dismantle or revisit in a very different way.”

This is probably not going to happen, Ajami said. “It could be seen as political suicide.” But that doesn’t make it the wrong solution. In fact, what’s best for the Colorado, for the Western United States, for the whole country might be a combination of what Israel and Australia mapped out. Deploy the full extent of the technology that is available to eliminate waste and maximize efficiency. Prioritize which crops and uses are “beneficial” in a way that attaches the true value of the resource to the societal benefit produced from using it. Grow California and Arizona’s crops in the wintertime but not in the summer heat. And rewrite the system of water allocation as equitably as possible so that it ensures the modern population of the West has the resources it needs while the nation’s growers produce what they can.

What would that look like in Colorado? It might turn the system upside down. Lawsuits could fly. The biggest, wealthiest ranches with the oldest water rights stand to lose a lot. The Lower and Upper Basin states, though, could all divide the water in the river proportionately, each taking a percentage of what flowed. The users would, if not benefit, at least equally and predictably share the misery. Pope’s irrigation district and the smallholder farmers who depend on it would likely get something closer to what they need and, combined with new irrigation equipment subsidized by the government, could produce what they want. It wouldn’t be pretty. But something there would survive.

The alternative is worse. The water goes away or gets bought up or both. The land of Western Colorado dries up, and the economies around it shrivel. Montrose, with little left to offer, boards up its windows, consolidates its schools as people move away, and the few who remain have less. Until one day, there is nothing left at all.

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Correction

Dec. 23, 2022: This story originally misspelled the surname of the commissioner of the U.S. Bureau of Reclamation. She is Camille Touton, not Touten.

by Andrea Suozzo

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As Americans scramble to make their year-end charitable contributions, they may have to do so without a key tool for understanding how those charities spend their money: their most recent tax forms.

According to a ProPublica review of public IRS data, which powers our Nonprofit Explorer database, the agency is behind on releasing nearly half a million tax records, known as Form 990s, for tax-exempt organizations. The delays, which began two years ago, are stymying access to key financial information that governments, the public and grantmakers use to evaluate the nation’s tax-exempt companies.

The gap in reporting has become so profound that state charitable enforcement officers are sounding the alarm. In November, the National Association of State Charity Officials sent a letter urging the IRS to address backlogged 990 data releases.

“For charity regulators, the Form 990 series not only helps ensure transparency and accountability, but also provides vital information for state investigations into potential fraud and misuse of charitable resources,” the organization wrote. “It is critical that the availability of that data be timely.”

The filings, which tax-exempt organizations must submit annually, detail how organizations have carried out their public-interest mission and disclose executive pay, as well as grantmaking and fundraising activities.

These documents provide insight into a key sector of the U.S. economy, one that employs more than 12 million Americans.

“It’s a big aspect of our economy,” said Carl Malamud, a technologist whose organization, Public.Resource.Org, brought a lawsuit in 2015 that originally prompted the IRS to release the 990 data. “It’s one of the major sectors, and without those Form 990s, you can’t have an efficient market.”

Nonprofit organizations perform many core social service roles in the U.S., including medical institutions like St. Jude Children’s Research Hospital, disaster relief organizations like the Red Cross, aid networks like Feeding America and the National Alliance to End Homelessness, as well as advocacy organizations like the National Rifle Association or the American Civil Liberties Union.

The filings can help people assess the operations of an organization before making a financial donation. And they can help regulators and journalists to uncover wrongdoing like misuse of funds at the Trump Foundation or a bribery and kickback scheme at a major operator of New York City homeless shelters.

“This is having an impact on nonprofits, fundraising, donors ... and charity regulators,” said Cinthia Schuman Ottinger of the Aspen Institute, who coordinates a group of practitioners who work with nonprofit tax data (ProPublica is a part of this group). “The whole ecosystem suffers when there are delays of this kind.”

Michael Thatcher, the CEO of Charity Navigator, said the end of the year is a crucial time for charitable giving.

“Now’s when people really need it and want it,” said Thatcher of the information disclosed in 990 filings. His company uses the data to provide ratings that help potential donors vet organizations.

And, he said, “it’s not just the donors that are upset by this.” Many organizations want their latest information out there as well, especially if their finances have improved or they’ve done significant work in recent years. “They want to show that to the world, and guess what, when you go to Charity Navigator, you’re seeing two-year-old information.”

Many of the missing filings could help shed light on how organizations — and the nonprofit sector as a whole — have fared during tumultuous years marked by a pandemic, economic upheaval and large infusions of federal relief dollars.

Courtney Aladro, a charity regulator for the Massachusetts attorney general and NASCO board member, said that regulators across the country use the IRS repository of documents to confirm or corroborate the information that charities submit to their states. Recent holdups make it harder to access that information, and the delays ramped up just as the agency would typically be releasing filings that shed light on how organizations operated in 2020 and 2021.

“Those are some pretty important years because of some of the difficulties over the last few years,” Aladro said. “The use and expenditure of COVID relief funds, for example. It’s pretty important for charity regulators and law enforcement to monitor that, and not having that information will make it more difficult.”

In a statement, the IRS said it is “making progress” and aims to resume posting the information soon. “This is an important tool, and the IRS is committed to keeping information up to date on the site to help taxpayers and others who use the data,” a spokesperson said. The agency noted that its organization search does show up-to-date information on whether a charity is currently eligible to receive tax deductible donations.

The agency began releasing machine-readable data files for Form 990s in 2015, after the lawsuit won by Malamud. In the years since, an ecosystem of tools and documentation has grown up around the 990 data sets, powering more advanced tools and resources for the public to inspect the finances and other operations of nonprofits.

The IRS posted the information on a monthly basis to a public Amazon storage account for years, but amid COVID-19-era staffing struggles, updates began to lag. Then, in November 2021, the IRS announced it would begin publishing the information on its own website. Since then, the agency has not just fallen further behind but even uploaded several hundred thousand nonpublic forms by accident not just once, but twice. Three months after the agency notified Congress of the first mistake, downloads for some 2021 and 2022 files reappeared on the IRS’ download page on Nov. 30. After this reporter notified the agency that the page still contained nonpublic documents, the files were removed once again. The agency blamed this second release on a contractor, Accenture Federal Services, which it said is responsible for posting the documents to the IRS website.

Neither Accenture Federal Services nor its parent company, Accenture, responded to a request for comment.

The IRS has not only taken heat for the disclosure of those forms, but also from Republicans who have attacked the agency over ProPublica’s use of tax information for a series of stories that showed how the wealthy avoid taxes.

The IRS has faced repeated budget cuts over the past decade, and it has struggled with backlogs in all types of tax returns since 2020. In a letter to Congress in June, the Treasury Department pointed to historic staffing shortages: “The IRS has been stretched thin at a time when its workforce, already depleted to 1970s levels, has been battling personal and familial health challenges posed by the pandemic.”

This year’s Inflation Reduction Act allocates $80 billion to the IRS over the next decade to boost enforcement, operations, taxpayer services and modernization of technical systems.

“We understand that there have been staffing shortages, the pandemic has caused problems, but we do have to wonder if the posting of 990 data to the public are being given the priority they deserve,” Schuman Ottinger said.

The delays have prompted private companies to try to collect this information on their own, doing an end run around the IRS’ unreliable systems. Both Charity Navigator and Candid, another platform that provides 990 information, have built systems for nonprofits to send their forms directly to the companies. So far the organizations that have done that are “in the hundreds, not the thousands,” Thatcher said.

The prolonged delays even drove one company to shut down. In September, Open990.org, which offered a nonprofit organization search tool and downloadable data sets for things like executive compensation and hospital finances, announced it was closing its doors. In its farewell message, the organization cited prolonged delays and inaccuracies in data released by the IRS.

David Borenstein, who was Open990’s chief technology officer, said as data releases and updates slowed, the small organization was receiving large volumes of complaints and requests to update or correct information, beyond what it could keep up with.

“The lack of data undercuts a critical accountability mechanism for organizations seeking tax exemption,” he wrote.

Borenstein said he doesn’t fault the IRS, though. “Their budget has been cut to the bone, and they are unable to perform many responsibilities that are vital to the national interest.”

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by Debbie Cenziper, ProPublica; Will Fitzgibbon, International Consortium of Investigative Journalists; and Eva Herscowitz, Emily Anderson Stern and Jordan Anderson, Medill Investigative Lab

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The deal to pay off the treasurer of Detroit was forged in a booth at a strip club named Bouzouki.

“You’re basically paying all these other guys. … You should be paying me,” the city’s treasurer told local business owner Robert Shumake that day in 2007 during a conversation that Shumake would later recount to federal prosecutors.

Shumake, a self-described community organizer and philanthropist, agreed to make payments to several officials who ran the city’s pension funds. The money was used, among other things, to cover gambling expenses, airline tickets and a day cruise to the Bahamas.

Robert Shumake (Illustration by Matt Rota for ProPublica and ICIJ)

In return, Shumake received a lucrative reward: Detroit steered millions of pension dollars to his investment company and paid him $1.2 million in fees. Prosecutors would later say it was “the worst possible deal for the pension systems.”

A series of city officials and businessmen were convicted in the sweeping scandal, but Shumake struck a deal in exchange for his testimony in 2011 and avoided prosecution.

Soon after, he landed another fortunate break. The southern African country of Botswana nominated him as an honorary consul in the United States, a diplomatic position that came with legal protections, travel benefits and political connections unavailable to most Americans.

The State Department approved the appointment, granting Shumake entry into the privileged world of international diplomacy. Honorary consuls, though not as prominent as ambassadors and other career diplomats, have for centuries worked from their home countries to represent foreign nations.

The department did not respond to questions about what steps, if any, it took to review Shumake’s background. Had officials done even a cursory internet search, they would have discovered that Shumake’s real estate broker’s license was suspended in 2002 and that he settled a bank fraud case in 2008, agreeing to pay hundreds of thousands of dollars.

Shumake was among at least 500 current and former honorary consuls in the United States and around the world who have been implicated in criminal investigations or other controversies — including scores named to their posts despite past convictions or other red flags, ProPublica and the International Consortium of Investigative Journalists disclosed in a series of stories this year.

Reports of exploitation, scandal and criminal behavior by the little-known volunteer diplomats have surfaced for years. But the vast majority of governments have failed to strengthen oversight or press to reform the international law that protects thousands of honorary consuls worldwide, a new review found.

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All told, the “Shadow Diplomats” investigation identified criminal or controversial consuls connected to at least 168 governments, including Russia, which has leveraged the system to install dozens of pro-Kremlin advocates on foreign soil as a soft-power strategy.

In the wake of the reporting, Paraguay, Finland, Brazil and other countries announced investigations of consuls and the system that empowers them. In some cases, government officials acknowledged not knowing how many consuls they had appointed or whether any had been convicted of crimes.

Experts in international diplomacy and national security say that more governments must demand change, examine nominees before they are approved and track their activities once they become consuls.

ProPublica and ICIJ identified more than 150 current and former consuls accused or convicted of tax evasion, fraud, bribery, corruption or money laundering. Nearly 60 were tied to drug or weapons offenses, at least 20 others to violent crimes and 10 to environmental abuses. Thirty honorary consuls have been sanctioned by the United States and other governments; nine have been linked to terrorist groups by law enforcement and governments. Once accused, dozens of consuls have invoked their status to avoid prosecution, police inquiries or fines.

“No one is checking them out,” said Bob Jarvis, an international law and constitutional law professor at Florida’s Nova Southeastern University who first examined the honorary consul system in the 1980s. “What are we doing? Who are these people?”

The United States does not appoint its own honorary consuls overseas but has for decades allowed foreign countries to appoint U.S. citizens as consuls in America. An estimated 1,100 were in place this year.

The State Department, responsible for approving consul nominations, noted years ago that the United States was “not in a position” to conduct background checks or analyze the qualifications or suitability of nominees on U.S. soil and instead entrusted foreign countries to review credentials.

Unlike some other countries, the United States has no code of conduct for honorary consuls. The State Department previously fought an effort by Congress to review whether diplomatic pouches, protected from searches under international law, had been used to move contraband. The department at the time said the measure would impact U.S. diplomats overseas.

In 2020, the department reached out to foreign embassies with a simple request: an updated list of their honorary consuls in the United States. The last time the department inquired was five years earlier, records show.

“You’re looking at a pretty large universe, so to engage in a detailed review for every nominee would be rather difficult,” Lawrence Dunham, former assistant chief of protocol at the State Department, said in an interview.

The State Department did not respond to specific questions about its oversight of consuls. In a statement, Cliff Seagroves, principal deputy director of the Office of Foreign Missions, said the department works to “protect the U.S. public from abuse of diplomatic privileges and immunities. This oversight includes the accreditation of honorary consuls and their performance of official duties in the United States. The Department has zero tolerance for evidence of inappropriate activity by any member of a foreign mission, including honorary consuls.”

The department did not respond to questions about the appointment of Shumake.

Shumake did not respond to questions about his activities before becoming consul. He has previously said he cooperated with the government in the pension case; Detroit’s former treasurer was sentenced in 2015 to 11 years in prison.

Shumake has also said he never sought to misrepresent his professional background. He has denied wrongdoing in the bank fraud probe.

Outside the United States, a small number of governments faced with scandals have adopted more stringent protocols for appointing and accepting honorary consuls.

Three years ago, the Canadian government launched a review after Syrian refugees in Montreal discovered newly approved honorary consul Waseem Ramli in a red Hummer fitted with an image of the Syrian flag and a picture of President Bashar al-Assad, whose regime has killed tens of thousands of civilians through airstrikes and chemical weapons.

“To us, that is not the Syrian flag. It represents horrors for us. It represents evil,” said Farouq Habib, a Syrian father of two who was granted asylum in Canada. “It was shocking for me to see it on the streets of Canada. How can Canada adopt someone … without any due diligence or vetting? It undermines the credibility of the system itself.”

Materials released by the Canadian government show Waseem Ramli’s Hummer and social media posts.

The Canadian government dismissed Ramli before his term began and reported that consuls appointed by 15 countries warranted closer scrutiny.

Ramli could not be reached for comment. At the time of his nomination, he said he would represent Syrians regardless of their political views.

“I need some [information] on what happened to let this one pass,” a Canadian official wrote at the time, according to emails released by the government. “Where did we ‘fail?’”

“The Honor System”

The honorary consul system was created with great promise centuries ago, when governments began to promote their cultural and economic interests in foreign countries by appointing prominent private citizens to serve as liaisons from their home countries. Under international law, when a foreign government nominates a consul, local governments must in turn approve the appointment.

Many consuls are diligent advocates, forging country-to-country alliances in the arts, industry, science and academia while drawing far less attention than ambassadors and other career diplomats.

But the perks of diplomacy have long attracted some dubious appointees. Honorary consuls receive legal immunity in matters involving their work. Their correspondence cannot be seized, and their offices and consular bags are protected from searches. Their status provides access to leaders of politics and industry.

In the United States, an honorary consul for Malaysia tried to use his diplomatic status to get out of a $10 traffic ticket in Portland, Oregon, taking a lawsuit to the state’s Court of Appeals in 1979 before he lost, court records show.

In Los Angeles in the 1990s, honorary consul Latchezar “Lucky” Christov conspired with lawyers, a firefighter, a police officer and a rabbi, among others, to help move tens of millions of dollars for a Colombian drug cartel.

To avoid unwanted attention, Christov planned to pick up drug money in a car with a diplomatic license plate, records show. He also held cash in his office on Wilshire Boulevard, where the sign over the door read: Consul Bulgaria.

An FBI special agent’s affidavit submitted to a federal court in 1994

Christov, whose exploits were later described in a report to Congress, pleaded guilty to laundering drug money. He died in 2015.

In 2005, an honorary consul representing the Czech Republic in Michigan and Ohio tried to avoid paying property taxes on a 16,000-square-foot home near Detroit with a six-car garage and elevator. He argued the property had been transferred to the Czech government.

“Does the embassy pay property taxes? Of course not! Does the consulate in New York pay property taxes? Of course not!” Thomas Prose was quoted as saying at the time. Local officials denied a tax exemption, and Prose resigned as honorary consul. Prose could not be reached for comment; he previously said he paid the taxes “out of goodwill.”

One of the more high-profile honorary consuls in the United States was Jill Kelley, who gained notoriety in 2012 for triggering an FBI investigation that ultimately exposed an extramarital affair between then-CIA Director David H. Petraeus and his biographer.

During the media coverage, Kelley reportedly called 911 to complain about trespassers. “I’m an honorary consul general … so they should not be able to cross my property,” she said.

Kelley, appointed consul by South Korea, lost her consul post that year. At the time, a New York businessman said she had sought millions of dollars to help him win a gas contract in South Korea.

“It’s not suitable to the status of honorary consul that (she) sought to be involved in commercial projects and peddle influence,” South Korea’s deputy foreign minister told the Seoul-based news agency Yonhap.

Kelley denied wrongdoing, telling ProPublica and ICIJ that she did not monetize her role as honorary consul. “I never made a dollar or capitalized from my work,” she said.

In response to questions, Kelley shared a copy of a 2013 civil lawsuit that she and her husband filed against the U.S. government, alleging their privacy was violated by the disclosure of “personal, private and confidential information” during the Petraeus scandal. The loss of her consulship deprived Kelley of “years of significant public service, social and financial opportunities,” according to the lawsuit, which she later dropped. Kelley declined to elaborate.

In recent years, more than 100 countries, including Russia, Guatemala, Liberia and Malta, have had consuls in the United States, State Department records show. France had the most: 53 as of March.

The State Department has several requirements, including that a consul is 21 or older, a U.S. citizen or permanent resident and holds no government position with duties that could conflict with the post.

A State Department memo to foreign embassies in 2003 noted that the U.S. government “trusts” foreign countries to completely review the credentials of nominees. Once consuls are in place, the memo said, they would remain accountable to the governments they represent.

“It’s on the honor system,” Dunham said.

He added that the United States can always refuse to accept honorary consul nominees or, later, remove them from their posts.

Efforts to strengthen oversight of diplomatic privilege over the years have been sporadic. In the 1980s, the State Department enacted a one-year moratorium on the appointments of new honorary consuls in response to concerns from Congress about the number of people in the U.S. with diplomatic protection.

Around the same time, a bipartisan group of U.S. lawmakers sought to review whether diplomats were exploiting protections that allowed them to receive bags, boxes and containers in the United States without inspection. Under international law, diplomatic pouches are protected from scrutiny, even by X-ray.

The measure would have required the government to adopt safeguards to ensure bags were not used to smuggle drugs, explosives, weapons or any other materials used to advance terrorism.

“We are concerned that terrorists could, and we have every reason to believe, have shipped under the protection of diplomatic immunity pouches carrying such items as small armed weapons and explosives to be used against law enforcement officers,” Dennis Martin, then-president of the American Federation of Police, testified at a congressional hearing.

The State Department opposed the measure, arguing that the United States was the largest sender of diplomatic pouches. “The beneficiary of diplomatic immunity fundamentally is the United States government because our personnel abroad could not function without it,” the department’s head of protocol said.

The measure died in Congress.

Last year, the department requested that states stop issuing special license plates to honorary consuls, saying they “may imply privileges and immunities to which honorary consular officers are not entitled.”

Some states, however, are still issuing the plates, including Oregon, Arizona and Georgia, ProPublica and ICIJ found. Texas has issued or renewed more than 3,900 plates to honorary consuls since 1994, records show.

One financial crime expert pointed to another vulnerability.

Some foreign governments have chosen to classify honorary consuls as “politically exposed persons” who present a higher risk of financial crime and are more closely scrutinized by financial institutions.

The United States has not done so, leaving that determination to financial institutions.

“An honorary consul can be used much like a gatekeeper,” said Sarah Beth Felix, a former banking compliance executive. “It’s a great way to run dirty money because honorary consuls are typically not tagged as higher risk in a monitoring system and they get the benefit of not being subjected to law enforcement searches.”

The Treasury Department said that U.S. regulations do not define politically exposed persons. “Whether honorary consuls are PEPs depends on the facts and circumstances surrounding the consul’s appointment and role,” said Jayna Desai, spokesperson for the department’s Financial Crimes Enforcement Network.

Watch the documentary “The Global Threat of Rogue Diplomacy” Worldwide Warning Signs

For years, government investigations around the world have chronicled lawlessness and abuse among consuls that appear to eclipse incidents in the United States.

Twenty-five years ago, Bolivia announced a review of the honorary consul system there after high-profile scandals, including one in which the country’s consul in Haiti was dismissed after police reportedly found an arsenal of weapons inside the consul’s home, including rifles, pistols and a grenade launcher. Authorities suspected that the consul was linked to paramilitary groups fighting against the Haitian government, local media reported.

“It is well worth reviewing completely this outdated custom of honorary consuls,” local newspaper La Razón wrote after the arrest in an editorial titled “The Chronic Problem of Honorary Consuls.”

“It is a thousand times preferable not to have anyone to represent us in a nation than to go through undignified situations,” the newspaper wrote.

In 2003, Hungary overhauled its system after a stockbroker wanted for fraud and embezzlement fled the country in an honorary consul’s Mercedes. The stockbroker also held an ID card from another honorary consulate, according to media reports.

After the incident, the Hungarian government announced a review of the honorary consul system and stopped issuing identity cards to employees of honorary consulates. The stockbroker was convicted and jailed for five years; the consuls were not charged.

In 2007, Liberia dismissed nearly all of its consuls overseas after reports from Europe, Asia and the Middle East of drug smugglers and money launderers holding honorary consul passports, according to a U.S. State Department cable at the time.

In 2019, Canada became one of the largest governments to review the system, initiating the probe after reports about Ramli, nominated by Syria, surfaced in Montreal.

“I cried at the time. How come this person was appointed?” said Muzna Dureid, a Syrian refugee. “Even in Canada, we don’t feel safe.”

The government investigation found that “time constraints and lack of information management expertise” limited an initial review of Ramli, who went on to say in an interview with Maclean’s magazine that a prominent Syrian volunteer rescue group was a “terrorist organization.”

Canada introduced a new process to examine and appoint honorary consuls, adding a code of conduct.

A Family of Consuls

Despite the findings by governments, most countries have not called for widespread reforms. That includes Spain, where authorities are currently investigating three honorary consuls accused of helping to launder money for Simón Montero Jodorovich, an accused drug dealer.

In a 2,000-page report, police wrote in 2019 that the consuls representing Mali, Croatia and Albania allegedly called Jodorovich “big boss.”

Honorary consuls, the police reported, work without pay for the countries they represent. “What is obtained,” police wrote, “is compensation in terms of prestige, privileges and social relations, not to mention the coveted diplomatic bag … that crosses borders without any control.”

The consuls, who have not been criminally charged, have denied wrongdoing. An attorney for Jodorovich said his client is innocent and “has never manipulated any consul,” adding that Jodorovich’s relationship with them was transactional.

In Central America, the government of Honduras has previously reviewed its honorary consuls overseas, but consuls within the country have received less attention.

The powerful Kafie family has counted eight honorary consuls among its members, representing an eclectic group of countries that include Finland, Latvia and Panama.

In 2015, Schucry Kafie, a prominent businessman who has served for years as honorary consul for Jordan, was arrested in a Honduran corruption scandal, accused with others of overcharging the government for medical supplies.

Others implicated in the scandal were detained, but Kafie was released by a judge, who noted that his status as consul required him to sometimes leave the country, court records show.

The charges against Kafie were ultimately dismissed.

In a written statement, Kafie said that the government’s case was politically motivated and that the company did not overcharge for equipment. He added that the court allowed him to leave the country for health reasons and not because of his job as honorary consul.

Watch video ➜

In Panama, the Kafie family has a power plant that has for years drawn complaints from nearby residents, who say they fear it emits toxic gas.

Martin Ibáñez, 66, said his skin itches and his eyes burn from the smoke. He has written to the Panamanian government and others, hoping someone will determine whether the plant is operating safely.

“It’s like they dropped an atomic bomb,” he said this year. “I will die one of these days, but I want to go down fighting.”

Kafie said the plant did not cause health problems.

Martin Ibáñez, who lives on a farm near the plant, said he believes that gasses from the plant have made members of his community sick. (Linus Hoeller/Medill Investigative Lab) “Harm and Abuse”

In 2020, the United Nations Institute for Training and Research offered a course for honorary consuls that explored diplomatic law and ethics.

“Without a strong governance and reporting process, honorary consuls can become isolated and remote and their activities can be contrary to the interests of the sending state,” the institute noted at the time.

The course was offered only once. An institute official told ProPublica and ICIJ that there were not enough participants.

Diplomatic law experts said governments should require training and also make public the names and locations of honorary consuls. Of more than 180 countries that appoint and receive honorary consuls, only 42 publish up-to-date information, including names of consuls. Dozens of countries report no information at all, ProPublica and ICIJ found. Governments could also introduce an honorary consul code of conduct, evaluate the records of those currently holding the posts and start investigating new nominees, experts said.

“The harm and abuse,” said Jarvis, the law professor from Florida, “far outweighs whatever benefit the system is providing.”

In Michigan, Shumake’s honorary consul post for Botswana ended in 2015. He had also been appointed honorary consul by the government of Tanzania; that post ended in 2015 as well.

While consul, he won a contract to build a rail line in Tanzania in a deal that opponents criticized as improper and opaque. Shumake defended the project; the rail line was never built.

The Botswana Ministry of Foreign Affairs told ProPublica and ICIJ that Shumake’s tenure was terminated after the U.S. State Department disclosed that he had been accused of misconduct. The ministry did not elaborate. The government of Tanzania did not respond to requests for comment.

One year after the consul posts ended, U.S. authorities seized more than $250,000 in cash at the Charlotte Douglas International Airport in North Carolina from one of Shumake’s associates. The money was stashed in a carry-on bag, which later tested positive for traces of cocaine, according to documents from a subsequent civil forfeiture case.

The courier referred authorities to Shumake, who said he had raised the money to support communities in Africa and the Caribbean and that as “an ambassador” of an international commission, he had diplomatic immunity in transporting it, according to court documents. Authorities seized the cash.

Shumake declined to respond to detailed questions from ProPublica and ICIJ, but he said the U.S. returned the money. Court records show the government agreed to return half the money to the international commission.

In an unrelated case in 2017, Shumake pleaded guilty to misdemeanor violations in a Michigan court after his mortgage auditing company was accused of improperly taking fees from distressed homeowners.

“You preyed on people at their lowest possible moment,” a county judge told Shumake at his sentencing hearing.

Last year, the U.S. Securities and Exchange Commission alleged that Shumake and others had set up a fraudulent crowdfunding scheme that promised investors profits from the cannabis industry. The SEC filed a lawsuit, which is ongoing. Shumake has denied wrongdoing.

A screenshot from a video posted this year about former honorary consul Shumake

In May, seven years after his honorary consul positions ended, he posted a video online titled “Robert Shumake Holds the Titles of Honorary Consul.” The video includes an image of two men shaking hands — while exchanging wads of cash.

Reporting was contributed by Jennifer Avila, Jesus Albalat, Robert Cribb, Atanas Tchobanov, Zsuzsanna Wirth, Delphine Reuter, Nicole Sadek and Michael Korsh, Hannah Feuer, Michelle Liu, Grace Wu, Linus Hoeller, Dhivya Sridar, Quinn Clark, Henry Roach, Evan Robinson-Johnson, Susanti Sarkar, Margaret Fleming, Julian Andreone, Sela Breen and Belinda Clarke, of the Medill Investigative Lab.

Video by Matthew Orr for ProPublica and International Consortium of Investigative Journalists, reporting by Debbie Cenziper, ProPublica, and Will Fitzgibbon, International Consortium of Investigative Journalists

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

The idea seemed simple centuries ago when governments began to deploy a different kind of diplomat to advance their cultural and economic interests in outposts around the world.

Honorary consuls are not nearly as high-profile as ambassadors and other career diplomats. As private citizens, the volunteer consuls work from their home countries to represent the foreign governments that nominate them. The arrangement was meant to build country-to-country alliances without the need for embassies and staff, an inexpensive and benign diplomatic arrangement that over the years was embraced by a majority of the world’s governments.

But a first-of-its-kind global investigation by ProPublica and the International Consortium of Investigative Journalists found that corrupt, violent and dangerous honorary consul appointees — including those accused of aiding terrorist regimes — have turned a system meant to leverage the work of honorary citizens into a perilous form of rogue diplomacy that has threatened the rule of law around the world.

Watch the documentary and read the series by ProPublica, ICIJ and more than 50 international media organizations.

Reporting was contributed by Eva Herscowitz, Emily Anderson Stern, Hannah Feuer, Michael Korsh, Jordan Anderson, Diana Moukalled, Hala Nasreddine, Nicole Sadek and Dejan Milovac, of the Medill Investigative Lab.

by Craig Silverman and Ruth Talbot

In late 2021, the right-wing site Conservative Beaver published a story falsely claiming the FBI had arrested Pfizer’s CEO for fraud.

It wasn’t Conservative Beaver’s first brush with fabricated news. The site had falsely claimed Barack Obama was arrested for espionage, Pope Francis was arrested for possession of child pornography and “human trafficking,” and the Pfizer CEO’s wife died after being compelled to take a COVID-19 vaccine. As Conservative Beaver pumped out these and other lies, Google placed ads on the site and split the revenue with its then-anonymous owner.

Its owner was eventually identified as a Canadian man, Mark Slapinski, after Pfizer threatened to sue him for defamation, and Google removed ads from the site in November of last year due to public pressure. Soon, Conservative Beaver went offline.

But today, roughly a year later, Slapinski is still making money from Google ads.

He runs the conservative political site Toronto 99 and uses the same Google publisher account he had for Conservative Beaver to collect ad revenue. Google simply allowed Slapinski to start a new site and keep earning money. It’s the equivalent of taking away an unsafe driver’s car instead of their license.

In the nearly half-trillion-dollar digital ad industry, Google sets the rules of the road. More than any other company, Google determines the online ads we see, what they cost and who gets paid for them. It runs the biggest search ad business and provides the industry’s leading tools for buying, selling and displaying ads.

And if you have a website and want to earn money from digital ads, you can join the Display Network, where Google places ads on what it has publicly said are more than 2 million websites and an untold number of mobile apps. It’s the modern equivalent of a national network of billboards on nearly every highway being controlled by a single company — and reportedly generated $31 billion in revenue for Google last year.

But if you’re Slapinski, Google’s Display Network has another benefit besides its market share: its secrecy. Google is the only major ad platform that hides the vast majority of its ad-selling partners. This means Google does not disclose all the websites and apps where it places ads or the people and companies behind them. The company conceals this information even after helping establish and publicly supporting an industry transparency standard for disclosing such sellers, which its competitors have largely adopted.

Nandini Jammi of industry watchdog group Check My Ads called out Google’s relationship with Conservative Beaver in a Nov. 7, 2021 tweet. (ProPublica screenshot)

In response to questions, Slapinski denied running Conservative Beaver. “That’s fake news!” he wrote in a Facebook message, despite the large body of evidence he was behind the site. He acknowledged operating Toronto 99, but declined to explain why that site uses the same Google publisher account as Conservative Beaver. He did not respond to questions about Google ads and said he does not publish disinformation.

“I don't publish fake news,” he said. “I follow strict editorial standards.”

Google’s embrace of publisher confidentiality means roughly 1 million publishers can remain anonymous to companies and individuals who buy ads on its network to reach customers. This opens the door to a range of abuses and schemes that steal potentially billions of dollars a year and put lives and livelihoods at risk due to dangerous disinformation, fraud and scams.

Google’s ad business helps fund dangerous disinformation that puts public health and democracy at risk around the world, earns money from millions of gun ads while publicly claiming to block them, and allowed a sanctioned Russian ad tech company to harvest data on potentially millions of people, including possibly those in Ukraine, putting their security and privacy at risk.

It all makes the Display Network one of the world’s most lucrative black boxes. Ads are placed where they shouldn’t be. Money flows to someone other than the intended website or app owner. Publishers of banned sites can easily keep collecting ads and revenue from unsuspecting brands. But because of Google’s allegedly monopolistic dominance of the digital ad industry, companies ranging from mom and pop shops to the biggest brands in the world keep shoveling money into it, hoping for the best.

A Glossary for Understanding Digital Ad Buying and Selling

• A seller refers to an entity with ad space available for purchase. This is typically a publisher that runs websites and/or apps and makes money selling ads. ProPublica is a seller; Candy Crush is a seller. Or it can be an intermediary like an ad consultancy that works with many publishers to help them earn ad revenue from Google ads.
• The advertiser is the buyer.
• An ad network like Google’s Display Network aggregates the ad space available from sellers and makes it available for buyers to purchase via an automated auction system.
• Once accepted into the Display Network, each seller is given a unique ID that looks like this: pub-6728307037029826. A seller can use their ID on multiple websites or apps. A seller can also have multiple IDs. Money earned from ads placed on these properties is deposited by Google into the seller’s account(s).
• Ad networks like the Display Network release a public list of sellers they work with. This is called a sellers.json file. It is supposed to confirm if an ID is active in Google’s system, whether it belongs to a publisher or intermediary and the person/company and domain(s) associated with it.
• But unlike every other major ad network, Google’s sellers file is almost completely confidential. It is mostly a list of IDs like pub-6728307037029826, with no company, individuals or domains listed.

Google spokesperson Michael Aciman said the company uses a combination of human oversight, automation and self-serve tools to protect ad buyers and said publisher confidentiality is not associated with abuse or low quality.

“We want to see more publishers embrace greater transparency, and we conduct regular outreach to our partners to explain the benefits of opting out of confidentiality,” he said. “We do see a lag in consent among small-scale publishers, which may be because they are unaware of this option, or because their account includes personal information and they have legitimate privacy concerns.”

Aciman said the vast majority of ad revenue from Google’s systems goes to publishers who do not keep their information confidential.

ProPublica spent months trying to crack open Google’s black box ad business. We wrote thousands of lines of code to scan more than 7 million website domains looking for Google ad activity, sourced and analyzed data on millions more domains from half a dozen data partners, and spoke to some of the most knowledgeable experts about Google’s display ad business.

In the end, we matched 70% of the accounts in Google’s ad sellers list to one or more domains or apps, more than any dataset ProPublica is aware of. But we couldn’t find all of Google’s publisher partners. What we did find was a system so large, secretive and bafflingly complex that it proved impossible to uncover everyone Google works with and where it’s sending advertisers’ money.

Alongside reputable publishers and popular games and online tools, we uncovered scores of previously unreported peddlers of pirated content, porn and fake audiences that take advantage of Google’s lax oversight to rake in revenue.

In one example, a Bulgarian company helped scores of piracy sites with close to 1 billion monthly visitors earn money from Google ads. Most alarming, Google knew from its own data that these sites were engaging in mass copyright theft, yet it allowed the sites to receive ads and money from major brands such as Nike and HSBC Bank right up until we contacted Google.

As for what else lurks in the black box, only Google knows.

Most Google Sellers Are Confidential

Each time someone visits Toronto 99, the site sends digital requests to Google asking it to place ads on the page. Each of those requests contains this series of numbers and letters: pub-5958167306013620.

It’s a unique ID that identifies Slapinksi’s Google publisher account, much like how your Social Security number identifies you to the government. Google issued Slapinski the account ID when it accepted him as a publisher in the Google Display Network, greenlighting sites he launched to receive ads. The same ID was used by Conservative Beaver.

Google has issued millions of account IDs in the more than 200 countries where its Display Network is active. Anyone operating a website or app in those countries can apply to join.

Once a publisher has an ID, they can add it to new sites and apps that they operate, as Slapinski apparently did. Google also allows publishers to register for more than one ID. The result is an ad network with millions of constantly shifting publishers, sites, apps and IDs.

To help ad buyers navigate this murky ecosystem, ad networks are supposed to disclose a list of the publisher accounts they work with. For Google, this list — which is called a sellers.json file or sellers list — should contain all the websites and apps Google has authorized to earn money in its Display Network, from big publishers like The New York Times to small bloggers. When done correctly, the list should allow advertisers to match Slapinski and the ID pub-5958167306013620 to Toronto 99 and block the site if they wish.

Google itself helped create this concept three years ago and publicly champions it and related standards, saying they “provide advertisers with a greater visibility into the overall supply chain, which can help them inform future buying decisions.”

But among the roughly 1.3 million IDs in Google’s sellers list, over 75% are marked “confidential” and contain only the ID, including Slapinki’s. It’s the default setting in Google’s system. ProPublica’s Google ID was also marked confidential but is being changed to disclose the organization name and affiliated domains.

As of this fall, only 23% of Google’s records listed a person or company name, and just 11% also included the domain of their organization. Google’s competitors almost always publicly list all account IDs alongside such information as the name of a person or company connected to it and the associated domain or domains.

Google Is Less Transparent Than Its Competitors

Google’s list of the websites and apps it provides ads to has far more confidential and partially confidential entries than its competitors, meaning it hides either the name or the domain associated with the account, or both.

(Jounce Media)

On their own, a list of these IDs provides no useful information — it’s like wiping the names from your phone’s contact list, leaving just the numbers.

The upshot is that the largest ad network in the world won’t reveal the identities of the vast majority of its publisher partners. The risks go beyond a lone disinformation peddler like Slapinski. Legislators, including Sen. Mark Warner, chair of the Senate Intelligence Committee, have warned that the opaque and fraud-ridden digital ad ecosystem led by Google poses a national security risk. Each layer of confidentiality further obscures where money and consumer data flows in the digital ad industry, undermining trust and exacerbating risks.

“The lack of transparency and regulation in the digital advertising space is an issue that I have been concerned about for many years,” Warner said in a statement to ProPublica. “Unfortunately, the industry hasn’t improved its practices since I first raised concerns back in 2017, as advertisers consistently appear to lack meaningful control over the types of content that is seen alongside their ads and are oftentimes completely unaware of where their advertisements are being displayed.”

Last year, Warner and a bipartisan group of senators expressed alarm that Google and other companies share data about Americans with undisclosed foreign partners as part of the ad buying and selling process, and that billions of dollars flow through Google to unknown parties around the world.

After the U.S. sanctioned several Russian websites following the invasion of Ukraine, ad tech researcher Krzysztof Franaszek showed that two months later, Google continued to allow many of them to earn money from ads. He also revealed the company placed ads on other sanctioned Russian, Iranian and Syrian sites for years. Critically, nearly 90% of the sanctioned sites earning money from Google ads contained no identifying information in Google’s master ad sellers list, according to Franaszek. Like Slapinski, their accounts were confidential, listing nothing more than a Google account ID.

Aciman said Google works to comply with all relevant sanctions and emphasized that publisher confidentiality should not be seen as nefarious.

“By no means does confidentiality indicate that a publisher is engaging in fraud or other nefarious activity,” he said. “The vast majority of our publishers, including those who are listed as confidential in their sellers.json, are well intentioned, policy compliant, and contribute to the overall vibrancy of our network.”

But industry experts and critics say there’s no way to prove that without Google meeting the same standard as its competitors.

“Google has manufactured a uniquely explosive situation: sending billions of ad dollars everyday to unknown individuals around the world. It is effectively one of the largest dark money transfers in the world — and it’s funded by all our ad campaigns,” wrote Nandini Jammi and Claire Atkin of the Check My Ads Institute, an ad industry watchdog, in a recent article.

They called upon Google to release a full deanonymized sellers file.

Google’s actions thus far suggest major changes are unlikely to happen quickly. The company waited a year after other ad networks began publishing their sellers files to release its own, overwhelmingly anonymous version in 2020. Following pushback, the company offered excuses, including having to update help center documentation, conduct training and contact all the account owners. The company also said there could be privacy and security risks to requiring all of its publisher partners to disclose the individual or company associated with an ID. It said things would improve.

Two years later, Google has increased the total number of fully public entries in its sellers file from 5% to 11% — still by far the worst in the industry. Google’s file also carries a notice not seen in its competitors’: “This file is a beta and is unverified.”

Google declined to comment on the notice. Aciman said publisher transparency is a “critical” part of the ad ecosystem, and pointed to a Google Help Center article that encourages publishers to make their information transparent.

“Google has a unique publisher base and we want to ensure we’re balancing both industry transparency and publisher confidentiality and choice,” he said.

But as of today, new publishers signing up with Google’s ad network are still confidential by default.

Over 380,000 of Google’s Partners Remain a Mystery

After months of data collection and analysis, 70% of the account IDs in Google’s sellers file were matched to one or more websites or apps (11% of these were accounts that Google provided public information on). But 30% of these accounts weren’t declared by Google or in our or our partners’ data, leaving us and Google’s advertising partners in the dark about where their money might be getting spent.

So we attempted to do what Google would not: connect the company’s list of more than 1 million account IDs to the actual sites and apps where ads appear. We were able to match almost 900,000, or 70%, of the accounts in Google’s file to one or more domains or apps and found over 5 million sites that are or were associated with Google publisher accounts. But over 380,000 account IDs remain ghosts, perhaps never used by the entity that registered them or used in a way our data couldn’t capture, perhaps active on a mobile app or site outside of the roughly 300 million available to us in our data and that of our partners.

Some accounts were associated with hundreds of sites, some moved from site to site like a game of whack-a-mole, some were seen on sites before or after being publicly listed in Google’s sellers file. And thousands of accounts are added and removed to the file every week, rendering a given week’s list of publishing partners almost immediately obsolete. This effectively prevents ad buyers from having a basic understanding of the sites and apps where their ads could appear, and who they fund as a result.

Google’s reasons for not disclosing its publisher partners are “rubbish,” according to Ruben Schreurs, the chief product officer of Ebiquity, a media research company that has worked with such brands as L’Oréal, Sony, Nestlé, and Audi. He said it’s in Google’s business interest to keep ad buyers in the dark, because the Display Network is filled with sites and apps most advertisers would not want to do business with.

“They have so many obviously nefarious or even sanctioned partners that use Google’s technology,” Schreurs said.

Porn and “Crap”

Google placed ads on Female Prison Pals, where inmates share photos and answer adult-oriented questions such as their favorite sexual position. (ProPublica screenshot)

Our effort to deanonymize Google’s vast network of publishers revealed a bewildering array of sites and apps. There are news and sports sites in many languages, food blogs, utility sites such as spell-checkers and percentage calculators, and gaming sites. There are sources of disinformation, such as OANN and many others around the world, and the fetish site WikiFeet, which features photos of women’s feet, often without their permission.

In spite of a policy banning sexually explicit content, we found Google placing ads on adult sites like Sexlexikon.net, iSexyChat and Female Prison Pals. On the last of these, Google showed ads to us when we visited pages with photos of female inmates in the United States accompanied by their responses to a questionnaire with prompts such as their favorite sexual position and the age at which they lost their virginity.

Since Google doesn’t release a list of the sites and apps where it places ads, ad buyers ranging from major brands like Nike to small local businesses can’t exclude all of the unsuitable publishers in Google’s network. They can preemptively block problematic sites and apps they know about, but then they must await reports from Google about where their ads were placed.

Even then, Google keeps customers partially in the dark. In most campaigns, the company conceals a percentage of ad placements. This means Google does not reveal all the sites and apps that received the ads and associated revenue. Call it the black hole in Google’s black box.

In an example revealed by watchdog group Check My Ads in May, 10% of all the ads in a million-dollar campaign run via Google were listed as “anonymous” in the report generated for the advertiser. Roughly $100,000 worth of ads were placed on sites and apps, but Google wouldn’t say which ones. (The campaign data was shared with Check My Ads on the condition it not name the brand that ran the ads.)

Schreurs analyzed $1 billion worth of ads placed for his company’s clients and found that 3.6%, or $36 million worth, went to unknown websites and apps. Google isn’t the only company that conceals a percentage of advertiser placements and spending. But the company combines the practice with other methods of obfuscation, like its largely anonymized sellers file, that thwart transparency and accountability.

Google also doesn’t allow ad buyers to block by account ID. Even if buyers know that pub-5958167306013620 is the publisher account for the owner of Conservative Beaver, they can’t direct Google to block their ads from appearing on sites or apps using that ID.

Aciman said the company is currently beta-testing a tool that allows ad buyers to block by seller ID.

“This would enable buyers to block confidential sellers by adding those sellers to their blocklist,” he said. “The tool is expected to launch for general availability in 2023. This would go beyond our existing tools that provide advertisers with robust controls that lets them decide where their ads appear.”

Ruben Schreurs, chief product officer of Ebiquity, a media research firm (Ebiquity)

Schreurs said Google has a financial interest in concealing which sites and apps it works with. The company earns money by taking a cut of each ad placement — the higher the volume, the more Google makes. To maintain that volume, the company needs to work with low-quality and risky publishers, he said.

“We all know that most of Google’s inventory is crap,” he said.

Aciman disputed the quality concerns and said that most of the money flowing through Google’s ad system does not go to confidential publishers. In late 2020, a Google executive said more than 90% of revenue goes to the small percentage of partners that are publicly identified in its sellers file. Aciman said the percentage is even higher now.

If that’s true, it begs the question of why Google risks working with so many sites and apps. But the concerns about Google’s ad network go beyond the hidden identities of its publishers and sites.

Attack of the Manga Pirates

PapayAds, a Bulgarian company, works with piracy sites and listed false information in its public Google account information. (ProPublica screenshot)

Last year, a marketer working for a Fortune 500 company launched a multimillion-dollar ad campaign.

The goal was to reach business owners in the U.S. by placing digital ads on websites and apps in Google’s Display Network. Using Google’s DV360 ad buying tool, the marketer entered details about their desired audience, uploaded a list of risky or otherwise inappropriate sites and apps to block from receiving ads and launched the campaign. The marketer said they were not authorized to share campaign data publicly, and did so on the condition that their name and that of the Fortune 500 company not be disclosed.

Over the next few months, Google placed more than 1.3 trillion of the company’s ads on over 150,000 different websites and apps. The biggest recipient of ads — more than 49 million — was a website called PapayAds. The company was registered in Bulgaria less than two years ago and lists one employee, CEO Andrea De Donatis, on LinkedIn. Its site is a single page that says it helps publishers increase their ad revenue. PapayAds has just one ad slot on its page, which is presented as a demo for prospective clients to see what banner ads look like. One of its customer testimonials comes from someone using a pseudonym.

That’s not the only time De Donatis used fake or misleading names. PapayAds is among the small percentage of Google partners that list both the name or names of people associated with the company and its domain in Google's sellers file. At least two of PapayAds’ sellers accounts list the name of De Donatis. But the rest are registered to his girlfriend, his brother and a set of dubious names that Google and De Donatis confirmed are also not associated with the company. One account is in the name of Luca Brasi, the famed character in the first Godfather film.

Google placed ads in a single slot on the PapayAds’ corporate website, such as this one from Royal Caribbean. (ProPublica screenshot)

It seems impossible that 49 million ads were legitimately placed and viewed on PapayAds’ site over the span of several months. In an interview with ProPublica, even De Donatis expressed skepticism. “I don’t have an explanation for this,” he said, adding that he does not recall receiving payment for such a large volume of ads.

Google declined to comment on the campaign, rendering the 50 million ads it charged a Fortune 500 company for one of many mysteries of its black box.

But the story of Google’s relationship with PapayAds goes deeper. It also includes a possibly related scheme involving online piracy, fraudulent advertising and fake online traffic. And even after discovering at least part of the operation, Google didn’t take steps to remove PapayAds or the many piracy sites it works with from the Display Network.

Here’s how the scheme worked. First, PapayAds signed up website publishers to help them earn money from ads. At least 679 websites list PapayAds as their Google Ads partner, based on our findings and data from Well-Known, a site that tracks advertising systems. This means these sites publicly declare that they use PapayAds account IDs to help receive ads and money from Google.

Nearly all of the of PapayAds client sites we examined specialize in publishing pirated versions of Japanese comics, known as manga, or Korean comics, known as manhwa. Others feature pirated Japanese animated films and shows, or pornographic manga known as hentai. Google and other ad networks ban ads from appearing on copyright infringing content. Google also bans ads from appearing on pages containing hentai.

This past summer, PapayAds used code that misled Google and ad buyers into thinking Google ads were being placed on PapayAds’ site when they in fact appeared on manga piracy sites, according to Pixalate, a digital ad fraud protection and privacy compliance company that examined PapayAds at our request.

De Donatis described this as a “test” he attempted with some manga sites, and said his company did not realize it broke Google’s rules. PapayAds is merely providing a service to clients approved by Google, he said.

“I’m just providing some IT technology,” De Donatis said. “I don’t think I did anything bad.” (His first language is Italian, but he spoke English during two phone interviews.)

Pixalate also found the operation included an element of deception to maximize profit: bots. It found that some of the web traffic on PapayAds and its manga piracy partners was automated. Bots artificially inflate the number of ads viewed on a website, thereby increasing revenue.

“I can tell you that we never used bot traffic or fake traffic,” De Donatis said.

Pixalate’s findings did not attribute the automated traffic to a particular entity. It’s possible the bot activity was connected to PapayAds’ clients or another entity.

Google detected the improper activity over the summer and withheld the associated ad revenue earned by PapayAds clients from their August and September payments, according to De Donatis. According to Google policy, that money should have been refunded to advertisers.

De Donatis didn’t say how much was withheld, but described it as a large amount relative to his and his partners’ typical earnings. (He claimed on his LinkedIn profile that PapayAds generates $400,000 in revenue per month, but removed that information after speaking with ProPublica.)

Google declined to comment on the withheld revenue and overall scheme. Speaking generally, Aciman said the company is “engaged in a comprehensive effort to detect and stop invalid traffic, which is powered by a combination of technology, operations teams, and policy.”

But what did Google do after detecting what by industry definition is an ad fraud scheme involving a set of manga piracy sites filled with stolen content? It kept placing ads on them, and kept working with PapayAds up until being contacted by ProPublica.

This occurred in spite of the fact that Google has at least two years of data showing that many manga sites working with PapayAds are serial copyright infringers.

We selected a sample of 50 manga sites from the list of more than 650 sites that publicly said they work with PapayAds to receive Google ads. Data from Google’s transparency report shows that since 2020 Google has removed 1.9 million of these manga sites’ URLs from search results due to copyright infringing content. Yet 34 of the 50 sites appeared in the Fortune 500 company ad buy under their own domains, and the full list of 50 continued to receive Google ads until very recently.

Google could see in its own data that these sites were engaging in mass piracy, and that they were working with PapayAds to receive ads and revenue. But it did not take action to kick them, or PapayAds, out of its ad system.

The 50 sites in our sample collectively received close to 750 million visits in September, according to analytics company Similarweb, and were able to make money from that traffic thanks in part to Google. We were shown ads placed by Google for major brands including Nike, Sephora and HSBC Bank when visiting manga piracy sites. The brands did not respond to requests for comment.

Google placed a Nike ad on TV y Manga, a site it has delisted more than 10,000 URLs from in its search engine due to copyright infringement. (ProPublica screenshot)

Jalal Nasir, the CEO of Pixalate, expressed concern that Google is directly placing ads on such obvious piracy sites.

“I’m a little surprised that Google with their big team is not able to detect this stuff happening,” he said.

Nasir also said it’s a huge red flag that PapayAds does not have a privacy policy, a requirement for any Google partner and a necessity for compliance with data protection laws. “Do they have proper due diligence in place?” he said of Google.

After speaking with ProPublica, De Donatis added a privacy policy to his site. He said he’s not responsible for the content of the sites that use his platform, and noted that nearly all of the manga sites were approved by Google to receive ads before signing on with him.

An ad for Google appeared on Reaper Scans, a manga piracy site. (Source: Rocky Moss)

“Like 90% of them already have Google ads when they come to us,” he said.

Google also failed to take action against PapayAds and the raft of manga sites it works with after being warned about them almost two months ago. Rocky Moss, the co-founder of fraud detection company DeepSee.io, identified PapayAds as a major player helping piracy sites earn money. On Oct. 25, he emailed his contact at Google to draw their attention to the company.

“Just wanted to flag a particularly egregious pirate traffic seller,” he wrote. Moss attached an image of a concerning ad he’d seen placed on Reaper Scans, a manga piracy site working with PapayAds for which Google has received and acted on thousands of copyright infringement reports.

The advertiser in question? Google.

Moss said the tech giant’s inaction is disappointing but not surprising.

“There are good people working at Google who want to do the right thing. They just can’t get the approval to solve the problem,” he said.

After we contacted Google with our findings, the company removed all of PapayAds’ seller accounts.

“We are in the process of reviewing the specific sites shared with us by ProPublica and have already removed ads from several and have terminated the accounts associated with PapayAds,” Aciman said. “We will continue to take action as we detect any additional policy violating content.”

Nasir and Moss expressed dismay that Google failed to stop PapayAds and the piracy sites sooner. They said there are likely an untold number of companies like PapayAds operating in the Display Network.

“It’s probably a drop in the ocean of what’s happening out there,” Nasir said.

Jeff Kao contributed reporting.

by Katie Campbell, ProPublica, and Tony Schick, Oregon Public Broadcasting

This video 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.

When the salmon are running up the Columbia River, Native people are there with them. They live, eat and sleep at the river. Their children grow up at the river. They catch salmon for subsistence, for ceremonies and for their living.

This is the life of the Wy-Kan-Ush-Pum, the Salmon People. It is a life Columbia River tribal people have lived for generations and have fought for decades to protect. Over the last century and a half, they have watched as forces eroded their access to salmon. Treaties removed them from their traditional fishing areas; dams massively reduced the numbers of salmon that swam in the waters; environmental contamination further poisoned the well.

And now, as climate change threatens the salmon throughout its life, the stakes of that fight are existential.

Watch the documentary, and read all of ProPublica and Oregon Public Broadcasting’s team reporting on the threats facing salmon and the broken treaties that the government swore would protect tribes’ right to fish.

by Bryant Furlow, New Mexico In Depth, with additional reporting by Asia Fields, Maya Miller and Joel Jacobs, ProPublica

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

Are you part of the Gallup-McKinley County Schools community? We’d like to hear from you.

One chilly March afternoon, dozens of Navajo children spilled out of their middle school to play in the snow before heading home. Students in jackets and parkas can be seen on grainy security camera footage chasing and pushing one another to the ground.

The next day, the principal called one of the children into her office. “She said I was expelled,” the child said in an interview, looking at his feet as he sat with his grandmother on their living room couch. “We were just playing around.”

His offense, according to school records, was “assault and battery” for pushing another student down.

The seventh grader, whose middle name is Matthew, said that was the culmination of months of being written up for “everything” — from being off-task in class to playing on the school elevator. (Out of concern that the boy will be stigmatized at school, his grandmother agreed to speak on the condition that she not be identified and that he be identified only by his middle name.)

In New Mexico, Native American students are expelled far more often than any other group and at least four times as often as white students.

Matthew’s school district, Gallup-McKinley County Schools, is responsible for most of that disparity, according to an analysis of state records by New Mexico In Depth and ProPublica. The district has a quarter of New Mexico’s Native students, but it accounted for at least three-quarters of Native student expulsions in the state during the four school years ending in 2020.

Gallup-McKinley is one of the largest school districts in the state by enrollment and geography, but even so, it has just 4% of the state’s students. Twice the size of Delaware, the district sits along the western edge of New Mexico and includes wide swaths of the Navajo Nation. The Chuska Mountains stretch northward, overlooking sandstone cliffs, mesas and canyons, in a landscape dotted with piñon pine, juniper and the fossilized remnants of long-gone oceans.

About three-quarters of Gallup-McKinley’s roughly 12,000 students are Native American, most of them Navajo. It has the largest Native enrollment of any public school district in the United States, according to federal figures.

Gallup and other towns that ring the Navajo Nation have a history of bias and exploitation. In a recent book, University of New Mexico professor David Correia wrote that Gallup’s businesses, including payday lenders, unscrupulous art dealers and liquor stores, have a history of exploiting Native people.

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Wendy Greyeyes, who is Navajo and an assistant professor of Native American Studies at the University of New Mexico in Albuquerque, said that history plays out today in a more subtle way: through school practices that lead to Native students being disciplined more harshly than others. School policies “are used to justify racist behavior,” she said.

In addition to analyzing statewide discipline data, New Mexico In Depth and ProPublica interviewed 80 people, including 47 parents, grandparents and current and former students, to understand discipline practices in Gallup-McKinley schools. District officials, including Superintendent Mike Hyatt and school board President Christopher Mortenson, did not respond to repeated interview requests.

The state education department requires school districts to report all disciplinary incidents. Those reports track the type of discipline, such as suspensions and expulsions, and note whether police were involved. Gallup-McKinley school officials sometimes called the police or juvenile probation officers over physical altercations, tobacco or drug possession and disorderly conduct, those records show.

Over the past decade or so, the number of expulsions and incidents involving law enforcement has dropped substantially in New Mexico. While Gallup-McKinley’s discipline rate has fluctuated over the past decade, it has remained far higher than the rest of the state.

Native Students Face Harsher Punishment Across New Mexico

Native students in New Mexico experience higher annual rates of expulsions and incidents involving police than white students. In Gallup-McKinley, students across the board are punished more harshly than those in the rest of the state, but the large Native student body is still disciplined at higher rates than white students.

(ProPublica analysis of New Mexico Public Education Department STARS data. Chart by Joel Jacobs.)

That has happened under the nose of the state.

Since 2018, New Mexico has been under a state district court order to remedy its failure to provide a sufficient education to Native Americans, students learning English as a second language and other underserved youth. The child of one of the lead plaintiffs in the case that led to the order attended school at Gallup-McKinley. Though most of the court order dealt with state funding and oversight, the judge did address school discipline, noting that high discipline rates are a signal students need more help in school.

The New Mexico Public Education Department uses school districts’ annual reports to track racial disparities among special education students, as required by federal law. Unlike some other states, it doesn’t otherwise track racial disparities in discipline.

The department declined to address the news outlets’ findings. Kelly Pearce, a department spokesperson, said the state could discuss only the “big picture” because school districts are in charge of discipline. If families have complaints about school discipline, she said, they should go to the federal Office for Civil Rights. No one has complained to that office regarding school discipline in Gallup-McKinley from the 2015-16 through the 2020-21 school years.

A spokesperson for New Mexico Attorney General-elect Raúl Torrez called the news outlets’ findings “alarming” but said the office doesn’t have authority to investigate civil rights abuses by school districts or other public bodies. Torrez will advocate for legislation to change that, spokesperson Taylor Bui said.

Daniel Losen, who studies racial disparities in school discipline as director of the Center for Civil Rights Remedies at the University of California, Los Angeles, said someone needs to investigate discipline rates in Gallup-McKinley.

School districts with higher concentrations of students of color often “have higher use of police and just more draconian discipline practices,” Losen said. “Why is what’s happening to kids in Gallup so much worse than what’s happening to kids in the rest of the state?”

Gallup-McKinley’s Discipline Rates Tower Above the Rest of New Mexico

Students in Gallup-McKinley County Schools were disciplined far more frequently and severely than those in the rest of the state in the 2016-17 to 2019-20 school years. The district especially stands out when it comes to expulsions and incidents in which students were referred to police or juvenile probation.

Gallup-McKinley reported at least 211 expulsions over the four school years, an annual rate of 4.6 per 1,000 students. That’s at least 10 times as high as the rest of the state. Students in Gallup-McKinley schools also faced 735 disciplinary incidents involving law enforcement, which amounts to a rate nearly four times as high as the rest of the state. The disparities persisted from elementary through high school.

Gallup-McKinley Students Face More Frequent Severe Punishment

From elementary through high school, kids in Gallup-McKinley schools were expelled and faced discipline involving law enforcement at annual rates far higher than their peers in the rest of the state.

(Source: ProPublica analysis of New Mexico Public Education Department STARS data. Chart by Joel Jacobs.)

Native students within the district are subjected to these punishments at roughly twice the rate of their white peers. The district’s Hispanic students face similarly high rates, but because Gallup-McKinley’s Hispanic student population is relatively small, these numbers don’t significantly drive up the state’s discipline rates for Hispanics overall.

Gallup-McKinley’s student behavior handbook states that the rules will be “enforced fairly in an age-appropriate manner” and that the district is committed to providing all students safe school environments “free of discrimination, violence, and bullying.”

Ben Chavez, who directed discipline in the district until earlier this year, told New Mexico In Depth and ProPublica he was not given permission to speak about the issue.

Rachel A. Rodriguez, a former Gallup-McKinley County Schools discipline administrator, attributed Native students’ higher disciplinary rates to problems among rural families, like poverty, trauma and substance abuse.

The belief that alcohol abuse is more frequent among Native Americans is widespread, but it’s not borne out by the facts. And neighboring districts with large numbers of Native students and similarly high rates of unemployment and poverty don’t dispense as much harsh discipline as Gallup-McKinley.

For example, Gallup-McKinley reported significantly higher rates of expulsions and incidents involving law enforcement than the Central Consolidated district in neighboring San Juan County. Central Consolidated has an even higher proportion of Native students than Gallup-McKinley and a similar “at-risk index,” which is used by the state to identify school districts that need additional money to educate high-needs kids.

One of the main drivers of Gallup-McKinley’s discipline rates is disorderly conduct — an infraction that until the current school year wasn’t even defined in its or state education department policies, rulebooks, parent handbooks or regulations. The 2022-23 Gallup-McKinley student handbook defines it simply as “action(s) which substantially disrupt(s) the orderly conduct of a school environment.”

(Gabriella Trujillo, special to ProPublica)

“Disorderly conduct,” said former Gallup-McKinley Assistant Principal Ron Triplehorn, “is going to be kind of your catchall, just kind of a generic term for general misbehavior.”

Statewide, Native students were expelled for disorderly conduct at least 76 times and law enforcement was involved in 193 such incidents from 2016-17 to 2019-20. About 90% of these incidents occurred in Gallup-McKinley schools.

Across the United States, students of color tend to be disciplined at higher rates for vaguely defined, catchall minor infractions like disorderly conduct, Losen said. “That’s where the largest racial disparities are usually found,” he said.

Gina Laura Gullo, assistant director of education services at the Pennsylvania State Education Association, did her Ph.D. dissertation on unconscious bias in school discipline. She found that school administrators who scored higher on measures of implicit racial bias assigned harsher discipline to students of color than white pupils.

“Infractions that are more subjective in nature,” she said, “such as disorderly conduct, insubordination, classroom disturbance and the like, are those that are specifically subject to more implicit bias.”

How Matthew Got Kicked Out of School

For 13-year-old Matthew, inattentiveness, playing on an elevator, not following instructions and pouring glue on a desk were all classified as disorderly conduct.

He said his discipline problems started after the principal caught him making fun of her in the hallway. Over the next two months, she suspended him four times and wrote him up four other times.

The first time, Matthew was suspended for a day because a teacher reported that he didn’t follow instructions and poured glue on his desk. Matthew told New Mexico In Depth and ProPublica that he was putting glue on his hand when some got on the desk, and that he peeled it off.

Matthew’s grandmother allowed the news outlets to review his school disciplinary records. The principal did not respond to interview requests.

In November, Matthew’s teacher wrote that he objected to Matthew’s “behavior towards learning.” He “is always off-task, disrespectful, and defiant,” his teacher wrote in a note to the principal.

When Matthew wore a blue shirt to school, a dress code violation, the principal wrote him up for “gang-related activity.”

She wrote him up for “bullying” after she used security camera footage to conclude he and another student banged on her office window and ran off. Matthew told the news outlets he didn’t do it; the only evidence in his file is two blurry images taken from the video.

The principal suspended Matthew for a day after confiscating a miniature toy butterfly knife. “Weapons possession,” she wrote. He said he had bought the plastic and tin toy from a vending machine.

Two weeks later, she suspended him for a week for allegedly cutting a classroom chair with the elastic band of his face mask. That, the principal wrote, was “vandalism.” Matthew told the news outlets he slipped the band into an existing cut in the back of the plastic chair, and the teacher saw him pulling it back and forth.

In December, the principal ordered a disciplinary hearing, citing his “multiple misbehaviors.” Matthew and his grandmother signed a behavior contract, agreeing he would stay out of trouble.

“It would have been nice if she had asked why he was acting like this,” Matthew’s grandmother said. She said she would’ve told the principal that Matthew has been diagnosed with attention deficit hyperactivity disorder. Though Matthew once took medication at school, he doesn’t have an individualized education plan, or IEP, which would afford him protections for discipline related to his diagnosis.

Matthew had reason to be distracted at school: His grandmother, who is raising him, was undergoing radiation treatment for breast cancer. A judge awarded her custody of Matthew when he was little, after his father died. He sees his mother only occasionally.

Then came the incident in March, when Matthew was kicked out of school for pushing the student to the ground. In a letter to his grandmother, the principal wrote that a security video showed Matthew “chasing and shoving” a “female student into the snow multiple times” and that when the girl was questioned the next morning, she reported back pain.

(Gabriella Trujillo, special to ProPublica)

Matthew’s grandmother said the principal refused to show her the video or allow her to hear the girl’s version of events. Instead, the principal provided a single picture. It “just showed a girl in the snow with two boys standing there,” the grandmother said. “I didn’t recognize him.”

New Mexico In Depth and ProPublica reviewed the video, which had no audio. It shows groups of children talking and roughhousing. The student identified in the report as Matthew pushed another student down, possibly twice. Earlier, another student had pushed the same student down but apparently was not disciplined, according to the district’s response to a public records request for other disciplinary reports from that afternoon. All three students appeared to interact afterward.

Matthew’s grandmother told the principal she wanted to appeal the decision to kick Matthew out of school. “She told me, ‘Good luck.’”

Normally the school district must hold a hearing before expelling or suspending a student for more than 10 days. But the behavior contract Matthew and his grandmother had signed said if he broke the rules again, he would be disciplined without a hearing.

Although Matthew said the principal told him he was expelled, her letter to the grandmother called it a long-term suspension. Under the district’s rules at the time, that meant Matthew could have returned to school after 90 days. But when Matthew’s grandmother later tried to enroll him in summer school, which fell outside that time, the principal refused, the grandmother said.

After Matthew was kicked out, his grandmother asked that he be allowed to take online classes or complete homework so he didn’t fall hopelessly behind. Schools allowed both when they were closed during the pandemic. The principal refused, the grandmother said.

Over the following weeks, Matthew became increasingly withdrawn, his grandmother said. “He stopped talking to me very much,” she said. “I worry.”

Delores Greyeyes, director of the Navajo Department of Corrections and mother of Wendy Greyeyes, said some parts of Matthew’s story sounded familiar. When she was a girl, she said, she and her friends poured glue on their hands.

“We let it dry and pulled it off to see our palm and fingerprints,” she said. “So when you tell me this student was disciplined for disorderly conduct because glue got on his desk, I have to wonder: Was that curiosity?”

Greyeyes, a former social worker, interviewed inmates at the state prison in Winslow for her dissertation research. They told her their first encounters with police happened in school. Trouble often started small — missed homework or sleeping in class. Teachers saw them as defiant rather than asking them what was wrong, she said, leading to escalating discipline.

“One of these young men said his school administrator told him he was a ‘no-good Indian’ and put it in his head his destiny would be to be in jail or dead,” she said.

The Unintended Consequences of Harsh Discipline

Karl Lohmann, a retired Gallup-McKinley elementary school teacher, remembers when the school district established a “zero tolerance” policy in the early 1990s. Many teachers welcomed it, he said, because they thought it would give them more support and more say in student suspensions.

Several years later, he sent a fifth grade Native American boy to the principal’s office for stealing a handheld electronic spelling game. “I expected the principal to call in the parents and get it back,” Lohmann said.

Instead, the boy was handcuffed and taken away in a patrol car. “That was part of my education about how policies can have unintended consequences,” Lohmann said.

Research has shown that “zero tolerance” or “no excuses” policies, adopted in many school districts around that time, can do more harm than good and even serve as a vehicle for bias. After calls for reform, many school districts have shifted away from zero tolerance in favor of prevention of misbehavior and a focus on students’ emotional needs.

Gallup-McKinley’s current discipline policy doesn’t mention zero tolerance. But neither does it embrace an approach gaining favor in the state: restorative justice practices such as talking circle mediation. The state has announced that it will conduct a pilot study of restorative justice practices to reduce expulsion and suspension rates. Twelve schools across the state will participate; none are in Gallup-McKinley.

Severe discipline practices criminalize student misbehavior, said Regis Pecos, a former governor of Cochiti Pueblo and a leader in efforts to reform education in New Mexico.

Harsh forms of discipline, coupled with a lack of emotional support or restorative justice practices, create a “hostile education environment,” Pecos said. Students become demoralized and come to see themselves as the problem. That fuels high dropout rates, underachievement, poverty, health disparities and high suicide rates, he said, “compounding the challenges for students, parents and communities.”

Gallup-McKinley’s three-year strategic plan, completed in February, says one desired outcome is a reduction in the number of disciplinary referrals that result in charges against students, but district officials did not answer questions about how that would be achieved. The plan was removed from the district’s website after New Mexico In Depth and ProPublica asked about it.

About a dozen students and parents told New Mexico In Depth and ProPublica they supported the district’s strict discipline measures. About twice as many said some students are singled out while others are handled lightly, and punishments can be arbitrary and counterproductive.

This spring, dozens of students, mostly Native, were suspended for a senior prank in which they threw streamers, toilet paper and glitter and sprayed shaving cream throughout the school.

(Gabriella Trujillo, special to ProPublica)

Some of the students’ parents said the district pressured them to waive their right to a hearing in exchange for allowing the students to graduate. Several parents instead sued after their children had been suspended for more than 10 days without a hearing — a violation of the school district’s policies.

A judge ordered Gallup-McKinley to allow the students to return to class. The school district held hearings and suspended the students a week before graduation, although they did graduate.

Students, parents and alumni protested what they saw as a strict response to an annual prank, which the district called “criminal activity.” District officials called police over the incident, although they told police they would handle student discipline and no one was charged.

Rodriguez, the former Gallup-McKinley discipline administrator, said school officials sometimes can’t avoid calling the police. She described one such incident involving a fifth grade boy.

“He was so angry,” she said. “We called the police and three officers had to put him down and put him in handcuffs. When I came home that night, I cried. I said, ‘I never want to see a fifth grade student put in handcuffs again.’ It was traumatizing to me. But we had to.”

Other times, she said, police were called to help retrieve children, including elementary students, who left campus. “They run — take off running from the school and we chase them, but they’re faster than us,” she said. “So we have to call the police to find them.”

McKinley County Sheriff-elect James Maiorano III said his office has been contacted a few times over the years for missing students. The Gallup Police Department didn’t respond to requests for comment.

Maiorano, who has been with the sheriff's office for 18 years, said the agency is increasing its presence in Gallup-McKinley schools to deal with fights and drug possession.

Discipline involving police can have profound consequences. Rhonda Goodenough, who once ran the state probation and parole office in Gallup, said even a sealed juvenile record of a minor offense sometimes stops a young person from joining the military. Recruiters would call, asking her to unseal or explain a minor’s criminal record, but she wasn’t allowed to say anything.

“There was nothing I could do,” Goodenough said. “They couldn’t get it off their record.”

By the end of the school year, Matthew had missed close to 100 days of class. In August, he learned he would be forced to repeat seventh grade.

“He’s really quiet. He used to talk with me, but now it’s just ‘yes,’ ‘no,’ ‘I dunno,’” his grandmother said in September. “Before, he used to talk to me about class and what they did, but since he started getting in trouble there, he’s just not interested in school anymore.”

Matthew said his favorite subjects are math and science. In elementary school, he participated in an after-school STEM club. Before his string of suspensions, his grandmother said, he had talked about going to college to become an engineer.

“If we can just get him through high school and into college,” she sighed, “I can die content.”

Josh Peck contributed reporting. Mariam Elba contributed research.

by Joel Jacobs, ProPublica, and Bryant Furlow, New Mexico In Depth

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

New Mexico In Depth and ProPublica used data from the New Mexico Public Education Department to analyze student discipline rates across the state. The news outlets found that one district, Gallup-McKinley County Schools, played an outsized role in the disproportionate discipline of Native American students in the state. That district enrolls more Native students than any other public school district in the United States and a quarter of Native students in the state.

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Through public records requests, the news organizations obtained a spreadsheet of all disciplinary incidents reported by school districts to the state Public Education Department. The data was extracted from the state’s public schools database, called the Student Teacher Accountability Reporting System, and covered the 2010-11 to 2021-22 school years.

We chose to analyze multiple recent years to account for fluctuations in discipline from year to year. Discipline data for the 2020-21 school year was not included in our analysis because of school closures during the pandemic. Data for 2021-22 was excluded as well because it was incomplete. Ultimately, our analysis focused on the 2016-17 to 2019-20 school years.

To calculate the annual discipline rate per 1,000 students, we used state enrollment figures covering the same years, also from STARS. To compare the district’s Native student population to other districts nationwide, we used data from the National Center for Education Statistics, which showed Gallup-McKinley enrolled more Native students than any other public school district in the 2021-22 school year, the most recent year for which national data is available.

Because of how race and ethnicity are reported in state enrollment and disciplinary data, any student who identifies as ethnically Hispanic, which includes some Native Americans, is counted only as Hispanic. Hispanic students make up about 18% of the Gallup-McKinley student body, while Native Americans make up about 73% as of the 2021-22 school year. Both groups were disciplined at similarly high rates compared with white students. However, because Gallup-McKinley accounts for a much smaller portion of the state’s Hispanic students, the district’s high discipline rates did not significantly impact statewide Hispanic discipline rates.

Our analysis included disciplinary incidents involving students from kindergarten through 12th grade. The enrollment data used for our rate calculations included pre-kindergarten students; the Public Education Department did not provide data that allowed us to remove those students from all of our rate calculations. Pre-kindergarten students make up a small percentage of overall enrollment; including them in our denominator slightly reduced calculated discipline rates.

We included charter schools that are part of traditional school districts as well as alternative learning environments such as home schools that are included in districts’ reports. Statewide, they account for roughly 5% of student enrollment and 1% of infractions. Our analysis excluded charter schools that are treated as their own school districts, which enroll about 5% of the state’s students.

Each record included a “Discipline Response” field, which noted the most severe punishment imposed for a given infraction. School district staff choose from a list of options to populate this field. The options include “Expulsion” and “Modified Expulsion,” in which expelled students receive some educational services. We included both when tallying expulsions.

Arrests and referrals to law enforcement are grouped in a single option in the “Discipline Response” field, called “Arrest/referral to justice system.” That meant we were unable to determine the precise number of arrests. Referrals mean calls to law enforcement agencies or to the state-run juvenile probation office.

The data included a separate “Criminal Charge Code” field, which is meant to indicate whether a police report had been filed, according to the STARS manual. A few districts contacted by New Mexico In Depth and ProPublica said they use this field to record when they call law enforcement, instead of selecting the “Arrest/referral to justice” system option in the “Discipline Response” field. (Gallup-McKinley officials did not respond to multiple requests over a period of months to discuss their discipline practices and data entry.) When referring to incidents involving law enforcement, we included any record marked with “Arrest/referral to justice system” or “Criminal Charge Code.”

During the time period we analyzed, if a student faced multiple types of discipline (such as an arrest and suspension), schools were instructed to record only the most severe punishment, according to the STARS manual. The most severe punishment in the system is “Arrest/referral to justice system,” and the second-most severe response is expulsion. As a result, if a student was arrested and expelled in response to an incident, it may appear only as an “Arrest/referral to justice system” in the data. State officials told us they don’t know how often that happened.

Not accounting for incidents marked as “Arrest/referral to justice system,” Native students had an expulsion rate roughly 13 times that of white students statewide from the 2016-17 to the 2019-20 school years. If all arrest/referral incidents of white students involved expulsions, and none of Native students did, this disparity was reduced to four times. We used the most conservative figure in our story, although the true disparity is likely larger. We used a similarly conservative method when comparing Gallup’s expulsion rate to the rest of the state.

Here are the details on how we reached our conservative estimates:

• To compare Native and white expulsion rates, we divided the Native expulsion rate (1.53) by the sum of the white rates for expulsion and arrest/referral to the justice system (0.12 + 0.23).
• To compare Gallup-McKinley and the rest of the state, we divided the district’s expulsion rate (4.58) by the sum of the rest of the state’s rates for expulsion and arrest/referral to the justice system (0.16 + 0.26)

When analyzing the data, we found about 20 cases in which a school district, including Gallup-McKinley, reported few or no disciplinary incidents for the first several months of a school year, despite reporting significant numbers in the rest of the year. We ran a separate analysis to account for those gaps, which produced similar findings.

Because of the limitations of the “Discipline Response” field and differences in how districts report law enforcement interactions, we compared rates across a variety of measures. For all measures of severe punishment, stark disparities persisted between Gallup-McKinley and the rest of the state and between Native American and white students statewide.

Gallup-McKinley Has Higher Rates of Severe Discipline Than the Rest of the State

We looked at annual rates of discipline per 1,000 students, averaged across the 2016-17 to 2019-20 school years, for several different measures of punishment.

Native Students Are Severely Disciplined More Than Their White Peers in New Mexico

We looked at annual rates of discipline per 1,000 students, averaged across the 2016-17 to 2019-20 school years, for several different measures of punishment.

by Mike Hixenbaugh, NBC News, and Jeremy Schwartz, ProPublica and The Texas Tribune

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The story was also produced in partnership with NBC News.

The U.S. Education Department’s civil rights enforcement arm has launched an investigation into a North Texas school district whose superintendent was secretly recorded ordering librarians to remove LGBTQ-themed library books.

Education and legal experts say the federal probe of the Granbury Independent School District — which stemmed from a complaint by the American Civil Liberties Union of Texas and reporting by NBC News, ProPublica and The Texas Tribune — appears to be the first such investigation explicitly tied to the nationwide movement to ban school library books dealing with sexuality and gender.

The Education Department’s Office for Civil Rights notified Granbury school officials on Dec. 6 that it had opened the investigation following a July complaint by the ACLU, which accused the district of violating a federal law that prohibits discrimination based on sexual orientation and gender. The ACLU complaint was based largely on an investigation published in March by NBC News, ProPublica and the Tribune that revealed that Granbury’s superintendent, Jeremy Glenn, instructed librarians to remove books dealing with sexual orientation and people who are transgender.

“I acknowledge that there are men that think they’re women and there are women that think they’re men,” Glenn told librarians in January, according to a leaked recording of the meeting obtained, verified and published exclusively by the news outlets. “I don’t have any issues with what people want to believe, but there’s no place for it in our libraries.”

Later in the meeting, Glenn clarified that he was specifically focused on removing books geared toward queer students: “It’s the transgender, LGBTQ and the sex — sexuality — in books,” he said, according to the recording.

The comments, combined with the district’s subsequent decision to remove dozens of library books pending a review, fostered a “pervasively hostile” environment for LGBTQ students, the ACLU wrote in its complaint. Chloe Kempf, an ACLU attorney, said the Education Department’s decision to open the investigation into Granbury ISD signals that the agency is concerned about what she described as “a wave” of anti-LGBTQ policies and book removals nationally.

“In this case it was made very clear, because the superintendent kind of said the quiet part out loud,” Kempf said in an interview. “It’s pretty clear that that kind of motivation is animating a lot of these policies nationwide.”

An Education Department spokesperson confirmed the investigation and said it was related to Title IX of the Education Amendments of 1972, which prohibits schools from discriminating on the basis of sex, gender and sexual orientation. The Office for Civil Rights doesn’t comment on pending investigations, the spokesperson said.

If the investigation confirms violations of students’ rights in Granbury schools, the agency can require the district to make policy changes and submit to federal monitoring.

Neither Glenn nor the district responded to messages Monday. In an earlier statement following the news outlets’ reporting in March, the district said it was committed to supporting students of all backgrounds. And the district said that its primary focus is educating students but that “the values of our community will always be reflected in our schools.”

Granbury, a town 40 miles west of Fort Worth, has been embroiled in a heated debate over what types of books children should be allowed to read at school.

Last year, voters in Granbury elected a pair of school board members who campaigned against LGBTQ-affirming school curricula and library books. Afterward, Glenn began asking district administrators about several books that an unnamed school board member had found in the district’s online catalog, according to text messages reviewed by NBC News, ProPublica and The Tribune. The messages from the board member to Glenn included screenshots of eight titles, all of which dealt with LGBTQ topics, with the words “gay,” “trans” and “gender” highlighted in some of the book descriptions.

In January, when Glenn met with librarians, he told them that the new school board was “very, very conservative” and that any employee who holds different political views had “better hide it,” according to the recording of his comments. In the days that followed, the district embarked on one of the largest mass book removals in the state, pulling 130 titles, most of which featured LGBTQ characters or themes.

After a volunteer review committee voted to return all but a few of the titles, two disgruntled members of the committee filed a police report in May accusing district employees of providing “pornography” to children, triggering a monthslong criminal investigation by Hood County Constable Chad Jordan, which remained open as of August. Jordan didn’t respond to messages requesting an update on the investigation.

All of that — including the fact that Glenn has never apologized or walked back his comments — has created an unwelcoming environment for LGBTQ students in the Granbury district, the ACLU argued in its complaint.

“These comments, combined with the book removals, really send a message to LGBTQ students in the districts that: ‘You don’t belong here. Your existence is shameful. It should be censored,’” Kempf said.

In recent months, Granbury parents and voters have continued to pressure the district to remove books with LGBTQ themes or descriptions of sex. Last month, Karen Lowery, one of the women who sought criminal charges against Granbury librarians, won a seat on the school board; she has vowed to purge books that she has deemed inappropriate for children. Of the nearly 80 titles conservative activists want banned, 3 out of 5 feature LGBTQ characters or themes, according to an analysis of books posted on GranburyTexasBooks.org, a website where they have compiled parent reviews.

Lowery didn’t respond to messages requesting comment.

At her first meeting as a school board trustee on Dec. 12 — one week after the Office for Civil Rights notified the district it had opened an investigation — Lowery called for all “obscene” books to be pulled from shelves. In response, Glenn asked her to provide a list of titles so the board could discuss it at a future meeting.

"I think as a district, we do want to resolve this," Glenn said of the library book controversy. "Speaking on behalf of every administrator in the room, and probably community members because I know there are a few of you that are ready to have this behind you, too."

Education and legal experts said the Education Department’s decision to open an investigation in Granbury is significant because it sets up a test of a somewhat novel legal argument by the ACLU: the idea that book removals themselves can create a hostile environment for certain classes of students.

“It’s certainly the first investigation I’ve seen by the agency testing that argument in this way,” said W. Scott Lewis, a managing partner at TNG, a consulting firm that advises school districts on complying with federal civil rights laws.

The ACLU of Texas made similar legal arguments in another civil rights complaint filed last month against the Keller Independent School District in North Texas in response to a policy banning any books that mention “gender fluidity.” The Education Department has yet to decide whether to open an investigation in Keller, Kempf said.

Jonathan Friedman, the director of free expression and education at the nonprofit PEN America, which has tracked thousands of school book bans since last year, said the same legal argument could be made in districts across the country where parents, school board members and administrators have expressed anti-LGBTQ motivations.

“It’s not uncommon to see people explicitly saying that they want to remove LGBTQ books because they believe they are indoctrinating students,” said Friedman, who cited a case in Florida in which a teacher called for the removal of a children’s picture book about two male penguins because, she said, it promoted the “LGBTQ agenda.”

Granbury isn’t the only North Texas school district facing federal scrutiny.

The Office for Civil Rights over the past year has opened five investigations into allegations of discrimination at the Carroll Independent School District in Southlake, a wealthy Fort Worth suburb that has been at the center of the national political fight over the ways schools address racism, gender and sexuality. If the Education Department finds Carroll students’ rights have been violated, experts said, the federal agency could require the district to implement the same types of diversity and inclusion training programs that conservative activists have fought to block in Southlake.

Carroll Superintendent Lane Ledbetter has said the district has taken steps, including retraining staff members in how to handle bullying complaints, to ensure students from all backgrounds feel safe at school.

“If OCR determines that there are steps that we can take beyond what we have implemented, then we will absolutely comply,” Ledbetter said in a video address to the community after news of the federal civil rights investigation broke last year. “My priorities are kids, and we’re going to keep them safe.”

As in Southlake, some students and parents in Granbury say they’re counting on federal investigators to force changes.

Lou Whiting, 17, a nonbinary senior at Granbury High School, said Glenn’s recorded comments made them feel unsafe and unwelcome at school. Whiting, who helped organize student protests of the book removals, cried when they learned that the federal government had opened an investigation.

“It’s just really good to hear that there are people who are listening to us and actually doing something about it,” Whiting said. “It means a lot to hear that our efforts meant something.”

by Agnel Philip and Eli Hager, ProPublica, and Suzy Khimm, NBC News, photography by Stephanie Mei-Ling, special to ProPublica and NBC News

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CHARLESTON, W.Va. — In the months after a West Virginia court permanently took away their right to parent their daughters this past April, Jackie Snodgrass and her husband were left in a quiet house. The kids’ rooms remained untouched. The same dolls and stuffed animals were arranged on their younger daughter’s bed. The same clothes in the closets, becoming outgrown. The same photos on the walls, outdated.

The court had denied a final visit — despite the children continually saying they missed their mother — so the parents never got to say goodbye to them in person. Snodgrass worried about them constantly, especially her older daughter, who has diabetes. An app pinged her intermittently with updates on her child’s blood sugar. Occasionally, it would dip too low or spike too high.

“What if something happens to her?” Snodgrass said. “And if it does, I’m not going to be allowed to be there.”

Once considered a last resort reserved for parents who abandon their children, the involuntary and permanent termination of parental rights now hangs over every mother and father accused of any form of abuse or neglect — including allegations of nonviolent behavior like drug use or truancy, the two central parenting issues in the Snodgrasses’ case. Known in the legal world as the “death penalty” of child welfare, it can happen in a matter of months.

No state terminates parental rights more frequently or faster than West Virginia, according to a ProPublica and NBC News analysis. One in 50 children here experienced the severing of their relationships with both of their parents from 2015 to 2019, the last full year of federal child welfare data available before the pandemic. For most of them, it occurred within 11 months of being removed from their home for the first time.

In the Snodgrasses’ case, it took only five months.

Nationally, the parents of about 327,000 children lost their rights from 2015 to 2019, the analysis found. In one-fifth of those cases, it happened in less than a year.

Over the past 25 years, courts and child protective services agencies have increasingly turned to this ultimate consequence, partly in response to Clinton-era federal policies that support faster adoptions. According to a recent study, the risk that a child will experience the loss of their legal relationship with their parents roughly doubled from 2000 to 2016. One in 100 U.S. children — disproportionately Black and Native American — experience termination through the child welfare system before they turn 18, the study found.

Most of those families became entangled in the system because of allegations of neglect, a broad category closely linked to poverty and substance use. Just 15% of children whose parents’ rights were severed around the country from 2015 to 2019 had been removed from their homes because of concerns about physical or sexual abuse, according to the ProPublica and NBC News analysis. (The reasons ultimately cited for the terminations themselves weren’t provided in the data.)

“None of us believes banishing a child from a family of origin is a perfectly fine result,” said Marty Guggenheim, a retired New York University law professor and child welfare expert who has argued termination cases before the Supreme Court. “But that’s where we are today. We are off of our moral compass.”

West Virginia Terminates Parental Rights Faster Than Any Other State

States differ widely in how quickly they terminate parental rights after a child is first removed from a home.

Note: Dots represent the median time between a child’s first removal from the home and when both of their parents’ rights are terminated. Washington D.C. is included as a state. (Source: ProPublica analysis of National Data Archive on Child Abuse and Neglect records. Graphic by Lucas Waldron/ProPublica.)

The hurry to end families can be traced to the 1997 Adoption and Safe Families Act, passed with bipartisan support in Congress and signed by President Bill Clinton.

In a tough-on-crime era, the new law was supposed to keep fragile, abused children from languishing for too long in foster care. It created a rigid timeline — a ticking clock — for every child who entered state custody after having been removed from home because of an allegation of child maltreatment. After 15 months, barring specific exemptions, state and local agencies were required to file for termination of the birth parents’ rights or face losing federal funding. And states that increased adoptions were rewarded with bonuses for every additional child they placed.

Despite the law’s goal of getting more kids adopted, tens of thousands of such children have remained in foster care for months or years after being cut off from their parents. They are known as “legal orphans,” with no birth families anymore but no adoptive ones, either.

And research shows that many children who experience termination of their parents’ rights will suffer what is known as ambiguous loss, similar to grieving after a death but without the closure of knowing a loved one is gone forever.

To understand the impact of the child welfare system’s most extreme outcome, ProPublica and NBC News surveyed hundreds of families who experienced termination of parental rights and interviewed dozens of parents, children, caretakers, caseworkers and attorneys. Those we spoke to described a confusing legal system that at times seemed stacked against birth families trying to reunite and inured to the pain of long-term family separation.

“There was all this lost time when me and my dad had wanted to talk to each other but were being prevented by the state government,” said Reed Ridens, a graduate student in Albuquerque, New Mexico, who spent years in foster care as a legal orphan. “There was a lot of damage and a lot of repair that needed to be done between us, and a lot that had been taken away.”

Snodgrass’ kids’ rooms remain untouched. She and her husband, Wes, haven’t seen them in person for over a year.

Some of the 1997 law’s original supporters — and even some top child welfare officials — now warn that the timeline Congress prescribed is too rigid and that some states may have taken the reforms too far.

Maureen Flatley, a child welfare consultant who helped craft the law, said she now believes it urgently needs to be revamped, including the prescribed timeline for terminating parental rights. “We can’t pretend anymore that adoption is just some magic panacea,” she said in an interview.

The federal government also has voiced concerns about focusing too narrowly on termination time frames. In the final days of the Trump administration, the Department of Health and Human Services’ Administration for Children and Families issued a memo warning states against rushing to end rights.

Jerry Milner, a top official at the agency under President Donald Trump, said the Clinton-era law should be overhauled or repealed. Its timeline was the product of political negotiation, he said, not scientific research on how long parents should be given for recovery or redemption before they lose their rights to their children. “But it’s hanging over parents’ heads like a death sentence,” he said.

Yet the Biden administration has continued to defend the law. The statute allows states to make exceptions to the timeline if they believe termination would not be “in the best interest of the child” or if the state has failed to provide adequate reunification services, an ACF spokesperson said in response to written questions. Decisions are to be made on a case-by-case basis, the agency added.

And recent attempts by Congress to revise the timeline have failed to gain much traction.

Rep. Sheila Cherfilus-McCormick, D-Fla., believes it’s imperative for lawmakers to try once more: She plans to introduce a child welfare bill in the next Congress to allow states to extend the timeline for termination to 24 months, among other changes.

“The harsh timeline doesn’t allow people to be rehabilitated or give them a chance to be reunited with their children,” she said.

Five Months to End a Family

Jackie Snodgrass and her husband, Wes, attracted the attention of West Virginia’s Department of Health and Human Resources in February 2021 because their girls had missed too many days of school. It was a problem that the family and the child protective services agency had tussled over for years, according to court documents Snodgrass provided to ProPublica and NBC News, but it came to a head when their absences piled up amid virtual schooling during the pandemic. Both parents were placed under court-ordered supervision.

The family moved from their tiny town of 1,400 to Wes Snodgrass’ mother’s home in the capital city, Charleston, to be closer to school for the girls, whose attendance was improving. They started a tree-trimming business and were making ends meet.

By October 2021, Jackie Snodgrass was busy planning her older daughter’s dream 16th birthday party — with pink decorations and a DJ, like on MTV.

“I like their birthdays better than Christmas, because it’s just their day,” she said of her children.

But the stress of the move and the truancy case had taken a toll. Snodgrass’ husband said he had used methamphetamine during that time, and in November, on an impulse, she tried it too. When the court overseeing their case started mandating drug screens, both parents failed.

The child welfare agency’s response was immediate: Like many states, West Virginia considers failed drug tests to be proof that a child is in danger, which can lead to the child’s removal. Snodgrass said a caseworker told her and her husband over the phone that they had to immediately pack up and leave the children with her husband’s mother.

After just five months and a few hearings, as the Snodgrasses struggled to comply with court orders, the judge ruled that they were unfit to raise their girls ever again.

They haven’t seen them in person for over a year.

The property in the tiny town of Liberty, West Virginia, where the Snodgrasses lived before they moved their family to Charleston

Jackie Snodgrass’ parents now have custody of the children and plan to adopt them. Her mother said the girls have taken the separation hard, acting out and asking why they can’t see their mom and dad. Visiting is prohibited even though they live 5 miles apart.

In West Virginia, which has been ravaged by drug epidemics in recent decades, children are more likely to enter foster care than anywhere else in the country. Substance use was the most common reason cited for removing children from their homes in the state’s parental rights termination cases, according to the ProPublica and NBC News analysis.

Nearly every state acts more quickly when drugs are involved than when children are removed based on concerns about physical or sexual abuse. But West Virginia is particularly aggressive, giving parents the least amount of time to recover: More than a fifth of the state’s terminations involving parental drug use occurred less than six months after the children were first removed, the news organizations found.

In response to ProPublica and NBC News’ findings, state Del. Danielle Walker, a Democrat, expressed outrage at West Virginia’s haste in terminating parental rights and said the Legislature needed to conduct an intensive study to look at termination and related issues.

“There is no advocacy for the biological parents in this state. There’s none,” said Walker, who said her office would research the subject and compare West Virginia’s child welfare practices to those in other states. “Since when is six months enough to have proper recovery — any kind of recovery?”

Family attorneys and advocates say this posture toward addiction and recreational drug use punishes many parents whose children may not be in danger. Parents who are committed to seeking help to get their children back can be penalized if they relapse, even though drug treatment experts have long said such setbacks are a normal part of recovery.

“It’s a race against the clock for these families to oftentimes deal with a generational trauma,” said Jim McKay, director of Prevent Child Abuse West Virginia, an advocacy group. “We should be partnering with families and working alongside them rather than having it be a prisoner of an arbitrary date on the calendar.”

Ray Kendall, a former caseworker for the state’s Department of Health and Human Resources, said the agency’s “astronomical” workload caused many of his colleagues to become jaded toward substance use cases. West Virginia had 1 caseworker for every 167 children it investigated in 2019. That was among the nation’s highest caseloads, leaving less time for workers to help parents access services that can prevent termination.

“I don’t think six months is enough time to truly become completely sober and able to be in control of your life and take care of your kids, so it is a bit unrealistic,” said Kendall, who left the agency in 2019 in part because of frustrations that he couldn’t do more for families.

West Virginia has also been rewarded by the federal government for acting quickly to end families, having received $24 million in incentive payments under the 1997 law for increasing the number of adoptions it finalizes. (The program expanded in 2014 to include payments for guardianships, in which responsibility for children is transferred to other adults without completely severing parental rights.) Adjusted for child population, West Virginia has brought in 65% more in these incentives than the next highest state, Alaska.

The state’s Department of Health and Human Resources declined to make officials available for interviews. In response to written questions, the department didn’t dispute ProPublica and NBC News’ findings about the frequency and speed of termination in the state; it denied that the state’s statutes and policies fail to provide parents enough time for reunification.

Courts have the discretion “to make individualized decisions based upon the actions of the parents and the best interest of the child,” said Jessica Holstein, a spokesperson for the agency, who added that parents can also appeal the decisions.

Holstein said the agency has tried to reduce caseloads by adding staff members, increasing salaries and using temporary “crisis teams” to backfill vacancies.

“The culture at DHHR supports family connections,” she said, noting that the department prioritizes foster care placements with relatives when possible, as happened in the Snodgrasses’ case.

A trampoline that Snodgrass’ daughters used to play on at their Charleston home

Cindy Largent-Hill, director of the juvenile division of the West Virginia Administrative Office of the Courts, said the state’s termination schedule is meant to prevent cases from dragging on too long.

“They may look a bit unfair because three months doesn’t sound like a long time, or six months, or 12 months,” said Largent-Hill, who works with the state’s circuit court judges. But, she said, “you don’t want cases to languish in court for three, four or five years.”

Snodgrass said she still is shocked by how quickly her case devolved. After the judge’s decision, whenever she felt a glimmer of hope, she would reread the order: “Any and all parental, guardianship, and custodial rights of the respondent parents … are hereby permanently and forever TERMINATED.”

“There’s, like, anger or something behind it,” Snodgrass said. “It seemed way too fast, but it also feels like years since I’ve seen my kids.”

The Push for Permanency

For most of U.S. history, it was rare for courts to permanently cut parents’ legal ties to their children without consent, according to a forthcoming paper by Chris Gottlieb, director of the New York University School of Law Family Defense Clinic. Typically, child welfare cases would end in termination only when states could prove that parents had abandoned their kids or as part of voluntary adoptions.

After states began requiring teachers, doctors and other professionals to report suspected child abuse or neglect in the 1970s, the number of kids entering foster care rose dramatically. In many cases, children stayed for years in out-of-home placements.

By the 1990s, a substantial body of research showed that such long foster care stays could harm child development. At the same time, increased access to birth control and abortion had led to a sharp decline in the number of children available for prospective adoptive parents, according to Gottlieb’s research.

The 1997 federal law was meant to address both trends. Its prominent supporters pointed to high-profile cases in which children were brutally beaten or killed after having been returned to their parents from foster care. Many argued that it was far more important to move children quickly into permanent homes than to spend an indeterminate amount of time trying to “fix” birth families. That ultimately would make more kids available for adoption.

Adoptions out of foster care increased from 31,000 in 1997 to 66,200 by 2019, according to federal data, while the foster care population has declined.

All states now have statutes that meet the federal law’s timeline requiring them to pursue termination if a child has spent 15 of the previous 22 months in the foster system, according to a ProPublica and NBC News survey of all 50 states and Washington, D.C. The law allows states to move slower if a child is placed with relatives but also faster under certain circumstances, such as if a parent has committed a serious criminal offense.

More than 30 states have even tighter timelines, the news organizations found — in some cases when young children are involved, under the rationale that they are in greatest need of immediately stable homes where they can start bonding with permanent families.

In Texas — the only state other than West Virginia with a median time to termination of less than a year — most counties put the penalty on the table the moment children are temporarily removed from a home, in order to place “parents on notice from the beginning of the case,” according to the state child welfare agency’s policy handbook.

A sign points to the Department of Health and Human Resources, the agency that handles child welfare cases, in Romney, West Virginia.

Not every state moves so quickly: ProPublica and NBC News’ analysis found 16 states where the median time to termination is more than two years. Those longer cases, in some instances, can signal systems aren’t working as they should, reflecting bureaucratic dysfunction or what some child welfare officials describe as a pattern of giving parents “too many chances” that ultimately doesn’t help reduce termination rates, according to a 2021 report on state child welfare practices by the federal Department of Health and Human Services.

Still, longer timelines can also reflect a stronger focus on family reunification and a willingness to devote greater resources to meet that goal, child welfare experts say. New York and Illinois, for example, offer more robust social services, and they are also places with influential parent advocacy groups, said Christopher Wildeman, a child welfare expert and sociology professor at Duke University. (Wildeman is the director of the National Data Archive on Child Abuse and Neglect, which provided the data used in the ProPublica and NBC News analysis.)

In the wake of the opioid crisis, which has led to more kids being in foster care, Congress has tried to increase support for parents involved in the child welfare system. In 2018, it passed the Family First Prevention Services Act, approved with bipartisan support and signed by Trump. The law allows states to put federal funding previously restricted for foster care expenses toward mental health services, substance use treatment and parenting classes to help keep families together.

The Administration for Children and Families “is committed to focusing on prevention and early intervention so that families who come into contact with child welfare systems do not find themselves in the position of facing a termination of parental rights,” a spokesperson said.

But the legislation has strict requirements for which programs it will fund, and states have been slow to implement it. Eleven states are still waiting for their plans to be approved by the federal government, according to recent agency data, and six haven’t submitted plans at all. And some child welfare advocates have criticized the law’s focus on narrow initiatives like parenting classes, which they say fail to address poverty and the other root causes of neglect that prompt most child welfare cases.

“If I don’t have a house and I’m struggling, how are some parent education classes going to help?” said Christine James-Brown, the president and CEO of the Child Welfare League of America, a Washington, D.C.-based advocacy group.

West Virginia has drawn on the new federal funding but has spent only $125,000 since the summer of 2021, according to agency officials. The state is also trying to expand “family treatment courts,” designed to promote reunification rather than termination.

West Virginia’s senators, Joe Manchin, a Democrat, and Shelley Moore Capito, a Republican, told ProPublica and NBC News that they are committed to keeping families together when possible. Capito added that the news organizations’ findings are “concerning” and that her staff would look into those issues.

But when they were asked whether the state has adequate resources for family reunification — or whether the federal timeline for termination should be altered — neither senator responded directly.

Test Clean or Else

Some family advocates doubt that any new funding would have a significant impact on termination rates without a fundamental change in attitudes among local agencies and courts toward parents accused of child maltreatment, especially those struggling with substance use.

Judges have ultimate authority in such cases, but there is limited scrutiny of what happens in their courtrooms. In many states, including West Virginia, the public isn’t allowed to observe child welfare proceedings, and documents are typically kept under seal. Some judges order parents not to speak about their cases to anyone who isn’t involved, and if they disobey, it can be held against them.

What’s more, West Virginia judges often require parents to admit in court that they have a drug problem before they grant them an “improvement period,” said Joshua Edwards, a public defender in the state. If they refuse and the state proves to a judge that they used drugs, it becomes highly unlikely they will get their kids back, he said.

Jackie Snodgrass admitted in court to using drugs and neglecting her children’s education; she acknowledged in an interview that she regretted that her instances of meth use had put her family in jeopardy. But she never thought the mistake could lead to the end of her relationship with her daughters. After all, Snodgrass said, she had never hurt the girls, and according to court documents, they wanted to go home.

But the outcome hinged on whether the Snodgrasses complied with the services they were offered, including parenting classes and drug tests. And the government had little patience for mistakes or disagreements.

Snodgrass said she was required to call daily before 10 a.m. to find out whether she needed to be drug-screened. Once, around Thanksgiving, she said, she called a few minutes late, and the test was considered a failure.

Snodgrass goes through drawings left behind by her daughters.

From the start, Snodgrass and her husband were prohibited from seeing their daughters, even for supervised visits, because they couldn’t test clean consistently. She was testing positive for marijuana at the time, but she said she soon became so hopeless about the prospect of losing the girls forever that she used methamphetamine again to cope.

Snodgrass said she saw the phrase “termination of parental rights” in court papers for the first time early this year. Soon after, she said, a caseworker told her she would have to enter a long-term inpatient drug treatment program, probably for at least 45 days.

The family’s tree-trimming business didn’t have many clients yet, and Snodgrass, who was working as an assistant at a nursing home, was the primary earner. She said she feared they wouldn’t be able to pay their rent if she took an extended leave from work, and she told the caseworker that she was open to outpatient treatment, instead.

Her reluctance to enter an inpatient program proved critical, according to case documents. West Virginia is among 22 states with statutes saying that parents’ failure to comply with court-ordered rehabilitation or drug treatment plans, regardless of any evidence of harm to children, can itself be grounds for permanent termination of parental rights, according to a ProPublica and NBC News analysis of state laws.

Near the end of the case, Snodgrass said, her lawyer suggested that she divorce her husband because she was testing clean more often than he was. But the two were childhood sweethearts, and despite his drug use, he was a good father and her best friend, she said.

Still, she told the judge, “If I need to leave my husband, I’m willing to do that to bring my kids home.”

Her husband said in an interview that he was shocked to hear this in court but that he understood the position she was being put in. “I felt real low,” Wes Snodgrass said. “I felt like I didn’t have a family no more.”

It didn’t matter. In their case file, DHHR listed five general criteria for determining whether to recommend termination of parental rights to the court, including how long a child has been in foster care, whether a case involves serious abuse or abandonment by the parents or whether their rights have been severed before.

The couple met just one of the criteria: The agency concluded that there was “no reasonable likelihood” that the neglect allegations against them could be “substantially corrected in the near future,” citing their failure to comply with the court’s requirements within the previous five months.

Still denied any visits with the girls, they had no chance to hug them goodbye.

Rethinking the “Death Penalty” of Child Welfare

Fueled in part by the 2020 demonstrations for racial justice nationwide, family rights activists have made a renewed push to change the child welfare system — including the repeal of the Clinton law.

At the start of the new Congress, Cherfilus-McCormick, the representative from Florida, plans to introduce a bill to allow states to extend the timeline for termination and exempt parents who are actively participating in classes, treatment or other services; it would also encourage states to place more foster children with relatives instead of strangers. The bill was originally introduced last year by Rep. Karen Bass, D-Calif., but it failed to move forward, and Bass recently was sworn in as the new mayor of Los Angeles.

Cherfilus-McCormick and other Democratic lawmakers say they plan to make the issue a priority next year.

But that could be challenging given the changing balance of power in the House. Republicans, who will take the majority in January, have yet to co-sponsor any of the recent proposals to alter the federal timeline for termination.

Meanwhile, there has been growing support for alternative custody arrangements that don’t require termination of birth parents’ rights. In 2008, Congress passed a law allowing states to access federal funds to support guardianship by family members, and 40 states and the District of Columbia now have such programs.

And about half of states have laws that would allow parental rights to be reinstated or restored, although that is still rare and is often limited to cases in which the children lack permanent homes.

Support for such reforms varies widely among states, and the changes have yet to have a major impact on national adoption or reunification rates.

Washington, D.C.’s nonvoting delegate in the House of Representatives, Democrat Eleanor Holmes Norton, said the outsize impact of termination on low-income and Black families makes it especially urgent for Congress to fix the mistakes it made in the 1997 law. “It’s indefensible to have such short timelines,” said Norton, a longtime member of the Congressional Foster Care Caucus.

“The most important relationship in a family is the relationship between parents and children,” she said. “We should do everything we can to preserve that.”

Lost Time

“There’s, like, anger or something behind it,” Snodgrass said of the order that terminated her parental rights. “It seemed way too fast, but it also feels like years since I’ve seen my kids.”

Jackie Snodgrass said the gravity of what was happening in court didn’t hit her until the judge finally said the words: He was terminating her parental rights.

“My heart just fell to my knees,” she said. “It felt like I had just died. Like everything had been taken out of me.”

Snodgrass and her husband say they’ve been clean for several months, and they recently have had a new reason to hope. Her parents said state adoption officials told them that they will most likely be allowed to let the Snodgrasses see their children again, once the adoption is finalized.

But for now, they still aren’t supposed to have contact with their girls or even ask how they are doing. Since being separated, the older daughter has reached out to Snodgrass and they’ve talked by phone and instant messaging. Snodgrass is worried her daughters won’t think she cares about them if she keeps missing major life events like birthdays.

Still, she is more fortunate than many parents whose rights are terminated. When foster children are adopted by strangers, they can be cut off completely from their biological parents. Another mother in West Virginia who spoke with ProPublica and NBC News said she scours social media for photos of her daughters and stares at their adoptive home in a nearby town on Google Street View.

Snodgrass said that even if she is allowed back in her children’s lives, it still scares her that she has no control over their relationship, including any legal rights to make decisions about their medical treatment.

In between phone calls they’re not supposed to have, Snodgrass continues to get updates from her daughter’s blood sugar app. She said it provides a small comfort.

Hannah Rappleye, of NBC News, and Asia Fields, of ProPublica, contributed reporting. Alex Mierjeski and Mollie Simon, of ProPublica, contributed research.

by Jake Pearson

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

This story is a collaboration between New York magazine and ProPublica.

By the time Karl Ashanti neared his office in the New York City Law Department’s headquarters in March 2018, the police were shutting down Park Place. Ice had fallen from the buildings above, so an officer had cordoned off the area. Ashanti flashed his work ID and the cop let him through. Then, about two-thirds of the way down the block, he ran into a second officer. “Turn around now,” John Shapiro barked. “I said now.”

Ashanti stiffened. The two men were about the same size, each around 6 feet tall and 240 pounds. Shapiro was in his blue New York Police Department uniform. Ashanti, a city lawyer, wasn’t due in court that day and had dressed casually in dark slacks, a button-down, an overcoat and a winter hat. The two had never met before, but there was something about Shapiro’s brusque demeanor that Ashanti recognized.

For 11 years, Ashanti had defended NYPD officers against lawsuits alleging civil-rights violations in federal court. He was a senior litigator in a little-known Law Department unit that exclusively handles such cases, the Special Federal Litigation Division, known simply as Special Fed. As a Black man who’d grown up in Jamaica, Queens, Ashanti thought he brought valuable perspective to the work. He’d seen how Black people, and Black men in particular, could, through no fault of their own, be targeted by prejudiced men in uniform. Still, Ashanti took pride in his legal skills and had come to embrace the combative approach that Special Fed typically took in fighting claims of police abuse, even in the face of compelling evidence that police behavior violated the constitutional rights of the people they had sworn to protect.

On Park Place, Ashanti told Shapiro, who is white, that he was trying to get to his office. Shapiro insisted he go back the way he came. Ashanti moved between two parked cars to cross the street and Shapiro hustled to cut off his path, repeating his order. The two men faced each other in the middle of the road. Shapiro tapped Ashanti on his shoulder. Ashanti backpedaled and asked to speak to a supervisor. Shapiro took out his handcuffs. Within 90 seconds of their first encounter, the officer arrested the attorney.

Shapiro claimed in criminal filings that Ashanti resisted arrest and shoved him twice, so forcefully that Shapiro had to step back to catch his balance. The New York Post splashed the allegations in its pages, calling Ashanti a “livid lawyer.” It wasn’t true. Security-camera footage showed no shoving during the incident. As it unfolded, nine other people freely walked up and down Park Place. Court records revealed it wasn’t the first time Shapiro had been accused of abusing his power. By the time he detained Ashanti, the officer had already been named in three false-arrest lawsuits. (Two were settled, and one was dismissed.) Ashanti’s own unit had handled those cases.

Within days of the incident, the Law Department gave Ashanti an ultimatum: resign or be fired. After more than a decade defending the police, Ashanti was finding out what it was like on the other side of the law.

Footage of the incident between Ashanti and officer John Shapiro (New York Supreme Court)

On Oct. 29, 1984, when Ashanti was 11 years old, police officers in Morris Heights entered Eleanor Bumpurs’ apartment and killed her with a shotgun. Bumpurs was 66 and mentally ill. Her family had instructed her not to let strangers into her home, and when the police showed up to assist in her eviction that day, she lunged at them with a kitchen knife. Her death inflamed the city. In Ashanti’s neighborhood — a predominantly Black community of working-class Caribbean immigrants and city employees — the shooting entered a canon of police killings that, over decades, have shaped attitudes on race and the police. Ashanti remembers that this was about the time when his mother first gave him the Talk. “It’s not like she didn’t have respect for authority,” Ashanti says. “It was not that I should dislike the police. It was more like, ‘There are some police officers who will abuse their power, and unless you capitulate, things might escalate.’ She was like, ‘I want my son alive.’ She said that more than once to me.”

Not long after, three Black men whose car had broken down in Howard Beach were chased by a pack of white teenagers with tire irons and baseball bats. One of the men fleeing the mob was struck by a car and killed. Another was savagely beaten. For Ashanti, the takeaway was clear: Don’t ever ride your bike into Howard Beach. “It’s the ironic thing about growing up in New York City, which is such a quote, unquote liberal city,” he says. “You have these incidents of not just police but private racial violence.” Police racism was real, he thought, but cops didn’t have a monopoly on prejudice; it was simply everywhere.

In sixth grade, Ashanti did well on an exam given by Prep for Prep, a nonprofit group that sends promising students of color to elite, mostly white private schools. He attended Buckley, the tony all-boys academy on the Upper East Side, where he was a few years ahead of Donald Trump Jr., then high school at St. Paul’s, the exclusive New Hampshire boarding school.

One Friday during sophomore year, it was his turn to choose a film for movie night. Students normally picked comedies, but Ashanti went with “Colors,” the 1988 drama about Los Angeles cops patrolling gangland beats. One of the older boys “rolled his eyes about the selection and shit,” Ashanti says. “And then maybe like one or two other people joined in. A What the fuck is this? kind of thing. Just, like, a complete rejection of anything that had to do with the ghetto, with Black and Latino culture.” With him. “I just remember looking at them like: You fucking privileged assholes. Everything has to be your way all the fucking time.”

On several occasions, upperclassmen barged into his room in the middle of the night and pelted him with water balloons. He thought they were sending a message: “Here’s this motherfucker who won’t fall in line.” At 23, he legally changed his last name to Ashanti, shedding the birth name, Francis, that his enslaved African ancestors had been “branded” with. “I’m sure one of their goals was for one of their descendants to one day be free of that name,” he says. “I know that’s what it would be for me.”

Ashanti is impeccably credentialed — he went on to Stanford, where he was president of his all-Black fraternity, and then Georgetown Law — but when he returned to New York and entered the workforce, his trajectory slackened. At a succession of run-of-the-mill firms, Ashanti took cases involving businesses suing businesses, personal injury and insurance. The work could be challenging, but it didn’t satisfy his civic or lawyerly ambitions. A landlord and tenant arguing the terms of a 20-year lease? Boring. Cattle-call appearances in state courts before overworked judges? Uninspiring.

One morning on his way to the office, Ashanti says, an officer pulled him over for “erratic driving” and falsely cited him for having lapsed insurance. He was held for 12 hours. Another time, while applying to a new firm, his interviews seemed to be going well until he met with an elderly white partner. Ashanti later testified that the man said “something more malicious than ‘You’re articulate for a Negro.’” (The firm settled an Equal Employment Opportunity Commission complaint. Ashanti said he received an apology that implied the partner was “like the grandpa you don’t want to bring out to the party.”)

Nine years passed in the lower tiers of corporate law. Ashanti wanted autonomy, and he wanted to conduct trials — maybe even change lanes to civil-rights law. From an early age, he’d been inspired by Thurgood Marshall. But he didn’t have a civil-rights background, and the longer he spent doing corporate law, the less possible switching tracks felt. He started talking with a recruiter, and when an opportunity arose at Special Fed, Ashanti listened with great interest.

The cases would be in the federal courts, where the smartest jurists operate, and he’d be handling them soup to nuts, appearing before judges and juries. And the subject matter was appealingly complex. The main statute governing Special Fed’s work, Section 1983, traces its roots to a Reconstruction-era bill known as the Ku Klux Klan Act that lets individuals sue local government officials for violations of their civil rights. It’s an extremely technical platform to litigate, with a century and a half of accumulated case law. “That’s the heart of our legal system: the relationship between government and individuals,” Ashanti says.

He would have preferred to do civil-rights work on behalf of plaintiffs, but the firms that handled such cases weren’t offering him a job. Plus, for a native New Yorker, joining the Law Department had a special attraction. “Representing the City of New York did fill me with a sense of pride,” he says.

The idea that he’d be arguing the side of the police just wasn’t much of a factor in his decision to join the division, he says. “I didn’t feel any kind of way about representing police officers and correctional officers because I always knew — I always knew — it was all about the work and the cases,” he says. “It’s always a case-by-case situation.”

Special Fed was created in 1998 by the administration of Rudy Giuliani to deal with a surge in lawsuits against police officers, jail guards and prosecutors. Its dozens of attorneys investigate citizens’ allegations of beatings, false arrests and other civil-rights abuses and decide whether to mount a defense or settle. Generally, they fight.

Many Special Fed veterans say the unit prizes winning at all costs, even when there is merit to a plaintiff’s case. Victory can still be had in making the process as difficult as possible for citizens — getting suits thrown out, abandoned or negotiated down to the smallest possible payout. The lawyers tend to see themselves as guardians of the public fisc, pitted against those who would drain the coffers: criminals looking for a payday, greedy lawyers, bleeding-heart juries. They litigate aggressively, sometimes drawing rebukes from judges for violating court rules, blowing deadlines and pressing the boundaries of professional conduct. Earlier this year, a judge dressed down a senior Special Fed lawyer for failing to obey court orders. “If I order something and you can’t do it, you can’t just blow it off,” the judge said. One plaintiff’s attorney told the New York Daily News, “They get away with things that no other litigant would ever get away with.” (A spokesman for the Law Department says, “We take our ethical responsibilities very seriously and have zero tolerance for misconduct that undermines our mission.”)

Sometimes even a victory at trial isn’t enough for Special Fed. In 2020, after defeating a Bronx man in an excessive-force case, the division sought sanctions against him and his legal team for bringing the suit in the first place. A federal judge wrote scathingly that the effort to penalize the plaintiff was “wildly inappropriate” because the man had had a reasonable case. More troubling, the judge wrote, was the chilling message that the episode sent to the law firms that do pro bono work for low-income people “with facially valid claims against powerful defendants.”

Ashanti believed he could be a more nuanced operator at Special Fed. Shortly before he started, in November 2006, plainclothes officers shot 50 bullets at a car driven by a Black 23-year-old named Sean Bell in the early hours of his wedding day. It was the city’s most incendiary police killing in years, and Ashanti felt it personally — Bell was from his neighborhood. “Sean Bell was me,” he says. He decided that at his new job, the Bell case would serve as his moral barometer. The family would inevitably file a civil suit against the police; would Special Fed settle it judiciously, or would the unit reflexively fight to minimize the payout? “That was the biggest question to me: Are we going to defend the indefensible?” Ashanti says.

Joseph Guzman, who was wounded in the police shooting that killed Sean Bell, speaks outside the Queens Criminal Court in March 2007. (Michael Nagle/Getty Images)

He showed up to his first day of work in March 2007. The third floor of the New York City Law Department was like a relic of the drab municipal offices of the 1970s, with paralegals and claims specialists sitting in cubicles in the middle of the floor and attorneys occupying small windowless offices. Conference rooms had removable walls so they could double in size when teams of litigators fielded especially big cases. Armed NYPD officers — liaisons between Special Fed and its police clients — walked the halls.

Ashanti handled about 40 lawsuits a year, and he found that few fit his Sean Bell binary. Most presented as murky, with imperfect evidence and plaintiffs who might have been breaking the law, introducing questions of credibility and sympathy with juries. One of his first assignments involved a class-action suit alleging that Rikers Island jailers were unconstitutionally strip-searching female inmates and conducting nonconsensual gynecological exams. Ashanti was one of eight or so lawyers on the Special Fed team. Questions about constitutional violations and public accountability receded as the day-to-day work ground on with arguments over records, process and liability. (The suit was settled years later for $33 million.)

Like most in his profession, Ashanti believed in some core tenets about representation: Attorneys are not their clients, and our adversarial system demands that each side have zealous counsel. But at Special Fed, almost from the start, he struggled to moderate that zeal. In a performance review, a superior noted that “Karl’s passion for an issue many times comes across as temper and this detracts from his professional demeanor.” Another report in 2011 chided Ashanti for getting into two “public confrontations,” one with a colleague and another with opposing counsel. At the same time, his bosses — all but a few of whom were white — were thrilled with the results he was getting. They praised him for settling cases for even less money than they had authorized.

The lawyers who stood across the courtroom from Ashanti knew all about zealous advocacy, and they saw his behavior as needlessly hostile. Several felt he embodied what was wrong with Special Fed — a relentless sparring that obscured what was really at stake in the cases: civil rights and public accountability. Rose Weber, a longtime civil-rights lawyer who had worked at Special Fed in its early days, was especially disturbed by Ashanti’s tactics in a 2010 excessive-force case. Her client claimed to have been slammed to the ground by a plainclothes officer, rupturing discs in his back. In a motion, Ashanti wrote dismissively that the alleged abuse was “of minor importance.” The judge called the argument “as groundless as it is troubling.” Weber, who would go on to lose the case, spoke to other plaintiffs’ attorneys about Ashanti and collected a handful of confrontational anecdotes in a folder on her computer. Compared to that of other Special Fed lawyers, she says, Ashanti’s approach “wasn’t even beyond the realm. It was a realm of its own.”

Another frequent opponent, Robert Quackenbush, had a more civil relationship with Ashanti. In a case with video evidence showing that police had lied in sworn testimony, he got into a dispute with Ashanti about compensation for his client, who had been punched and pepper-sprayed. Quackenbush cited two precedents that he believed supported his reasoning. Ashanti wrote, “I’ve read those cases and disagree but if we agreed about everything we wouldn’t be adversaries. Be well.”

“The most charitable assessment is that he was extremely combative,” Quackenbush says. “People wanted to attribute his litigation style to his soul or something. I don’t personally do that. He was a Black man working for the City of New York on police cases at a time judges were finding the police were discriminating against Black people. That had to have been an impossible job and an impossible situation.”

Ashanti was one of just a handful of Black lawyers within Special Fed. He said in a 2020 deposition that he detected a racial dimension to the way he was perceived by some opposing counsel. “If I push back on any issue, they’re like: ‘You don’t have to get so worked up. You don’t have to get so upset.’ And I’m like, ‘What are you talking about?’” he said. “There’s no use of the N-word, but it was the underlying idea of an overly-aggressive-Black-man kind of thing.”

On a separate occasion, Ashanti took the testimony of a witness at an opposing attorney’s home office. It grew so contentious the other lawyer, Carmen Giordano, called 911. Giordano told a judge in the case that Ashanti “refused to stop yelling in a startling and menacing manner” and wouldn’t leave when asked. Ashanti denied that; he told the judge he had had a “momentary lapse in professionalism” that didn’t merit a “call for a police presence to put me back ‘in my place.’” He added that the idea that he was “threatening” was “predicated on an expectation of violence due to racist notions about Black men having an inherent propensity to commit violence, rather than the actual behavior of the individual.” His supervisor took his side.

Within Special Fed, Ashanti talked with Black colleagues about the difficulties of advancement. “It was kind of harder to build a career as a Black attorney than as a white attorney,” he said in the 2020 deposition. But he also put that observation in context: “It’s not specific to the Law Department,” he said. “It’s just society. The Law Department is a microcosm of society.”

When it came to his own cases, Ashanti says, he never felt angst. He could reconcile using his legal skills in defense of the police while at the same time recognizing that Black people were at greater risk of police maltreatment. Besides, the job provided him with a stable, middle-class life. He got married, and he and his wife, Jovanna, moved to Staten Island, where they would go on to raise two sons and be active in their church as born-again Christians.

Ashanti compartmentalized. “Professionals do professional shit,” he says. “Excuse my language. But, like, if you’re a basketball player, you fucking play basketball. You do what you do, and I am a lawyer, so I lawyered up. I did my work.”

Whom exactly does the city lawyer represent? The straightforward answer is the city, of course. But the issue gets more complicated if you consider whether New York is its citizens or its employees. When residents file lawsuits against the police, the text of the municipal charter turns into something of a paradox. It requires the Law Department to represent “the city and every agency thereof” but also says it should “maintain, defend and establish” the interests of “the people thereof.” Is it acting in anyone’s best interest to get a civil case against a police officer thrown out if it enables the officer to cross the line again?

For years, Special Fed took the narrow view — that its lawyers represented the police and that its chief obligation was to minimize payouts over officers’ misconduct. That was especially true at the end of the Bloomberg administration, which clamped down by designating more cases “No Pay” and forcing the Special Fed lawyers who fielded them to go to trial.

In 2014, however, Bill de Blasio was sworn in as mayor after campaigning on police reform, and it looked as though his administration would answer the question of representation in a dramatically more expansive way. De Blasio’s pick to lead the Law Department was Zachary Carter, an esteemed Black lawyer who had served as a U.S. attorney and federal judge. Carter began telling city lawyers that they represented, in some fashion, the names on both sides of the v. in a lawsuit’s title. And he unveiled a new doctrine, “Justice in Our Work,” that he hoped would change the culture inside the agency.

Curiously, Carter wanted the defense lawyers to act more like prosecutors — but only in the sense that they should exercise a degree of forbearance. Defense lawyers must argue every point in service of their clients, but the Supreme Court has held that prosecutors have an ethical obligation to deliver not just convictions but justice. They are meant to drop cases and withdraw charges when it seems like “the right thing” to do. In New York, that is the title of the District Attorneys Association’s ethics handbook, which opens by telling members there is a higher civic duty that goes beyond defeating the opposition. “Unlike other lawyers,” it reads, “the client we represent is the public, whose interests are not necessarily served by winning every case.”

Zachary Carter (Erik McGregor/LightRocket via Getty Images)

“Justice in Our Work” was a radical approach to city lawyering. It challenged Special Fed’s standard playbook: seeking dismissal, fighting disclosure, putting the screws to plaintiffs during depositions. In a memo to senior staff, Carter said he was not asking city attorneys to “turn a blind eye to clearly established law or fail to aggressively litigate when faced with sympathetic opposing parties.” Instead, he argued, they should use those analyses as starting points before settling on an outcome that would advance the “nebulous question” of what it means to act in the city’s best interest. “Failing to identify the just option among alternative legal positions is a failure to counsel the City in a way that allows it to fulfill one of its most fundamental obligations: to govern in a just manner,” he wrote.

For a while, the new doctrine had a big impact. In January 2014, the administration ended the city’s efforts to defend its stop-and-frisk program. Later that year, Carter directed Special Fed to settle its highest-profile civil-rights case — brought by five Black and Hispanic men wrongly convicted of raping and beating a woman in Central Park in 1989 — for $41 million. But “Justice in Our Work” was not to last.

That December, two police officers were assassinated while sitting in their patrol car, destroying what little remained of de Blasio’s relationship with the NYPD and its unions. Then Special Fed settled a case involving a Brooklyn man who was shot by police after he brandished a machete. The man had a weak claim, but city lawyers agreed to pay $5,000 to erase the chance that it could be heard by a sympathetic jury. The Post put it on the front page under the headline “Ax & You Shall Receive.” Then-Commissioner Bill Bratton condemned the settlement, saying it was “outrageous” that the agency “is continuing to not support the men and women in this department.” The blowback was so hot that even de  Blasio chimed in to say the payment was “wrong.”

In a memo to union leaders, one of the mayor’s top aides clarified the administration’s police litigation policy, writing that the Law Department would “enhance the representation of police officers” sued while on the job. The NYPD created a new legal team to augment the Law Department. And Carter appointed a new head of Special Fed, Patricia Miller, who championed the “No Pay” approach. She is still in charge. This past March, during an interview on John Catsimatidis’ talk-radio show, a host asked Miller how hard it was to combat the media’s demonization of “the men and women in blue.” She responded: “I think you hit on a good point. We provide a voice for police officers.”

Joel Berger, a civil-rights lawyer who served as a Law Department executive during the administration of David Dinkins, says there is a “buddy-buddy relationship between the NYPD and the Law Department that would’ve been unheard of in my day.” From the perspective of the civil-rights bar, Special Fed has for years put the interests of the police above those of its primary client: the city and the people who live there.

A few years after Ashanti joined Special Fed, the city resolved a lawsuit brought by Sean Bell’s fiancée and others for $7 million. Ashanti thought it showed that his employer had a limit — that it would pay up in egregious cases — and that the settlement represented something like justice. “The cop isn’t going to sit down in a room and apologize to you,” he says. “In our civil system, it is money.”

How much Special Fed agrees to pay plaintiffs is decided by a process known as “seeking authority.” In memos, lawyers present their bosses with the facts of their cases, including confidential details like internal NYPD disciplinary records, and request an amount they think will put the matter to rest. Ashanti says he came up with figures by weighing several factors: a fiscal responsibility to protect the Treasury, how likely he was to win and precedents, adding more money when “the actions of the police were egregious or there was more of an injustice.”

In general, Ashanti considered himself a force for good within a flawed system — an arbiter of civil-side justice, denying awards to those who would wrongly accuse good cops of bad deeds while working behind closed doors to get deserving clients justly compensated. But if that was true, it was well disguised from the New Yorkers who alleged their civil rights had been violated.

In 2015, Ashanti was assigned a lawsuit against four officers accused of false arrest, excessive force and other offenses. A 21-year-old man named Allen Brown had been a passenger in a car driven by a friend of a friend when police in an unmarked vehicle attempted to pull them over. To Brown’s shock, the driver sped off, then left the car and fled by foot. Brown, who is Black, panicked. He ran, too, hiding in the basement stairwell of a nearby house. A resident called 911. Brown later testified that even though he emerged with his hands raised, the cops beat him up, kicking him in the face multiple times while he was handcuffed.

The officers denied this, but it wasn’t the first time they had been accused of misconduct. Ashanti’s unit had represented each of the officers in at least one prior case. One had already been named in three. Collectively, the cases cost taxpayers $158,000.

Ashanti fought Brown vigorously. In the courtroom one day, he seemed to suggest that because Brown ran, he brought whatever happened upon himself. “Any force that was used was the product of the fact that not only did he flee from the vehicle but then trespassed on someone else’s property,” Ashanti said.

Taken aback, Judge Ramon Reyes Jr. told Ashanti he thought he’d just “made a misstatement.”

“Which is?” Ashanti asked.

“That the force used was related to the fact that he was trespassing,” Reyes said. Ashanti started to talk, but the judge cut him off: “You can’t use force. Period.”

Ashanti said he hadn’t meant to imply that. They went back and forth, and Reyes got exasperated. “Lower your voice,” he told Ashanti. “You think because you raise your voice, your arguments are more persuasive. They’re not.”

Ashanti offered Brown $20,000 to settle. But Brown’s lawyers soon discovered that Ashanti hadn’t provided them with a key Internal Affairs report. A judge sanctioned the city for the failure. Ashanti protested that an “inadvertent clerical error” was to blame, but another judge upheld the penalty. The case, which Brown once offered to resolve for $200,000, eventually settled for $325,000.

Brown is now 29. He says the purpose of his lawsuit was mostly to get some accountability for what had happened to him. He still feels particular resentment toward Ashanti, whose full-throated lawyering had made Brown seem like a liar. “It was the undermining — and the sort of sweeping under the rug — of what had happened to me,” Brown says. “I just feel it was very unfair.” He adds, “I don’t know if this is even the job to be empathetic, but he definitely lacked any sort of empathy or any level of understanding.”

When told how Brown feels, Ashanti is unmoved. “How can I put this?” he says. “Civil rights can be violated and that person can still be a knucklehead, you know what I’m saying?” He claims that back at Special Fed, he had tried to advocate for Brown. “He wasn’t there, wasn’t privy to the conversations where I was trying to get authority for the case because I thought his civil rights were violated.” Ashanti says. “Mature people know these things, right? I’m not going to say, ‘Yeah, you’re right — these cops really fucked him up badly. How much do you want, Allen?’ Like, come on. Come the fuck on — excuse my language. Like, that’s not how things are done.”

Ashanti sees the Brown case as an instance of his furthering the cause of justice, not the opposite. “It’s why you need people like me in those positions,” he says. “That’s what a fucking idiot like him is too stupid to see. You need someone like me in those positions versus a white guy who doesn’t give a fuck about you. Any intelligent person can see that, who’s actually mature enough to understand that two things can be true that are seemingly — seemingly — contradictory.”

Not everyone at Special Fed could handle the dissonance. At the same time that he was working the Brown case, Ashanti was asked to mentor a new hire named David Ferrari, who was 25 and fresh out of law school. Like Ashanti eight years earlier, he was immediately assigned complex litigation. Unlike Ashanti, he revolted.

Ferrari was besieged with cases, many of which were frivolous on their face. But he also found that in many of his assignments, officers accused of brutality or other civil-rights violations refused to tell him clearly what had happened. Interviewing cops in his third-floor office, he’d try and fail to get them to go beyond blanket statements like “I was forced to administer a blow.” Ferrari would tell his bosses that it was impossible for him to determine if the plaintiffs’ cases had merit. Ferrari recalls, “The response was: ‘What are you talking about? He told you everything you need to know to make the case.’”

Ferrari turned to Ashanti. Ferrari remembers him saying: “I hear you. I empathize. We’re all very stressed. We just have to keep our head down and keep pushing.” The job ate at Ferrari so much that his health suffered. “Doing the job well was different than doing the right thing,” he says. “Certainly, nobody encouraged me to do something unethical. The culture, the atmosphere, the need to not settle these cases lends itself to a toxic environment.” Ferrari quit after about two years, making sure the office knew he had nothing else lined up. “When I left, I had at least six different attorneys come to my office,” he says. “‘How did you escape this place? How do I get out of here?’ That’s when I felt really vindicated.”

Ferrari says that when he heard about Ashanti’s arrest on Park Place in March 2018, he felt nothing but sympathy. “The job was not easy on him either,” he says. “My intuition was that as overworked as I was, I know he was more overworked. I knew that whatever cases that had the gray area we were struggling with, those were chosen for me because a first-year could handle it. His were a lot more complex.”

Allen Brown’s reaction to Ashanti’s arrest is less generous. Ashanti, he says, is “getting a taste of his own medicine.”

After his altercation with Officer Shapiro on the icy street, Ashanti spent 14 hours in custody. The experience was surreal. “The main component of my job was defending police officers in similar situations who are sometimes guilty of falsely arresting people. And this was one of them,” he says. “That irony hit me immediately.”

His bosses suspended him while they investigated. Ashanti soon learned the breadth of Shapiro’s allegations — that not only had he supposedly shoved the officer but he’d also gone on a tirade, claiming that he’d be “contacting the media” and could no longer “work for this police department or this city anymore.” Ashanti denied saying those things. But then the Post published its “livid lawyer” article.

Ashanti’s superiors did not see his arrest as an isolated incident. A year earlier, he had been brought before top management for violating city rules. Ashanti had represented his wife in small-claims court in a dispute with her former employer, a nonprofit wholly owned by a city agency — a clear conflict of interest. (He was later fined $8,500.) To the Law Department, Ashanti’s use of his city ID to enter a roped-off block was further proof that he felt the rules didn’t apply to him.

With his job in the balance, Ashanti got on the phone with Muriel Goode-Trufant, the agency’s managing attorney. “I knew it was a done deal,” he later testified, “but I expressed my disappointment in her as a Black woman to basically take the racist actions of this police officer that led to my false arrest and then to compound the problem, in order to appease the NYPD, by making me, in essence, a sacrificial lamb. I don’t think I used that term, sacrificial lamb, but that was it in sum and substance. So she was putting the interest of appearances, or the relationship between the Law Department and the NYPD, over what’s right and what’s just.” It was the same argument that Ashanti’s opponents had been leveling against Special Fed for years.

The conversation didn’t help. Within a week of his arrest, Ashanti was told he could resign or be fired. “Despite our frustrations with Karl, it did not mean that we disliked him, so we gave him the opportunity to make the choice,” Goode-Trufant said in a deposition.

Over the next few months, prosecutors withdrew all the charges against Ashanti except for one count of harassment, which is punishable by up to 15 days in jail. That August, wearing a light-blue dress shirt and blue tie with white dots, Ashanti walked into a Manhattan courtroom for a bench trial. He sat at a table as his lawyer walked Shapiro through a crucial 12 seconds of surveillance footage, which doesn’t show any obvious shoves or step-backs.

The judge issued her decision: not guilty. “You know how we always complain we’re under surveillance everywhere?” says Ashanti’s wife, Jovanna. “Thank God for that. That’s what saved Karl.”

After his acquittal, Ashanti turned to reputation repair, hiring a company to scrub his Google results and enlisting members of his church to lobby the Post until the paper removed the story about his arrest from its website. He got a job at a firm representing plaintiffs in civil-rights litigation, advocating for them against the city. He was finally realizing his original ambitions of using the law to help others. “It just took a long, long time — a long, circuitous route to get here,” he says.

Ashanti also sued the city and Shapiro for damages. (The officer has since drawn yet another lawsuit, his fifth in less than a decade. A Canal Street vendor claims that Shapiro yanked her arm so forcefully while arresting her that he broke her shoulder bone, an injury that required a plate and screws to repair. The city denies that claim and is defending him in state court.) Shapiro declined to comment. In a statement, a police spokesperson also declined to comment and denied, generally, that the police have “undue influence on the Special Fed and its work,” saying any claim that it does “is outrageous and inaccurate.”

Ashanti v. The City of New York is ongoing. The city says it’s treating the case as it would any other. “While we work to vigorously protect the interests of the city in every case, we are always mindful that opposing parties are also citizens who should be treated with respect and whose claims should be evaluated fairly,” a spokesman says. “We have upheld all of these values in defending against the meritless case brought by Mr. Ashanti.”

As the case drags on, Ashanti sometimes sounds a bit like Brown. He complains that the city lawyer assigned to his lawsuit is treating it like a “No Pay” case and “fighting tooth and nail against me.” There is a deep sense of outrage, even hurt, in his voice. And yet when I asked him recently about the parallel to Brown, and whether his experience has made him rethink his own hardball tactics at Special Fed, he was unequivocal. “I did my job the right way,” he says.

Over a decade at Special Fed, Ashanti defended the police and jail guards in more than 300 cases accusing them of violating New Yorkers’ constitutional rights. “I didn’t become a Law Department counsel because I was afraid of how people would view me or I was afraid my liberal card would get snatched away, or my Black card,” he says. “I know who I  am. I know what I’ve been through. I know what I believe.”

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by Zach Despart, The Texas Tribune, Lomi Kriel, ProPublica and The Texas Tribune, Alejandro Serrano, The Texas Tribune, Joyce Sohyun Lee, Arelis R. Hernández, Sarah Cahlan and Imogen Piper, The Washington Post, and Uriel J. García, The Texas Tribune

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, and with The Washington Post. Sign up for newsletters from The Texas Tribune and The Post.

This story includes graphic descriptions of injuries sustained in an elementary school shooting. Graphic videos reviewed by reporters are not included.

UVALDE, Texas — Bullets had pierced Eva Mireles’ chest as she tried to shield students from a gunman’s semiautomatic rifle. But the fourth grade teacher at Robb Elementary was still conscious when police carried her out of classroom 112 and through a hallway crowded with dead and dying victims.

“You’re fine. You’re fine,” said her husband, Uvalde school district police officer Ruben Ruiz, who had been frantically trying to rescue her since the attack began. Mireles looked at him but could not speak. She’d been losing blood for more than an hour.

Officers placed Mireles on the sidewalk just beyond one of the school’s exits and started treating her wounds. A medic later told investigators he did not see any ambulances, though video footage showed two parked just past the corner of the building, about 100 feet away.

The chaotic scene exemplified the flawed medical response — captured in video footage, investigative documents, interviews and radio traffic — that experts said undermined the chances of survival for some victims of the May 24 massacre. Two teachers and 19 students died.

Law enforcement’s well-documented failure to confront the shooter who terrorized the school for 77 minutes was the most serious problem in getting victims timely care, experts said. But previously unreleased records obtained by ProPublica, The Texas Tribune and The Washington Post for the first time show that communication lapses and muddled lines of authority among medical responders further hampered treatment.

Footage from body and dashboard cameras showed that two ambulances were outside the school when officers killed the gunman inside Robb Elementary on May 24 in Uvalde, Texas. (Graphics by Imogen Piper/The Washington Post)

Three victims who emerged from the school with a pulse later died. In the case of two of those victims, critical resources were not available when medics expected they would be, delaying hospital treatment for Mireles, 44, and student Xavier Lopez, 10, records show.

Another student, Jacklyn “Jackie” Cazares, 9, likely survived for more than an hour after being shot and was promptly placed in an ambulance after medics finally gained access to her classroom. She died in transport.

The disjointed medical response frustrated medics while delaying efforts to get ambulances, air transport and other emergency services to victims. Medical helicopters with critical supplies of blood tried to land at the school, but an unidentified fire department official told them to wait at an airport 3 miles away. Dozens of parked police vehicles blocked the paths of ambulances trying to reach victims.

Multiple cameras worn by officers and one on the dashboard of a police car showed two ambulances positioned outside the school when the shooter was killed. That was not nearly enough for the 10 or more gunshot victims then still alive, though additional ambulances began arriving 10 minutes later. Six students, including one who was seriously wounded, were taken to a hospital in a school bus with no trained medics on board, according to Texas EMS records.

Dozens of officers from federal, state and local agencies, as well as school buses, parked in the street leading to the school.

(Helicopter footage gathered by the Texas Rangers and obtained by The Texas Tribune, The Washington Post and ProPublica)

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Two ambulances were at the scene when police killed the gunman. But additional EMS responders struggled to get there.

Uvalde EMS radio traffic (12:58 p.m.) “10-4 we are [inaudible] at Grove Street and Grove Street is blocked off by law enforcement.”

One minute later, six students, including one who was seriously wounded, were taken to a hospital in a school bus with no trained medics on board, according to the Texas EMS records.

(Helicopter footage gathered by the Texas Rangers and obtained by The Texas Tribune, The Washington Post and ProPublica. Graphics by Imogen Piper/The Washington Post.)

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Some law enforcement cars were left locked and could not quickly be moved, forcing medics to frantically try various routes to the school, crisscrossing through residents’ yards.

Thirty-three minutes after police killed the gunman, an ambulance struggled to access the school via South Grove Street.

(Helicopter footage gathered by the Texas Rangers and obtained by The Texas Tribune, The Washington Post and ProPublica. Graphics by Imogen Piper/The Washington Post.)

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Although helicopters were available, none were used to carry victims directly from the school. At least four patients who survived were flown by helicopter to a more fully equipped trauma center in San Antonio after first being driven by ambulance to a nearby hospital or airport.

In public statements made since May, law enforcement officials have defended their officers’ actions as reasonable under difficult circumstances. Federal, state and local agencies that responded to the shooting have not directly addressed the medical response, nor did they answer detailed questions from the news organizations that worked jointly on this investigation.

Eric Epley, executive director of the Southwest Texas Regional Advisory Council, a nonprofit that helps coordinate trauma care in Southwest Texas during mass-casualty events, said medics encountered challenges, including a faulty radio system.

“These scenes are inherently confusing, challenging, and chaotic,” Epley said in an email. He later added, “We remain steadfast that the decisions by the on-scene medical leadership were sound and appropriate.”

The Texas Rangers, an arm of the state Department of Public Safety, are investigating what went wrong in Uvalde, including whether any victims might have survived if they had received prompt medical care. The local district attorney has said she will use that investigation to determine whether to charge anyone with a crime, including law enforcement officers.

Mireles, an avid hiker and CrossFit enthusiast who was fiercely proud of her college-graduate daughter, was shot within the first minutes of the attack, according to interviews students gave to investigators and a DPS analysis of gunfire obtained by the news organizations.

It’s difficult to know whether Mireles or anyone else who died that day might have survived their wounds, in part because local officials have refused to release autopsy reports. But footage shows that Mireles was conscious and responsive when she was pulled from the classroom, an indicator that she probably had survivable wounds, according to medical experts.

“Had medics gotten to her quickly, there’s a good chance she would’ve survived,” said Babak Sarani, director of critical care at George Washington University Hospital.

The flawed coordination among police and medical crews echoes missteps during other mass shootings, despite the development of recommended practices after the 1999 massacre at Columbine High School. In several of those cases, the communication problems resulted in delays in getting medical care for victims.

Medics on helicopters and in ambulances who responded to the Uvalde shooting told investigators they were confused about who was in charge, where they should be stationed and how many victims to expect. Some of them pleaded to be allowed closer to the scene. In the absence of clear guidance, experts said medics did the best they could while trying to save lives.

“They were told, essentially, to go to the airport and wait,” according to an interview the Texas Rangers conducted with Julie Lewis, the regional manager for AirLIFE, an air medical transport service that sent three helicopters from the greater San Antonio area. “They couldn’t figure out who was in command.”

Pleading for Help

The morning of May 24 was warm and sunny in Uvalde, the seat of a rural county of about 25,000 residents near the Texas border with Mexico. It was one of the last days of class, and teachers had planned a festive, celebratory day.

Mireles left her home wearing a flowery blouse and pair of black pants, feeling happy, her daughter said.

“My dad had just told her how beautiful she looked,” Adalynn Ruiz, 23, recalled in a text message to a reporter.

Eva Mireles, 44, was an educator for 17 years who taught fourth graders at Robb Elementary. (Courtesy of Lydia Martinez Delgado)

About two dozen fourth graders were in Rooms 111 and 112, adjoining classrooms, that day. They included Jackie, who relished cherry limeades with extra cherries, and Xavier, who loved art class and couldn’t wait to start middle school.

They’d just finished a student awards ceremony and settled into watching the Disney movie “Lilo & Stitch” when a teenage gunman dressed in black scaled the school’s fence and fired shots at 11:32 a.m.

Hearing the gunfire, Mireles quickly called her husband.

“There’s somebody shooting at the school,” she said, Ruben Ruiz recalled in an interview with investigators.

“We’re coming up,” he told her as he drove to the school with a state police officer, who later described the comment to investigators. “We’ll be there.”

The gunman got there first, entering Mireles’ classroom and firing his AR-15-style rifle. Officers rushed into the school minutes later and approached her classroom, but they retreated after the gunman fired through the door, grazing two of them.

Ruiz, who declined to comment for this report but spoke with state investigators, ran into the hallway at 11:36 a.m., according to video footage. But none of the officers tried to enter the classrooms, where the gunman continued to fire sporadically.

Desperate to reach his wife, Ruiz told the other officers what he knew.

Ruben Ruiz: ‘He’s in my wife’s classroom’ (Uvalde Police footage obtained by The Texas Tribune, The Washington Post and ProPublica)

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“He’s in my wife’s classroom,” he said, according to the footage. He later recalled to investigators that it felt “like my soul had left my body.”

About twenty minutes later, his wife called again.

At 11:56 a.m., he shouted, “She says she’s shot!”

That information was a key indication that officers were dealing with an active shooter, not a barricaded subject as school district police Chief Pete Arredondo incorrectly assumed, according to a legislative report on the shooting. But Ruiz’s comment did not change how law enforcement officers, following Arredondo’s lead, responded to the attack.

The school district’s active-shooter protocol designated the chief as the incident commander. Arredondo has repeatedly defended his role in the delay, telling Texas lawmakers investigating the massacre that he did not consider himself to be in charge. The Uvalde school board fired Arredondo in August, amid sharp public criticism of the police response to the shooting.

Trapped inside her classroom, Mireles tied a plastic bag around her arm to help slow the blood loss, one of her students told investigators. Another child in Room 112 told investigators that Mireles tried to protect him. The boy was hit in the back of his shoulder but survived.

At least two students used Mireles’ phone to call 911, begging officers to send help.

Officers confiscated Ruiz’s gun and forced him to wait outside the school, where he told “anybody that would get next to me” that his wife was in danger, according to his law enforcement interview. He tried to get back in, but fellow officers stopped him. They later told investigators they had seized his gun for his own safety.

Inside Rooms 111 and 112, students anxiously tried to get officers’ attention. They knew that for Mireles, there was little time to spare.

One girl later recalled to investigators that Mireles “was telling us she was going to die.”

“We as a Nation Are Not Ready”

More than two decades after the Columbine school shooting shocked the nation, key failures continue to repeat themselves.

After that shooting, officers across the country received training on what they should do first when a mass shooting is reported: Subdue the shooter and stop the killing. Next, trainers tell first responders, they must “stop the dying.”

Over time, that insistence on prompt, effective medical care became an established mantra, as did the idea that all first responders — police, fire and EMS — should work under a joint command overseeing and coordinating the response. An overall incident commander is supposed to coordinate with the head paramedic or lead fire department supervisor to organize the medical response, experts said.

“If you don’t have a system, the whole response goes awry,” said Bob Harrison, a former police chief and a homeland security researcher at the Rand Corp., a think tank based in California.

A Justice Department review of the response to the 2016 Pulse nightclub shooting in Orlando, Florida, that killed 49 people found that the police and fire departments’ decision to operate separate command posts for hours led to a lack of coordination.

A review by local authorities of the 2012 Aurora, Colorado, movie theater shooting that killed 12 people discovered that the delayed establishment of a unified command led to communication problems between police and fire responders, slowing medical care for victims.

“We as a nation are not ready,” said Sarani, the director of critical care at George Washington University Hospital. “The air assets and the ground assets do not talk to each other very well. The fire, the police do not talk to each other very well.”

Experts said that the Uvalde shooting response appeared to lack both an overall incident commander and someone clearly in charge of coordinating the emergency medical response.

The rural community’s emergency medical services are contracted out to private companies. On that day in May, Stephen Stephens, the director of Uvalde EMS, was in charge of organizing helicopters and ambulances responding to Robb Elementary, he later told investigators.

“My job was to manage assets,” he said, noting that Juan Martinez, his deputy, instructed medics arriving at the scene.

After police breached the classrooms where the shooter had been holed up, Stephens said he handed command over to the fire chief of neighboring Medina County. The Medina fire chief declined to comment to the news organizations.

It’s unclear what information Stephens had about how many victims first responders should expect to find. Multiple medics expressed confusion over who was in charge of the medical response and where to go.

“There was no EMS command and control,” said Julio Perez, a medic for AirLIFE, who told investigators he was pleading to help. “Nobody could tell me anything.”

His account was backed up by Lewis, the manager for the air transport service, who said several of her medics were upset. “They feel like the resources weren’t used as they should have been.”

The school district declined to release its active-shooter response plans or protocols and did not answer questions posed by ProPublica, the Tribune and The Post. Separately, the state has fought the release of the active-shooter plans it requires school districts to submit, with the backing of Texas Attorney General Ken Paxton, whose office determines whether government information is open to the public. The news organizations also have sued state and city officials for some records related to the shooting and its response.

The city of Uvalde did not respond to detailed questions about the communication between police and medics or about its training for mass shootings, citing ongoing litigation. But a spokesperson said in an email that the city’s police department has not conducted any formal training with Uvalde EMS, a nonprofit that provides emergency medical services for the city and county.

A document from a March active shooter training conducted by the school district, later published by San Antonio television station KSAT, provides only general guidance on how police and EMS should work together.

The plan states that EMS, fire and law enforcement need to know “the exact location of the injured, as well as the number and types of injuries to expect upon their arrival.” It does not detail a process for communicating that information.

Stephens, Martinez and representatives for Uvalde EMS did not respond to requests for comment, including queries sent by certified letter. Five other private ambulance companies seen responding to the shooting also did not answer written questions or phone calls seeking comment.

Confusion and Delays

Martinez told investigators that he directed other medics to park their ambulances nearby until they knew whether it was safe to move closer. Experts said it’s not unusual to keep ambulances at a short distance from crime scenes with active shooters.

He soon identified a pressing obstacle: As dozens of officers descended on the scene, they left their vehicles blocking the roads that ambulances needed to get to the school.

Martinez instructed the county’s two dispatchers to ask law enforcement to create a clear path.

“We were anticipating essentially just grabbing whatever patients we had and running out,” he later told investigators.

While outside, Martinez and a second medic treated a Uvalde police lieutenant who had been grazed in the head when the gunman shot through the classroom door. Then they waited, with no clear sense of the horror unfolding inside the school.

“We didn’t know the numbers of patients, number of injuries, number of fatalities,” Martinez recalled in interviews with investigators. “Nobody was relaying that.”

Other emergency crews were also struggling to get crucial information and figure out where to go.

The crew of an AirLIFE helicopter grounded in Uvalde for maintenance heard the unfolding chaos on the radio and offered to help. The crew later told investigators that the emergency responders they talked to had rejected their assistance repeatedly. They did not provide the names of those responders.

“Nobody knew what was really going on,” said Perez, one of the helicopter medics. He said the officials told his crew to “stand by, stay there — don’t come.”

With no one clearly in charge of the police or medical responses, an elite Border Patrol tactical team that began arriving at the school at 12:10 p.m. assumed both roles, according to a July report by a state House committee tasked with investigating the response.

Merino-Ruiz: ‘They’ve been bleeding for a while’ (Uvalde Police footage obtained by The Texas Tribune, The Washington Post and ProPublica)

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The team, which typically handles dangerous situations involving migrants at the border, devised a plan to breach the adjoining classrooms while its medics set up a triage station.

Medical triage area set up inside the school (Texas state trooper body-camera footage obtained by The Texas Tribune, The Washington Post and ProPublica)

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At 12:50 p.m., a Border Patrol-led unit that included local police breached the classrooms. The gunman sprung from a closet and fired. They shot back, killing him.

The team gave the all-clear.

Officers who had packed the hallway now filled the classrooms. Ruiz ran back into the school, looking for his wife. Children lay on the floor, many near or on top of each other, most of them dead.

“I Can Still Feel the Heart”

Officers quickly began taking victims to a triage area inside the school, carrying some by their limbs. With so many law enforcement officers and first responders at the scene, there was little space to move. Some children were placed in a line on each side of the hallway.

One local medic later complained to investigators that the response was so chaotic that emergency crews were stepping on victims.

Several medics expressed frustration to investigators that law enforcement officers brought them students who could not be saved.

“You’re doing this wrong,” Martinez, the Uvalde EMS deputy supervisor, recalled yelling to police after being handed a child with a significant head injury. “There’s nothing I can do for this patient.”

Within minutes, medics determined that several critically wounded patients with pulses needed to be urgently taken to a hospital where surgeons could provide advanced care.

A girl matching the description of Jackie — wearing the same red shirt and black shorts she’d had on earlier in the day — was placed in one of the two ambulances at the school. The 9-year-old, described by her family as a “firecracker” for being so full of life, died on the way to the hospital.

Andrew Aviles, a regional trainer for the Border Patrol’s medic team, began treating a young boy, doing everything he could to revive him.

“I can still feel the heart,” Aviles yelled, as he later recounted to investigators in an interview punctuated with sobs. “I need a fucking plane. I need a helicopter down. I need to get a kid inside there!”

The boy needed to be taken to San Antonio’s University Hospital, the nearest Level 1 trauma center, which is equipped to handle the most serious cases. It was about 45 minutes away by helicopter, 90 minutes in an ambulance.

Uvalde is more than 80 miles from the nearest Level 1 trauma centers, which provide the most advanced care for seriously injured patients. (Graphic by Imogen Piper/The Washington Post)

The child seen in the police body-camera footage fits the description of Xavier. A law enforcement document listing what students were wearing indicates that Xavier had on a black shirt, blue jeans and black-and-white shoes. That is similar to the clothing worn by the boy Aviles was treating, the officer video shows.

Xavier Lopez, 10, was a fourth grader at Robb Elementary School. (Courtesy of Felicha Martinez)

Aviles had heard that the wounded were being airlifted from a field on the west side of the school, so he and other medics put the boy on a stretcher and began rushing him out to the dusty patch of grass at 12:56 p.m.

There was no helicopter.

Although at least five medical helicopters responded to the shooting, not one picked up anyone from Rooms 111 and 112 at the school, according to a review of flight data, satellite imagery and photographs, as well as interviews with air crew members by Texas Rangers.

Epley, the executive director of the regional coordinating agency for trauma care, said it was not safe to have medical helicopters at a scene with an active shooter. But Uvalde police could be heard on radio transmissions asking where medical helicopters were 10 minutes after the gunman was killed. It took 15 minutes more for the first to land near the school.

Spokespeople for the ambulance helicopter companies, Air Methods, which includes AirLIFE, and Air Evac Lifeteam, both of which responded to the shooting, said they rely on local medics to decide who should be airlifted. They declined to respond to detailed questions.

Each passing second dimmed the odds for the boy who appeared to be Xavier.

Dread set in when Aviles felt softness on the back of the child’s head, indicating a significant injury. The wounds were consistent with those detailed in the autopsy report shared with Xavier’s family, which revealed that the boy had been shot five times.

“I was like, ‘Guys, he’s …,’” Aviles said, pausing for a moment to take a breath as he spoke with investigators. “That took the wind out of my sails.”

First responders waited 11 minutes for a helicopter but decided to drive to San Antonio when it didn’t arrive. At that point, the boy had already gone into cardiac arrest. Overwhelmed medics enlisted state Trooper Matthew Neese to help with CPR in the ambulance.

Once a gunshot victim’s heart stops beating, the likelihood of survival diminishes sharply, experts said. A patient in that condition should immediately be brought to an operating room, where a surgeon can attempt to stop internal bleeding.

State records show that Neese did not have an EMT or paramedic license in Texas, but he performed CPR on Xavier for more than 30 minutes while a medic tried to treat the boy’s wounds. The ambulance diverted to Medina Regional Hospital in Hondo, about 40 miles from Uvalde, where doctors declared the child dead shortly after 2 p.m., according to his family.

A helicopter arrived near Robb Elementary at 1:15 p.m., eight minutes after the ambulance departed.

Hospital officials did not respond to a request for comment and neither did Neese. The trooper later attended Xavier’s funeral, according to the boy’s family.

Reached on his cellphone, Aviles declined to comment, referring questions to his supervisors at U.S. Customs and Border Protection. In a statement, a CBP spokesperson said the agency is investigating the role of its officers in the response and could not comment while that was ongoing.

Xavier’s mother, Felicha Martinez, said an awful premonition hit her as she stood outside the school waiting for news. Her body went limp and she collapsed. His father, Abel Lopez, searched for any sign of his son, peering between the buses blocking the view of the school.

They have since learned bits and pieces about what happened to their son but are left with questions, including why Xavier wasn’t taken to a hospital by helicopter.

“If the cops had done their job, the medics might’ve had a chance,” Lopez said.

Martinez added: “I’m so full of anger. I don’t know how to put into words how much I am hurting.”

“Don’t Give Up”

On the day of the shooting, emergency responders frantically tried to keep Mireles alive on the sidewalk outside Robb Elementary. She was deteriorating quickly. Within minutes, her heart had stopped and first responders began to administer CPR.

More ambulances arrived at the school, but it wasn’t until 16 minutes after the breach that medics put her inside one.

Eva Mireles was carried out of her classroom, Room 112, and through the school hallway by four police officers, her husband following behind.

A Border Patrol medic said in an interview with investigators: “I asked the guys, ‘Hey let’s not work on her here.’ But we look to the right and there’s no ambulances. So we had to work on her there.”

But there were two ambulances parked about 100 feet away.

(Graphics by Imogen Piper/The Washington Post)

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Medics laid Mireles on the ground and performed chest compressions.

She lay on the ground for more than 10 minutes, during which six ambulances arrived and two left. It’s unclear why Mireles was not immediately put into one of these ambulances.

(Graphics by Imogen Piper/The Washington Post)

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Ultimately, medics moved Mireles off the ground and into an ambulance.

(Graphics by Imogen Piper/The Washington Post)

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“Come on, ma’am, don’t give up,” a voice can be heard saying in a state trooper’s body-camera footage.

By then, the teacher’s chances of survival had sunk.

In the ambulance, medics began a blood transfusion and used an automatic compression device to try to get the teacher’s heart pumping again. They gave her fluids and intubated her.

But they did not take her to a hospital, a decision some experts described as a mistake and others said could indicate that medics thought Mireles had no chance of survival.

First responders continued CPR in the ambulance for about 40 minutes before the chief medic for Uvalde EMS declared her dead.

The ambulance that Mireles was inside never left the school curb.

by Ava Kofman

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

Less than three weeks after ProPublica and the New Yorker published an exposé of hospice fraud, members of Congress have called on the Department of Health and Human Services to “immediately investigate this situation.”

In a letter sent Friday to the Centers for Medicare and Medicaid Services and the Office of Inspector General, the bipartisan leaders of the Comprehensive Care Caucus wrote that “Medicare fraud cannot be tolerated, especially when it is being perpetrated on our nation’s most vulnerable patients.”

The ProPublica-New Yorker investigation described how the lucrative design of the Medicare benefit incentivizes many profit-seeking hospices to cut corners on care and target patients who are not actually dying. It chronicled the lack of regulation and the frustrated efforts of whistleblowers to hold end-of-life care conglomerates accountable. And it drew on state and federal data to reveal how, in the absence of oversight, the number of for-profit hospice providers in California, Texas, Arizona and Nevada has lately exploded.

The letter’s signatories — Sen. John Barrasso, R-Wyo., Sen. Jacky Rosen, D-Nev., Sen. Deb Fischer, R-Neb., and Sen. Tammy Baldwin, D-Wis. — decried the “troubling trend” spotlighted by the reporting and requested a briefing from the agencies within two weeks about plans to “address the proliferation of fraudulent hospice providers.”

The story’s findings are also being cited by lawmakers and lobbyists in New York, where Gov. Kathy Hochul is considering signing legislation to outlaw the creation of new for-profit hospice providers in the state. At the moment, all but two of New York’s 41 hospices are nonprofit. Assemblyman Richard Gottfried introduced a bill, which passed this summer, to keep things that way. “We can close the barn door before the horses have gotten out,” he said. “The article raised the level of awareness around issues with for-profit care.”

Published last month, the investigation provoked what industry leaders have called a “much-needed” conversation on how Americans die — along with demands to improve those deaths. “The abuses detailed in the article call for a reform of the Medicare hospice benefit that can reduce the opportunities for fraud and abuse,” the National Partnership for Healthcare and Hospice Innovation, a group for nonprofits, said in a statement. In public letters, LeadingAge, another association for nonprofit providers, and the American Academy of Hospice and Palliative Medicine, an organization for hospice professionals, separately emphasized that “change is needed.”

Lobbying groups whose members include for-profit providers — the National Hospice and Palliative Care Organization and the National Association for Home Care & Hospice — took issue with the investigation’s focus on “bad actors” but said in a joint statement that its members look forward to working with lawmakers “to implement solutions to address the isolated problems highlighted by the article without jeopardizing access to the Medicare hospice benefit.”

Dr. Ira Byock, a palliative care physician, author and former president of the American Academy of Hospice and Palliative Medicine, echoed the calls for greater monitoring of the hospice system in the wake of the investigation. “Hospice in America is gravely ill,” Dr. Byock wrote in an op-ed published last week by STAT, the health care news site. “I am hopeful that the article will spark a long-overdue internal reckoning by the field — my field — and the industry we gave rise to.”

Hospice began more than 60 years ago as a countercultural charity movement to help patients die with comfort, support and as little pain as possible. After the 1980s, when President Ronald Reagan authorized Medicare to cover the service, dying became a big business. In 2000, less than a third of all hospices were for-profit. Today, more than 70% are. Between 2011 and 2019, the number of hospices owned by private equity firms tripled. For profit-seeking providers, hospice is lucrative: Medicare pays a fixed rate per patient a day, regardless of how much help is offered. The aggregate Medicare margins of for-profit providers hover around 20% compared with just 5% for nonprofits.

Studies have found that for-profit hospices are more likely than their nonprofit counterparts to have less skilled staff, reduced clinical services and fewer home visits in the last days of life. Their patients have longer stays and leave hospice alive at higher rates. Last year, citing the research, three members of the Senate Finance Committee requested information on the quality of hospice services provided by Kindred at Home, the country’s largest home care chain. (Kindred’s hospice subsidiary was recently spun-off and sold to a private equity firm.) “We are concerned that when applied to hospice care, the private equity model of generating profit on a rapid turnaround can occur at the expense of dying patients and their families,” they wrote. Analysis of the data is ongoing, senate staffers said.

Assemblyman Gottfried said that the pending legislation in New York is an attempt to prevent the profiteering that’s unfolded elsewhere from seizing his home state. Jeanne Chirico, who heads the Hospice and Palliative Care Association of New York State, said that her group regularly fields calls from venture capitalists looking to break into the market. So do her members. Mary Crosby, the CEO of East End Hospice, a nonprofit located on Long Island, said that once or twice a month investors make offers. “We’re a particularly attractive acquisition target because we struggle financially and we’re not linked to a larger health care system,” Crosby told me. “But if you’re actually providing the kind of interdisciplinary care that is based on the original hospice mission, as we are right now, you’re not going to be making a lot of money.” Her hospice covers around 20% of its operating costs from donations, she said.

New York would not be the first state to bear down on its hospice sector. California has enacted a temporary ban on new hospice licenses, after the Los Angeles Times uncovered a dramatic increase in hospices that far outpaced the demand for services. In a report released this spring, state auditors found that since 2015 the Department of Public Health had never suspended a hospice license and had revoked a license only once. “The state’s weak controls have created the opportunity for large-scale fraud and abuse,” they said.

ProPublica and the New Yorker’s reporting outlined how California’s pattern of disproportionate growth is spreading to other states. In Arizona, Nevada and Texas, the rise in new Medicare-approved hospices since 2018 now accounts for around half of all hospices in each state. Unlike New York, these states don’t have “certificate of need” requirements for hospices, which means there’s no strict limit to the number of providers that can open in a given area.

The simplest way to understand the recent hospice boom is to see it.

Rapid Rise in Hospices Concentrated in West and Southwest

A ProPublica analysis of Medicare data reveals a sharp uptick in providers since 2018.

(Source: <a href="https://data.cms.gov/provider-data/topics/hospice-care">CMS data set of Medicare-certified hospices.</a> Chart by Lena Groeger.)

This chart represents Medicare hospices — it does not include the dizzying rise in state licenses — and therefore undercounts the total explosion in end-of-life care providers. (Hospices must first obtain a state license before they can be certified to bill Medicare for their services.) Federal data, for instance, shows just 22 Medicare-certified hospices packed into a building on Friar Street in Los Angeles, but California’s data reveals an additional 107 state hospice licenses registered at the same address. (Although California’s moratorium bars new providers, it does not stop the thousand-plus owners already in possession of state licenses from obtaining Medicare certification and billing the government.)

Industry leaders have expressed alarm about the loopholes in the state and federal certification process that enable sudden clusters of for-profit providers to materialize. A ProPublica review of hospice data in Phoenix showed that a raft of new entities shared the same addresses and network of owners. Some of the Arizona entrepreneurs already operate several hospices in Los Angeles, including out of the building on Friar Street. “These small entities aren’t required to publicly report quality of care data, are often not audited and, because of how the per diem is set up, it’s a gold mine,” said Larry Atkins, the chief policy officer of the National Partnership for Healthcare and Hospice Innovation. “You could very quickly figure out whether a hospice is a real place or a mill that’s simply signing up and burning through patients to bill Medicare. But no one is really doing that.”

Eric Rubenstein, who worked as a special agent at the Department of Health and Human Services’ Office of Inspector General until 2019, said that the Centers for Medicare and Medicaid Services and its contractors are often focused on auditing bigger billers. For the “smaller circuses and clowns,” the government’s lax payment system can be easy to exploit. “The demand for these licenses is predicated on the fact that there’s a huge amount of money to be made quickly in hospice fraud,” he said.

CMS said in a statement to ProPublica that the agency “is aware of the increase in the number of new hospices” requesting Medicare certification, and is “working to ensure they meet all applicable requirements for participation in the Medicare program.”

Last month, four national hospice associations banded together to ask CMS to enact targeted moratoriums in high-growth regions. “In addition to action at the state level, increased federal oversight is needed to protect hospice patients and their families,” they wrote. The groups are currently scheduling a meeting with CMS to discuss their concerns.

by Jeremy Kohler

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

Three months after a St. Louis public safety official said the city planned to review how off-duty police officers are used by private companies to patrol some neighborhoods, city officials said they had identified a consultant to do the work but were still looking for a way to pay for it.

The pledge to review police moonlighting came in September, after ProPublica revealed how the use of private police forces in St. Louis exacerbates disparities in how the city is protected. Deputy Public Safety Director Heather Taylor, responding to ProPublica’s findings, said the city would hire a consultant to study the issue.

Mayor Tishaura O. Jones said more recently that she intends to make changes to the private policing system to eliminate the disparities. “The well-heeled few, or those who pay extra taxes, shouldn’t get extra protection,” Jones said in a St. Louis Public Radio interview this month. “We all pay taxes in order to make sure that we get equal protection from our police department.”

The police department could be set for an overhaul with Jones’ appointment last week of its first chief from outside the agency in its 214-year history. Robert Tracy, the chief in Wilmington, Delaware, will start Jan. 9.

Tracy could not be reached; Jones and Taylor did not respond to requests for comment. But Monte Chambers, a program manager for the Public Safety Department, said the city planned to hire a consultant who is already working on another project for the city to review other policing issues, including the city’s private policing system.

The review would begin “once I have found a funding source,” Chambers said in an email last week.

Chambers did not respond to additional questions seeking details about the review.

While the publicly funded St. Louis Metropolitan Police Department struggles to deploy officers in visible roles across the city, ProPublica found that about 200 of them work part time for the city’s biggest private policing firm in some of the wealthier and predominantly white neighborhoods.

Unlike in other places where officers moonlight in security roles, St. Louis officers wear their city police uniforms and can investigate crimes, stop pedestrians or vehicles, and make arrests while working for private policing companies.

The investigation found that city employees working as private police officers were sometimes offered monetary rewards for working on specific cases and that St. Louis’ largest policing firm, The City’s Finest, employs many of the department’s highest ranking officers, including four of the six district commanders.

Some of those commanders sometimes work on trivial matters for their private clients while the police department struggles to deploy officers to parts of the city grappling with violent crime.

Jones, elected in 2021, has criticized policing in St. Louis as “inefficient and ineffective” and, in the radio interview, lamented that private policing makes the city stand out for its disparities. She has talked about restructuring the department and shifting funding to programs that try to prevent crime, such as mental health services and job training initiatives.

Megan Green, who in November was elected president of the city’s Board of Aldermen and is the city’s second-highest ranking official, said private policing was an issue that the new chief “needs to take up pretty quickly.” She also said the Board of Aldermen should examine the source of funding for private policing: the neighborhood taxing districts that raise millions of dollars a year.

Many affluent city neighborhoods have created taxing districts, the latest formed this summer in south-side Holly Hills. The districts are authorized by state law, but they periodically need to be renewed by property owners and the city. Green said the board could try to determine if “there are some taxing districts that need to be dissolved.”

“I think that the special taxing districts definitely create inequities in our city,” Green said. She said the city should “be more strategic about where special taxing districts are created. We historically have not had a lot of strategies around that as a city, which I think has created even greater inequities.”

The Board of Aldermen’s Public Safety Committee had planned to talk about private policing during a meeting last week, but officials from the city’s Public Safety Department did not show up and the discussion wasn’t held.

Eliminating private policing could potentially roil the city. Luke Reynolds, chair of a taxing district in the city’s Soulard neighborhood that raises about $300,000 a year for private policing, said that if city police officers were barred from working for the private company that patrols his area, the neighborhood would look at other ways to enhance public safety. “I have no idea what that would look like,” he said.

“I have said all along that I don’t necessarily think the system is really necessarily fair. But then again, there is a lot of inequity in the world, unfortunately,” said Reynolds, who owns a bar in Soulard. “We’re going to try to make our neighborhood as safe as we can within the system that exists.”

Don Bellon, who owns a wrecking and salvage business and serves on a board that hires private police in the Grove entertainment district near the city’s central corridor, said paying for policing was necessary “because the city can’t provide it.”

But he said he was frustrated with a lack of accountability for private officers. At a recent Grove board meeting, he questioned what the private officers were doing on a night when several crimes were committed.

“There’s really no oversight on them,” he said. “They’re freelancing. They just decide where to go.”

Charles “Rob” Betts, who owns The City’s Finest, did not respond to a request for comment. Betts has called his company “essentially an extension of the police department” for neighborhoods who want to hire more police. And he has defended giving officers rewards for working on specific cases as not unlike an officer being recognized for good police work at a luncheon.

In reporting on policing in St. Louis this year, ProPublica showed that police and neighborhood advocates have sought court orders to banish individuals from large sections of the city and officers have enforced those mandates through arrests — a practice legal experts said few cities have taken to such extremes. Representatives for the mayor did not respond to requests for comment.

In a partnership with APM Reports this year, ProPublica also found St. Louis had massaged its murder totals in a way that may have violated FBI crime reporting guidelines and created false optimism about police performance. The city quietly lowered its murder counts for 2020 and 2021 by classifying more than three dozen killings as justifiable homicides — deaths not included in the city’s murder count. Neither the department nor representatives for Jones responded to requests for comment for the story.

by Adriana Gallardo, Anna Clark and Mariam Elba

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

Expecting parents want to do the right thing. When the doctor suggests a prenatal screening test, many say yes. Learning more about the baby-to-be seems like it has no downside.

But they often don’t realize these popular tests aren’t regulated by the U.S. Food and Drug Administration. This means that no federal agency makes sure that marketing claims are backed up by evidence before the tests reach patients. Even many health care providers find it hard to understand their nuances.

Testing companies told ProPublica that, even without the FDA, there is significant oversight over the screening tests. They said health care providers, who order them, should make sure patients understand what they can and cannot do.

That’s not always how it plays out. We published an investigation about this: “They Trusted Their Prenatal Test. They Didn’t Know the Industry is an Unregulated ‘Wild West’.” During our reporting, we heard from more than a thousand people in six countries, 47 states and Washington, D.C., about their experiences with noninvasive prenatal screening tests — often called NIPTs, or NIPS. Several reached out after reading our story.

We heard from a lot of people who were grateful for the screenings. They gave them peace of mind. But others told us they were left confused, frustrated and sometimes even shattered. We also heard that it can be difficult to find independent information about NIPTs.

This guide is meant to help fill the information gap. It includes basics on what the tests are, how to understand the results and even a glossary for the many confusing terms test-makers toss around. Our information is based on hundreds of conversations with parents, health care providers, researchers, genetic counselors and other experts. If you or your family is considering an NIPT, or you’re trying to understand your results, we hope this will help. We also encourage you to do your own research and consult with doctors or genetic counselors you trust.

Table of Contents

• What is noninvasive prenatal genetic testing?
• Understanding your NIPT results
• Paying for an NIPT
• NIPT glossary
• Get in touch with our reporters

What is noninvasive prenatal genetic testing?

What are NIPTs?

Noninvasive prenatal tests, or NIPTs, screen for an array of rare genetic conditions. In most cases, the results will say that a genetic condition is unlikely. In some cases, they will flag a possible issue.

Here’s how it works: A health care provider takes a blood sample. They send it to a lab for analysis. The lab looks for cells from the placenta that float in your bloodstream. They can give a picture of the fetus’s development. The cells don’t come directly from the fetus — that’s why this is a screening test, not one that gives a more definitive diagnosis. The lab then lets you and/or your doctor know what the screening found.

You can get a screening as early as nine weeks into pregnancy.

Are NIPTs the same as NIPS?

Yes. Many health care organizations call them NIPS (noninvasive prenatal screening) instead of NIPT (noninvasive prenatal test).

There has long been concern about the name. Some experts say that calling it a “test” implies the results are more certain than they really are. In the industry’s early days, some even called it noninvasive prenatal diagnosis, or NIPD.

They’re also sometimes known as cell-free DNA screening tests, or cfDNA tests.

What do NIPTs test for?

NIPTs check for genetic conditions that can affect the health of the fetus. This includes trisomies, or extra chromosomes. The standard bundle of tests usually checks for these conditions:

• Down syndrome, also known as trisomy 21
• Edwards syndrome, also known as trisomy 18
• Patau syndrome, also known as trisomy 13

It may also check for unexpected numbers of X or Y chromosomes — one or three, for example, instead of the usual two. These are called sex chromosome aneuploidies. They may be associated with certain health and developmental issues.

Companies may offer extra tests, too, which they often describe as “premium,” “plus” or “advanced” options. These tests screen for even more genetic conditions. But the American College of Obstetricians and Gynecologists, the leading professional society for OB-GYNs, doesn’t recommend that doctors offer them to patients. Also, as the New York Times reported, when the extra tests have a positive result, they are “usually wrong.”

NIPTs don’t screen for nongenetic conditions, such as heart defects. For younger people, nongenetic conditions may be more likely to affect their pregnancies.

Are NIPTs regulated?

NIPTs are not regulated by the FDA. No federal agency checks to make sure they work the way they claim before they’re sold to health care providers. The FDA doesn’t make sure that marketing claims are backed up by evidence before screenings reach patients. And companies aren’t required to publicly report instances of when the tests get it wrong.

Testing companies said that, even without the FDA, there is still significant oversight. Labs must abide by state regulations, and another federal agency, the Centers for Medicare and Medicaid Services, monitors quality standards. It does not, however, check whether the tests the labs perform are clinically valid.

You can read more about this in our investigation about the prenatal testing industry.

Are NIPTs the “gender reveal” test?

Yes. Hundreds of women told us that this early chance to learn the likely fetal sex was the main reason they got screenings.

Experts emphasize that NIPTs should be treated primarily as a genetic screening test, rather than as a way to learn the likely sex early.

It’s rare, but there is a small possibility that the tests will predict the sex incorrectly.

What if I want an NIPT, but don’t want to learn the sex?

Let your doctor know. Testing companies can deliver results in a way that doesn’t disclose the sex. Know that if the screening is positive for some conditions, such as Turner syndrome, it may reveal the sex by default.

Are there other prenatal screening options besides NIPT?

Yes. ACOG and the Society for Maternal-Fetal Medicine, the leading professional societies for doctors who handle pregnancies, wrote about the different prenatal screening options in their guidance on NIPTs. Each test has benefits and limitations. It said that health care providers should discuss NIPTs, along with other screening and testing options, with expectant parents. Counseling can help you decide what to choose.

ACOG also has a FAQ about screening options.

How are NIPTs different from carrier screenings?

Carrier screenings calculate the chances that a person could pass an inherited condition on to their future child. They analyze a blood or tissue sample from one or both prospective parents to learn about their genetic makeup.

NIPTs, on the other hand, use a blood sample from the pregnant parent to analyze cells from the placenta and learn more about the possible genetic condition of the fetus.

I’m not sure if I should get an NIPT. How do I decide?

Deciding whether to get an NIPT depends on your personal situation. Your age, your health and how far along you are in pregnancy are all important considerations, as are your concerns, values and questions.

Your health care providers and, ideally, a genetic counselor can help you decide if an NIPT is a good choice for you. To think through the benefits and limits, you might want to check out these resources:

• ACOG’s guidance on NIPTs
• ACOG’s FAQ on prenatal genetic screening tests
• The FDA’s safety communication on NIPTs
• The Genetic Support Foundation’s Pregnancy 101 guide
• The r/NIPT Reddit community

Also, in the next section of this guide, you’ll see more information on factors that affect the performance of the screenings.

Katie Stoll, executive director of the nonprofit Genetic Support Foundation, said it’s important to weigh what information from a screening will mean for you. She suggested reflecting on the following questions:

• How would you feel if results indicated a higher chance for a genetic condition or birth defect?
• Would you consider a diagnostic test, such as amniocentesis, if the NIPT indicated an increased chance for a genetic condition? -- If not, would you be okay waiting until the baby is born to know for sure if the condition is present?
• Do you think this information would help you feel more prepared?
• Does more information that comes with the possibility of uncertainty make you anxious?

Rachel Ray, 36, of Binghamton, New York, said it’s also important to have honest conversations with your partner or loved ones.

“No one expects the results to come back positive, or worse, false positive,” said Ray, who had the test in 2019. For those who haven’t had these conversations ahead of time, she said, “this kind of result could cause a huge ripple effect on a relationship.”

We heard from many people who were happy they got these tests. They said that it was helpful for making decisions about pregnancy and future parenting.

Others said their experience of the tests was traumatic. Alexis Reprogle, 28, from Fort Wayne, Indiana, had an NIPT that came back with inconclusive results. When she got a second screening, she said, it was positive for trisomy 18. But further testing showed that it was a false positive. Her daughter, now 2, has no unusual genetic conditions. “I wish I never would have taken the test,” said Reprogle. “It caused so much stress and the need to go back and forth with the insurance company over costs.”

Still others said their decision about the screenings is affected by state laws that ban abortions or restrict them to early in pregnancy.

In many states, abortion bans start before you will be able to confirm the screening results with a diagnostic test. In some places, they become restricted before you can even get the screening.

To stay up to date on the policies affecting you, The New York Times is tracking the current legal status of abortion in all 50 states and Washington, D.C.

What happens if I say no to the NIPT?

You have a right to say no to testing, said Mary-Nevaire Marsh, 34, of Atlanta. In 2020, she had a false positive for trisomy 18.

“It is meant to be a conversation,” Marsh said. Doctors “are an expert in their field, and you should be going to them for advice and counsel, but ultimately, the decision is completely in your hands and yours alone.”

If you’re anxious about this conversation, Marsh suggested bringing someone you trust with you.

“Bring a buddy or a partner with you if you feel like you’re going to need someone to help back you up,” she said. If doctors aren’t accepting your decision, she said, “say, ‘Let’s table it. We’ll talk about it next time.’”

“Another really good question to ask is ‘If we don’t do this, what other options are there?’” Marsh added.

Understanding your NIPT results

How accurate are NIPTs?

It depends. NIPTs are often quite good at identifying Down syndrome (trisomy 21) and Edwards syndrome (trisomy 18), especially for older parents who are more likely to have pregnancies affected by these conditions. They are less likely to correctly predict Patau syndrome (trisomy 13).

Test performance drops with the optional extra screenings that look for rarer conditions. The New York Times wrote about this: “When They Warn of Rare Disorders, These Prenatal Tests Are Usually Wrong.”

What other factors affect the NIPT results?

A number of factors can affect the performance of NIPTs, though companies sometimes sidestep this in their promotional materials. Readers and experts told us that health care providers, too, may not be clear about it.

These factors may include:

• Your age
• Your body mass index (BMI)
• Gestational age (how far along you are in the pregnancy)
• Your race and ethnicity
• Pregnancy by in vitro fertilization
• Twin pregnancies or vanishing twins
• If you have been the recipient of an organ transplant

Rachel Ray said her providers failed to mention that her weight could affect the performance of her screening. In 2019, she had a false positive for trisomy 18.

“If I had been informed that higher BMIs have a significant impact on the reliability of the NIPT, I would have still taken the test, but I would not have experienced nearly the amount of stress I did,” said Ray.

She’s opting to skip an NIPT for her current pregnancy in favor of other screening tests. “I have declined because I do not want to experience what I experienced the first time, as I am still obese,” Ray said. “So far this pregnancy has been healthy and uneventful.”

How do I read my NIPT results?

After you have an NIPT done, it can take a week or two to get your results. Companies report results differently. Some describe conditions as "positive" or "negative.” At least one company describes them as "high-risk" or "low-risk,” which, it said, is meant to reinforce that NIPT is screening and not diagnostic.

A positive or high-risk NIPT result means there may be a higher possibility that the fetus has a genetic condition. This can affect its health and development. A negative or low-risk result means a genetic condition may be less likely.

To confirm your results — or if you simply want to go straight for a more comprehensive testing option — you may want an amniocentesis or chorionic villus sampling, or CVS, test.

In some cases, there will not be enough information in the blood sample from your NIPT to report results. It may read as “inconclusive,” “no call” or “no result.” In general, inconclusive results suggest a heightened risk of the fetus being affected by a genetic condition.

If this happens, you can consult with your doctor about doing the screening again, or getting a diagnostic test.

I got a positive result! What should I do?

While you’re probably feeling a lot of fear, please remember the information is not definitive.

“It is important to remember that NIPT results, just like other screening results, do not give a ‘yes’ or ‘no’ answer to whether a pregnancy has a chromosome condition,” said Stoll of the Genetic Support Foundation.

Your health care providers should talk to you about diagnostic options for confirming or refuting the results. They may also refer you to a maternal-fetal medicine specialist. Your second trimester scans, instructions from your doctors and further testing can all help you learn more about your pregnancy.

You also may want to talk with a genetic counselor who can help you understand your NIPT results and think through their implications.

In some cases, a positive result may have implications for your own health. “This, too, can be discussed with your provider,” Stoll said.

Also, know you are not alone. The people we talked to say the weeks or months in between the screening and finding out for sure if it’s a true positive can be filled with anxiety.

“Find somebody who you can talk to who can just listen,” said Daniela Weiss-Bronstein, 43, of Westhampton Beach, New York. She appreciated how one friend put it to her: “Tell me all the things that are in your head that you can’t say.”

In 2015, Weiss-Bronstein was expecting her fourth child when an NIPT came back positive for Down syndrome. For her, dear friends and the Down Syndrome Diagnosis Network were the most supportive outlets as she struggled with her feelings about the result.

Mary-Nevaire Marsh recommends taking time to process, even when some decisions need to be made soon.“You do have time,” she said. It’s important to think through your options and “decide what really feels like the right thing for you and your baby and your family.”

If follow-up testing shows it to be a true positive, this will likely affect your birthing plans. Some people told us they decided to end their pregnancies after a diagnosis. Others adjusted their medical care and parenting expectations.

Weiss-Bronstein chose not to get a diagnostic test after her positive NIPT. She supports abortion rights, but she knew she wouldn’t end her pregnancy even if an amnio confirmed the presence of Down syndrome. To her, it seemed like an unnecessary risk to add to an already complicated pregnancy. It wasn’t until the day her son was born that she and her husband found out it was a true positive, an experience she and a friend chronicled in a comic.

For those who receive a positive test for Down syndrome, Weiss-Bronstein said she wishes there was more awareness about how modern interventions and support systems have improved life outcomes for people who have the condition.

I got a negative result! What should I do?

Many people said that a negative NIPT result is a huge relief. They told us that it gave them peace of mind during their pregnancies. True negatives are the most common outcome of the screening tests.

False negatives are extremely rare — far more rare than false positives or inconclusive results — but they do happen, as we reported in our investigation.

Second trimester scans and diagnostic testing can provide additional information about nongenetic conditions that may affect your pregnancy. Reader V.G. had a negative NIPT in 2019 and declined a CVS test. But she decided to have an amniocentesis to confirm the screening. Between the amnio and the NIPT, she felt reassured that all was well. (For privacy, she asked not to be identified with her full name.). For her, it was a very positive experience.

I got an inconclusive, or “no-call” result! What does this mean?

This happens when a lab is unable to provide information about the conditions it screened. There are many possible explanations for this, Stoll said, “and sometimes we are never really able to determine the reason.” It may be that the blood sample contained too low a percentage of DNA from the placenta. This is called “low fetal fraction.” Or it could be a problem with the shipping of the sample, Stoll said.

In general, an inconclusive result can signal a higher likelihood of a chromosomal condition. But it may not. Your health care provider may recommend a redraw of the blood sample for another NIPT, or a diagnostic test.

Alexis Reprogle in Indiana, who had a second NIPT after her first was inconclusive, said it’s sometimes helpful to wait to do further testing.

“Most of the time you will have your blood drawn again for a second test,” she said. “If you are feeling overwhelmed with anxiety over the entire process, you can always back out of the second test. You may have the option to wait a few more weeks, as this could provide a more accurate reading.”

How can I confirm my NIPT results?

Diagnostic tests, such as amniocentesis and CVS, offer the most definitive and comprehensive information about the health of the fetus. An “amnio” is a test that analyzes a small amount of amniotic fluid from the area around the fetus. CVS analyzes a small piece of tissue from the placenta.

Both are considered invasive tests, with a small risk to the pregnancy, though experts say it is extremely low.

I want more advice and guidance. Where can I find genetic counseling?

Genetic counselors are trained professionals who can help you understand the tests, think through their results and, potentially, prepare for a pregnancy affected by a genetic condition. ACOG’s guidance on prenatal screening recommends both pre-test and post-test counseling.

​​Some testing companies offer patients genetic counseling services with their on-staff experts. They typically offer these at no additional charge and some people said they received helpful guidance. But several experts we spoke to emphasized the value of genetic counselors who aren’t employed by labs. That way, you can be confident there are no conflicts of interest. Independent counseling may be more expensive, though.

A good place to start is talking with your health care provider about a referral to a genetic counselor in your area. The Genetic Support Foundation in Olympia, Washington, is one source for independent guidance on a range of genetic health decisions, including pregnancy. It offers telehealth appointments. (Stoll, GSF’s executive director, was a source for this guide.)

The National Society of Genetic Counselors offers a directory of in-person and telehealth options in Canada and in the United States.

Adriana Ludé, 36, of Oakland, California, enlisted a geneticist after she received an inconclusive result. She said it’s important to find a good communicator, not just someone with technical qualifications.

“Having someone who is able to explain it in simple words our overwrought and emotional brains could understand was huge,” Ludé said.

Weiss-Bronstein said those with positive results might also want to consult with a developmental pediatrician’s office. There can be waitlists, she said, but if you can get in the office, it gives you a chance to talk to someone who works with kids with these genetic conditions in real life. It’s a chance to ask, as she put it: “Not pie in the sky, and not doom and gloom, what does this actually look like?”

Speech and physical therapists who work with kids with these conditions can be helpful too, she said.

Paying for an NIPT

How much do NIPTs cost?

In our reporting, we heard about bills that ranged from a few hundred to many thousands of dollars, even for people who said they had good health insurance. We also heard from people who had the test covered completely by their insurance, or paid low-cost rates offered by the NIPT companies.

Stoll suggested asking your doctor for details about:

• Which lab your testing will be sent to
• Which conditions the test screens for
• Which CPT codes will be used to bill for this test

Then, she said, you can follow up directly with your insurance company “to learn about coverage for the specific lab and codes being used.”

Patients give this advice:

• Let your doctor know if you have limited funds. The practice may be able to budget for your care, or your doctor may be able to share information about financial assistance options.
• Keep detailed records of your communication with the testing companies, your doctor and insurance company. Arbitrary billing was among the most common complaints we heard. Confusing pricing often led patients to make multiple phone calls to the labs and their insurers to get clarity on their responsibility for the cost.

NIPT Glossary

Aneuploidy: Broad term for conditions that involve an unusual number of chromosomes. (Most people have 46.)

Chromosomes: Thread-like structures in our cells that are made of our DNA. Together, they make a blueprint for our unique physical characteristics.

Fetal fraction: Percentage of DNA in the sample of the maternal blood that is from the placenta. If the fetal fraction is too low, it can result in an inconclusive, or “no call,” result.

False negative: When a screening shows a negative or low-risk result for a certain condition, but it turns out the condition is actually present.

False positive: When a screening shows a positive or high-risk result for a certain condition, but it turns out the condition is actually not present.

Karyotype: An individual’s complete set of chromosomes.

Prevalence: How common, or “prevalent,” a condition is in a certain group of people.

Positive Predictive Value, or PPV: The likelihood that a positive or high-risk screening result will prove to be true. If you get a positive result for a certain condition, this is an important indicator of how likely it is that the fetus actually has it.

Different genetic conditions have different PPVs. You can use an online calculator to estimate more personalized PPVs for certain conditions.

Microdeletion: A missing fragment of a chromosome, which can cause a number of rare genetic conditions, such as DiGeorge syndrome or Prader-Willi syndrome. Many testing companies offer optional extra screenings for microdeletions, as well as additional trisomies. But ACOG does not recommend them.

Monosomy: Term for having only one chromosome (“mono”) where there would usually be a pair.

Mosaic, or Mosaicism: When different cells have different numbers of chromosomes in them. Some cells might have the usual 46 chromosomes, but other cells might have 47 chromosomes. This can result in health issues. Mosaicism may also mean there’s a difference between the cells in the placenta — which is what an NIPT analyzes — and the cells in the fetus. This can lead to false positives or false negatives.

Negative Predictive Value, or NPV: The likelihood that a negative or low-risk screening result will prove to be true. If you get a negative result for a certain condition, this is an important indicator of how likely it is that the fetus is actually unaffected by it.

Different genetic conditions have different NPVs. You can use an online calculator to estimate more personalized NPVs for certain conditions.

Sensitivity: The proportion of those who have the condition who are correctly identified by the test. It is the “detection rate.”

Specificity: The proportion of those who do not have the condition who are correctly identified by the test.

Soft markers: Features detected in the fetus that aren’t necessarily related to a genetic condition but can be correlated with one. For example, shortened long bones in the arm and leg may be associated with Down syndrome.

Trisomy: Term for conditions with an extra third (“tri”) chromosome alongside one of the usual pairs of chromosomes. Down syndrome, for example, is known as trisomy 21 because it’s a condition involving three copies of the 21st chromosome.

True Negative: When a screening has a negative or low-risk result for a certain condition and it turns out the condition is indeed not present.

True Positive: When a screening has a positive or high-risk result for a certain condition and it turns out the condition is indeed present.

Have You Had an Experience With Prenatal Genetic Testing? We’d Like to Hear About It — and See the Bill.

Sophia Kovatch contributed research.

by Jennifer Smith Richards, Chicago Tribune, and Jodi S. Cohen, ProPublica

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

On the last street before leaving Jacksonville, there’s a dark brick one-story building that the locals know as the school for “bad” kids. It’s actually a tiny public school for children with disabilities. It sits across the street from farmland and is 2 miles from the Illinois city’s police department, which makes for a short trip when the school calls 911.

Administrators at the Garrison School call the police to report student misbehavior every other school day, on average. And because staff members regularly press charges against the children — some as young as 9 — officers have arrested students more than 100 times in the last five school years, an investigation by the Chicago Tribune and ProPublica found. That is an astounding number given that Garrison, the only school that is part of the Four Rivers Special Education District, has fewer than 65 students in most years.

No other school district — not just in Illinois, but in the entire country — had a higher student arrest rate than Four Rivers the last time data was collected nationwide. That school year, 2017-18, more than half of all Garrison students were arrested.

Officers typically handcuff students and take them to the police station, where they are fingerprinted, photographed and placed in a holding room. For at least a decade, the local newspaper has included the arrests in its daily police blotter for all to see.

((Jacksonville Journal-Courier))

The students enrolled each year at Garrison have severe emotional or behavioral disabilities that kept them from succeeding at previous schools. Some also have been diagnosed with autism, ADHD or other disorders. Many have experienced horrifying trauma, including sexual abuse, the death of parents and incarceration of family members, according to interviews with families and school employees.

Getting arrested for behavior at school is not inevitable for students with such challenges. There are about 60 similar public special education schools across Illinois, but none comes anywhere close to Garrison in their number of student arrests, the investigation found.

The ProPublica-Tribune investigation — built on hundreds of school reports and police records, as well as dozens of interviews with employees, students and parents — reveals how a public school intended to be a therapeutic option for students with severe emotional disabilities has instead subjected many of them to the justice system.

It is “just backwards if you are sending kids to a therapeutic day school and then locking them up. That is not what therapeutic day schools are for,” said Jessica Gingold, an attorney in the special education clinic at Equip for Equality, the state’s federally appointed watchdog for people with disabilities.

Doors lead to classrooms at the Garrison School, a public special education school for students with severe emotional or behavioral disabilities. (Armando L. Sanchez/Chicago Tribune)

“If the school exists for young people who need support, to think of them as delinquents is basically the worst you could do. It’s counter to what should be happening,” Gingold said.

Because of the difficulties the students face in regulating their emotions, these specialized schools are tasked with recognizing what triggers their behavior, teaching calming strategies and reinforcing good behavior. But Garrison doesn’t even offer students the type of help many traditional schools have: a curriculum known as social emotional learning that is aimed at teaching students how to develop social skills, manage their emotions and show empathy toward others.

Tracey Fair, director of the Four Rivers Special Education District, said it is the only public school in this part of west central Illinois for students with severe behavioral disabilities, and there are few options for private placement. School workers deal with challenging behavior from Garrison students every day, she said.

Tracey Fair, director of the Four Rivers Special Education District, which runs the Garrison School, speaks at a November meeting of the district’s board. (Armando L. Sanchez/Chicago Tribune)

“There are consequences to their behavior and this behavior would not be tolerated anywhere else in the community,” Fair said in written answers to reporters’ questions.

Fair, who has overseen Four Rivers since July 2020, said Garrison administrators call police only when students are being physically aggressive or in response to “ongoing” misbehavior. But records detail multiple instances when staff called police because students were being disobedient: spraying water, punching a desk or damaging a filing cabinet, for example.

“The students were still not calming down, so police arrested them,” wrote Fair, speaking on behalf of the district and the school.

This year, the Tribune and ProPublica have been exposing the consequences for students when their schools use police as disciplinarians. The investigation “The Price Kids Pay” uncovered the practice of Illinois schools working with local law enforcement to ticket students for minor misbehavior. Reporters documented nearly 12,000 tickets in dozens of school districts, and state officials moved quickly to denounce the practice.

This latest investigation further reveals the harm to children when schools abdicate student discipline to police. Arrested students miss time in the classroom and get entangled in the justice system. They come to view adults as hostile and school as prison-like, a place where they regularly are confined to classrooms when the school is “on restriction” because of police presence.

A “Police Incident Report” form used by the Garrison School details a student’s behavior and arrest. (Obtained by ProPublica and Chicago Tribune; identifying information removed by the school.)

U.S. Department of Education and Illinois officials have reminded educators in recent months that if school officials fail to consider whether a student’s behavior is related to their disability, they risk running afoul of federal law.

But unlike some other states, Illinois does not require schools to report student arrest data to the state or direct its education department to monitor police involvement in school incidents. Legislative efforts to do so have stalled over the past few years.

In response to questions from reporters about Garrison, Illinois Superintendent of Education Carmen Ayala said the frequent arrests there were “concerning.” An Illinois State Board of Education spokesperson said a state team visited the school this month to examine “potential violations” raised through ProPublica and Tribune reporting.

The team confirmed an overreliance on police and, as a result, the state will provide training and other professional development, spokesperson Jackie Matthews said.

“It is not illegal to call the police, but there are tactics and strategies to use to keep it from getting to that point,” Matthews said.

Ayala said educators cannot ignore their responsibility to help students work through behavioral issues.

“Involving the police in any student issue can escalate the situation and lead to criminal justice involvement, so calling the police should be a last resort,” she said in a written statement.

In 2018, Jacksonville police arrested a student named Christian just a few weeks into his first year at Garrison, when he was 12 years old. His “disruptive” behavior earlier in the day — he had knocked on doors and bounced a ball in the hallway — had led to a warning: “One more thing” and he would be arrested, a school report said. He then removed items from an aide’s desk and was “being disrespectful,” so police were summoned. They took him into custody for disorderly conduct.

Christian has attention-deficit/hyperactivity disorder, post-traumatic stress disorder and oppositional defiant disorder. Now 16, he has been arrested at Garrison several more times and was sent to a detention center after at least one of the arrests, he and his mother said.

He stopped going to school in October; his mother said it’s heartbreaking that he’s not in class, but at Garrison, “it’s more hectic than productive. He’s more in trouble than learning anything.”

“If they call the police on you, you are going to jail,” Christian told reporters. “It is not just one coming to get you. It will be two or three of them. They handcuff you and walk you out, right out the door.”

Handcuffs and Holding Rooms

Just over an hour into the school day on Nov. 15, two police cars rushed into the Garrison school parking lot and stopped outside the front doors. Three more squad cars pulled in behind them but quickly moved on.

Principal Denise Waggener had called the Jacksonville police to report that a 14-year-old student had been spitting at staff members. When police arrived, one of the officers recognized the boy, because he had driven him to school that morning. The student had missed the bus and called police for help, according to a police report and 911 call.

School staff had placed the boy in one of Garrison’s small cinder-block seclusion rooms for “misbehavior,” police records show. A school worker told the officer she had been standing in the doorway of the seclusion room when the boy spit and it landed on her face, glasses and shirt.

“He Spit in the Staff’s Face” Denise Waggener, the Garrison School principal, called Jacksonville police in November after a student spit on an employee. The student was arrested for aggravated battery. (Audio obtained by the Tribune and ProPublica from the Jacksonville Police Department. Audio was condensed for clarity.)

The child “initially stated he did not spit at anyone, but then said he did spit,” according to the police report, “but instantly regretted doing so.” The report said the child “stated he knew right from wrong, but often had violent outbursts.”

The worker asked to press charges, and the officer arrested the boy for aggravated battery.

((Jacksonville Journal-Courier))

One officer told the child he was under arrest while another searched and handcuffed him. They put him in the back seat of a squad car, drove him to the police station, read him his rights and booked him. Officers told the boy the county’s probation department would contact him later, and then they dropped him off with a guardian, records show.

The Tribune and ProPublica documented and analyzed 415 of Garrison’s “police incident reports” dating to 2015 and found the school has called police, on average, once every two school days.

The reports, written by school staff and obtained through public records requests, describe in detail what happened up until the moment police were called. These narratives, along with recordings of 911 calls, show that school workers often summon police not amid an emergency but because someone at the school wants police to hold the child responsible for their behavior.

Jacksonville police respond in November to a call from a Garrison School administrator about a student’s misbehavior. Officers arrested the student. (Armando L. Sanchez/Chicago Tribune)

About half the calls were made for safety reasons because students had fled the school. Those students rarely were arrested. Students whom police did arrest were most often accused of aggravated battery and had been involved in physical interactions such as spitting or pushing; by state law, any physical interaction with a school employee elevates what would otherwise be a battery charge to aggravated battery. The next most common arrest reasons were disorderly conduct, resisting arrest and property damage.

The school once called police after a student was told he couldn’t use the restroom because he “had done nothing all morning,” records show. The boy got upset, left the classroom anyway and broke a desk in the hallway.

The school called police on a 12-year-old who was “running the halls, cussing staff.”

And the school called the police when a 15-year-old boy who was made to eat lunch inside one of the school’s seclusion rooms threw his applesauce and milk against the wall.

Police arrested them all.

“These students, I would imagine, feel like potential criminals under threat,” said Aaron Kupchik, a sociologist at the University of Delaware who studies punishment and policing in schools.

“We are taking the actions of young people, and, rather than trying to invest in solving real behavioral problems that are very difficult, we are just exposing them to the legal system and legal system consequences.”

Jacksonville Chief of Police Adam Mefford said officers respond to every 911 call from Garrison on the assumption it’s an emergency, and as many as five squad cars can respond. Police often find a child in a seclusion room, Mefford said.

Adam Mefford, Jacksonville police chief. (Armando L. Sanchez/Chicago Tribune)

Officers determine whether a law has been broken but leave the decision whether to press charges to the school staff, he said. Police sometimes issue tickets to Garrison students for violating local ordinances, though arrests are far more common.

“The school errs on the side of pressing charges,” Mefford said. “They typically have the student arrested.”

He wondered whether school administrators call police so frequently because it’s become a habit that’s difficult to stop. “The school has gotten used to us handling some of these problems,” Mefford said.

Once arrested, the students are taken to the police station until parents pick them up or an officer takes them home. One mother told reporters that her 10-year-old son, who has autism and ADHD, was “bawling, freaking out,” when she picked him up after he was booked at the jail.

Mefford said he tried to make the experience less traumatic by moving the booking process from the county detention facility to the police station in 2021. He also said police refer students and their families to services in the community, such as counseling or substance abuse help.

After they are booked, students are screened to determine if they should be sent to a juvenile detention facility. Most are assigned to an informal alternative to juvenile court that Morgan County court officials regularly use, said Tod Dillard, director of the county’s probation department.

Jacksonville police bring the Garrison School students they arrest to this booking area at the police station to be fingerprinted and photographed. Students often wait in the room for a guardian to pick them up. (Armando L. Sanchez/Chicago Tribune)

These young people avoid going to juvenile court, but the “probation adjustment” process also requires them to admit guilt and denies them a public defender. Students must periodically report to a probation officer, typically for a year.

Violating the probation terms, such as by skipping school or getting arrested again, could lead to juvenile delinquency charges. In a juvenile court case, a student’s record of previous informal probation can be used when considering bail or sentencing.

Garrison has some students who are 18 and older, and they can be charged as adults. In 2020, an 18-year-old Garrison student was arrested for disorderly conduct after he “caused a disturbance” when he threw a cup of water and punched a pencil sharpener, court records show. That student spent four days in jail and was held on $3,000 bail. He pleaded guilty and was ordered to pay $439 in court costs and $10 a month in probation fees.

An 18-year-old student was charged with disorderly conduct after an incident at the Garrison School. (Obtained from the Morgan County Circuit Court. Redacted by ProPublica.)

Even for younger students, juvenile charges related to Garrison can later have consequences in adult court. If they are arrested again after they turn 18, prior cases can be used to illustrate that they have a police record.

The boy who spit in anger this fall at Garrison now has an aggravated battery arrest on his record. Even Fair, the school’s director, found the decision to arrest the child troubling.

The day after the boy was taken into custody, Fair told reporters she knew the child had been arrested but said she did not know why school administrators had called police. Reporters told her it had been for spitting on one of her employees.

“That’s not arrestworthy. That is not what we should be about,” Fair said. In a later interview, after learning more about the incident, Fair said staff considered the student aggressive and said, “I guess they did what they thought was right.”

From Empathy to “Coercive Babysitting”

Bev Johns, a local educator, founded Garrison in 1981 with just two students — and a belief that with a caring staff and the right support, they could be successful.

The children had exhibited such disruptive behavior that staffers at their home schools felt ill-equipped to teach them. Her solution: Open a school designed to teach students not just academic subjects but how to manage their behavior. It became part of the Four Rivers Special Education District, a regional cooperative that today provides services to students in school districts across eight mostly rural counties.

The school was considered groundbreaking, and many of the techniques that Johns implemented at Garrison are still widely considered best practice for managing challenging behavior: giving students space when they’re upset, teaching them ways to manage their emotions and giving them choices rather than shouting demands.

Those techniques often involve trying to understand what’s driving a student’s behavior. A student shoving papers off their desk may feel overwhelmed and need assignments in smaller increments. A student struggling to sit still may need classwork that involves them moving around the room.

Taking the students’ disabilities into account when they misbehave is now a firmly entrenched concept in education. In fact, it’s federal law.

“There’s a requirement both in the law — and just morally — that kids with disabilities are not supposed to be punished for behaviors that are related to their disability, or caused by it, or caused by the school’s failure to meet their needs,” said Dan Losen, director of the Center for Civil Rights Remedies at the University of California, Los Angeles.

Johns, who led Garrison until 2003, has dedicated her career to these ideas. She published research about “the Garrison method” to help other educators, taught at a nearby college and continues to speak regularly at conferences.

“Choice is such a powerful strategy. It’s such an easy intervention,” Johns recently told a standing-room-only crowd at an Illinois special education convention in Naperville. And schools should look welcoming too, she said. “I see some schools that look like prisons. Why would a child want to go there?”

Buses from school districts throughout an eight-county region of rural Illinois bring students to the Garrison School on a morning in November. (Armando L. Sanchez/Chicago Tribune)

The Garrison of today isn’t a prison, but it relies on rules and methods meant to manage students.

In recent years, staffers sometimes took away students’ shoes to discourage them from fleeing, though Fair said that has not happened under her watch. Before a recent Illinois law banned locked seclusion in schools, Garrison workers used to shut students inside one of the school’s several seclusion rooms — staff members would stand outside and press a button to engage a magnetic lock. The doors have since been removed, but the “crisis rooms” are still used. The Four Rivers district reported to ISBE that workers had restrained or secluded students 155 times in the 2021-2022 school year — three times as many incidents as students.

One of the seclusion rooms at the Garrison School, called “crisis rooms,” shown in 2019. (Obtained by ProPublica and the Tribune)

“They would lock me in a concrete room and then close the door on me and lock it. I would freak out even worse,” said an 18-year-old named Max, who left the school in 2020.

Some of the school’s aides are assigned to one of two “crisis teams” of four employees each that respond to classrooms and can remove students who are upset, disobedient or aggressive.

Employees’ handwritten records describe several incidents where they confined a child to a small area inside the classroom. In one case, the crisis team made a “human wall” around a 14-year-old student who was wandering in the classroom, swearing and being disruptive. A 16-year-old student told reporters that school employees drew a box around his desk in chalk and told him not to leave the area or there would be consequences.

Charles Cropp, who has worked as part of crisis teams at Garrison on and off since 2009, said he and his colleagues try to help students learn how to calm down when they are upset. He said teams aim to help students learn how to manage their emotions but that sometimes the young people also need to be held “accountable” when they are physical or disruptive.

“I was one that never really cared to watch kids get escorted out in handcuffs,” said Cropp, who returned to the school full time in late November. “I never liked it but in the same sense, they have to learn when you graduate and you are an adult in the public, you can't do those things.”

Garrison workers were recently trained in the Ukeru method, a crisis intervention system that uses blue shields to block students' physical aggression in place of physical restraint. (Armando L. Sanchez/Chicago Tribune)

Jen Frakes, a board-certified behavior analyst who worked at Garrison in 2015-16, described the culture at Garrison as “coercive babysitting.” She said she never saw a situation that warranted arresting a student.

“It seemed more of a power dynamic of ‘You’ll either follow my rules or I will show you who’s in charge,’” said Frakes, who runs a Springfield business that helps schools and families learn to work through challenging behavior. “When I saw a kid get arrested, he was sitting underneath his desk calm and quiet, and they came in and arrested him.”

This isn’t how other schools similar to Garrison are handling difficult student behavior.

Reporters identified 57 other public schools throughout Illinois that also exclusively serve students with severe behavioral disabilities. To determine how often police were involved at those schools and why, reporters made public records requests to all of the schools and to the police or sheriff’s departments that serve each one. Reporters were able to examine police records for 50 schools.

The two schools with the most arrests during the last four school years had 16 and 18, respectively. At 23 of the schools, no students were arrested in that period; six schools had only one arrest.

By comparison, five students were arrested at Garrison by mid-November of this school year alone, according to school and police records.

John McKenna, an assistant professor specializing in special education at the University of Massachusetts Lowell, said arresting students not only criminalizes them but also takes them out of the classroom.

“Kids are supposed to be receiving instruction and support and not opportunities to enter the school-to-prison pipeline,” he said.

“If you don’t provide kids with academic instruction, particularly those with behavior and emotional needs, the gaps between their performance and the peers who don’t have disabilities grows exponentially and sets them up for failure,” McKenna said.

The fact that Garrison students have disabilities that may explain some of their behavior appears to be lost on many of the officials who encounter them in the justice system; some described Garrison as a school for delinquents, not disabled children. A public defender tasked with representing students in juvenile court described the children as having been “kicked out” of their regular schools. An assistant state’s attorney thought students at Garrison had been “expelled” from traditional schools. Neither of those descriptions is accurate.

Rhea Welch, who worked under Johns and retired in 2016, said that during her 26 years as a teacher at Garrison it was not a place that relied heavily on police. “You don’t want your kids arrested, for heaven’s sake. You want to be able to work with them so that doesn’t happen, so they’re more in control,” she said.

For Johns, Garrison is no longer the school she remembers. Students need positive feedback, she said, not constant reprimands from and clashes with the adults they are supposed to trust.

“I always say when you’re having trouble with a child, the first place you look is yourself,” she said.

Johns read some of the school’s recent police incident reports and said she found them “bothersome,” adding, “It’s obviously hard for me to watch what’s happened.”

“I Did Everything I Could to Get Him Out”

Gabe, a 12-year-old boy with autism, likes to share with anyone who will listen all the details of his Pokemon collection and has gotten good at using online translators to read the cards with Japanese lettering on them. His stepmother, Lena, said that over the years Gabe has learned to ask for what he needs. When he gets overstimulated at home, he asks for space by saying: “I need you to back up.”

(When using the last name of a parent would identify the student —– and in doing so, create a publicly available record of the student’s arrest —– ProPublica and the Tribune are referring to the parent by first name only.)

After an incident at the Garrison School, Gabe and his family decided he couldn’t go back. Shown with his father, Billy, and stepmother Lena, Gabe, who is 12 and has autism, now goes to a school 90 minutes away. (Armando L. Sanchez/Chicago Tribune)

Gabe ended up at Garrison in 2019 after having difficulty in traditional schools. He will sometimes yell and lash out when frustrated.

Lena said school officials asked her to pick up Gabe if he got upset. “I would hear Gabe screaming, and then heard them screaming back at him,” she said. “He’d say, ‘Leave me alone! Leave me alone!’ And they’d still get up in his face.”

And then one day, Gabe and Lena said, school workers barricaded him at his desk by pushing filing cabinets around it. He pushed over one of the cabinets while trying to get away, and the school called the police, Lena said.

“We had to pick up our 10-year-old at the police station,” Lena said. “I would freak out if I got boxed in with filing cabinets.”

It got so that Gabe would wake up angry and not want to go to school.

“That school is at the bottom of the food chain. If you got all the schools in the world, they would be at the bottom of the food chain. The workers there are mean,” said Gabe.

Other parents described their children becoming angrier, more withdrawn; the students dreaded going to school at Garrison. Some families begged their home districts to find another school for them.

“It was like hell,” said one mother, who said her son was miserable while he was a student there. “I did everything I could to get him out.” Her son attended Garrison for about five years before she got him returned to his home school. He is in his first year of college now.

Michelle Prather, whose daughter Destiny attended Garrison from fifth grade until she graduated in 2021, said school employees threatened to call police over minor missteps: throwing a piece of paper, or pushing a desk.

“She would walk out of a room and they’d say, ‘We’re going to call police,’” Prather said. Destiny was arrested at least once after she shoved an aide while trying to leave a classroom.

Prather and other caregivers said watching their children be arrested over and over was troubling, but it was also upsetting to realize that the school wasn’t providing the support services the students needed.

Destiny has intellectual disabilities and ADHD as well as acute spina bifida, a defect of the spine. Because of her medical condition, Destiny had difficulty sensing when she needed to use the restroom. She would sometimes get up from her desk and tell staff that she urgently needed to go.

“They would say, ‘No you don’t,’” said her mother. “She would have accidents. I would have to bring her clothes.”

Destiny, 19, who graduated from Garrison in 2021, plays with her family’s dog inside their home. (Armando L. Sanchez/Chicago Tribune)

Madisen Hohimer, who is now 22 and working as a bartender, said she transferred to Garrison in sixth grade when her home school recommended it. She remembers Garrison as a place that failed to help her. Hohimer said she frequently ran away from the school and employees took her shoes to try to keep her from fleeing.

“I was never involved with the police before Garrison. I started mostly acting out when I got sent over there because I felt like I had nobody,” she said. One time, she said, she swung and kicked at staff after they cornered her in a seclusion room. She wound up being arrested for aggravated battery.

Just weeks before Hohimer was set to graduate, she left for good. “I wish they would have found a way to help me,” she said.

After Gabe’s filing cabinet incident, his parents kept him home until he could be placed at a private therapeutic school three counties away. He’s been going there since last year.

“It’s an hour and a half ride and he’d rather do that than go to Garrison,” said Lena, a nursing student. He’s thriving there, she said, and noted that the school has never called police about Gabe’s behavior.

At their home in Jacksonville, Gabe shows his mother, Lena, a record player he made at school out of a cup and paper clip. (Armando L. Sanchez/Chicago Tribune)

But one of Lena’s other children, Nathan, remained at Garrison.

Then one morning in late September, she got a text from her son:

“I’M AT THE POLICE STATION THERE GOING TO GET MY FINGERPRINTS AND TAKE A PICTURE OF ME AND BRING ME BACK TO THE HOUSE.”

“A Staff Member Will Probably Press Charges” A 14-year-old student pushed an aide and then left the school. A school employee called police to request help finding the student and having a school worker press charges. (Audio obtained by the Tribune and ProPublica from the Jacksonville Police Department. Audio was condensed for clarity.)

Nathan, who was 14 at the time, had been arrested after he hit a classmate and then shoved an aide who was trying to physically keep him in the classroom, according to a school report. He then left the school. In a 911 call, a school administrator asked police to find Nathan and also to come to the school “because a staff member will probably press charges.”

Nathan’s family decided not to send him back to Garrison. He’s taking classes online instead.

“That was my worst mistake, putting either of my kids in Garrison,” Lena said. “If I could take it back, I would.”

((Jacksonville Journal-Courier)) No One Watching

Warning signs that Garrison was punishing students with policing have been there for years, waiting for someone to take notice.

Since as far back as 2011, the federal government has published data online about police involvement and arrests at schools. That year, the data showed, Garrison called police on 54% of its students and 14% were arrested. Three subsequent publications of similar data show the arrest rate climbing each time — until, in 2017-18, more than half of Garrison’s students were arrested.

Though the federal data could have raised red flags, Illinois does not collect data on police involvement in schools and does not require that the state education board monitor it. The state does monitor other punitive practices in schools, such as their numbers of suspensions and expulsions, and requires schools to make improvements when the data shows excessive use.

Illinois legislation that would have required ISBE to collect data annually on school-related arrests and other discipline stalled last year.

The state board, however, has issued guidance about involving police in school discipline. Earlier this year, ISBE and the state attorney general’s office told school districts across the state to use social workers, mental health professionals and counselors — not police — to create a “positive and safe school climate.”

Before last week, no one from ISBE had been to Garrison for at least the last seven school years. There had been no complaints that would have triggered a monitoring visit, said Matthews, the state board spokesperson.

Garrison has its own school board, and it — not the state board — is responsible for monitoring the school, including police activity, ISBE officials said. The school board is made up of representatives from some of the 18 school districts that rely on Four Rivers for special education staffing and placements at Garrison.

The board president, Linda Eades, said after a November board meeting that she couldn’t answer questions about the police involvement at Garrison and described the board as hands-off. “We don’t get down in the trenches,” she said.

Fair, the district’s director, said she is trying to understand the scope of police involvement at Garrison and is “digging into” school reports. “I’m trying so hard. It’s a lot of stuff to change,” she said in an interview. “There are a lot of things that need to improve.”

Earlier this year, Garrison was awarded a $635,000 “Community Partnership Grant” through ISBE for training to help students with their behavioral and mental health needs and help schools reduce their reliance on punitive discipline. ​

Some of the grant money has been used to pay for training in Ukeru, a method of addressing physical aggression that doesn’t involve physically restraining a child.

The Ukeru method focuses on training workers in how to prevent challenging behavior from becoming a crisis and uses soft blue pads to block kicks and punches if necessary. Garrison workers were trained in the method in October; blue pads are now propped up in the hallways in the building.

Starting two weeks ago, Fair said, the school began using its two social workers and a social work intern in a new way. One of the social workers is now available to go into a classroom when a student needs help, providing a way to intervene before behavior escalates into a crisis. Fair said she also plans to incorporate social emotional learning into the curriculum.

School administrators mentioned the Ukeru training and some of Garrison’s latest efforts at the November board meeting, which lasted about 20 minutes. Fair said the school had begun to monitor police involvement and arrests and said she is trying to “boost up some of the supports for the kids.”

Her priority now, she assured them, is to “really help make it a therapeutic place for the kids.”

That’s what it was always supposed to be.

Lynn Dombek contributed research.

by Ian MacDougall

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

Congress this week passed a bill that takes aim at the risk of improper influence when government contractors work for both federal agencies and private-sector clients. President Joe Biden is expected to sign the bill.

The bill, which the House passed on Wednesday after the Senate approved it in August, orders several changes to federal contracting rules. They include provisions requiring contractors to disclose information about potential conflicts of interest and clarifying when a contractor’s work for outside clients may create such a conflict.

In a press release announcing the results of the vote this week, the bipartisan group of senators who sponsored the bill cited ProPublica’s reporting on the consulting giant McKinsey & Company’s work for the Food and Drug Administration. McKinsey earned tens of millions of dollars providing a wide range of advice to the FDA division responsible for regulating drugs, much of it directly affecting the pharmaceutical industry. Among the subjects of McKinsey’s input: an overhaul of drug-approval processes and an assessment tool for monitoring drug safety.

At the same time, McKinsey was working for some of the country’s largest pharmaceutical companies. Its clients included Purdue Pharma and Johnson & Johnson, which were responsible for producing and distributing opioids that have gutted communities nationwide and contributed to many thousands of deaths. Yet the consultancy, which jealously guards its client roster, never disclosed those corporate projects to the FDA.

A report released in April by the House Committee on Oversight and Reform revealed just how deeply entwined the two streams of work were. Committee investigators found that at least 22 McKinsey consultants, including senior partners, worked for both the FDA and opioid makers on overlapping topics, with some advising both simultaneously. McKinsey consultants sought to leverage their FDA work to solicit pharmaceutical industry business, according to the committee’s report, and consultants with ties to Purdue influenced statements made by top public health officials about the opioid epidemic.

McKinsey has denied that its work for the FDA posed a conflict of interest and has insisted it was under no obligation to disclose its work for drug companies to its government clients. The firm has characterized its FDA work as focused on administration and operations, not decisions about when and how to regulate specific drugs. Still, McKinsey acknowledged in response to the house report that “this work, while lawful, fell short of the high standards we set for ourselves.” More broadly, the firm has sworn off any further opioid-related projects and stated that it “did not adequately acknowledge the epidemic unfolding in our communities or the terrible impact of opioid misuse and addiction on millions of families across the country.” (The firm has been a sponsor of ProPublica events.)

Existing federal rulescall for government contractors to disclose actual and potential conflicts of interest, information necessary for agencies to decide whether the situation can be mitigated or whether conflicts merit disqualifying a would-be contractor. But experts in federal contracting say that, until recently, little attention has been paid to how those rules apply to a company’s work for corporate clients — an oversight that the bill sent to the president’s desk this week seeks to remedy.

“The federal government should not have been hiring the same McKinsey employees who were simultaneously working for opioid manufacturers,” Sen. Maggie Hassan, D-N.H., one of the bill’s sponsors, said in a statement after the House voted to pass the legislation. “It is imperative that we make sure that this type of conflict of interest does not happen again.”

The bill, which is titled the Preventing Organizational Conflicts of Interest in Federal Acquisition Act, was co-sponsored by Sens. Joni Ernst, R-Iowa, Chuck Grassley, R-Iowa, and Gary Peters, D-Mich. It passed by unanimous consent in the Senate, but the House vote fell roughly along partisan lines, with three Republicans joining their Democratic colleagues in voting for passage.

The extent of McKinsey’s consulting for opioid makers began to become clear in 2019, when ProPublica first reported on it. The firm helped Purdue Pharma “turbocharge,” as its consultants put it, sales of OxyContin, the company’s highly addictive flagship painkiller. Last year, McKinsey settled legal claims brought by the governments of 47 states, the District of Columbia and five U.S. territories. Related litigation over McKinsey’s opioid work — a consolidated set of lawsuits brought by individuals, city governments, Native American tribes and school districts — remains pending before a federal judge in San Francisco.

A top FDA official told a Senate committee earlier this year that the agency would not sign new contracts with McKinsey while congressional investigations into the firm’s possible conflicts remain ongoing.

by Mick Dumke

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

It was called the Plan for Transformation, the most ambitious public housing makeover in U.S. history.

Under the plan, launched in 2000, the Chicago Housing Authority would demolish most of the city’s public housing developments, displacing thousands of families. Then, over the next 10 years, the agency would replace or repair 25,000 units of housing while bringing new investment to low-income communities.

More than two decades later, the CHA used just a few sentences in an obscure report to declare that the “revitalization” of 25,000 housing units — the plan’s central promise — was complete.

“CHA has achieved the goal of this activity,” the agency informed the U.S. Department of Housing and Urban Development in March.

But the agency’s claim hides a fundamental failure to meet its original commitments.

The agency padded its unit count by including types of housing and assistance that weren’t in the original plan, an analysis by ProPublica found. The questionable units add up to more than a fifth of the 25,000 total.

At the same time, the CHA has fallen short of providing the family housing it promised, leaving it with less than half the family units it once had.

In claiming to meet its overall unit goal, the CHA also sidesteps the fact that it is nowhere close to fulfilling its obligations to build homes and redevelop communities where its high-rises once stood. Agency officials told ProPublica they remain committed to those goals but can’t provide a timetable on when they’ll achieve them.

Community leaders, local politicians and families seeking homes have been frustrated by the CHA’s delays and unfulfilled promises. The criticism grew in recent months after ProPublica reported on the agency’s plans to turn over prime vacant land to a soccer team owned by a billionaire supporter of Chicago Mayor Lori Lightfoot. ProPublica also revealed how HUD has allowed CHA to sell, lease and give away parcels of land it says it no longer needs, even though its redevelopment work is far from done.

David Moore, a former agency official who is now alderman of the 17th Ward on the South Side, said HUD needs to pressure the CHA to finish redeveloping its former public housing communities. He said the growing number of homeless encampments around the city is tied to the agency’s slow pace of housing construction.

“We should be building more public housing units so people have options,” Moore said.

In a written statement, a CHA spokesperson said the agency remains committed to its mission of providing housing and “building strong communities.” The statement did not mention the Plan for Transformation.

“CHA’s investments today go beyond replacing the failed public housing model of the past,” the statement said. By partnering with developers, nonprofits and other government entities, “CHA will continue to leverage all available tools to accelerate the pace of new mixed-use, mixed-income development projects to ensure that more subsidized and affordable homes are available to people in need.”

The CHA’s claim to have revitalized 25,000 units is misleading in several ways, ProPublica’s analysis found.

For starters, the math doesn’t add up, the analysis found. The agency boosted the numbers by including apartments that aren’t finished yet or had no direct connection to the public housing communities the CHA promised to redevelop.

For example, the CHA has counted more than 5,000 privately owned units that it subsidizes through what are called project-based vouchers. But unlike public housing, these vouchers aren’t necessarily permanent: They keep the units affordable for a set amount of time, usually five to 30 years. The Plan for Transformation made no mention of replacing permanent public housing with project-based vouchers.

And more than a third of these same voucher units were designated as affordable housing years before the plan was launched or before the CHA subsidized them.

That’s true of the Major Jenkins Apartments, a privately owned, 156-unit building in the Uptown neighborhood on the North Side. Built in the 1920s, the building was fixed up to provide apartments for homeless and other low-income people in 1995, five years before the Plan for Transformation. That’s also when the CHA began subsidizing half the units with project-based vouchers.

The Major Jenkins Apartments in Chicago’s Uptown neighborhood were fixed up to provide housing for homeless and other low-income people in 1995. (Carlos Javier Ortiz, special to ProPublica)

Yet in 2010, the agency began counting those apartments toward its 25,000-unit goal. That happened after the CHA argued to HUD that it should be allowed to count project-based vouchers toward its Plan for Transformation total. The vouchers offered “more opportunity to provide affordable units” and options in neighborhoods long resistant to affordable housing, the CHA told HUD. Agreeing that the vouchers would be “beneficial,” a HUD official signed off.

None of the project-based vouchers should be included in the Plan for Transformation tally, Moore said.

“It’s a skirt around,” he said. “If they’re claiming those, they need to build more units. And HUD should be holding them accountable.”

The CHA’s claim also ignores the sites where the city’s major public housing complexes once stood. Most of the locations still have stretches of empty land.

Two decades ago, while displacing thousands of residents and razing most of its large developments, the agency promised to rebuild the sites with new homes for people with a range of incomes. At least a third of these would be sold at market value. But the agency also agreed in court to reserve thousands of units as public housing, and former residents were guaranteed a right to return.

Since then, the CHA has been slow to build the new homes. It’s now sitting on blocks of vacant, undeveloped land on every side of the city.

The CHA’s largest development, the Robert Taylor Homes, once stretched along 2 miles of South State Street. Under the Plan for Transformation, all 28 Taylor high-rises were razed — a loss of more than 4,400 apartments altogether.

The Robert Taylor Homes in 1988 (Archival photo by Camilo Vergara)

Eventually the CHA proposed replacing them with a new development, Legends South, that included about 2,400 total units, a quarter of them reserved for CHA residents. So far the agency has finished 335 of the public housing units, while more than 25 acres at the Taylor site remain vacant and “not prioritized” for redevelopment, according to a city planning document.

The CHA is also required to build hundreds of additional public housing units at the Lathrop Homes, on the North Side; the Ickes Homes, now renamed Southbridge, on the South Side; and the ABLA Homes, now known as Roosevelt Square, on the West Side. The CHA has offered to lease 23 acres at the ABLA site to the Chicago Fire soccer team, which is owned by billionaire Joe Mansueto, an ally of the mayor’s.

“You have not done your work at bringing back all of the units under the Plan for Transformation,” said Etta Davis, a housing activist and vice president of the residents’ group at the Dearborn Homes on the South Side.

She noted that more than 44,000 people are on the CHA’s public housing waiting list: “So you’re way behind in the market in what’s needed.”

CHA officials said they remain committed to redeveloping Lathrop, Ickes, ABLA and other sites. More than 500 new homes are under construction, including 83 public housing units and 238 supported by project-based vouchers, and others are on the way, they said.

There’s another way the CHA’s 25,000-unit count fails to deliver what the Plan for Transformation promised: It includes far less housing designated for families.

The Past 20 Years Have Seen a Drop in CHA Units, Especially Apartments for Families (Sources: Plan for Transformation, CHA records. Note: “Supportive” includes housing for people who are disabled or homeless, veterans, and others.)

At the time the plan was launched, the CHA had about 29,000 units for families. The plan pledged to replace or rehab 15,000 of them.

But even if project-based voucher units are included, the CHA now has about 13,000 units for families — 2,000 fewer than the plan envisioned. That means the CHA lost 16,000 homes for families over the last 22 years.

Adella Bass, a mother of three who’s been on the agency’s waiting list for 13 years, sees the CHA falling short.

“Everybody deserves a place to live — a clean place to live, a suitable place to live,” Bass said. But apartments have grown so expensive that many families are concluding “there’s just no hope for housing in Chicago.”

Bass serves as a home-aide caretaker for her mother while working on her college degree. Several years ago, after struggling to pay bills, she moved into a North Side homeless shelter with her kids and her boyfriend, now her husband.

Eventually they were able to find a subsidized apartment on the South Side, which she’s grateful for. But she said it’s infested with mice and mold, and she would like something better. Bass is still hoping the CHA will call, and her long-term goal is to get into a program that leads to homeownership.

Adella Bass said she’s been on a waiting list for housing for 13 years. (Carlos Javier Ortiz, special to ProPublica)

Bass noted that the CHA is sitting on empty land and unoccupied apartments — more than 1,200 as of earlier this year, records show. “All of their steps, protocols, procedures, just their way of doing things needs a complete and total transformation,” she said.

The Plan for Transformation was not intended to replace all of the city’s public housing.

At its peak, the CHA had more than 42,000 units. But in 1995, citing mismanagement, HUD took direct control over the CHA. The agency then began emptying and tearing down thousands of its apartments, leaving it with just under 39,000 citywide. About a third of those units were vacant or occupied by people without a lease, which would have a significant impact on the Plan for Transformation.

In the mid-1990s, for instance, the Robert Taylor Homes included more than 4,400 units stretching over 2 miles on the South Side. By 1999, the development was down to 3,800 units, only 1,600 of them occupied by leaseholders.

Theresa Boler lived at the Taylor Homes in the late 1990s and recalled the CHA picking up the pace of evictions. “They were putting people out for any little reason,” she said.

When the word spread that the CHA planned to tear the high-rises down, many residents were scared and angry. “They’d never lived outside the projects,” she said. “They really had no place to go.”

Theresa Boler, a former resident of the Robert Taylor Homes, now lives in a Chicago Housing Authority senior building. (Carlos Javier Ortiz, special to ProPublica)

In 1999, HUD agreed to return control of the CHA to a board and leaders selected by Chicago’s mayor, Richard M. Daley. As part of the deal, federal and local officials worked together on a new set of goals for the agency. Decades of inadequate funding and poor maintenance had left many of the CHA’s buildings so rundown that they would cost billions of dollars to fix up. The Plan for Transformation mapped out how the CHA would dismantle most of its aging developments and replace them with mixed-income communities.

The plan’s goal of 25,000 units was based on the number that were leased to tenants at the end of 1999, after the agency had already emptied thousands of apartments.

The plan acknowledged that thousands of family units would be lost in the transition. “There is no alternative,” the plan stated.

The CHA can claim some successes over the last two decades. The agency has used project-based vouchers and other partnerships to help provide almost 1,800 apartments to disabled people, veterans and others struggling with homelessness or mental illness. Many of these residents live in the units with their families, the agency says. The CHA has also expanded its options for seniors.

Over the last 20 years, the Chicago Housing Authority has subsidized apartments around the city for veterans, disabled people and low-income families, including 30 units in this building on the Northwest Side. (Carlos Javier Ortiz, special to ProPublica)

The CHA said it serves more total households than it did 20 years ago, largely through the expanded use of vouchers to subsidize rent in privately owned apartments. But rents continue to climb, and the city is struggling with a shortage of affordable housing. In addition to the list for public housing units, 35,000 people are waiting for a voucher. The number would be even higher if the CHA hadn’t closed the list.

Boler now lives in the Lincoln Perry Annex, a CHA senior building. She’s also a member of the Kenwood-Oakland Community Organization, a neighborhood group that has pressed the CHA to build more replacement housing. She said the need is greater than ever.

“We’re not stopping,” she said. “You can’t just take things from us.”

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by Seth Freed Wessler

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.

Nobody working to bring a $346 million Microsoft project to rural Virginia expected to find graves in the woods. But in a cluster of yucca plants and cedar that needed to be cleared, surveyors happened upon a cemetery. The largest of the stones bore the name Stephen Moseley, “died December 3, 1930,” in a layer of cracking plaster. Another stone, in near perfect condition and engraved with a branch on the top, belonged to Stephen’s toddler son, Fred, who died in 1906.

“This is not as bad as it sounds,” an engineering consultant wrote in March 2014 to Microsoft and to an official in Mecklenburg County, Virginia, who was helping clear hurdles for the project — an expansion of a massive data center. “We should be able to relocate these graves.”

Mecklenburg County, along with Microsoft and a pair of consulting firms, immediately began a campaign to downplay the cemetery’s significance. Their most urgent task was to make sure the cemetery wouldn’t be deemed eligible for the National Register of Historic Places, the federal government’s list of sites worthy of protection. That designation would likely trigger an archaeological investigation overseen by the state and could force the developers to steer clear of the graves. Without such a designation, the graveyard could be moved with relative ease.

After the discovery of the cemetery, the county and its consultants turned to archaeologists, which federal law required they retain. But that didn’t go as they hoped. In a detailed report, the archaeologists determined that the cemetery “is eligible for inclusion” on the historic registry. The report stressed the cemetery’s significance to African American life and death in Southside Virginia, citing the fact that Stephen Moseley and his relatives were Black. “It is recommended that the area be avoided,” the report said.

To the county and its consultants, whose costs Microsoft covered, this was unacceptable. “We will challenge his recommendation,” wrote Alexis Jones, a consultant with a firm called Enviro-Utilities.

The firm and the county pressed the archaeologists to reverse their conclusion that the cemetery belongs on the National Register. And they asked the team to cast doubt on the central finding that made the cemetery historically significant: that all the people buried there — members of a community of landowners who farmed tobacco in the wake of the Civil War and Reconstruction — were Black.

The archaeologists would only comply with the latter request. They edited their report to say, “It cannot be ruled out that the burials are associated with white tenant farmers.” But when they sent Jones and her boss the revised report, they acknowledged that the new assertion was dubious: “All the evidence available at this stage suggests” the cemetery was the final resting place of an African American community, they wrote.

Asked about the addition of the white tenant farmer claim, one of the archaeologists, David Dutton, told ProPublica: “We hadn’t exhumed any bodies. We hadn’t done any DNA. We hadn’t done any analysis. So could we say 100%? I mean, look, this is archaeology, you don’t know until you actually know.”

Jones and her colleagues still wanted the eligibility for the historic registry designation nixed, so they sent the report to another archaeologist, seeking a second opinion. But the archaeologist didn’t go along, and in fact he rejected the notion that some of the people buried there might be white. “Jim Crow would not have had whites and blacks buried that closely together,” he wrote.

He suggested that the original firm conduct additional historical research. “More work needs to be done on Moseley family members to identify who’s in the graves,” he wrote in an email to Jones’ boss, who forwarded it to the county.

The county and its consultants ignored the advice.

What the county had to do, because Virginia law requires it, was run a legal notice tucked among the ads and classifieds in several weekly print editions of The Mecklenburg Sun. Even that, Jones had warned in an email to Microsoft and the county, would “risk” the “chance of a local family member coming forward.”

The second week the notice ran, in November of 2014, the paper published a front-page story about a controversy over new helmets for the high school football team following the death of a player from blunt force trauma. It appeared under the byline Mike Moseley. Moseley is a staff writer. He is also Stephen Moseley’s great-grandson.

“The Moseleys have been here a long time,” Mike Moseley said of his family’s roots in that part of Virginia.

When asked if he’d seen the notice in the pages of his own newspaper, he responded: “Do you read the classifieds and the ads? I do not.”

Mike Moseley would not have been hard to locate, had the county actually tried to find Stephen Moseley’s descendants. The tall, lanky 60-year-old went to high school in Mecklenburg County and played basketball on the school team. After high school, he moved away for a time — he wasn’t interested in following his father into the funeral home business — but he returned to Mecklenburg more than two decades ago. Since then, he’s worked a series of jobs at local papers, including at the Sun, where he is still a reporter.

“Everyone who works for the county knows me,” he said. “They know who we are. It’s hard to understand how they didn’t come talk to us.”

Mike and David Moseley (Christopher Smith, special to ProPublica)

Mecklenburg County did not reply to detailed questions about the handling of the cemetery and the contents of the emails, which were obtained through state open records requests. But in a phone interview, County Administrator Wayne Carter said that the newspaper notice was sufficient to comply with the law. He added that he asked some people who hunted on the land if they’d noticed anyone visiting the cemetery. “They had not seen anyone down there,” Carter said.

Jones, the consultant, declined to answer questions, referring them to Microsoft. Enviro-Utilities did not respond to emailed questions and multiple calls and text messages. In response to questions, a Microsoft spokesperson said, “the County followed all applicable federal, state and local laws.”

Like his nephew, David Moseley heard nothing from the county about the threat to the cemetery. The soft-spoken retired schoolteacher and administrator, who is now 85, grew up on the land adjacent to where Microsoft was building its data center and currently lives outside of Lynchburg, Virginia. “Yes,” he said, when asked in August about his relatives’ resting place, “there’s a cemetery there.” He did not at first believe that the remains of his grandfather, Stephen Moseley, were somewhere else. “Somebody would have called me if they moved the cemetery,” he said.

Plaques and a handle found during the archaeological excavation of the Moseley family cemetery (Obtained by ProPublica through a public records request)

In the months after the notice that ran in The Mecklenburg Sun, workers kept finding graves, ultimately 37 of them. Some of the plots were marked with pieces of quartz or with yucca plants, which were used by many Southern Black families who could not afford stones. Each burial site added days to the excavation, to the frustration of the county and its consultants. A crew dug up each of the graves, collecting bones, casket fragments, metal handles and hinges, etched epitaph plaques, a pair of eyeglasses, an ivory comb. The remains and other items were packed in plastic crates and stored in an office. Months later, all of it was reburied in four tightly packed, $500 cemetery plots one town to the north.

David Moseley’s grandparents, Stephen and Lucy Moseley, and great-grandparents, James and Ellen Walker, in 1899 purchased 169 acres in a fertile region near the North Carolina border. His father, Douglas Moseley, inherited the Moseley homestead, and as a teenager, David woke in the early mornings to work with an uncle harvesting their tobacco crop. As far back as David knew, his ancestors had been buried on that land. In one of his earliest memories, from when he was about 4, he joined his parents in the graveyard to bury his stillborn sibling. “I remember being out there and the open grave,” he said.

David, along with his last living sister, Christine Moseley, and their children, nieces and nephews, still own the eastern 83 acres of the property, which they call “the farm.” The family sold the adjacent tract, which Microsoft now owns, generations ago; David said his family entered a handshake agreement with the white people who bought the other half of the property that allowed the Moseleys to continue to visit the graves. Today, the farm is surrounded on nearly every side by land zoned for industrial use, including three of the 17 parcels that Microsoft has acquired in Mecklenburg County for the ongoing expansion of its data center there. Every so often, David Moseley or his niece who lives outside Washington, D.C., gets an offer to buy their remaining land. Sometimes the correspondence is signed by Wayne Carter, the county administrator who oversaw the permitting process for the Microsoft data center.

“If they can find us to buy the land,” David said, as he sat at his dining room table, beside a stack of papers about the family property, “why couldn’t they find us for the cemetery?”

The relocated gravestone of Fred D. Moseley, who died in 1906 at the age of 2 (Christopher Smith, special to ProPublica)

The cemetery’s disappearance proceeded despite layers of federal and state regulations nominally intended to protect places like it and to facilitate consultation with people who might have an interest in what happens to historic sites.

But in Virginia, as in most of the country, the power over what ultimately happens to these sites often belongs to whoever owns the land. And the labor of investigating what could make the site historic is often outsourced to for-profit archaeological firms working for property owners who have a financial stake in finding as little as possible.

“We are among the only developed countries in the world that considers archaeological sites on private property to be private property themselves rather than cultural heritage,” said Fred McGhee, Ph.D., an African American archaeologist in an overwhelmingly white field.

“Black historic places are some of the first to get maligned,” he said.

African American cemeteries that are deemed abandoned or untended have routinely been treated as little more than a nuisance in the path to development. Historic preservation laws and regulations rarely protect them.

On the campus of the University of Georgia, builders discovered a cemetery of enslaved people, and in 2017 the remains were reportedly loaded onto a moving truck and reburied “in secret,” according to a faculty review. In Texas in 2018, the graveyard of dozens of men held as convict laborers, a site whose significance was long known to community members, was found by construction workers, and the remains were exhumed. In each case, the developers have said they treated the burials with dignity.

Earlier this year, an agricultural company called Greenfield LLC applied for a federal permit to build a Statue of Liberty-sized grain transfer facility on 248 acres along the Mississippi River in Louisiana. An archaeological firm had initially concluded that the development put several notable Black historic sites, including a restored plantation that serves as a memorial to enslaved people, in harm’s way. But in May, ProPublica revealed that the firm changed its report to back away from that conclusion after facing pressure from its client. The firm told ProPublica at the time that no one had forced it to make the revisions and that the report itself was a draft, noting that drafts often change “after clients review them.”

Without first consulting the communities that live beside the development site and trace their ancestry to the people enslaved on the same land, the Army Corps of Engineers, the agency considering the permit, allowed Greenfield to drive enormous metal beams into a sugar cane field — even before the Corps signed off on the project. That field, researchers and community members say, likely holds unmarked graves of people who were held as slaves. Greenfield has said that it considers the protection of historic sites a priority and that it would stop construction if any such sites were discovered.

For decades, the Army Corps has been criticized by other federal agencies, advocates and community and tribal organizations for failing to engage with affected groups about potential damage to cultural sites, as the 1966 National Historic Preservation Act requires.

“The way this is supposed to work is that the Army Corps, or whatever federal agency is issuing a permit, should have told the developers that the descendant community needs to be identified and interviewed and that their perspectives need to be taken into account,” said J.W. Joseph, an archaeologist with New South Associates, a cultural resources firm in Georgia that has done archaeological work in dozens of cemeteries, often as part of projects regulated by the federal law. “Far too often, that doesn’t really happen.”

In Mecklenburg County, before Microsoft took possession of the land — for free, with significant tax breaks, along with state development dollars earmarked for struggling tobacco farming regions — the Army Corps raised no concerns about the development’s compliance with the Preservation Act. Nor did the Virginia Department of Historic Resources, the agency tasked with enforcing state and federal preservation laws, make any effort to step in and protect the site. (The department said it has never denied a landowner application for a reburial permit and preservation experts said Virginia judges almost never do either.)

The Army Corps and the Department of Historic Resources facilitated the cemetery’s legal erasure. The graves were dug up in near silence.

“Although the Department’s position is that those laid to rest should be left undisturbed,” a Department of Historic Resources spokesperson said, “we also understand that this is not always possible.”

Once they had permission from the state Department of Historic Resources to excavate the remains, Microsoft, Mecklenburg County and its consultants showed little concern for anything other than speed and cost. It was a rainy spring in 2015, and the ground was soaked. The graves that an excavation crew dug open would sometimes fill with water. According to one crew member, Eric Mai, who had recently started a master’s program in archaeology, the already-fragile remains were further degraded — exposed, sometimes for days, to the wet muck.

Everyone knew it was the wrong time for the work. “The conditions on site are about as bad as they can be for exhumation,” Jones, the consultant, wrote to Microsoft and the county, explaining why the dig was taking longer than expected. “It’s a nasty sticky wet clay,” she said of the soil that had primed the land decades ago for prolific tobacco yields. But Jones pressed the gas. “THEY need [to] find additional help and work 7 days a week until it is done.”

The “remains were saturated and in very poor condition,” according to a report by the firm hired to do the excavation, Circa-Cultural Resource Management LLC. The Department of Historic Resources agreed with Circa that there wasn’t enough physical matter left to justify sending the bones to the Radford University forensic anthropologist they’d planned to hire to study markers of age, race and sex. It “would probably not add any new information to the record,” a Circa report said.

“WAYNE, this is a GOOD thing!” Jones, the consultant, wrote to Carter, the county administrator. “This would be a huge money and time savings for us.” (This year, Jones took a job with Microsoft, as an environmental permitting program manager, according to her LinkedIn profile.)

Mai said in an interview that he worried that in the rush to dig up the Moseley cemetery, the Circa team may have missed important artifacts and grave offerings. “I think it would probably be concerning for descendants to learn that the people out there doing the work, me included, did not really know what we were looking at,” said Mai. “Nobody on the team knew anything about African American burials.”

Circa CEO Carol Tyrer wrote in response to questions that the team members did have “knowledge of African American cemeteries and burial practices.” Tyrer referred other questions about the Moseley cemetery excavation to Microsoft.

In part because of his ethical concerns, Mai left the field of for-profit archaeological and historic survey work. “There is a disrespect in this process,” Mai said recently. “The people, the descendants, are not really part of what we do.”

Had the county or any of its consultants made more of an effort to determine who they were digging up, they might have learned from public death certificates and census records that in one of the graves lay the remains of Ellen Walker and likely her husband, James Walker, the parents of Lucy Walker, who married Stephen Moseley, a preacher’s son from one county away. They might also have found living relatives like Mary Taylor, who is now 83 and is one of Stephen and Lucy Moseley’s many great-grandchildren. She lives in Norfolk and keeps a worn folder full of records showing that one of her mother’s brothers was buried in the Moseley cemetery. They might have come upon the records of other cousins and aunts and uncles by marriage, who formed their own branches of the family tree, whose descendants still own other plots of land in Mecklenburg County, and who appear to have been laid to rest there, too.

In the final weeks of the dig, Microsoft began pushing harder, flying a drone over the Circa workers to monitor their progress. “There will be no hiding place!” a Microsoft project manager wrote in an email as crews prepared to cut down the trees still standing in a ring around the cemetery.

Microsoft flew a drone over the grave excavation site and took photos of its location in the middle of a ring of trees. (Obtained by ProPublica through a public records request)

Once the dig was complete, the Army Corps told Mecklenburg County that it had met its obligations under federal law. Construction crews leveled the ground where the cemetery had been. Ownership of the land was transferred from the county to Microsoft.

In response to questions, the Corps wrote that it had consulted with the Department of Historic Resources and with Mecklenburg County before issuing the permit. A spokesperson also stated that the Corps had posted a notice on its own website around the same time the county ran its notice in the Sun “soliciting comments on the project.” Nobody responded.

Aerial photos of Mecklenburg County going back to the 1990s show rows of evergreen trees that wind across both of the old Moseley plots like the whorls and arches of a thumbprint. Then, in a 2016 satellite image of the terrain, the contours of trees and their center point have disappeared. A row of rectangles, the backfilled graves, appear in the tan earth. By 2020, an aerial view shows only an undeveloped dirt patch on the far eastern edge of the Microsoft site, just over the line from the land the Moseleys still own.

“Because the cemetery has been relocated from its original location,” the final archaeological record on file with the state said, “it is no longer eligible for listing on the National Register of Historic Places.”

The portion of the Microsoft data center that was built where the Moseley cemetery used to be (Christopher Smith, special to ProPublica)

In 2019, four years after the Moseley cemetery was dug up, Mecklenburg County began building a sorely needed new middle and high school. On the uncleared land, surveyors discovered a cluster of headstones inscribed with the last name Tunstall, a white family with a long history in the region. The graves would need to be moved for construction to proceed as planned, and the school board put a notice in the newspaper, like the one that had been placed about the Moseley cemetery. But in this case, the relocation was also discussed in open school board meetings. A construction firm that worked on the project trumpeted its effort to help find relatives.

A Mecklenburg County sheriff’s deputy named Dustyne Lett saw the news of the cemetery on Facebook. She is a descendant of the Tunstalls.

“By us being involved, we could have a say about where they would be moved,” Lett said recently.

A county judge issued an order giving the school board permission to disinter the remains. They were reburied in a family cemetery several towns away.

“Family members need to be buried with family members,” Lett said. “It’s not like they get together to have dinner. But for us living people, we want to have one spot where we can visit them, talk to them.”

David and Mike Moseley do not imagine that they would have won a fight against Microsoft or the county to keep the cemetery where it was, though they would have wanted the chance to wage one. They also were denied the chance to decide where their ancestors would be reburied.

“We would have wanted them to be moved here, where the rest of the family is,” David Moseley told me when we met in the Jerusalem Temple United Holy Church Cemetery, where the Moseleys have buried their relatives since the 1960s, after they moved off the farm. David’s sister Dorothy Tolbert, who passed away in New Jersey in May, is buried there, not far from Lucy Moseley’s grave — a grave that had been publicly logged online three years before the Microsoft project. “That would have been respectful, that would have allowed them to be together,” David said. In 1967, when Lucy Moseley died at the age of 96, relatives figured moving her husband’s grave to the Jerusalem Temple cemetery would have been too expensive. They would let their ancestors rest in peace.

At least, David Moseley said, Microsoft or the county could have placed a sign or historical marker on the land where the cemetery had been, noting the names of everyone who’d been buried in the old graveyard.

Mike and David Moseley visit the cemetery where the family chose to bury many of its members in recent decades. If they’d known that the old family cemetery was being relocated, they would have asked to rebury the remains at this church, they said. (Christopher Smith, special to ProPublica)

State and local officials have actively worked to honor and preserve white cemeteries in Mecklenburg County. In a 2003 book about the successful effort to have several historic town centers listed on the National Register of Historic Places, the view from a white cemetery is described as “bucolic.” That view has been protected by a Virginia historic preservation easement. Another cemetery, with only three visible stones, is noted for its impressive gateposts, which are inscribed with the words “Love Makes Memorial Eternal” and which were donated in 1941 by the United Daughters of the Confederacy.

In August, I met David and Mike Moseley to look for their relatives’ reburied graves in a cemetery in Chase City, 15 minutes north of the Microsoft data center. The final excavation report had said there would be a marker placed “indicating how many remains, where they were removed from, date, and known family names.”

We drove slowly through the cemetery, looking for a sign. We did not find one. Over lunch at a local restaurant, we called the Chase City municipal office. A clerk told us that she thought she knew what we were talking about; in the new section of the town cemetery, past the mausoleum, we’d find “the graves the county sent.”

“There are no names. It just says ‘assorted bones,’” she said, reading off a paper on file in the town office. She gave us directions, listing the names on several other stones in the vicinity of the reburial plots.

Past the mausoleum, we spotted a grave with one of those names and stopped the car. David peered out the window. “I know that stone,” he said quietly. “It’s been a long time since I’ve seen it.”

Stephen Moseley’s gravestone had been set in the ground. Six feet to the right stood the stone of his toddler son, Fred D. Moseley. There is nothing noting the existence of any other remains, just an unmarked stretch of grass.

David and Mike Moseley placed their hands on the top of Stephen’s gravestone. “I would not have known where he was buried,” Mike Moseley said, repeatedly, and then sat down in front of the stone, his hand still resting on the top, and cried. Being here with them now, he said, “this connects us.”

(Christopher Smith, special to ProPublica)

Mollie Simon contributed research.