Gov. Gavin Newsom may have been prescient when he acknowledged free speech concerns as he signed California’s covid misinformation bill last fall. In a message to lawmakers, the governor warned of “the chilling effect other potential laws may have” on the ability of doctors to speak frankly with patients but expressed confidence that the one he was signing did not cross that line.
Yet the law — meant to discipline doctors who give patients false information about covid-19 — is now in legal limbo after two federal judges issued conflicting rulings in recent lawsuits that say it violates free speech and is too vague for doctors to know what it bars them from telling patients.
In two of the lawsuits, Senior U.S. District Judge William Shubb in Sacramento issued a temporary halt on enforcing the law, but it applies only to the plaintiffs in those cases. Shubb said the law was “unconstitutionally vague,” in part because it “fails to provide a person of ordinary intelligence fair notice of what is prohibited.” His ruling last month clashed with one handed down in Santa Ana in December; in that case, U.S. District Judge Fred Slaughter refused to halt the law and said it was “likely to promote the health and safety of California covid-19 patients.”
The legal fight in the nation’s most populous state is to some extent a perpetuation of the pandemic-era tussle pitting supporters of public health guidelines against groups and individuals who resisted masking orders, school shutdowns, and vaccine mandates.
California’s covid misinformation law, which took effect Jan. 1, is being challenged by vaccine skeptics and civil liberties groups. Among those suing to get the law declared unconstitutional is a group founded by Robert F. Kennedy Jr., who has questioned the science and safety of vaccines for years.
But doubts about the law are not confined to those who have battled the scientific mainstream.
Dr. Leana Wen, a health policy professor at George Washington University who previously served as president of Planned Parenthood and as Baltimore’s health commissioner, wrote in an op-ed a few weeks before Newsom signed the law that it would exert “a chilling effect on medical practice, with widespread repercussions that could paradoxically worsen patient care.”
The Northern California affiliate of the American Civil Liberties Union has weighed in against the law on free speech grounds, though the national organization has affirmed the constitutionality of covid vaccine mandates.
“If doctors are scared of losing their licenses for giving advice that they think is helpful and appropriate, but they don’t quite know what the law means, they will be less likely to speak openly and frankly with their patients,” said Hannah Kieschnick, an attorney with the ACLU of Northern California.
The law establishes that doctors who give false information about covid to patients are engaging in unprofessional conduct, which could subject them to discipline by the Medical Board of California or the Osteopathic Medical Board of California.
Proponents of the law sought to crack down on what they believe are the most clear-cut cases: Doctors who tout treatments such as ivermectin, an anti-parasitic agent that is unproven as a covid treatment and can be dangerous; who exaggerate the risk of getting vaccinated compared with the dangers of the disease; or who spread unfounded theories about the vaccines, including that they can cause infertility or harm DNA.
But the law lacks such specifics, defining misinformation only as “false information that is contradicted by contemporary scientific consensus contrary to the standard of care.”
Michelle Mello, a professor of law and health policy at Stanford University, said the wording is confusing.
“On a matter like covid, science is changing all the time, so what does it mean to say there is scientific consensus?” she asked. “To me, there are lots of examples of statements that clearly, with no vagueness involved, meet the definition of the kind of conduct that the legislature was going after. The problem is that there are all kinds of other hypothetical things that people can say that don’t clearly violate it.”
Dr. Christine Cassel, a professor of medicine at the University of California-San Francisco, said she expects the law to be applied only in the most flagrant cases. “I trust scientists enough to know where there’s a legitimate dispute,” she said.
Cassel’s view mirrors Newsom’s rationale for signing the legislation despite his awareness of potential free speech concerns. “I am confident,” he wrote in his message to lawmakers, “that discussing emerging ideas or treatments including the subsequent risks and benefits does not constitute misinformation or disinformation under this bill’s criteria.”
Plaintiffs in the Santa Ana case, two doctors who have sometimes diverged from public health guidelines, appealed Slaughter’s ruling allowing the law to stand. The case has been combined in the 9th U.S. Circuit Court of Appeals with another case in which a San Diego judge declined to rule on a similar request to temporarily halt the law.
Newsom spokesperson Brandon Richards said in early February that the administration would not appeal the two Sacramento cases in which Shubb issued the narrow injunction. The plaintiffs’ lawyers had expected the state to appeal the decision, thinking all four lawsuits would then be decided by the appeals court, providing greater clarity for all parties.
Richard Jaffe, lead attorney in one of the Sacramento cases — brought by a doctor, Kennedy’s Children’s Health Defense, and a group called Physicians for Informed Consent — said Newsom’s decision not to appeal is “just going to increase the level of chaos in terms of who the law applies to.”
But the Newsom administration has decided to wait for the appeals court to rule on the other two judges’ decisions that left the law intact for now.
Jenin Younes, a lawyer with the New Civil Liberties Alliance who is lead counsel in the other Sacramento case in which Shubb issued his injunction, said Newsom may be calculating that “you’re in a stronger position going up on a win than on a loss.”
A victory for Newsom in the appeals court, Jaffe and others said, could dampen the impact of the two Sacramento cases.
Opponents of California’s covid misinformation law question why it is needed at all, since the medical boards already have authority to discipline doctors for unprofessional conduct. Yet only about 3% of the nearly 90,000 complaints the Medical Board of California received over a decade resulted in doctors being disciplined, according to a 2021 investigation by the Los Angeles Times.
That could be good news for doctors who worry the new law could constrain their ability to advise patients.
“I don’t see medical boards being particularly vigorous in policing physicians’ competence in general,” said Stanford’s Mello. “You have to be really bad to get their attention.”
This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
Gov. Gavin Newsom may have been prescient when he acknowledged free speech concerns as he signed California’s covid misinformation bill last fall. In a message to lawmakers, the governor warned of “the chilling effect other potential laws may have” on the ability of doctors to speak frankly with patients but expressed confidence that the one he was signing did not cross that line.
Yet the law — meant to discipline doctors who give patients false information about covid-19 — is now in legal limbo after two federal judges issued conflicting rulings in recent lawsuits that say it violates free speech and is too vague for doctors to know what it bars them from telling patients.
In two of the lawsuits, Senior U.S. District Judge William Shubb in Sacramento issued a temporary halt on enforcing the law, but it applies only to the plaintiffs in those cases. Shubb said the law was “unconstitutionally vague,” in part because it “fails to provide a person of ordinary intelligence fair notice of what is prohibited.” His ruling last month clashed with one handed down in Santa Ana in December; in that case, U.S. District Judge Fred Slaughter refused to halt the law and said it was “likely to promote the health and safety of California covid-19 patients.”
The legal fight in the nation’s most populous state is to some extent a perpetuation of the pandemic-era tussle pitting supporters of public health guidelines against groups and individuals who resisted masking orders, school shutdowns, and vaccine mandates.
California’s covid misinformation law, which took effect Jan. 1, is being challenged by vaccine skeptics and civil liberties groups. Among those suing to get the law declared unconstitutional is a group founded by Robert F. Kennedy Jr., who has questioned the science and safety of vaccines for years.
But doubts about the law are not confined to those who have battled the scientific mainstream.
Dr. Leana Wen, a health policy professor at George Washington University who previously served as president of Planned Parenthood and as Baltimore’s health commissioner, wrote in an op-ed a few weeks before Newsom signed the law that it would exert “a chilling effect on medical practice, with widespread repercussions that could paradoxically worsen patient care.”
The Northern California affiliate of the American Civil Liberties Union has weighed in against the law on free speech grounds, though the national organization has affirmed the constitutionality of covid vaccine mandates.
“If doctors are scared of losing their licenses for giving advice that they think is helpful and appropriate, but they don’t quite know what the law means, they will be less likely to speak openly and frankly with their patients,” said Hannah Kieschnick, an attorney with the ACLU of Northern California.
The law establishes that doctors who give false information about covid to patients are engaging in unprofessional conduct, which could subject them to discipline by the Medical Board of California or the Osteopathic Medical Board of California.
Proponents of the law sought to crack down on what they believe are the most clear-cut cases: Doctors who tout treatments such as ivermectin, an anti-parasitic agent that is unproven as a covid treatment and can be dangerous; who exaggerate the risk of getting vaccinated compared with the dangers of the disease; or who spread unfounded theories about the vaccines, including that they can cause infertility or harm DNA.
But the law lacks such specifics, defining misinformation only as “false information that is contradicted by contemporary scientific consensus contrary to the standard of care.”
Michelle Mello, a professor of law and health policy at Stanford University, said the wording is confusing.
“On a matter like covid, science is changing all the time, so what does it mean to say there is scientific consensus?” she asked. “To me, there are lots of examples of statements that clearly, with no vagueness involved, meet the definition of the kind of conduct that the legislature was going after. The problem is that there are all kinds of other hypothetical things that people can say that don’t clearly violate it.”
Dr. Christine Cassel, a professor of medicine at the University of California-San Francisco, said she expects the law to be applied only in the most flagrant cases. “I trust scientists enough to know where there’s a legitimate dispute,” she said.
Cassel’s view mirrors Newsom’s rationale for signing the legislation despite his awareness of potential free speech concerns. “I am confident,” he wrote in his message to lawmakers, “that discussing emerging ideas or treatments including the subsequent risks and benefits does not constitute misinformation or disinformation under this bill’s criteria.”
Plaintiffs in the Santa Ana case, two doctors who have sometimes diverged from public health guidelines, appealed Slaughter’s ruling allowing the law to stand. The case has been combined in the 9th U.S. Circuit Court of Appeals with another case in which a San Diego judge declined to rule on a similar request to temporarily halt the law.
Newsom spokesperson Brandon Richards said in early February that the administration would not appeal the two Sacramento cases in which Shubb issued the narrow injunction. The plaintiffs’ lawyers had expected the state to appeal the decision, thinking all four lawsuits would then be decided by the appeals court, providing greater clarity for all parties.
Richard Jaffe, lead attorney in one of the Sacramento cases — brought by a doctor, Kennedy’s Children’s Health Defense, and a group called Physicians for Informed Consent — said Newsom’s decision not to appeal is “just going to increase the level of chaos in terms of who the law applies to.”
But the Newsom administration has decided to wait for the appeals court to rule on the other two judges’ decisions that left the law intact for now.
Jenin Younes, a lawyer with the New Civil Liberties Alliance who is lead counsel in the other Sacramento case in which Shubb issued his injunction, said Newsom may be calculating that “you’re in a stronger position going up on a win than on a loss.”
A victory for Newsom in the appeals court, Jaffe and others said, could dampen the impact of the two Sacramento cases.
Opponents of California’s covid misinformation law question why it is needed at all, since the medical boards already have authority to discipline doctors for unprofessional conduct. Yet only about 3% of the nearly 90,000 complaints the Medical Board of California received over a decade resulted in doctors being disciplined, according to a 2021 investigation by the Los Angeles Times.
That could be good news for doctors who worry the new law could constrain their ability to advise patients.
“I don’t see medical boards being particularly vigorous in policing physicians’ competence in general,” said Stanford’s Mello. “You have to be really bad to get their attention.”
This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
Deaths of pregnant women in the United States fell in 2022, dropping significantly from a six-decade high during the pandemic, new data suggests.
More than 1,200 U.S. women died in 2021 during pregnancy or shortly after childbirth, according to a final tally released Thursday by the Centers for Disease Control and Prevention. In 2022, there were 733 maternal deaths, according to preliminary agency data, though the final number is likely to be higher.
Officials say the 2022 maternal death rate is on track to get close to pre-pandemic levels. But that’s not great: The rate before COVID-19 was the highest it had been in decades.
“From the worst to the near worst? I wouldn’t exactly call that an accomplishment,” said Omari Maynard, a New Yorker whose partner died after childbirth in 2019.
Experts blame COVID-19
The CDC counts women who die while pregnant, during childbirth, and up to 42 days after birth. Excessive bleeding, blood vessel blockages, and infections are leading causes.
COVID-19 can be particularly dangerous to pregnant women, and experts believe it was the main reason for the 2021 spike. Burned-out physicians could have added to the risk by ignoring pregnant women’s worries, some advocates said.
In 2021, there were about 33 maternal deaths for every 100,000 live births. The last time the government recorded a rate that high was 1964.
What happened “isn’t that hard to explain,” said Eugene Declercq, a longtime maternal mortality researcher at Boston University. “The surge was COVID-related.”
Previous government analyses concluded that one quarter of maternal deaths in 2020 and 2021 were COVID-related — meaning that the entire increase in maternal deaths was due to coronavirus infections or the pandemic’s wider impact on health care. Pregnant women infected with the coronavirus were nearly eight times as likely to die as their uninfected peers, according to a recent study published by BMJ Global Health.
The bodies of pregnant women are already under strain, their heart forced to pump harder. Other health problems can make their condition more fragile. And then on top of that, “COVID is going to make all that much worse,” said Dr. Elizabeth Cherot, chief medical and health officer for the March of Dimes.
It didn’t help that vaccination rates among pregnant women were low in 2021 — particularly among Black women. Part of that was related to limited vaccine availability, and that the CDC did not fully recommend shots for pregnant women until August 2021.
“Initially, there was a lot of mistrust of the vaccine in Black communities,” said Samantha Griffin, who owns a doula service that mainly serves families of color in the Washington area.
But there’s more to it than that, she and others added. The 2021 maternal mortality rate for Black women was nearly three times higher than it was for white women. And the maternal death rate for Hispanic American women that year rose 54% compared with 2020, also surpassing the death rate for white moms.
More than a year into the pandemic, a lot of doctors and nurses were feeling burned out and they were getting less in-person time with patients.
Providers at the time “were needing to make snap decisions and maybe not listening to their patients as much,” Griffin said. “Women were saying that they thought something was wrong and they weren’t being heard.”
‘She wasn’t being heard’
Maynard, who is 41 and lives in Brooklyn, said he and his partner experienced that in 2019.
Shamony Gibson, a healthy 30-year-old, was set to have their second child. The pregnancy was smooth until her contractions stopped progressing and she underwent a cesarean section.
The operation was more involved than expected but their son Khari was born in September. A few days later, Shamony began complaining of chest pains and shortness of breath, Maynard said. Doctors told her she just needed to relax and let her body rest from the pregnancy, he said.
More than a week after giving birth, her health worsened and she begged to go to the hospital. Then her heart stopped, and loved ones called for help. The initial focus for paramedics and firefighters was whether Gibson was taking illicit drugs, Maynard said, adding that she didn’t.
She was hospitalized and died the next day of a blood clot in the lungs. Her son was 13 days old.
“She wasn’t being heard at all,” said Maynard, an artist who now does speaking engagements as a maternal health advocate.
Deaths of pregnant women in the United States fell in 2022, dropping significantly from a six-decade high during the pandemic, new data suggests.
More than 1,200 U.S. women died in 2021 during pregnancy or shortly after childbirth, according to a final tally released Thursday by the Centers for Disease Control and Prevention. In 2022, there were 733 maternal deaths, according to preliminary agency data, though the final number is likely to be higher.
Officials say the 2022 maternal death rate is on track to get close to pre-pandemic levels. But that’s not great: The rate before COVID-19 was the highest it had been in decades.
“From the worst to the near worst? I wouldn’t exactly call that an accomplishment,” said Omari Maynard, a New Yorker whose partner died after childbirth in 2019.
Experts blame COVID-19
The CDC counts women who die while pregnant, during childbirth, and up to 42 days after birth. Excessive bleeding, blood vessel blockages, and infections are leading causes.
COVID-19 can be particularly dangerous to pregnant women, and experts believe it was the main reason for the 2021 spike. Burned-out physicians could have added to the risk by ignoring pregnant women’s worries, some advocates said.
In 2021, there were about 33 maternal deaths for every 100,000 live births. The last time the government recorded a rate that high was 1964.
What happened “isn’t that hard to explain,” said Eugene Declercq, a longtime maternal mortality researcher at Boston University. “The surge was COVID-related.”
Previous government analyses concluded that one quarter of maternal deaths in 2020 and 2021 were COVID-related — meaning that the entire increase in maternal deaths was due to coronavirus infections or the pandemic’s wider impact on health care. Pregnant women infected with the coronavirus were nearly eight times as likely to die as their uninfected peers, according to a recent study published by BMJ Global Health.
The bodies of pregnant women are already under strain, their heart forced to pump harder. Other health problems can make their condition more fragile. And then on top of that, “COVID is going to make all that much worse,” said Dr. Elizabeth Cherot, chief medical and health officer for the March of Dimes.
It didn’t help that vaccination rates among pregnant women were low in 2021 — particularly among Black women. Part of that was related to limited vaccine availability, and that the CDC did not fully recommend shots for pregnant women until August 2021.
“Initially, there was a lot of mistrust of the vaccine in Black communities,” said Samantha Griffin, who owns a doula service that mainly serves families of color in the Washington area.
But there’s more to it than that, she and others added. The 2021 maternal mortality rate for Black women was nearly three times higher than it was for white women. And the maternal death rate for Hispanic American women that year rose 54% compared with 2020, also surpassing the death rate for white moms.
More than a year into the pandemic, a lot of doctors and nurses were feeling burned out and they were getting less in-person time with patients.
Providers at the time “were needing to make snap decisions and maybe not listening to their patients as much,” Griffin said. “Women were saying that they thought something was wrong and they weren’t being heard.”
‘She wasn’t being heard’
Maynard, who is 41 and lives in Brooklyn, said he and his partner experienced that in 2019.
Shamony Gibson, a healthy 30-year-old, was set to have their second child. The pregnancy was smooth until her contractions stopped progressing and she underwent a cesarean section.
The operation was more involved than expected but their son Khari was born in September. A few days later, Shamony began complaining of chest pains and shortness of breath, Maynard said. Doctors told her she just needed to relax and let her body rest from the pregnancy, he said.
More than a week after giving birth, her health worsened and she begged to go to the hospital. Then her heart stopped, and loved ones called for help. The initial focus for paramedics and firefighters was whether Gibson was taking illicit drugs, Maynard said, adding that she didn’t.
She was hospitalized and died the next day of a blood clot in the lungs. Her son was 13 days old.
“She wasn’t being heard at all,” said Maynard, an artist who now does speaking engagements as a maternal health advocate.
El segundo embarazo de Tamara Etienne estuvo lleno de riesgos y preocupaciones desde el principio, exacerbado porque ya había sufrido un aborto espontáneo.
Como maestra de tercer grado en una escuela pública del condado de Miami-Dade, pasaba todo el día parada. Le pesaban las preocupaciones financieras, incluso teniendo seguro de salud y algo de licencia paga.
Y, como mujer negra, toda una vida de racismo la volvió desconfiada de las reacciones impredecibles en la vida diaria. Estaba agotada por el trato despectivo y desigual en el trabajo. Justamente el tipo de estrés que puede liberar cortisol, que, según estudios, aumenta el riesgo de parto prematuro.
“Lo experimento todo el tiempo, no camino sola, o lo hago con alguien a quien debo proteger. Sí, el nivel de cortisol en mi cuerpo es incontable”, expresó.
A los dos meses de embarazo, las náuseas implacables cesaron de repente. “Empecé a sentir que mis síntomas de embarazo estaban desapareciendo”, dijo. Entonces comenzó un extraño dolor de espalda.
Etienne y su esposo corrieron a la sala de emergencias, donde confirmaron que corría un grave riesgo de aborto espontáneo. Una cascada de intervenciones médicas —inyecciones de progesterona, monitoreo fetal en el hogar y reposo en cama— salvó a la niña, que nació a las 37 semanas.
Las mujeres en Estados Unidos tienen más probabilidades de dar a luz prematuramente que las de la mayoría de los países desarrollados. Esto coincide con tasas más altas de mortalidad materno infantil, miles de millones de gastos en cuidado intensivo y a menudo una vida de discapacidad para los prematuros que sobreviven.
Aproximadamente uno de cada 10 nacimientos vivos en 2021 ocurrió antes de las 37 semanas de gestación, según un informe de March of Dimes publicado en 2022. En comparación, investigaciones recientes citan tasas de nacimientos prematuros del 7,4% en Inglaterra y Gales, del 6% en Francia y del 5,8% en Suecia.
En su informe, March of Dimes encontró que las tasas de nacimientos prematuros aumentaron en casi todos los estados de 2020 a 2021. Vermont, con una tasa del 8%, tuvo la calificación más alta del país: una “A-”. Los resultados más sombríos se concentraron en los estados del sur, que obtuvieron calificaciones equivalentes a una “F”, con tasas de nacimientos prematuros del 11,5% o más.
Mississippi (15 %), Louisiana (13,5 %) y Alabama (13,1 %) fueron los estados con peor desempeño. El informe encontró que, en 2021, el 10,9% de los nacidos vivos en Florida fueron partos prematuros, por lo que obtuvo una “D”.
Desde que la Corte Suprema anulara Roe vs. Wade, muchos especialistas temen que la incidencia de nacimientos prematuros se dispare. El aborto ahora está prohibido en al menos 13 estados y estrictamente restringido en otros 12: los estados que restringen el aborto tienen menos proveedores de atención materna, según un reciente análisis de Commonwealth Fund.
Eso incluye Florida, donde los legisladores republicanos han promulgado leyes contra el aborto, incluida la prohibición de realizarlo después de las 15 semanas de gestación.
Florida es uno de los estados menos generosos cuando se trata de seguro médico público. Aproximadamente una de cada 6 mujeres en edad fértil no tiene seguro, lo que dificulta mantener un embarazo saludable. Las mujeres de Florida tienen el doble de probabilidades de morir por causas relacionadas con el embarazo y el parto que las de California.
“Me quita el sueño”, dijo la doctora Elvire Jacques, especialista en medicina materno-fetal del Memorial Hospital en Miramar, Florida.
Jacques explicó que las causas de los partos prematuros son variadas. Alrededor del 25% se inducen médicamente, por condiciones como la preeclampsia. Pero la investigación sugiere que muchos más tendrían sus raíces en una misteriosa constelación de condiciones fisiológicas.
“Es muy difícil identificar que una paciente tendrá un parto prematuro”, dijo Jacques. “Pero sí puedes identificar los factores estresantes en sus embarazos”.
Los médicos dicen que aproximadamente la mitad de todos los nacimientos prematuros debido a factores sociales, económicos y ambientales, y al acceso inadecuado a la atención médica prenatal, se pueden prevenir.
En el Memorial Hospital en Miramar, parte de un gran sistema de atención médica pública, Jacques recibe embarazos de alto riesgo referidos por otros obstetras del sur de Florida.
En la primera cita les pregunta: ¿Con quién vives? ¿Donde duermes? ¿Tienes adicciones? ¿Dónde trabajas? “Si no supiera que trabajan en una fábrica paradas cómo les podría recomendar que usaran medias de compresión para prevenir coágulos de sangre?”.
Jacques instó al gerente de una tienda a que permitiera a su empleada embarazada trabajar sentada. Persuadió a un imán para que le concediera a una futura mamá con diabetes un aplazamiento del ayuno religioso.
Debido a que la diabetes es un factor de riesgo importante, a menudo habla con los pacientes sobre cómo comer de manera saludable. Les pregunta: “De los alimentos que estamos discutiendo, ¿cuál crees que puedes pagar?”.
El acceso a una atención asequible separa a Florida de estados como California y Massachusetts, que tienen licencia familiar paga y bajas tasas de residentes sin seguro; y a Estados Unidos de otros países, dicen expertos en políticas de salud.
En países con atención médica socializada, “las mujeres no tienen que preocuparse por el costo financiero de la atención”, apuntó la doctora Delisa Skeete-Henry, jefa del departamento de obstetricia y ginecología de Broward Health en Fort Lauderdale. Y tienen licencias por maternidad pagas.
Sin embargo, a medida que aumentan los nacimientos prematuros en Estados Unidos, la riqueza no garantiza mejores resultados.
Nuevas investigaciones revelan que, sorprendentemente, en todos los niveles de ingresos, las mujeres negras y sus bebés experimentan resultados de parto mucho peores que sus contrapartes blancas. En otras palabras, todos los recursos que ofrece la riqueza no protegen a las mujeres negras ni a sus bebés de complicaciones prematuras, según el estudio, publicado por la Oficina Nacional de Investigación Económica.
Jamarah Amani es testigo de esto como directora ejecutiva de Southern Birth Justice Network y defensora de la atención de parteras y doulas en el sur de Florida. A medida que evalúa nuevos pacientes, busca pistas sobre los riesgos de nacimiento en los antecedentes familiares, análisis de laboratorio y ecografías. Y se centra en el estrés relacionado con el trabajo, las relaciones, la comida, la familia y el racismo.
“Las mujeres negras que trabajan en ambientes de alto estrés, incluso si no tienen problemas económicos, pueden enfrentar un parto prematuro”, dijo.
Recientemente, cuando una paciente mostró signos de trabajo de parto prematuro, Amani descubrió que su factura de electricidad estaba vencida, y que la empresa amenazaba con cortar el servicio. Amani encontró una organización que pagó la deuda.
De los seis embarazos de Tamara Etienne, dos terminaron en aborto espontáneo y cuatro fueron de riesgo de parto prematuro. Harta de la avalancha de intervenciones médicas, encontró una doula y una partera locales que la ayudaron en el nacimiento de sus dos hijos más pequeños.
“Pudieron guiarme a través de formas saludables y naturales para mitigar todas esas complicaciones”, dijo.
Sus propias experiencias con el embarazo dejaron un profundo impacto en Etienne. Desde entonces, ella misma se ha convertido en una doula.
El segundo embarazo de Tamara Etienne estuvo lleno de riesgos y preocupaciones desde el principio, exacerbado porque ya había sufrido un aborto espontáneo.
Como maestra de tercer grado en una escuela pública del condado de Miami-Dade, pasaba todo el día parada. Le pesaban las preocupaciones financieras, incluso teniendo seguro de salud y algo de licencia paga.
Y, como mujer negra, toda una vida de racismo la volvió desconfiada de las reacciones impredecibles en la vida diaria. Estaba agotada por el trato despectivo y desigual en el trabajo. Justamente el tipo de estrés que puede liberar cortisol, que, según estudios, aumenta el riesgo de parto prematuro.
“Lo experimento todo el tiempo, no camino sola, o lo hago con alguien a quien debo proteger. Sí, el nivel de cortisol en mi cuerpo es incontable”, expresó.
A los dos meses de embarazo, las náuseas implacables cesaron de repente. “Empecé a sentir que mis síntomas de embarazo estaban desapareciendo”, dijo. Entonces comenzó un extraño dolor de espalda.
Etienne y su esposo corrieron a la sala de emergencias, donde confirmaron que corría un grave riesgo de aborto espontáneo. Una cascada de intervenciones médicas —inyecciones de progesterona, monitoreo fetal en el hogar y reposo en cama— salvó a la niña, que nació a las 37 semanas.
Las mujeres en Estados Unidos tienen más probabilidades de dar a luz prematuramente que las de la mayoría de los países desarrollados. Esto coincide con tasas más altas de mortalidad materno infantil, miles de millones de gastos en cuidado intensivo y a menudo una vida de discapacidad para los prematuros que sobreviven.
Aproximadamente uno de cada 10 nacimientos vivos en 2021 ocurrió antes de las 37 semanas de gestación, según un informe de March of Dimes publicado en 2022. En comparación, investigaciones recientes citan tasas de nacimientos prematuros del 7,4% en Inglaterra y Gales, del 6% en Francia y del 5,8% en Suecia.
En su informe, March of Dimes encontró que las tasas de nacimientos prematuros aumentaron en casi todos los estados de 2020 a 2021. Vermont, con una tasa del 8%, tuvo la calificación más alta del país: una “A-”. Los resultados más sombríos se concentraron en los estados del sur, que obtuvieron calificaciones equivalentes a una “F”, con tasas de nacimientos prematuros del 11,5% o más.
Mississippi (15 %), Louisiana (13,5 %) y Alabama (13,1 %) fueron los estados con peor desempeño. El informe encontró que, en 2021, el 10,9% de los nacidos vivos en Florida fueron partos prematuros, por lo que obtuvo una “D”.
Desde que la Corte Suprema anulara Roe vs. Wade, muchos especialistas temen que la incidencia de nacimientos prematuros se dispare. El aborto ahora está prohibido en al menos 13 estados y estrictamente restringido en otros 12: los estados que restringen el aborto tienen menos proveedores de atención materna, según un reciente análisis de Commonwealth Fund.
Eso incluye Florida, donde los legisladores republicanos han promulgado leyes contra el aborto, incluida la prohibición de realizarlo después de las 15 semanas de gestación.
Florida es uno de los estados menos generosos cuando se trata de seguro médico público. Aproximadamente una de cada 6 mujeres en edad fértil no tiene seguro, lo que dificulta mantener un embarazo saludable. Las mujeres de Florida tienen el doble de probabilidades de morir por causas relacionadas con el embarazo y el parto que las de California.
“Me quita el sueño”, dijo la doctora Elvire Jacques, especialista en medicina materno-fetal del Memorial Hospital en Miramar, Florida.
Jacques explicó que las causas de los partos prematuros son variadas. Alrededor del 25% se inducen médicamente, por condiciones como la preeclampsia. Pero la investigación sugiere que muchos más tendrían sus raíces en una misteriosa constelación de condiciones fisiológicas.
“Es muy difícil identificar que una paciente tendrá un parto prematuro”, dijo Jacques. “Pero sí puedes identificar los factores estresantes en sus embarazos”.
Los médicos dicen que aproximadamente la mitad de todos los nacimientos prematuros debido a factores sociales, económicos y ambientales, y al acceso inadecuado a la atención médica prenatal, se pueden prevenir.
En el Memorial Hospital en Miramar, parte de un gran sistema de atención médica pública, Jacques recibe embarazos de alto riesgo referidos por otros obstetras del sur de Florida.
En la primera cita les pregunta: ¿Con quién vives? ¿Donde duermes? ¿Tienes adicciones? ¿Dónde trabajas? “Si no supiera que trabajan en una fábrica paradas cómo les podría recomendar que usaran medias de compresión para prevenir coágulos de sangre?”.
Jacques instó al gerente de una tienda a que permitiera a su empleada embarazada trabajar sentada. Persuadió a un imán para que le concediera a una futura mamá con diabetes un aplazamiento del ayuno religioso.
Debido a que la diabetes es un factor de riesgo importante, a menudo habla con los pacientes sobre cómo comer de manera saludable. Les pregunta: “De los alimentos que estamos discutiendo, ¿cuál crees que puedes pagar?”.
El acceso a una atención asequible separa a Florida de estados como California y Massachusetts, que tienen licencia familiar paga y bajas tasas de residentes sin seguro; y a Estados Unidos de otros países, dicen expertos en políticas de salud.
En países con atención médica socializada, “las mujeres no tienen que preocuparse por el costo financiero de la atención”, apuntó la doctora Delisa Skeete-Henry, jefa del departamento de obstetricia y ginecología de Broward Health en Fort Lauderdale. Y tienen licencias por maternidad pagas.
Sin embargo, a medida que aumentan los nacimientos prematuros en Estados Unidos, la riqueza no garantiza mejores resultados.
Nuevas investigaciones revelan que, sorprendentemente, en todos los niveles de ingresos, las mujeres negras y sus bebés experimentan resultados de parto mucho peores que sus contrapartes blancas. En otras palabras, todos los recursos que ofrece la riqueza no protegen a las mujeres negras ni a sus bebés de complicaciones prematuras, según el estudio, publicado por la Oficina Nacional de Investigación Económica.
Jamarah Amani es testigo de esto como directora ejecutiva de Southern Birth Justice Network y defensora de la atención de parteras y doulas en el sur de Florida. A medida que evalúa nuevos pacientes, busca pistas sobre los riesgos de nacimiento en los antecedentes familiares, análisis de laboratorio y ecografías. Y se centra en el estrés relacionado con el trabajo, las relaciones, la comida, la familia y el racismo.
“Las mujeres negras que trabajan en ambientes de alto estrés, incluso si no tienen problemas económicos, pueden enfrentar un parto prematuro”, dijo.
Recientemente, cuando una paciente mostró signos de trabajo de parto prematuro, Amani descubrió que su factura de electricidad estaba vencida, y que la empresa amenazaba con cortar el servicio. Amani encontró una organización que pagó la deuda.
De los seis embarazos de Tamara Etienne, dos terminaron en aborto espontáneo y cuatro fueron de riesgo de parto prematuro. Harta de la avalancha de intervenciones médicas, encontró una doula y una partera locales que la ayudaron en el nacimiento de sus dos hijos más pequeños.
“Pudieron guiarme a través de formas saludables y naturales para mitigar todas esas complicaciones”, dijo.
Sus propias experiencias con el embarazo dejaron un profundo impacto en Etienne. Desde entonces, ella misma se ha convertido en una doula.
You must credit us as the original publisher, with a hyperlink to our khn.org site. If possible, please include the original author(s) and “Kaiser Health News” in the byline. Please preserve the hyperlinks in the story.
It’s important to note, not everything on khn.org is available for republishing. If a story is labeled “All Rights Reserved,” we cannot grant permission to republish that item.
Have questions? Let us know at KHNHelp@kff.org
You must credit us as the original publisher, with a hyperlink to our khn.org site. If possible, please include the original author(s) and “Kaiser Health News” in the byline. Please preserve the hyperlinks in the story.
It’s important to note, not everything on khn.org is available for republishing. If a story is labeled “All Rights Reserved,” we cannot grant permission to republish that item.
Have questions? Let us know at KHNHelp@kff.org
Tamara Etienne’s second pregnancy was freighted with risk and worry from its earliest days — exacerbated by a first pregnancy that had ended in miscarriage.
A third-grade teacher at an overcrowded Miami-Dade County public school, she spent harried days on her feet. Financial worries weighed heavy, even with health insurance and some paid time off through her job.
And as a Black woman, a lifetime of racism had left her wary of unpredictable reactions in daily life and drained by derogatory and unequal treatment at work. It’s the sort of stress that can release cortisol, which studies have shown heighten the risk for premature labor.
“I’m experiencing it every day, not walking alone, walking with someone I have to protect,” she said. “So the level of cortisol in my body when I’m pregnant? Immeasurable.”
Two months into the pregnancy, the unrelenting nausea suddenly stopped. “I started to feel like my pregnancy symptoms were going away,” she said. Then strange back pain started.
Etienne and her husband rushed to an emergency room, where a doctor confirmed she was at grave risk for a miscarriage. A cascade of medical interventions — progesterone injections, fetal monitoring at home, and bed rest while she took months off work — saved the child, who was born at 37 weeks.
Women in the U.S. are more likely to deliver their babies prematurely than those in most developed countries. It’s a distinction that coincides with high rates of maternal and infant death, billions of dollars in intensive care costs, and often lifelong disabilities for the children who survive.
About 1 in 10 live births in 2021 occurred before 37 weeks of gestation, according to a March of Dimes report released last year. By comparison, research in recent years has cited preterm birth rates of 7.4% in England and Wales, 6% in France, and 5.8% in Sweden.
In its 2022 report card, the March of Dimes found the preterm birth rates increased in nearly every U.S. state from 2020 to 2021. Vermont, with a rate of 8%, merited the nation’s highest grade: an “A-.” The grimmest outcomes were concentrated in the Southern states, which largely earned “F” ratings, with preterm birth rates of 11.5% or higher. Mississippi (15%), Louisiana (13.5%), and Alabama (13.1%) were the worst performers. The March of Dimes report found 10.9% of live births in Florida were delivered preterm in 2021, earning the state a “D” rating.
Since the U.S. Supreme Court overturned Roe v. Wade, many maternal-fetal specialists worry that the incidence of premature birth will soar. Abortion is now banned in at least 13 states and sharply restricted in 12 others — states that restrict abortion have fewer maternal care providers than states with abortion access, according to a recent analysis by the Commonwealth Fund.
That includes Florida, where Etienne lives, and where Republican lawmakers have enacted a series of anti-abortion laws, including a ban on abortion after 15 weeks of gestation. Florida is one of the least generous states when it comes to public health insurance. About 1 in 6 women of childbearing age in Florida are uninsured, making it more difficult to begin a healthy pregnancy. Women are twice as likely to die from pregnancy and childbirth-related causes in Florida than in California.
“I lose sleep over this,” said Dr. Elvire Jacques, a maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. “It’s hard to say, I expect [better birth outcomes] when I’m not investing anything from the beginning.”
***
The causes of preterm births are varied. About 25% are medically induced, Jacques said, when the woman or fetus is in distress because of conditions like preeclampsia, a pregnancy-related hypertensive disorder. But research suggests that far more early births are thought to be rooted in a mysterious constellation of physiological conditions.
“It’s very hard to identify that a patient will automatically have a preterm birth,” Jacques said. “But you can definitely identify stressors for their pregnancies.”
Physicians say that roughly half of all preterm births are preventable, caused by social, economic, and environmental factors, as well as inadequate access to prenatal health care. Risk factors include conditions such as diabetes and obesity, as well as more-hidden issues like stress or even dehydration.
At Memorial Hospital in Miramar, part of a large public health care system, Jacques takes on high-risk pregnancies referred from other OB-GYNs in South Florida.
When meeting a patient for the first time she asks: Who else is in your household? Where do you sleep? Do you have substance abuse issues? Where do you work? “If you don’t know that your patient works in a factory [standing] on an assembly line,” she said, “then how are you going to tell her to wear compression socks because that may help her prevent blood clots?”
Jacques has urged a store manager to let her pregnant patient sit while working. She persuaded an imam to grant a mom-to-be with diabetes a reprieve from religious fasting.
Because diabetes is a major risk factor, she often talks with patients about eating healthfully. For those who eat fast food, she asks them to try cooking at home. Instead of, “Can you pay for food?” she asks, “Of the foods we’re discussing, which one do you think you can afford?”
Access to affordable care separates Florida from states like California and Massachusetts — which have paid family leave and low rates of uninsured residents — and separates the U.S. from other countries, health policy experts say.
In countries with socialized health care, “women don’t have to worry about the financial cost of care,” said Dr. Delisa Skeete-Henry, chair of the obstetrics and gynecology department at Broward Health in Fort Lauderdale. “A lot of places have paid leave, [and pregnant patients] don’t have to worry about not being at work.”
Yet, as preterm births rise in the U.S., wealth does not ensure better pregnancy outcomes.
Startling new research shows that at every U.S. income level, Black women and their infants experience far worse birth outcomes than their white counterparts. In other words, all the resources that come with wealth do not protect Black women or their babies from preterm complications, according to the study, published by the National Bureau of Economic Research.
Jamarah Amani has seen this firsthand as executive director of the Southern Birth Justice Network and an advocate for midwifery and doula care in South Florida. As she evaluates new clients, she looks for clues about birth risks in a patient’s family history, lab work, and ultrasounds. She homes in quickly on stress related to work, relationships, food, family, and racism.
“I find Black women working in high-stress environments, even if they are not financially struggling, can face preterm birth,” she said. She develops “wellness plans” that include breathing, meditation, stretching, and walking.
Recently, when a patient showed signs of preterm labor, Amani discovered that her electricity bill was overdue and the utility was threatening to cut service. Amani found an organization to pay off the debt.
Of Tamara Etienne’s six pregnancies, two ended in miscarriage and four were threatened by preterm labor. Fed up with the onslaught of medical interventions, she found a local doula and midwife who helped guide her through the birth of her two youngest children.
“They were able to walk me through healthy, natural ways to mitigate all of those complications,” she said.
Her own pregnancy experiences left a profound impact on Etienne. She has since become a fertility doula herself.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
USE OUR CONTENT
This story can be republished for free (details).
Tamara Etienne’s second pregnancy was freighted with risk and worry from its earliest days — exacerbated by a first pregnancy that had ended in miscarriage.
A third-grade teacher at an overcrowded Miami-Dade County public school, she spent harried days on her feet. Financial worries weighed heavy, even with health insurance and some paid time off through her job.
And as a Black woman, a lifetime of racism had left her wary of unpredictable reactions in daily life and drained by derogatory and unequal treatment at work. It’s the sort of stress that can release cortisol, which studies have shown heighten the risk for premature labor.
“I’m experiencing it every day, not walking alone, walking with someone I have to protect,” she said. “So the level of cortisol in my body when I’m pregnant? Immeasurable.”
Two months into the pregnancy, the unrelenting nausea suddenly stopped. “I started to feel like my pregnancy symptoms were going away,” she said. Then strange back pain started.
Etienne and her husband rushed to an emergency room, where a doctor confirmed she was at grave risk for a miscarriage. A cascade of medical interventions — progesterone injections, fetal monitoring at home, and bed rest while she took months off work — saved the child, who was born at 37 weeks.
Women in the U.S. are more likely to deliver their babies prematurely than those in most developed countries. It’s a distinction that coincides with high rates of maternal and infant death, billions of dollars in intensive care costs, and often lifelong disabilities for the children who survive.
About 1 in 10 live births in 2021 occurred before 37 weeks of gestation, according to a March of Dimes report released last year. By comparison, research in recent years has cited preterm birth rates of 7.4% in England and Wales, 6% in France, and 5.8% in Sweden.
In its 2022 report card, the March of Dimes found the preterm birth rates increased in nearly every U.S. state from 2020 to 2021. Vermont, with a rate of 8%, merited the nation’s highest grade: an “A-.” The grimmest outcomes were concentrated in the Southern states, which largely earned “F” ratings, with preterm birth rates of 11.5% or higher. Mississippi (15%), Louisiana (13.5%), and Alabama (13.1%) were the worst performers. The March of Dimes report found 10.9% of live births in Florida were delivered preterm in 2021, earning the state a “D” rating.
Since the U.S. Supreme Court overturned Roe v. Wade, many maternal-fetal specialists worry that the incidence of premature birth will soar. Abortion is now banned in at least 13 states and sharply restricted in 12 others — states that restrict abortion have fewer maternal care providers than states with abortion access, according to a recent analysis by the Commonwealth Fund.
That includes Florida, where Etienne lives, and where Republican lawmakers have enacted a series of anti-abortion laws, including a ban on abortion after 15 weeks of gestation. Florida is one of the least generous states when it comes to public health insurance. About 1 in 6 women of childbearing age in Florida are uninsured, making it more difficult to begin a healthy pregnancy. Women are twice as likely to die from pregnancy and childbirth-related causes in Florida than in California.
“I lose sleep over this,” said Dr. Elvire Jacques, a maternal-fetal medicine specialist at Memorial Hospital in Miramar, Florida. “It’s hard to say, I expect [better birth outcomes] when I’m not investing anything from the beginning.”
***
The causes of preterm births are varied. About 25% are medically induced, Jacques said, when the woman or fetus is in distress because of conditions like preeclampsia, a pregnancy-related hypertensive disorder. But research suggests that far more early births are thought to be rooted in a mysterious constellation of physiological conditions.
“It’s very hard to identify that a patient will automatically have a preterm birth,” Jacques said. “But you can definitely identify stressors for their pregnancies.”
Physicians say that roughly half of all preterm births are preventable, caused by social, economic, and environmental factors, as well as inadequate access to prenatal health care. Risk factors include conditions such as diabetes and obesity, as well as more-hidden issues like stress or even dehydration.
At Memorial Hospital in Miramar, part of a large public health care system, Jacques takes on high-risk pregnancies referred from other OB-GYNs in South Florida.
When meeting a patient for the first time she asks: Who else is in your household? Where do you sleep? Do you have substance abuse issues? Where do you work? “If you don’t know that your patient works in a factory [standing] on an assembly line,” she said, “then how are you going to tell her to wear compression socks because that may help her prevent blood clots?”
Jacques has urged a store manager to let her pregnant patient sit while working. She persuaded an imam to grant a mom-to-be with diabetes a reprieve from religious fasting.
Because diabetes is a major risk factor, she often talks with patients about eating healthfully. For those who eat fast food, she asks them to try cooking at home. Instead of, “Can you pay for food?” she asks, “Of the foods we’re discussing, which one do you think you can afford?”
Access to affordable care separates Florida from states like California and Massachusetts — which have paid family leave and low rates of uninsured residents — and separates the U.S. from other countries, health policy experts say.
In countries with socialized health care, “women don’t have to worry about the financial cost of care,” said Dr. Delisa Skeete-Henry, chair of the obstetrics and gynecology department at Broward Health in Fort Lauderdale. “A lot of places have paid leave, [and pregnant patients] don’t have to worry about not being at work.”
Yet, as preterm births rise in the U.S., wealth does not ensure better pregnancy outcomes.
Startling new research shows that at every U.S. income level, Black women and their infants experience far worse birth outcomes than their white counterparts. In other words, all the resources that come with wealth do not protect Black women or their babies from preterm complications, according to the study, published by the National Bureau of Economic Research.
Jamarah Amani has seen this firsthand as executive director of the Southern Birth Justice Network and an advocate for midwifery and doula care in South Florida. As she evaluates new clients, she looks for clues about birth risks in a patient’s family history, lab work, and ultrasounds. She homes in quickly on stress related to work, relationships, food, family, and racism.
“I find Black women working in high-stress environments, even if they are not financially struggling, can face preterm birth,” she said. She develops “wellness plans” that include breathing, meditation, stretching, and walking.
Recently, when a patient showed signs of preterm labor, Amani discovered that her electricity bill was overdue and the utility was threatening to cut service. Amani found an organization to pay off the debt.
Of Tamara Etienne’s six pregnancies, two ended in miscarriage and four were threatened by preterm labor. Fed up with the onslaught of medical interventions, she found a local doula and midwife who helped guide her through the birth of her two youngest children.
“They were able to walk me through healthy, natural ways to mitigate all of those complications,” she said.
Her own pregnancy experiences left a profound impact on Etienne. She has since become a fertility doula herself.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
USE OUR CONTENT
This story can be republished for free (details).
In the wake of a joint investigation by KHN and CBS News into a dental appliance that multiple lawsuits allege caused grievous harm to patients, the FDA has begun looking into the product, the Anterior Growth Guidance Appliance, or AGGA, according to a former agency official.
Additionally, KHN and CBS News have learned that the Las Vegas Institute, a training company that previously taught dentists to use the AGGA, now trains dentists to use another device it has described as “almost exactly the same appliance.” That one is called the Anterior Remodeling Appliance, or ARA.
The FDA’s interest in the AGGA was revealed by Cara Tenenbaum, a former senior policy adviser in the agency’s device center who has said the FDA should investigate the product, which has been fitted on more than 10,000 dental patients, according to court records.
Tenenbaum said that after KHN and CBS News published their report, she was contacted by “very concerned” FDA officials who said they have begun “looking into” the AGGA but have yet to determine how much legal authority the agency has to regulate it.
“The FDA is looking at what authorities they may have around this device — what they may be able to do,” Tenenbaum said. “Now, of course, whether or not this device is FDA regulated, it still needs to be safe.”
KHN and CBS News have reviewed online messages verifying that an FDA official has communicated with Tenenbaum about the AGGA. The FDA declined to comment on the AGGA or confirm whether it was evaluating the device.
The KHN-CBS News investigation of the AGGA involved interviews with 11 patients who said they were hurt by the device — plus attorneys who said they represent or have represented at least 23 others — and dental specialists who said they’d examined patients who had experienced severe complications using the AGGA. The investigation also found no record of the AGGA being registered with the FDA, despite the agency’s role in regulating medical and dental devices.
The AGGA’s inventor, Tennessee dentist Dr. Steve Galella, has said in a sworn court deposition that the device was never submitted to the FDA, which he believes doesn’t have jurisdiction over it. Tenenbaum has said the lack of registration is “incredibly problematic” because that is one method by which the FDA collects reports of a device’s negative effects.
She encouraged anyone who has witnessed complications from the AGGA to assist the FDA by submitting a report through its MedWatch portal.
“Whether that’s a dentist, an orthodontist, a surgeon, a patient, family member, or caregiver,” Tenenbaum said, “anyone can and should submit these reports so the FDA has a better understanding of what’s happening.”
Victor Krauthamer, a former FDA official who worked in a division regulating medical devices at the agency for three decades, said it was normal for an FDA probe of a device to begin by researching the boundaries of the agency’s authority, ensuring any future action has a solid legal foundation.
Krauthamer said he expects the FDA to take regulatory action against the AGGA, including sending a warning letter to the manufacturer and potentially taking custody of the devices.
“At this point, I would be surprised if there wasn’t some sort of compliance action, such as a seizure,” Krauthamer said, adding later, “I think that’s probably where the FDA is — trying to make a case that will hold in court and won’t be thrown out.”
Jeffrey Oberlies, an attorney for AGGA manufacturer Johns Dental Laboratories, said in an email that the company “looks forward to resolving the allegations against it” and declined to comment on the AGGA or the FDA’s interest in the device.
Galella said in his deposition he personally used the AGGA on more than 600 patients and has for years trained other dentists how to use the appliance. In video footage of one training session, produced in discovery in an AGGA lawsuit, Galella said the device puts pressure on a patient’s palate and causes an adult’s jaw to “remodel” forward, making them more attractive and “curing” common ailments like sleep apnea and temporomandibular joint disorder, or TMJ.
“It’s OK to make a crapload of money,” Galella told dentists in the video. “You’re not ripping anybody off. You’re curing them. You’re helping them. You’re making their life totally beautiful forever and ever.”
Dentists across the country have drawn from Galella’s teachings on their websites, often saying the AGGA can “grow,” “remodel,” or “expand” an adult’s jaw without surgery. At least 11 of those dentists’ websites appear to have removed any mention of the AGGA since the KHN-CBS News investigation was published March 1.
“I think that’s good to hear,” said Boja Kragulj, a former professional clarinetist who has alleged in a lawsuit that the AGGA did catastrophic harm to her teeth. “I think when you take away this information from patients that are searching for the appliance and seeing these claims, that’s generally a good thing.”
Kragulj is one of at least 20 AGGA patients who have in the past three years filed lawsuits against Galella and other defendants claiming the AGGA did not — and cannot — work. The plaintiffs allege that instead of expanding their jawbones, the AGGA left them with damaged gums, loose teeth, and eroded bone.
Some allege in lawsuits they will lose teeth because of the device and added in interviews that they no longer have enough healthy bone to replace those teeth with dental implants.
“I can take my finger now and I can literally wiggle my front teeth,” said Melanie Pappalardi, 28, who said she wore an AGGA for a year and filed a lawsuit in Indiana. “I can’t bite into absolutely anything.”
The plaintiffs do not allege in their lawsuits that Galella treated them but that he or his company consulted with each of their dentists about their AGGA treatment.
Galella has declined to be interviewed by KHN and CBS News. His attorney, Alan Fumuso, has said in a written statement that the AGGA “is safe and can achieve beneficial results.”
All the AGGA lawsuits are ongoing. Attorneys for Galella and his company, the Facial Beauty Institute, have denied liability in court filings. Johns Dental Laboratories settled one lawsuit for an undisclosed amount but continues to fight allegations in the other cases. The Las Vegas Institute, which previously held AGGA classes for dentists and promoted the device on Facebook, denied liability in court and has a pending motion to end claims in one lawsuit in which it is named as a defendant.
In a sworn deposition filed in that lawsuit, Las Vegas Institute CEO Dr. Bill Dickerson said that in 2020 he began to question the claims about what the AGGA could accomplish, then severed all ties with Galella.
However, that same year the Las Vegas Institute pivoted to the Anterior Remodeling Appliance, or ARA, according to Facebook posts by Dickerson. Dickerson has said in multiple Facebook posts over the past three years that the AGGA and ARA are very similar, including in a June 2021 post that described ARA as “almost exactly the same appliance.” He also said that most dentists associated with the Las Vegas Institute have switched to the ARA, which is made by a different dental laboratory than AGGA’s manufacturer.
“Different lab. Same thing,” Dickerson said in another Facebook post.
The Las Vegas Institute did not respond to requests for comment on the ARA. Institute attorney William Schuller has previously declined to discuss the ARA.
Dental specialists who have warned about the AGGA said they are also alarmed by the ARA.
Dr. Kasey Li, a California maxillofacial surgeon, and Dr. George Mandelaris, a Chicago-area periodontist, each of whom have said they’ve examined multiple patients harmed by the AGGA, said after looking at a photo of the ARA from the manufacturer’s website, it appears to be very similar to the AGGA.
“It is very similar to the AGGA,” Mandelaris said in an email. “Almost identical.”
In the wake of a joint investigation by KHN and CBS News into a dental appliance that multiple lawsuits allege caused grievous harm to patients, the FDA has begun looking into the product, the Anterior Growth Guidance Appliance, or AGGA, according to a former agency official.
Additionally, KHN and CBS News have learned that the Las Vegas Institute, a training company that previously taught dentists to use the AGGA, now trains dentists to use another device it has described as “almost exactly the same appliance.” That one is called the Anterior Remodeling Appliance, or ARA.
The FDA’s interest in the AGGA was revealed by Cara Tenenbaum, a former senior policy adviser in the agency’s device center who has said the FDA should investigate the product, which has been fitted on more than 10,000 dental patients, according to court records.
Tenenbaum said that after KHN and CBS News published their report, she was contacted by “very concerned” FDA officials who said they have begun “looking into” the AGGA but have yet to determine how much legal authority the agency has to regulate it.
“The FDA is looking at what authorities they may have around this device — what they may be able to do,” Tenenbaum said. “Now, of course, whether or not this device is FDA regulated, it still needs to be safe.”
KHN and CBS News have reviewed online messages verifying that an FDA official has communicated with Tenenbaum about the AGGA. The FDA declined to comment on the AGGA or confirm whether it was evaluating the device.
The KHN-CBS News investigation of the AGGA involved interviews with 11 patients who said they were hurt by the device — plus attorneys who said they represent or have represented at least 23 others — and dental specialists who said they’d examined patients who had experienced severe complications using the AGGA. The investigation also found no record of the AGGA being registered with the FDA, despite the agency’s role in regulating medical and dental devices.
The AGGA’s inventor, Tennessee dentist Dr. Steve Galella, has said in a sworn court deposition that the device was never submitted to the FDA, which he believes doesn’t have jurisdiction over it. Tenenbaum has said the lack of registration is “incredibly problematic” because that is one method by which the FDA collects reports of a device’s negative effects.
She encouraged anyone who has witnessed complications from the AGGA to assist the FDA by submitting a report through its MedWatch portal.
“Whether that’s a dentist, an orthodontist, a surgeon, a patient, family member, or caregiver,” Tenenbaum said, “anyone can and should submit these reports so the FDA has a better understanding of what’s happening.”
Victor Krauthamer, a former FDA official who worked in a division regulating medical devices at the agency for three decades, said it was normal for an FDA probe of a device to begin by researching the boundaries of the agency’s authority, ensuring any future action has a solid legal foundation.
Krauthamer said he expects the FDA to take regulatory action against the AGGA, including sending a warning letter to the manufacturer and potentially taking custody of the devices.
“At this point, I would be surprised if there wasn’t some sort of compliance action, such as a seizure,” Krauthamer said, adding later, “I think that’s probably where the FDA is — trying to make a case that will hold in court and won’t be thrown out.”
Jeffrey Oberlies, an attorney for AGGA manufacturer Johns Dental Laboratories, said in an email that the company “looks forward to resolving the allegations against it” and declined to comment on the AGGA or the FDA’s interest in the device.
Galella said in his deposition he personally used the AGGA on more than 600 patients and has for years trained other dentists how to use the appliance. In video footage of one training session, produced in discovery in an AGGA lawsuit, Galella said the device puts pressure on a patient’s palate and causes an adult’s jaw to “remodel” forward, making them more attractive and “curing” common ailments like sleep apnea and temporomandibular joint disorder, or TMJ.
“It’s OK to make a crapload of money,” Galella told dentists in the video. “You’re not ripping anybody off. You’re curing them. You’re helping them. You’re making their life totally beautiful forever and ever.”
Dentists across the country have drawn from Galella’s teachings on their websites, often saying the AGGA can “grow,” “remodel,” or “expand” an adult’s jaw without surgery. At least 11 of those dentists’ websites appear to have removed any mention of the AGGA since the KHN-CBS News investigation was published March 1.
“I think that’s good to hear,” said Boja Kragulj, a former professional clarinetist who has alleged in a lawsuit that the AGGA did catastrophic harm to her teeth. “I think when you take away this information from patients that are searching for the appliance and seeing these claims, that’s generally a good thing.”
Kragulj is one of at least 20 AGGA patients who have in the past three years filed lawsuits against Galella and other defendants claiming the AGGA did not — and cannot — work. The plaintiffs allege that instead of expanding their jawbones, the AGGA left them with damaged gums, loose teeth, and eroded bone.
Some allege in lawsuits they will lose teeth because of the device and added in interviews that they no longer have enough healthy bone to replace those teeth with dental implants.
“I can take my finger now and I can literally wiggle my front teeth,” said Melanie Pappalardi, 28, who said she wore an AGGA for a year and filed a lawsuit in Indiana. “I can’t bite into absolutely anything.”
The plaintiffs do not allege in their lawsuits that Galella treated them but that he or his company consulted with each of their dentists about their AGGA treatment.
Galella has declined to be interviewed by KHN and CBS News. His attorney, Alan Fumuso, has said in a written statement that the AGGA “is safe and can achieve beneficial results.”
All the AGGA lawsuits are ongoing. Attorneys for Galella and his company, the Facial Beauty Institute, have denied liability in court filings. Johns Dental Laboratories settled one lawsuit for an undisclosed amount but continues to fight allegations in the other cases. The Las Vegas Institute, which previously held AGGA classes for dentists and promoted the device on Facebook, denied liability in court and has a pending motion to end claims in one lawsuit in which it is named as a defendant.
In a sworn deposition filed in that lawsuit, Las Vegas Institute CEO Dr. Bill Dickerson said that in 2020 he began to question the claims about what the AGGA could accomplish, then severed all ties with Galella.
However, that same year the Las Vegas Institute pivoted to the Anterior Remodeling Appliance, or ARA, according to Facebook posts by Dickerson. Dickerson has said in multiple Facebook posts over the past three years that the AGGA and ARA are very similar, including in a June 2021 post that described ARA as “almost exactly the same appliance.” He also said that most dentists associated with the Las Vegas Institute have switched to the ARA, which is made by a different dental laboratory than AGGA’s manufacturer.
“Different lab. Same thing,” Dickerson said in another Facebook post.
The Las Vegas Institute did not respond to requests for comment on the ARA. Institute attorney William Schuller has previously declined to discuss the ARA.
Dental specialists who have warned about the AGGA said they are also alarmed by the ARA.
Dr. Kasey Li, a California maxillofacial surgeon, and Dr. George Mandelaris, a Chicago-area periodontist, each of whom have said they’ve examined multiple patients harmed by the AGGA, said after looking at a photo of the ARA from the manufacturer’s website, it appears to be very similar to the AGGA.
“It is very similar to the AGGA,” Mandelaris said in an email. “Almost identical.”
Jessica Layman estimates she has called more than 150 doctors in the past few years in her search for someone to prescribe opioids for her chronic pain.
“A lot of them are straight-up insulting,” said the 40-year-old, who lives in Dallas. “They say things like ‘We don’t treat drug addicts.’”
Layman has tried a host of non-opioid treatments to help with the intense daily pain caused by double scoliosis, a collapsed spinal disc, and facet joint arthritis. But she said nothing worked as well as methadone, an opioid she has taken since 2013.
The latest phone calls came late last year, after her previous doctor shuttered his pain medicine practice, she said. She hopes her current doctor won’t do the same. “If something should happen to him, there’s nowhere for me to go,” she said.
Layman is one of the millions in the U.S. living with chronic pain. Many have struggled to get opioid prescriptions written and filled since 2016 guidelines from the Centers for Disease Control and Prevention inspired laws cracking down on doctor and pharmacy practices. The CDC recently updated those recommendations to try to ease their impact, but doctors, patients, researchers, and advocates say the damage is done.
“We had a massive opioid problem that needed to be rectified,” said Antonio Ciaccia, president of 3 Axis Advisors, a consulting firm that analyzes prescription drug pricing. “But the federal crackdowns and guidelines have created collateral damage: patients left high and dry.”
Born of an effort to fight the nation’s overdose crisis, the guidance led to legal restrictions on doctors’ ability to prescribe painkillers. The recommendations left many patients grappling with the mental and physical health consequences of rapid dose tapering or abruptly stopping medication they’d been taking for years, which carries risks of withdrawal, depression, anxiety, and even suicide.
In November, the agency released new guidelines, encouraging physicians to focus on the individual needs of patients. While the guidelines still say opioids should not be the go-to option for pain, they ease recommendations about dose limits, which were widely viewed as hard rules in the CDC’s 2016 guidance. The new standards also warn doctors about risks associated with rapid dose changes after long-term use.
But some doctors worry the new recommendations will take a long time to make a meaningful change — and may be too little, too late for some patients. The reasons include a lack of coordination from other federal agencies, fear of legal consequences among providers, state policymakers hesitant to tweak laws, and widespread stigma surrounding opioid medication.
The 2016 guidelines for prescribing opioids to people with chronic pain filled a vacuum for state officials searching for solutions to the overdose crisis, said Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School.
The dozens of laws that states passed limiting how providers prescribe or dispense those medications, she said, had an effect: a decline in opioid prescriptions even as overdoses continued to climb.
The first CDC guidelines “put everybody on notice,’’ said Dr. Bobby Mukkamala, chair of the American Medical Association’s Substance Use and Pain Care Task Force. Physicians reduced the number of opioid pills they prescribe after surgeries, he said. The 2022 revisions are “a dramatic change,” he said.
The human toll of the opioid crisis is hard to overstate. Opioid overdose deaths have risen steadily in the U.S. in the past two decades, with a spike early in the covid-19 pandemic. The CDC says illicit fentanyl has fueled a recent surge in overdose deaths.
Taking into account the perspective of chronic pain patients, the latest recommendations try to scale back some of the harms to people who had benefited from opioids but were cut off, said Dr. Jeanmarie Perrone, director of the Penn Medicine Center for Addiction Medicine and Policy.
“I hope we just continue to spread caution without spreading too much fear about never using opioids,” said Perrone, who helped craft the CDC’s latest recommendations.
Christopher Jones, director of the CDC’s National Center for Injury Prevention and Control, said the updated recommendations are not a regulatory mandate but only a tool to help doctors “make informed, person-centered decisions related to pain care.”
Multiple studies question whether opioids are the most effective way to treat chronic pain in the long term. But drug tapering is associated with deaths from overdose and suicide, with risk increasing the longer a person had been taking opioids, according to research by Dr. Stefan Kertesz, a professor of medicine at the University of Alabama-Birmingham.
He said the new CDC guidance reflects “an extraordinary amount of input” from chronic pain patients and their doctors but doubts it will have much of an impact if the FDA and the Drug Enforcement Administration don’t change how they enforce federal laws.
The FDA approves new drugs and their reformulations, but the guidance it provides for how to start or wean patients could urge clinicians to do so with caution, Kertesz said. The DEA, which investigates physicians suspected of illegally prescribing opioids, declined to comment.
The DEA’s pursuit of doctors put Danny Elliott of Warner Robins, Georgia, in a horrible predicament, said his brother, Jim.
In 1991, Danny, a pharmaceutical company rep, suffered an electric shock. He took pain medicine for the resulting brain injury for years until his doctor faced federal charges of illegally dispensing prescription opioids, Jim said.
Danny turned to doctors out of state — first in Texas and then in California. But Danny’s latest physician had his license suspended by the DEA last year, and he couldn’t find a new doctor who would prescribe those medications, Jim said.
Danny, 61, and his wife, Gretchen, 59, died by suicide in November. “I’m really frustrated and angry about pain patients being cut off,” Jim said.
Danny became an advocate against forced drug tapering before he died. Chronic pain patients who spoke with KHN pointed to his plight in calling for more access to opioid medications.
Even for people with prescriptions, it’s not always easy to get the drugs they need.
Pharmacy chains and drug wholesalers have settled lawsuits for billions of dollars over their alleged role in the opioid crisis. Some pharmacies have seen their opioid allocations limited or cut off, noted Ciaccia, with 3 Axis Advisors.
Rheba Smith, 61, of Atlanta, said that in December her pharmacy stopped filling her prescriptions for Percocet and MS Contin. She had taken those opioid medications for years to manage chronic pain after her iliac nerve was mistakenly cut during surgery, she said.
Smith said she visited nearly two dozen pharmacies in early January but could not find one that would fill her prescriptions. She finally found a local mail-order pharmacy that filled a one-month supply of Percocet. But now that drug and MS Contin are not available, the pharmacy told her.
“It has been a horrible three months. I have been in terrible pain,” Smith said.
Many patients fear a future of constant pain. Layman thinks about the lengths she’d go to in order to get medication.
“Would you be willing to buy drugs off the street? Would you be willing to go to an addiction clinic and try to get pain treatment there? What are you willing to do to stay alive?” she said. “That is what it comes down to.”
Jessica Layman estimates she has called more than 150 doctors in the past few years in her search for someone to prescribe opioids for her chronic pain.
“A lot of them are straight-up insulting,” said the 40-year-old, who lives in Dallas. “They say things like ‘We don’t treat drug addicts.’”
Layman has tried a host of non-opioid treatments to help with the intense daily pain caused by double scoliosis, a collapsed spinal disc, and facet joint arthritis. But she said nothing worked as well as methadone, an opioid she has taken since 2013.
The latest phone calls came late last year, after her previous doctor shuttered his pain medicine practice, she said. She hopes her current doctor won’t do the same. “If something should happen to him, there’s nowhere for me to go,” she said.
Layman is one of the millions in the U.S. living with chronic pain. Many have struggled to get opioid prescriptions written and filled since 2016 guidelines from the Centers for Disease Control and Prevention inspired laws cracking down on doctor and pharmacy practices. The CDC recently updated those recommendations to try to ease their impact, but doctors, patients, researchers, and advocates say the damage is done.
“We had a massive opioid problem that needed to be rectified,” said Antonio Ciaccia, president of 3 Axis Advisors, a consulting firm that analyzes prescription drug pricing. “But the federal crackdowns and guidelines have created collateral damage: patients left high and dry.”
Born of an effort to fight the nation’s overdose crisis, the guidance led to legal restrictions on doctors’ ability to prescribe painkillers. The recommendations left many patients grappling with the mental and physical health consequences of rapid dose tapering or abruptly stopping medication they’d been taking for years, which carries risks of withdrawal, depression, anxiety, and even suicide.
In November, the agency released new guidelines, encouraging physicians to focus on the individual needs of patients. While the guidelines still say opioids should not be the go-to option for pain, they ease recommendations about dose limits, which were widely viewed as hard rules in the CDC’s 2016 guidance. The new standards also warn doctors about risks associated with rapid dose changes after long-term use.
But some doctors worry the new recommendations will take a long time to make a meaningful change — and may be too little, too late for some patients. The reasons include a lack of coordination from other federal agencies, fear of legal consequences among providers, state policymakers hesitant to tweak laws, and widespread stigma surrounding opioid medication.
The 2016 guidelines for prescribing opioids to people with chronic pain filled a vacuum for state officials searching for solutions to the overdose crisis, said Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School.
The dozens of laws that states passed limiting how providers prescribe or dispense those medications, she said, had an effect: a decline in opioid prescriptions even as overdoses continued to climb.
The first CDC guidelines “put everybody on notice,’’ said Dr. Bobby Mukkamala, chair of the American Medical Association’s Substance Use and Pain Care Task Force. Physicians reduced the number of opioid pills they prescribe after surgeries, he said. The 2022 revisions are “a dramatic change,” he said.
The human toll of the opioid crisis is hard to overstate. Opioid overdose deaths have risen steadily in the U.S. in the past two decades, with a spike early in the covid-19 pandemic. The CDC says illicit fentanyl has fueled a recent surge in overdose deaths.
Taking into account the perspective of chronic pain patients, the latest recommendations try to scale back some of the harms to people who had benefited from opioids but were cut off, said Dr. Jeanmarie Perrone, director of the Penn Medicine Center for Addiction Medicine and Policy.
“I hope we just continue to spread caution without spreading too much fear about never using opioids,” said Perrone, who helped craft the CDC’s latest recommendations.
Christopher Jones, director of the CDC’s National Center for Injury Prevention and Control, said the updated recommendations are not a regulatory mandate but only a tool to help doctors “make informed, person-centered decisions related to pain care.”
Multiple studies question whether opioids are the most effective way to treat chronic pain in the long term. But drug tapering is associated with deaths from overdose and suicide, with risk increasing the longer a person had been taking opioids, according to research by Dr. Stefan Kertesz, a professor of medicine at the University of Alabama-Birmingham.
He said the new CDC guidance reflects “an extraordinary amount of input” from chronic pain patients and their doctors but doubts it will have much of an impact if the FDA and the Drug Enforcement Administration don’t change how they enforce federal laws.
The FDA approves new drugs and their reformulations, but the guidance it provides for how to start or wean patients could urge clinicians to do so with caution, Kertesz said. The DEA, which investigates physicians suspected of illegally prescribing opioids, declined to comment.
The DEA’s pursuit of doctors put Danny Elliott of Warner Robins, Georgia, in a horrible predicament, said his brother, Jim.
In 1991, Danny, a pharmaceutical company rep, suffered an electric shock. He took pain medicine for the resulting brain injury for years until his doctor faced federal charges of illegally dispensing prescription opioids, Jim said.
Danny turned to doctors out of state — first in Texas and then in California. But Danny’s latest physician had his license suspended by the DEA last year, and he couldn’t find a new doctor who would prescribe those medications, Jim said.
Danny, 61, and his wife, Gretchen, 59, died by suicide in November. “I’m really frustrated and angry about pain patients being cut off,” Jim said.
Danny became an advocate against forced drug tapering before he died. Chronic pain patients who spoke with KHN pointed to his plight in calling for more access to opioid medications.
Even for people with prescriptions, it’s not always easy to get the drugs they need.
Pharmacy chains and drug wholesalers have settled lawsuits for billions of dollars over their alleged role in the opioid crisis. Some pharmacies have seen their opioid allocations limited or cut off, noted Ciaccia, with 3 Axis Advisors.
Rheba Smith, 61, of Atlanta, said that in December her pharmacy stopped filling her prescriptions for Percocet and MS Contin. She had taken those opioid medications for years to manage chronic pain after her iliac nerve was mistakenly cut during surgery, she said.
Smith said she visited nearly two dozen pharmacies in early January but could not find one that would fill her prescriptions. She finally found a local mail-order pharmacy that filled a one-month supply of Percocet. But now that drug and MS Contin are not available, the pharmacy told her.
“It has been a horrible three months. I have been in terrible pain,” Smith said.
Many patients fear a future of constant pain. Layman thinks about the lengths she’d go to in order to get medication.
“Would you be willing to buy drugs off the street? Would you be willing to go to an addiction clinic and try to get pain treatment there? What are you willing to do to stay alive?” she said. “That is what it comes down to.”
Diego nunca imaginó que portaría un arma.
No lo pensó cuando niño, o durante un tiroteo fuera de su casa en el área de Chicago. Tampoco a los 12 años, cuando uno de sus amigos fue baleado.
La mente de Diego cambió a los 14, cuando él y sus amigos estaban listos para ir a la vigilia de Nuestra Señora de Guadalupe. Esa noche, en lugar de cánticos religiosos, escuchó disparos y gritos. Un pandillero le había disparado a dos personas, una de ellas un amigo suyo, quien recibió nueve balazos.
“Mi amigo se estaba desangrando”, dijo Diego, quien le pidió a KHN no utilizar su apellido para proteger su seguridad y privacidad. Mientras su amigo yacía en el suelo, “se estaba ahogando en su propia sangre”.
El ataque dejó al amigo de Diego paralizado de la cintura para abajo. Y a Diego, uno de un número creciente de adolescentes que son testigos de la violencia armada, traumatizado y con miedo de salir a la calle sin un arma.
Investigaciones muestran que los adolescentes expuestos a la violencia armada tienen el doble de probabilidades que otros de cometer un delito violento grave dentro de los dos años luego del trauma, lo que perpetúa un ciclo difícil de romper.
Diego pidió ayuda a sus amigos para tener una pistola y, en un país sobrecargado con armas de fuego, no tuvieron problemas para conseguirle una, que le dieron gratis.
“Me sentí más seguro con el arma”, dijo Diego, que ahora tiene 21 años. “Esperaba no usarla”.
Durante dos años, Diego mantuvo el arma solo como elemento de disuasión. Cuando finalmente apretó el gatillo, cambió su vida para siempre.
Tendencias inquietantes
Los medios de comunicación se centran en gran medida en los tiroteos masivos y el estado mental de las personas que los cometen.
Pero hay una epidemia mucho mayor de violencia armada —particularmente entre los jóvenes negros no hispanos, hispanos (que pueden ser de cualquier raza) y nativos americanos— que atrapa a muchos que ni siquiera tienen edad suficiente para obtener una licencia de conducir.
Estudios muestran que la exposición crónica al trauma puede cambiar la forma en que se desarrolla el cerebro de un niño. El trauma también puede desempeñar un papel central en la explicación de por qué algunos jóvenes buscan protección en las armas y terminan usándolas contra sus compañeros.
La cantidad de niños menores de 18 años que mataron a alguien con un arma de fuego aumentó de 836 en 2019 a 1,150 en 2020.
En la ciudad de Nueva York, la cantidad de jóvenes que mataron a alguien con un arma aumentó más del doble, pasando de 48 delincuentes juveniles en 2019 a 124 en 2022, según datos del departamento de policía de la ciudad.
La violencia armada juvenil aumentó más modestamente en otras ciudades; en muchos lugares, la cantidad de homicidios de adolescentes con armas de fuego subió en 2020, pero desde entonces se ha acercado a los niveles previos a la pandemia.
Investigadores que analizan las estadísticas del crimen enfatizan que los adolescentes no están impulsando el aumento general de la violencia armada, que ha aumentado en todas las edades. En 2020, el 7,5% de los arrestos por homicidio involucraron a menores de 18 años, una proporción ligeramente menor que en años anteriores.
A líderes locales les cuesta encontrar la mejor manera de responder a los tiroteos adolescentes.
Un puñado de comunidades, incluidas Pittsburgh; el condado de Fulton, en Georgia; y el condado de Prince George, en Maryland, han debatido o implementado toques de queda juveniles para frenar la violencia adolescente. Lo que no está en discusión: más personas de 1 a 19 años mueren por violencia armada que por cualquier otra causa.
Una vida de límites
El número devastador de la violencia armada se revela a diario en las salas de emergencia.
En el centro de trauma de UChicago Medicine, la cantidad de heridas de bala en menores de 16 años se ha duplicado en los últimos seis años, dijo el doctor Selwyn Rogers, director fundador del centro. La víctima más joven tenía 2 años.
“Escuchas a la madre gemir o al hermano decir: ‘No es cierto’”, dijo Rogers, quien trabaja con jóvenes locales como vicepresidente ejecutivo del hospital para salud comunitaria. “Tienes que estar presente en ese momento, pero luego salir por la puerta y lidiar con todo de nuevo”.
En los últimos años, el sistema judicial ha luchado por equilibrar la necesidad de seguridad pública con la compasión por los menores, según investigaciones que muestran que el cerebro de una persona joven no madura por completo hasta los 25 años.
La mayoría de los delincuentes jóvenes “superan la edad” del comportamiento delictivo o violento casi al mismo tiempo, a medida que desarrollan más autocontrol y habilidades de pensamiento de largo alcance.
Sin embargo, los adolescentes acusados de tiroteos a menudo son enjuiciados como adultos, lo que significa que enfrentan castigos más severos, dijo Josh Rovner, director de justicia juvenil en Sentencing Project, que aboga por la reforma del sistema judicial.
En 2019, aproximadamente 53,000 menores fueron acusados como adultos, lo que puede tener graves repercusiones para la salud. Estos adolescentes tienen más probabilidades de ser victimizados mientras están presos, dijo Rovner, y de ser arrestados nuevamente después de quedar libres.
Los jóvenes pueden pasar gran parte de sus vidas en un “aislamiento” impuesto por la pobreza, sin aventurarse más allá de sus vecindarios, aprendiendo poco sobre las oportunidades que existen en el resto del mundo, dijo Rogers. Millones de niños estadounidenses, en particular niños negros no hispanos, latinos y nativos americanos, viven en entornos plagados de pobreza, violencia y consumo de drogas.
La pandemia de covid-19 amplificó todos esos problemas, desde el desempleo hasta la inseguridad alimentaria y de vivienda.
Aunque nadie puede decir con certeza qué provocó el aumento de tiroteos en 2020, la investigación ha relacionado durante mucho tiempo la desesperanza y la falta de confianza en la policía, que aumentó después del asesinato de George Floyd ese año, con un mayor riesgo de violencia comunitaria.
Las ventas de armas se dispararon un 64% entre 2019 y 2020, mientras que se cancelaron muchos programas de prevención de la violencia.
Una de las pérdidas más graves que enfrentaron los niños durante la pandemia fue el cierre de las escuelas durante un año o más, justamente las instituciones que proporcionan tal vez la única fuerza estabilizadora en sus jóvenes vidas.
“La pandemia encendió el fuego debajo de la olla”, dijo Elise White, subdirectora de investigación Center for Justice Innovation, un entidad sin fines de lucro que trabaja con comunidades y sistemas de justicia. “Mirando hacia atrás, es fácil restar importancia ahora a lo incierto que se sintió ese momento [de la pandemia]. Cuanto más insegura se sienta la gente, cuanto más sientan que no hay seguridad a su alrededor, más probable es que porten armas”.
Por supuesto, la mayoría de los niños que experimentan dificultades nunca infringen la ley. Múltiples estudios han encontrado que la mayor parte de la violencia armada es perpetrada por un número relativamente pequeño de personas.
Incluso la presencia de un adulto solidario puede proteger a los niños de involucrarse en la delincuencia, explicó el doctor Abdullah Pratt, médico de emergencias de UChicago Medicine que perdió a su hermano por la violencia con armas de fuego.
Pratt también perdió a cuatro amigos por la violencia con armas durante la pandemia. Los cuatro murieron en su sala de emergencias; uno era el hijo de una enfermera del hospital.
Aunque Pratt creció en una parte de Chicago donde las pandillas callejeras eran comunes, se benefició del apoyo de padres amorosos y fuertes modelos a seguir, como maestros y entrenadores de fútbol americano. A Pratt también lo protegió su hermano mayor, quien lo cuidaba y se aseguraba de que las pandillas dejaran en paz al futuro médico.
“Todo lo que he podido lograr”, dijo Pratt, “es porque alguien me ayudó”.
Crecer en una “zona de guerra”
Diego no tenía adultos en casa que lo ayudaran a sentirse seguro.
A menudo, sus propios padres eran violentos. Una vez, en un ataque de ira por la borrachera, su padre lo agarró por la pierna y lo zarandeó por la habitación, contó Diego; y su madre una vez le arrojó una tostadora a su padre.
A los 12 años, los esfuerzos de Diego para ayudar a la familia a pagar las facturas atrasadas —vendiendo marihuana, y robando autos y apartamentos— llevaron a su padre a echarlo de la casa.
A los 13 años, Diego se unió a una pandilla del barrio. Los pandilleros, que contaron historias similares sobre huir del hogar para escapar del abuso, le dieron comida y un lugar para quedarse. “Éramos como una familia”, dijo Diego. Cuando tenían hambre y no había comida en casa, “íbamos juntos a una gasolinera a robar algo de desayuno”.
Pero Diego, que era más pequeño que la mayoría de los demás, vivía con miedo. A los 16, pesaba solo 100 libras. Los chicos más grandes lo intimidaban y lo golpeaban. Y su exitosa actividad, vender mercadería robada en la calle por dinero en efectivo, llamó la atención de pandilleros rivales, quienes amenazaron con robarle.
Los niños que experimentan violencia crónica pueden desarrollar una “mentalidad de zona de guerra”, volviéndose hipervigilantes ante las amenazas, a veces sintiendo peligro donde no existe, dijo James Garbarino, profesor emérito de psicología en la Universidad de Cornell y la Universidad de Loyola-Chicago.
Los niños que viven con miedo constante tienen más probabilidades de buscar protección en las armas de fuego o en las pandillas. Se puede activar para que tomen medidas preventivas, como disparar un arma sin pensar, contra lo que perciben como una amenaza.
“Sus cuerpos están constantemente listos para pelear”, dijo Gianna Tran, subdirectora ejecutiva del East Bay Asian Youth Center en Oakland, California, que trabaja con jóvenes en riesgo.
A diferencia de los perpetradores de tiroteos masivos, que compran armas y municiones porque tienen la intención de asesinar, la mayor parte de la violencia adolescente no es premeditada, dijo Garbarino.
En las encuestas, la mayoría de los jóvenes que portan armas, incluidos los pandilleros, dicen que lo hacen por miedo o para disuadir ataques, en lugar de perpetrarlos. Pero el miedo a la violencia comunitaria, tanto de los rivales como de la policía, puede avivar una carrera armamentista urbana, en la que los menores sienten que solo los tontos no portan armas.
“Fundamentalmente, la violencia es una enfermedad contagiosa”, dijo el doctor Gary Slutkin, fundador de Cure Violence Global, que trabaja para prevenir la violencia comunitaria.
Aunque un pequeño número de adolescentes se vuelven duros y despiadados, Pratt dijo que ve muchos más tiroteos causados por la “pobre resolución de un conflicto” y la impulsividad de los adolescentes en lugar de un deseo de matar.
De hecho, las armas de fuego y un cerebro adolescente inmaduro son una mezcla peligrosa, enfatizó Garbarino. El alcohol y las drogas pueden aumentar el riesgo. Cuando se enfrentan a una situación potencialmente de vida o muerte, pueden actuar sin pensar.
Cuando Diego tenía 16 años, estaba acompañando a una niña a la escuela y se les acercaron tres jóvenes, incluido un pandillero, quien, usando un lenguaje obsceno y amenazante, le preguntó a Diego si también estaba en una pandilla. Diego dijo que trató de pasar de largo, y uno de ellos parecía tener un arma.
“No sabía cómo disparar un arma”, dijo Diego. “Solo quería que huyeran”.
En las noticias sobre el tiroteo, testigos dijeron que escucharon cinco disparos. “Lo único que recuerdo es el sonido de los disparos”, dijo Diego. “Todo lo demás fue en cámara lenta”.
Diego había disparado a dos de los muchachos en las piernas. La niña corrió por un lado y él por otro. La policía lo arrestó en su casa unas horas después. Fue juzgado como adulto, condenado por dos cargos de intento de homicidio y sentenciado a 12 años.
Una segunda oportunidad
En las últimas dos décadas, el sistema judicial ha realizado cambios importantes en la forma en que trata a los niños.
Los arrestos de jóvenes por delitos violentos bajaron dramáticamente un 67% entre 2006 y 2020, y 40 estados han hecho que sea más difícil acusar a menores como adultos.
Los estados también están adoptando alternativas a la cárcel, como hogares grupales que permiten a los adolescentes permanecer en sus comunidades, al tiempo que brindan tratamiento para ayudarlos a cambiar su conducta.
Debido a que Diego tenía 17 años cuando fue sentenciado, fue enviado a un centro de menores, donde recibió terapia por primera vez.
Diego terminó la escuela secundaria mientras estaba tras las rejas, y obtuvo un título de un colegio comunitario. Con otros jóvenes reclusos fue de excursión a teatros y al acuario, lugares en los que nunca había estado. La directora del centro de detención le pidió que la acompañara a eventos sobre la reforma de la justicia juvenil, donde lo invitaron a contar su historia.
Para Diego, esas fueron experiencias reveladoras: se dio cuenta de que había visto muy poco de Chicago, a pesar de que había pasado su vida allí.
“Mientras estás creciendo, lo único que ves es a tu comunidad”, dijo Diego, quien fue liberado después de cuatro años, cuando el gobernador conmutó su sentencia. “Asumes que el mundo entero es así”.
La editora de datos de KHN Holly K. Hacker y la investigadora Megan Kalata contribuyeron con este informe.
Diego nunca imaginó que portaría un arma.
No lo pensó cuando niño, o durante un tiroteo fuera de su casa en el área de Chicago. Tampoco a los 12 años, cuando uno de sus amigos fue baleado.
La mente de Diego cambió a los 14, cuando él y sus amigos estaban listos para ir a la vigilia de Nuestra Señora de Guadalupe. Esa noche, en lugar de cánticos religiosos, escuchó disparos y gritos. Un pandillero le había disparado a dos personas, una de ellas un amigo suyo, quien recibió nueve balazos.
“Mi amigo se estaba desangrando”, dijo Diego, quien le pidió a KHN no utilizar su apellido para proteger su seguridad y privacidad. Mientras su amigo yacía en el suelo, “se estaba ahogando en su propia sangre”.
El ataque dejó al amigo de Diego paralizado de la cintura para abajo. Y a Diego, uno de un número creciente de adolescentes que son testigos de la violencia armada, traumatizado y con miedo de salir a la calle sin un arma.
Investigaciones muestran que los adolescentes expuestos a la violencia armada tienen el doble de probabilidades que otros de cometer un delito violento grave dentro de los dos años luego del trauma, lo que perpetúa un ciclo difícil de romper.
Diego pidió ayuda a sus amigos para tener una pistola y, en un país sobrecargado con armas de fuego, no tuvieron problemas para conseguirle una, que le dieron gratis.
“Me sentí más seguro con el arma”, dijo Diego, que ahora tiene 21 años. “Esperaba no usarla”.
Durante dos años, Diego mantuvo el arma solo como elemento de disuasión. Cuando finalmente apretó el gatillo, cambió su vida para siempre.
Tendencias inquietantes
Los medios de comunicación se centran en gran medida en los tiroteos masivos y el estado mental de las personas que los cometen.
Pero hay una epidemia mucho mayor de violencia armada —particularmente entre los jóvenes negros no hispanos, hispanos (que pueden ser de cualquier raza) y nativos americanos— que atrapa a muchos que ni siquiera tienen edad suficiente para obtener una licencia de conducir.
Estudios muestran que la exposición crónica al trauma puede cambiar la forma en que se desarrolla el cerebro de un niño. El trauma también puede desempeñar un papel central en la explicación de por qué algunos jóvenes buscan protección en las armas y terminan usándolas contra sus compañeros.
La cantidad de niños menores de 18 años que mataron a alguien con un arma de fuego aumentó de 836 en 2019 a 1,150 en 2020.
En la ciudad de Nueva York, la cantidad de jóvenes que mataron a alguien con un arma aumentó más del doble, pasando de 48 delincuentes juveniles en 2019 a 124 en 2022, según datos del departamento de policía de la ciudad.
La violencia armada juvenil aumentó más modestamente en otras ciudades; en muchos lugares, la cantidad de homicidios de adolescentes con armas de fuego subió en 2020, pero desde entonces se ha acercado a los niveles previos a la pandemia.
Investigadores que analizan las estadísticas del crimen enfatizan que los adolescentes no están impulsando el aumento general de la violencia armada, que ha aumentado en todas las edades. En 2020, el 7,5% de los arrestos por homicidio involucraron a menores de 18 años, una proporción ligeramente menor que en años anteriores.
A líderes locales les cuesta encontrar la mejor manera de responder a los tiroteos adolescentes.
Un puñado de comunidades, incluidas Pittsburgh; el condado de Fulton, en Georgia; y el condado de Prince George, en Maryland, han debatido o implementado toques de queda juveniles para frenar la violencia adolescente. Lo que no está en discusión: más personas de 1 a 19 años mueren por violencia armada que por cualquier otra causa.
Una vida de límites
El número devastador de la violencia armada se revela a diario en las salas de emergencia.
En el centro de trauma de UChicago Medicine, la cantidad de heridas de bala en menores de 16 años se ha duplicado en los últimos seis años, dijo el doctor Selwyn Rogers, director fundador del centro. La víctima más joven tenía 2 años.
“Escuchas a la madre gemir o al hermano decir: ‘No es cierto’”, dijo Rogers, quien trabaja con jóvenes locales como vicepresidente ejecutivo del hospital para salud comunitaria. “Tienes que estar presente en ese momento, pero luego salir por la puerta y lidiar con todo de nuevo”.
En los últimos años, el sistema judicial ha luchado por equilibrar la necesidad de seguridad pública con la compasión por los menores, según investigaciones que muestran que el cerebro de una persona joven no madura por completo hasta los 25 años.
La mayoría de los delincuentes jóvenes “superan la edad” del comportamiento delictivo o violento casi al mismo tiempo, a medida que desarrollan más autocontrol y habilidades de pensamiento de largo alcance.
Sin embargo, los adolescentes acusados de tiroteos a menudo son enjuiciados como adultos, lo que significa que enfrentan castigos más severos, dijo Josh Rovner, director de justicia juvenil en Sentencing Project, que aboga por la reforma del sistema judicial.
En 2019, aproximadamente 53,000 menores fueron acusados como adultos, lo que puede tener graves repercusiones para la salud. Estos adolescentes tienen más probabilidades de ser victimizados mientras están presos, dijo Rovner, y de ser arrestados nuevamente después de quedar libres.
Los jóvenes pueden pasar gran parte de sus vidas en un “aislamiento” impuesto por la pobreza, sin aventurarse más allá de sus vecindarios, aprendiendo poco sobre las oportunidades que existen en el resto del mundo, dijo Rogers. Millones de niños estadounidenses, en particular niños negros no hispanos, latinos y nativos americanos, viven en entornos plagados de pobreza, violencia y consumo de drogas.
La pandemia de covid-19 amplificó todos esos problemas, desde el desempleo hasta la inseguridad alimentaria y de vivienda.
Aunque nadie puede decir con certeza qué provocó el aumento de tiroteos en 2020, la investigación ha relacionado durante mucho tiempo la desesperanza y la falta de confianza en la policía, que aumentó después del asesinato de George Floyd ese año, con un mayor riesgo de violencia comunitaria.
Las ventas de armas se dispararon un 64% entre 2019 y 2020, mientras que se cancelaron muchos programas de prevención de la violencia.
Una de las pérdidas más graves que enfrentaron los niños durante la pandemia fue el cierre de las escuelas durante un año o más, justamente las instituciones que proporcionan tal vez la única fuerza estabilizadora en sus jóvenes vidas.
“La pandemia encendió el fuego debajo de la olla”, dijo Elise White, subdirectora de investigación Center for Justice Innovation, un entidad sin fines de lucro que trabaja con comunidades y sistemas de justicia. “Mirando hacia atrás, es fácil restar importancia ahora a lo incierto que se sintió ese momento [de la pandemia]. Cuanto más insegura se sienta la gente, cuanto más sientan que no hay seguridad a su alrededor, más probable es que porten armas”.
Por supuesto, la mayoría de los niños que experimentan dificultades nunca infringen la ley. Múltiples estudios han encontrado que la mayor parte de la violencia armada es perpetrada por un número relativamente pequeño de personas.
Incluso la presencia de un adulto solidario puede proteger a los niños de involucrarse en la delincuencia, explicó el doctor Abdullah Pratt, médico de emergencias de UChicago Medicine que perdió a su hermano por la violencia con armas de fuego.
Pratt también perdió a cuatro amigos por la violencia con armas durante la pandemia. Los cuatro murieron en su sala de emergencias; uno era el hijo de una enfermera del hospital.
Aunque Pratt creció en una parte de Chicago donde las pandillas callejeras eran comunes, se benefició del apoyo de padres amorosos y fuertes modelos a seguir, como maestros y entrenadores de fútbol americano. A Pratt también lo protegió su hermano mayor, quien lo cuidaba y se aseguraba de que las pandillas dejaran en paz al futuro médico.
“Todo lo que he podido lograr”, dijo Pratt, “es porque alguien me ayudó”.
Crecer en una “zona de guerra”
Diego no tenía adultos en casa que lo ayudaran a sentirse seguro.
A menudo, sus propios padres eran violentos. Una vez, en un ataque de ira por la borrachera, su padre lo agarró por la pierna y lo zarandeó por la habitación, contó Diego; y su madre una vez le arrojó una tostadora a su padre.
A los 12 años, los esfuerzos de Diego para ayudar a la familia a pagar las facturas atrasadas —vendiendo marihuana, y robando autos y apartamentos— llevaron a su padre a echarlo de la casa.
A los 13 años, Diego se unió a una pandilla del barrio. Los pandilleros, que contaron historias similares sobre huir del hogar para escapar del abuso, le dieron comida y un lugar para quedarse. “Éramos como una familia”, dijo Diego. Cuando tenían hambre y no había comida en casa, “íbamos juntos a una gasolinera a robar algo de desayuno”.
Pero Diego, que era más pequeño que la mayoría de los demás, vivía con miedo. A los 16, pesaba solo 100 libras. Los chicos más grandes lo intimidaban y lo golpeaban. Y su exitosa actividad, vender mercadería robada en la calle por dinero en efectivo, llamó la atención de pandilleros rivales, quienes amenazaron con robarle.
Los niños que experimentan violencia crónica pueden desarrollar una “mentalidad de zona de guerra”, volviéndose hipervigilantes ante las amenazas, a veces sintiendo peligro donde no existe, dijo James Garbarino, profesor emérito de psicología en la Universidad de Cornell y la Universidad de Loyola-Chicago.
Los niños que viven con miedo constante tienen más probabilidades de buscar protección en las armas de fuego o en las pandillas. Se puede activar para que tomen medidas preventivas, como disparar un arma sin pensar, contra lo que perciben como una amenaza.
“Sus cuerpos están constantemente listos para pelear”, dijo Gianna Tran, subdirectora ejecutiva del East Bay Asian Youth Center en Oakland, California, que trabaja con jóvenes en riesgo.
A diferencia de los perpetradores de tiroteos masivos, que compran armas y municiones porque tienen la intención de asesinar, la mayor parte de la violencia adolescente no es premeditada, dijo Garbarino.
En las encuestas, la mayoría de los jóvenes que portan armas, incluidos los pandilleros, dicen que lo hacen por miedo o para disuadir ataques, en lugar de perpetrarlos. Pero el miedo a la violencia comunitaria, tanto de los rivales como de la policía, puede avivar una carrera armamentista urbana, en la que los menores sienten que solo los tontos no portan armas.
“Fundamentalmente, la violencia es una enfermedad contagiosa”, dijo el doctor Gary Slutkin, fundador de Cure Violence Global, que trabaja para prevenir la violencia comunitaria.
Aunque un pequeño número de adolescentes se vuelven duros y despiadados, Pratt dijo que ve muchos más tiroteos causados por la “pobre resolución de un conflicto” y la impulsividad de los adolescentes en lugar de un deseo de matar.
De hecho, las armas de fuego y un cerebro adolescente inmaduro son una mezcla peligrosa, enfatizó Garbarino. El alcohol y las drogas pueden aumentar el riesgo. Cuando se enfrentan a una situación potencialmente de vida o muerte, pueden actuar sin pensar.
Cuando Diego tenía 16 años, estaba acompañando a una niña a la escuela y se les acercaron tres jóvenes, incluido un pandillero, quien, usando un lenguaje obsceno y amenazante, le preguntó a Diego si también estaba en una pandilla. Diego dijo que trató de pasar de largo, y uno de ellos parecía tener un arma.
“No sabía cómo disparar un arma”, dijo Diego. “Solo quería que huyeran”.
En las noticias sobre el tiroteo, testigos dijeron que escucharon cinco disparos. “Lo único que recuerdo es el sonido de los disparos”, dijo Diego. “Todo lo demás fue en cámara lenta”.
Diego había disparado a dos de los muchachos en las piernas. La niña corrió por un lado y él por otro. La policía lo arrestó en su casa unas horas después. Fue juzgado como adulto, condenado por dos cargos de intento de homicidio y sentenciado a 12 años.
Una segunda oportunidad
En las últimas dos décadas, el sistema judicial ha realizado cambios importantes en la forma en que trata a los niños.
Los arrestos de jóvenes por delitos violentos bajaron dramáticamente un 67% entre 2006 y 2020, y 40 estados han hecho que sea más difícil acusar a menores como adultos.
Los estados también están adoptando alternativas a la cárcel, como hogares grupales que permiten a los adolescentes permanecer en sus comunidades, al tiempo que brindan tratamiento para ayudarlos a cambiar su conducta.
Debido a que Diego tenía 17 años cuando fue sentenciado, fue enviado a un centro de menores, donde recibió terapia por primera vez.
Diego terminó la escuela secundaria mientras estaba tras las rejas, y obtuvo un título de un colegio comunitario. Con otros jóvenes reclusos fue de excursión a teatros y al acuario, lugares en los que nunca había estado. La directora del centro de detención le pidió que la acompañara a eventos sobre la reforma de la justicia juvenil, donde lo invitaron a contar su historia.
Para Diego, esas fueron experiencias reveladoras: se dio cuenta de que había visto muy poco de Chicago, a pesar de que había pasado su vida allí.
“Mientras estás creciendo, lo único que ves es a tu comunidad”, dijo Diego, quien fue liberado después de cuatro años, cuando el gobernador conmutó su sentencia. “Asumes que el mundo entero es así”.
La editora de datos de KHN Holly K. Hacker y la investigadora Megan Kalata contribuyeron con este informe.
McROBERTS, Ky. — Like most coal miners’ loved ones, Liz Williams has endured many days and nights of worry.
Throughout the four decades her husband, Michael, worked in underground Appalachian mines, Liz was aware of the risks: collapse, explosions, asphyxiation. But black lung — a chronic condition caused by breathing in coal dust — wasn’t on her mind.
That’s because the number of miners diagnosed with the often-deadly disease declined for decades, after federal officials introduced regulations more than 50 years ago.
But no more. The numbers have climbed precipitously as mining techniques have evolved to extract increasingly hard-to-reach coal reserves. After a career in the mines, Michael Williams, 62, now lives with an advanced stage of black lung.
Williams, a resident of the small town of McRoberts, is among a growing number of people diagnosed with the disease in central Appalachia, a region primarily comprising West Virginia, eastern Kentucky, and southwestern Virginia. The increase in the disease’s most deadly form, progressive massive fibrosis, has been especially pronounced. Since 2005, black lung cases have tripled in the region and PMF has increased tenfold among long-term miners. A study published last fall identified the driving force behind the spike in severe black lung disease as silica dust.
“We were seeing much more severe disease,” said Dr. Robert Cohen, director of the Mining Education and Research Center at the University of Illinois-Chicago and the study’s lead author. “We were seeing disease in younger miners, with lesser exposures, so, therefore, more intense exposure.”
Silica is the same toxic dust that has been pinpointed in recent years as the cause of deadly lung disease in workers in other industries, including those who make and install stone countertops. In mines, silica exposure comes from drilling into sandstone, which has become more common as thick coal seams peter out and miners move more rock to reach smaller veins. The dust turns to sharp particles that become trapped in lung tissue, causing inflammation and scarring and reducing the lungs’ capacity to take in oxygen. The condition is debilitating and potentially fatal.
Regulations allow miners to be exposed to twice as much airborne silica as the Occupational Safety and Health Administration permits for workers in other industries. Five U.S. senators representing parts of central Appalachia believe the Mine Safety and Health Administration has been dangerously slow to fix the discrepancy. They sent a letter in November demanding a new standard for miners nationwide. An announcement of a more restrictive proposed standard is expected from MSHA soon.
The more intense exposure is attributed, at least in part, to new technology that allows coal companies to drill deeper into rock to reach thin seams of coal. The process involves removing the silica-laden rock strata that surround coal seams, generating dangerous levels of dust.
Miners, Cohen said in a 2018 interview for a documentary, are “essentially suffocating while alive.”
Michael Williams said his most physically demanding stint in the mines was around Clinchco, Virginia, where he worked on his hands and knees, sandwiched between “sandstone, top and bottom.”
“The two years I worked in that seam — that’s what done the damage,” Williams said.
Popular belief once held that miners developed black lung only after spending decades toiling underground, according to Dr. Drew Harris, medical director of the Black Lung Clinic at Stone Mountain Health Services in southwestern Virginia. “And I think that’s not the case in central Appalachia anymore,” Harris said, “though, certainly, the longer the tenure, the worse and the more likely you are to develop the disease.”
Among the most susceptible mineworkers are roof bolters, who install supports to keep mine roofs from collapsing. It’s a job Paul White, 61, of Harlan, Kentucky, began at age 18. He left the mines at 25 after a wall collapsed on him, injuring his head and back and causing seizures he still experiences today.
It’s sometimes years before symptoms of black lung take hold. White, now a Baptist minister, said he began getting pneumonia he couldn’t shake around 2011 or 2012, two decades after he left the mines.
From there, his breathing capacity incrementally worsened, and now shortness of breath hinders his ability to preach.
William McCool, 68, was born and raised in Letcher County, Kentucky, and went to work in the mines after high school.
“I loved coal mining,” he said. “I mean, I loved it. I sure did.” Among his jobs was roof bolting.
McCool said that as the purer coal seams were depleted, crews cut through more rock.
Research has shown silica exposure is an issue also among workers who cut stone countertops, especially those who work with synthetic stone composed of crushed quartz. That workforce is generally immigrant and nonunionized, Cohen said. There hasn’t yet been a national surveillance program for any industry other than miners.
The resurgence of PMF in coal country startled those who advocate for miners. Wes Addington runs the Appalachian Citizens’ Law Center, an organization that provides, among other services, free legal representation to black lung victims and their families. When he began working on black lung cases in the early 2000s, he said, his firm would occasionally see X-rays that showed lung damage that Addington and his colleagues believed might qualify as a complicated diagnosis, which includes PMF. Often doctors they consulted would report back that it was not complicated black lung.
Addington and his team came to view complicated black lung as having been “basically eradicated in the United States by the mid-’90s.” Its apparent rarity led him to conclude “that it’s just not going to be part of the way we practice these cases.”
Then, around 2009, Addington said the firm began seeing a few more advanced cases. And in the following years, they “really started pouring in, to the point now, in the last decade or so, we’ve kind of been overwhelmed with just how many of these miners have progressive massive fibrosis.”
The five Appalachia-region senators, all Democrats, who wrote to Mine Safety and Health Administration Assistant Secretary Chris Williamson in November — Sherrod Brown of Ohio, Bob Casey of Pennsylvania, Joe Manchin of West Virginia, and Tim Kaine and Mark Warner of Virginia — asked the agency to explain its delay in announcing a new silica standard for miners.
“The Department of Labor has indicated that we could see a proposed rule as early as April, so I’ll be watching this closely and will continue to push for proper protections for coal miners,” Warner said.
“It’s cruel that this would happen in such a rich country,” Addington said of the persistence of black lung. “We know how to prevent it,” he said, “and never in my wildest dreams would I have imagined that we’d be in a situation where we’re having that same conversation” about progressive massive fibrosis.
Michael Williams can’t ignore the consequences of those long hours spent crawling under the earth. Over the past few months, he’s been repairing the damage July’s catastrophic flooding caused to his home. “I can go out there and shovel gravel for 15 minutes and I have to sit down; I’m losing my breath,” he said. “My mind says I can, but my body says I can’t.”
He’s troubled by the rattling in his chest: “You think it’s a cat or something outside. You don’t even know that you’re doing it.”
His wife, Liz, is proud of the many years of hard work Michael put in — that “he was willing to go into those dark mines to provide for his family.”
“But if we had hindsight,” she said, “and we could see what we know now, nothing is worth seeing him struggle to breathe. I would have encouraged him to do something different.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
USE OUR CONTENT
This story can be republished for free (details).
McROBERTS, Ky. — Like most coal miners’ loved ones, Liz Williams has endured many days and nights of worry.
Throughout the four decades her husband, Michael, worked in underground Appalachian mines, Liz was aware of the risks: collapse, explosions, asphyxiation. But black lung — a chronic condition caused by breathing in coal dust — wasn’t on her mind.
That’s because the number of miners diagnosed with the often-deadly disease declined for decades, after federal officials introduced regulations more than 50 years ago.
But no more. The numbers have climbed precipitously as mining techniques have evolved to extract increasingly hard-to-reach coal reserves. After a career in the mines, Michael Williams, 62, now lives with an advanced stage of black lung.
Williams, a resident of the small town of McRoberts, is among a growing number of people diagnosed with the disease in central Appalachia, a region primarily comprising West Virginia, eastern Kentucky, and southwestern Virginia. The increase in the disease’s most deadly form, progressive massive fibrosis, has been especially pronounced. Since 2005, black lung cases have tripled in the region and PMF has increased tenfold among long-term miners. A study published last fall identified the driving force behind the spike in severe black lung disease as silica dust.
“We were seeing much more severe disease,” said Dr. Robert Cohen, director of the Mining Education and Research Center at the University of Illinois-Chicago and the study’s lead author. “We were seeing disease in younger miners, with lesser exposures, so, therefore, more intense exposure.”
Silica is the same toxic dust that has been pinpointed in recent years as the cause of deadly lung disease in workers in other industries, including those who make and install stone countertops. In mines, silica exposure comes from drilling into sandstone, which has become more common as thick coal seams peter out and miners move more rock to reach smaller veins. The dust turns to sharp particles that become trapped in lung tissue, causing inflammation and scarring and reducing the lungs’ capacity to take in oxygen. The condition is debilitating and potentially fatal.
Regulations allow miners to be exposed to twice as much airborne silica as the Occupational Safety and Health Administration permits for workers in other industries. Five U.S. senators representing parts of central Appalachia believe the Mine Safety and Health Administration has been dangerously slow to fix the discrepancy. They sent a letter in November demanding a new standard for miners nationwide. An announcement of a more restrictive proposed standard is expected from MSHA soon.
The more intense exposure is attributed, at least in part, to new technology that allows coal companies to drill deeper into rock to reach thin seams of coal. The process involves removing the silica-laden rock strata that surround coal seams, generating dangerous levels of dust.
Miners, Cohen said in a 2018 interview for a documentary, are “essentially suffocating while alive.”
Michael Williams said his most physically demanding stint in the mines was around Clinchco, Virginia, where he worked on his hands and knees, sandwiched between “sandstone, top and bottom.”
“The two years I worked in that seam — that’s what done the damage,” Williams said.
Popular belief once held that miners developed black lung only after spending decades toiling underground, according to Dr. Drew Harris, medical director of the Black Lung Clinic at Stone Mountain Health Services in southwestern Virginia. “And I think that’s not the case in central Appalachia anymore,” Harris said, “though, certainly, the longer the tenure, the worse and the more likely you are to develop the disease.”
Among the most susceptible mineworkers are roof bolters, who install supports to keep mine roofs from collapsing. It’s a job Paul White, 61, of Harlan, Kentucky, began at age 18. He left the mines at 25 after a wall collapsed on him, injuring his head and back and causing seizures he still experiences today.
It’s sometimes years before symptoms of black lung take hold. White, now a Baptist minister, said he began getting pneumonia he couldn’t shake around 2011 or 2012, two decades after he left the mines.
From there, his breathing capacity incrementally worsened, and now shortness of breath hinders his ability to preach.
William McCool, 68, was born and raised in Letcher County, Kentucky, and went to work in the mines after high school.
“I loved coal mining,” he said. “I mean, I loved it. I sure did.” Among his jobs was roof bolting.
McCool said that as the purer coal seams were depleted, crews cut through more rock.
Research has shown silica exposure is an issue also among workers who cut stone countertops, especially those who work with synthetic stone composed of crushed quartz. That workforce is generally immigrant and nonunionized, Cohen said. There hasn’t yet been a national surveillance program for any industry other than miners.
The resurgence of PMF in coal country startled those who advocate for miners. Wes Addington runs the Appalachian Citizens’ Law Center, an organization that provides, among other services, free legal representation to black lung victims and their families. When he began working on black lung cases in the early 2000s, he said, his firm would occasionally see X-rays that showed lung damage that Addington and his colleagues believed might qualify as a complicated diagnosis, which includes PMF. Often doctors they consulted would report back that it was not complicated black lung.
Addington and his team came to view complicated black lung as having been “basically eradicated in the United States by the mid-’90s.” Its apparent rarity led him to conclude “that it’s just not going to be part of the way we practice these cases.”
Then, around 2009, Addington said the firm began seeing a few more advanced cases. And in the following years, they “really started pouring in, to the point now, in the last decade or so, we’ve kind of been overwhelmed with just how many of these miners have progressive massive fibrosis.”
The five Appalachia-region senators, all Democrats, who wrote to Mine Safety and Health Administration Assistant Secretary Chris Williamson in November — Sherrod Brown of Ohio, Bob Casey of Pennsylvania, Joe Manchin of West Virginia, and Tim Kaine and Mark Warner of Virginia — asked the agency to explain its delay in announcing a new silica standard for miners.
“The Department of Labor has indicated that we could see a proposed rule as early as April, so I’ll be watching this closely and will continue to push for proper protections for coal miners,” Warner said.
“It’s cruel that this would happen in such a rich country,” Addington said of the persistence of black lung. “We know how to prevent it,” he said, “and never in my wildest dreams would I have imagined that we’d be in a situation where we’re having that same conversation” about progressive massive fibrosis.
Michael Williams can’t ignore the consequences of those long hours spent crawling under the earth. Over the past few months, he’s been repairing the damage July’s catastrophic flooding caused to his home. “I can go out there and shovel gravel for 15 minutes and I have to sit down; I’m losing my breath,” he said. “My mind says I can, but my body says I can’t.”
He’s troubled by the rattling in his chest: “You think it’s a cat or something outside. You don’t even know that you’re doing it.”
His wife, Liz, is proud of the many years of hard work Michael put in — that “he was willing to go into those dark mines to provide for his family.”
“But if we had hindsight,” she said, “and we could see what we know now, nothing is worth seeing him struggle to breathe. I would have encouraged him to do something different.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
USE OUR CONTENT
This story can be republished for free (details).
Diego never imagined he’d carry a gun.
Not as a child, when shots were fired outside his Chicago-area home. Not at age 12, when one of his friends was gunned down.
Diego’s mind changed at 14, when he and his friends were getting ready to walk to midnight Mass for the feast of Our Lady of Guadalupe. But instead of hymns, Diego heard gunfire, and then screaming. A gang member shot two people, including one of Diego’s friends, who was hit nine times.
“My friend was bleeding out,” said Diego, who asked KHN not to use his last name to protect his safety and privacy. As his friend lay on the ground, “he was choking on his own blood.”
The attack left Diego’s friend paralyzed from the waist down. And it left Diego, one of a growing number of teens who witness gun violence, traumatized and afraid to go outside without a gun.
Research shows that adolescents exposed to gun violence are twice as likely as others to perpetrate a serious violent crime within two years, perpetuating a cycle that can be hard to interrupt.
Diego asked his friends for help finding a handgun and — in a country supersaturated with firearms — they had no trouble procuring one, which they gave him free.
“I felt safer with the gun,” said Diego, now 21. “I hoped I wouldn’t use it.”
For two years, Diego kept the gun only as a deterrent. When he finally pulled the trigger, it changed his life forever.
Disturbing Trends
The news media focuses heavily on mass shootings and the mental state of the people who commit them. But there is a far larger epidemic of gun violence — particularly among Black, Hispanic, and Native American youth — ensnaring some kids not even old enough to get a driver’s license.
Research shows that chronic exposure to trauma can change the way a child’s brain develops. Trauma also can play a central role in explaining why some young people look to guns for protection and wind up using them against their peers.
The number of children under 18 who killed someone with a firearm jumped from 836 in 2019 to 1,150 in 2020.
In New York City, the number of young people who killed someone with a gun more than doubled, rising from 48 juvenile offenders in 2019 to 124 in 2022, according to data from the city’s police department.
Youth gun violence increased more modestly in other cities; in many places, the number of teen gun homicides rose in 2020 but has since fallen closer to pre-pandemic levels.
Researchers who analyze crime statistics stress that teens are not driving the overall rise in gun violence, which has increased across all ages. In 2020, 7.5% of homicide arrests involved children under 18, a slightly smaller share than in previous years.
Local leaders have struggled with the best way to respond to teen shootings.
A handful of communities — including Pittsburgh; Fulton County, Georgia; and Prince George’s County, Maryland — have debated or implemented youth curfews to curb teen violence. What’s not in dispute: More people ages 1 to 19 die by gun violence than by any other cause.
A Lifetime of Limits
The devastating toll of gun violence shows up in emergency rooms every day.
At the UChicago Medicine trauma center, the number of gunshot wounds in children under 16 has doubled in the past six years, said Dr. Selwyn Rogers, the center’s founding director. The youngest victim was 2. “You hear the mother wail, or the brother say, ‘It’s not true,’” said Rogers, who works with local youth as the hospital’s executive vice president for community health engagement. “You have to be present in that moment, but then walk out the door and deal with it all over again.”
In recent years, the justice system has struggled to balance the need for public safety with compassion for kids, based on research that shows a young person’s brain doesn’t fully mature until age 25. Most young offenders “age out” of criminal or violent behavior around the same time, as they develop more self-control and long-range thinking skills.
Yet teens accused of shootings are often charged as adults, which means they face harsher punishments than kids charged as juveniles, said Josh Rovner, director of youth justice at the Sentencing Project, which advocates for justice system reform.
About 53,000 juveniles in 2019 were charged as adults, which can have serious health repercussions. These teens are more likely to be victimized while incarcerated, Rovner said, and to be arrested again after release.
Young people can spend much of their lives in a poverty-imposed lockdown, never venturing far beyond their neighborhoods, learning little about opportunities that exist in the wider world, Rogers said. Millions of American children — particularly Black, Hispanic, and Native American kids — live in environments plagued by poverty, violence, and drug use.
The covid-19 pandemic amplified all those problems, from unemployment to food and housing insecurity.
Although no one can say with certainty what spurred the surge in shootings in 2020, research has long linked hopelessness and lack of trust in police — which increased after the murder of George Floyd that year — to an increased risk of community violence. Gun sales soared 64% from 2019 to 2020, while many violence prevention programs shut down.
One of the most serious losses children faced during the pandemic was the closure of schools — institutions that might provide the only stabilizing force in their young lives — for a year or more in many places.
“The pandemic just turned up the fire under the pot,” said Elise White, deputy director of research at the nonprofit Center for Justice Innovation, which works with communities and justice systems. “Looking back, it’s easy to underplay now just how uncertain that time [during the pandemic] felt. The more that people feel uncertain, the more they feel there’s no safety around them, the more likely they are to carry weapons.”
Of course, most children who experience hardship never break the law. Multiple studies have found that most gun violence is perpetrated by a relatively small number of people.
The presence of even one supportive adult can protect children from becoming involved with crime, said Dr. Abdullah Pratt, a UChicago Medicine emergency physician who lost his brother to gun violence.
Pratt also lost four friends to gun violence during the pandemic. All four died in his emergency room; one was the son of a hospital nurse.
Although Pratt grew up in a part of Chicago where street gangs were common, he benefited from the support of loving parents and strong role models, such as teachers and football coaches. Pratt was also protected by his older brother, who looked out for him and made sure gangs left the future doctor alone.
“Everything I’ve been able to accomplish,” Pratt said, “is because someone helped me.”
Growing Up in a ‘War Zone’
Diego had no adults at home to help him feel safe.
His parents were often violent. Once, in a drunken rage, Diego’s father grabbed him by the leg and swung him around the room, Diego said, and his mother once threw a toaster at his father.
At age 12, Diego’s efforts to help the family pay overdue bills — by selling marijuana and stealing from unlocked cars and apartments — led his father to throw him out of the house.
At 13, Diego joined a gang made up of neighborhood kids. Gang members — who recounted similar stories about leaving the house to escape abuse — gave him food and a place to stay. “We were like a family,” Diego said. When the kids were hungry, and there was no food at home, “we’d go to a gas station together to steal some breakfast.”
But Diego, who was smaller than most of the others, lived in fear. At 16, Diego weighed only 100 pounds. Bigger boys bullied and beat him up. And his successful hustle — selling stolen merchandise on the street for cash — got the attention of rival gang members, who threatened to rob him.
Children who experience chronic violence can develop a “war zone mentality,” becoming hypervigilant to threats, sometimes sensing danger where it doesn’t exist, said James Garbarino, an emeritus professor of psychology at Cornell University and Loyola University-Chicago. Kids who live with constant fear are more likely to look to firearms or gangs for protection. They can be triggered to take preemptive action — such as firing a gun without thinking — against a perceived threat.
“Their bodies are constantly ready for a fight,” said Gianna Tran, deputy executive director of the East Bay Asian Youth Center in Oakland, California, which works with young people living in poverty, trauma, and neglect.
Unlike mass shooters, who buy guns and ammunition because they’re intent on murder, most teen violence is not premeditated, Garbarino said.
In surveys, most young people who carry guns — including gang members — say they do so out of fear or to deter attacks, rather than perpetrate them. But fear of community violence, both from rivals and the police, can stoke an urban arms race, in which kids feel that only the foolish walk around without a weapon.
“Fundamentally, violence is a contagious disease,” said Dr. Gary Slutkin, founder of Cure Violence Global, which works to prevent community violence.
Although a small number of teens become hardened and remorseless, Pratt said, he sees far more shootings caused by “poor conflict resolution” and teenage impulsivity rather than a desire to kill.
Indeed, firearms and an immature teenage brain are a dangerous mix, Garbarino said. Alcohol and drugs can magnify the risk. When confronted with a potentially life-or-death situation, kids may act without thinking.
When Diego was 16, he was walking a girl to school and they were approached by three boys, including a gang member who, using obscene and threatening language, asked if Diego was also in a gang. Diego said he tried to walk past the boys, one of whom appeared to have a gun.
“I didn’t know how to fire a gun,” Diego said. “I just wanted them to get away.”
In news accounts of the shooting, witnesses said they heard five gunshots. “The only thing I remember is the sound of the shots,” Diego said. “Everything else was going in slow motion.”
Diego had shot two of the boys in the legs. The girl ran one way, and he ran another. Police arrested Diego at home a few hours later. He was tried as an adult, convicted of two counts of attempted homicide, and sentenced to 12 years.
A Second Chance
In the past two decades, the justice system has made major changes in the way it treats children.
Youth arrests for violent crime plummeted 67% from 2006 to 2020, and 40 states have made it harder to charge minors as adults. States also are adopting alternatives to incarceration, such as group homes that allow teens to remain in their communities, while providing treatment to help them change their behavior.
Because Diego was 17 when he was sentenced, he was sent to a juvenile facility, where he received therapy for the first time.
Diego finished high school while behind bars and went on to earn an associate’s degree from a community college. He and other young inmates went on field trips to theaters and the aquarium — places he had never been. The detention center director asked Diego to accompany her to events about juvenile justice reform, where he was invited to tell his story.
Those were eye-opening experiences for Diego, who realized he had seen very little of Chicago, even though he had spent his life there.
“Growing up, the only thing you see is your community,” said Diego, who was released after four years in detention, when the governor commuted his sentence. “You assume that is what the whole world is like.”
KHN data editor Holly K. Hacker and researcher Megan Kalata contributed to this report.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
USE OUR CONTENT
This story can be republished for free (details).
Diego never imagined he’d carry a gun.
Not as a child, when shots were fired outside his Chicago-area home. Not at age 12, when one of his friends was gunned down.
Diego’s mind changed at 14, when he and his friends were getting ready to walk to midnight Mass for the feast of Our Lady of Guadalupe. But instead of hymns, Diego heard gunfire, and then screaming. A gang member shot two people, including one of Diego’s friends, who was hit nine times.
“My friend was bleeding out,” said Diego, who asked KHN not to use his last name to protect his safety and privacy. As his friend lay on the ground, “he was choking on his own blood.”
The attack left Diego’s friend paralyzed from the waist down. And it left Diego, one of a growing number of teens who witness gun violence, traumatized and afraid to go outside without a gun.
Research shows that adolescents exposed to gun violence are twice as likely as others to perpetrate a serious violent crime within two years, perpetuating a cycle that can be hard to interrupt.
Diego asked his friends for help finding a handgun and — in a country supersaturated with firearms — they had no trouble procuring one, which they gave him free.
“I felt safer with the gun,” said Diego, now 21. “I hoped I wouldn’t use it.”
For two years, Diego kept the gun only as a deterrent. When he finally pulled the trigger, it changed his life forever.
Disturbing Trends
The news media focuses heavily on mass shootings and the mental state of the people who commit them. But there is a far larger epidemic of gun violence — particularly among Black, Hispanic, and Native American youth — ensnaring some kids not even old enough to get a driver’s license.
Research shows that chronic exposure to trauma can change the way a child’s brain develops. Trauma also can play a central role in explaining why some young people look to guns for protection and wind up using them against their peers.
The number of children under 18 who killed someone with a firearm jumped from 836 in 2019 to 1,150 in 2020.
In New York City, the number of young people who killed someone with a gun more than doubled, rising from 48 juvenile offenders in 2019 to 124 in 2022, according to data from the city’s police department.
Youth gun violence increased more modestly in other cities; in many places, the number of teen gun homicides rose in 2020 but has since fallen closer to pre-pandemic levels.
Researchers who analyze crime statistics stress that teens are not driving the overall rise in gun violence, which has increased across all ages. In 2020, 7.5% of homicide arrests involved children under 18, a slightly smaller share than in previous years.
Local leaders have struggled with the best way to respond to teen shootings.
A handful of communities — including Pittsburgh; Fulton County, Georgia; and Prince George’s County, Maryland — have debated or implemented youth curfews to curb teen violence. What’s not in dispute: More people ages 1 to 19 die by gun violence than by any other cause.
A Lifetime of Limits
The devastating toll of gun violence shows up in emergency rooms every day.
At the UChicago Medicine trauma center, the number of gunshot wounds in children under 16 has doubled in the past six years, said Dr. Selwyn Rogers, the center’s founding director. The youngest victim was 2. “You hear the mother wail, or the brother say, ‘It’s not true,’” said Rogers, who works with local youth as the hospital’s executive vice president for community health engagement. “You have to be present in that moment, but then walk out the door and deal with it all over again.”
In recent years, the justice system has struggled to balance the need for public safety with compassion for kids, based on research that shows a young person’s brain doesn’t fully mature until age 25. Most young offenders “age out” of criminal or violent behavior around the same time, as they develop more self-control and long-range thinking skills.
Yet teens accused of shootings are often charged as adults, which means they face harsher punishments than kids charged as juveniles, said Josh Rovner, director of youth justice at the Sentencing Project, which advocates for justice system reform.
About 53,000 juveniles in 2019 were charged as adults, which can have serious health repercussions. These teens are more likely to be victimized while incarcerated, Rovner said, and to be arrested again after release.
Young people can spend much of their lives in a poverty-imposed lockdown, never venturing far beyond their neighborhoods, learning little about opportunities that exist in the wider world, Rogers said. Millions of American children — particularly Black, Hispanic, and Native American kids — live in environments plagued by poverty, violence, and drug use.
The covid-19 pandemic amplified all those problems, from unemployment to food and housing insecurity.
Although no one can say with certainty what spurred the surge in shootings in 2020, research has long linked hopelessness and lack of trust in police — which increased after the murder of George Floyd that year — to an increased risk of community violence. Gun sales soared 64% from 2019 to 2020, while many violence prevention programs shut down.
One of the most serious losses children faced during the pandemic was the closure of schools — institutions that might provide the only stabilizing force in their young lives — for a year or more in many places.
“The pandemic just turned up the fire under the pot,” said Elise White, deputy director of research at the nonprofit Center for Justice Innovation, which works with communities and justice systems. “Looking back, it’s easy to underplay now just how uncertain that time [during the pandemic] felt. The more that people feel uncertain, the more they feel there’s no safety around them, the more likely they are to carry weapons.”
Of course, most children who experience hardship never break the law. Multiple studies have found that most gun violence is perpetrated by a relatively small number of people.
The presence of even one supportive adult can protect children from becoming involved with crime, said Dr. Abdullah Pratt, a UChicago Medicine emergency physician who lost his brother to gun violence.
Pratt also lost four friends to gun violence during the pandemic. All four died in his emergency room; one was the son of a hospital nurse.
Although Pratt grew up in a part of Chicago where street gangs were common, he benefited from the support of loving parents and strong role models, such as teachers and football coaches. Pratt was also protected by his older brother, who looked out for him and made sure gangs left the future doctor alone.
“Everything I’ve been able to accomplish,” Pratt said, “is because someone helped me.”
Growing Up in a ‘War Zone’
Diego had no adults at home to help him feel safe.
His parents were often violent. Once, in a drunken rage, Diego’s father grabbed him by the leg and swung him around the room, Diego said, and his mother once threw a toaster at his father.
At age 12, Diego’s efforts to help the family pay overdue bills — by selling marijuana and stealing from unlocked cars and apartments — led his father to throw him out of the house.
At 13, Diego joined a gang made up of neighborhood kids. Gang members — who recounted similar stories about leaving the house to escape abuse — gave him food and a place to stay. “We were like a family,” Diego said. When the kids were hungry, and there was no food at home, “we’d go to a gas station together to steal some breakfast.”
But Diego, who was smaller than most of the others, lived in fear. At 16, Diego weighed only 100 pounds. Bigger boys bullied and beat him up. And his successful hustle — selling stolen merchandise on the street for cash — got the attention of rival gang members, who threatened to rob him.
Children who experience chronic violence can develop a “war zone mentality,” becoming hypervigilant to threats, sometimes sensing danger where it doesn’t exist, said James Garbarino, an emeritus professor of psychology at Cornell University and Loyola University-Chicago. Kids who live with constant fear are more likely to look to firearms or gangs for protection. They can be triggered to take preemptive action — such as firing a gun without thinking — against a perceived threat.
“Their bodies are constantly ready for a fight,” said Gianna Tran, deputy executive director of the East Bay Asian Youth Center in Oakland, California, which works with young people living in poverty, trauma, and neglect.
Unlike mass shooters, who buy guns and ammunition because they’re intent on murder, most teen violence is not premeditated, Garbarino said.
In surveys, most young people who carry guns — including gang members — say they do so out of fear or to deter attacks, rather than perpetrate them. But fear of community violence, both from rivals and the police, can stoke an urban arms race, in which kids feel that only the foolish walk around without a weapon.
“Fundamentally, violence is a contagious disease,” said Dr. Gary Slutkin, founder of Cure Violence Global, which works to prevent community violence.
Although a small number of teens become hardened and remorseless, Pratt said, he sees far more shootings caused by “poor conflict resolution” and teenage impulsivity rather than a desire to kill.
Indeed, firearms and an immature teenage brain are a dangerous mix, Garbarino said. Alcohol and drugs can magnify the risk. When confronted with a potentially life-or-death situation, kids may act without thinking.
When Diego was 16, he was walking a girl to school and they were approached by three boys, including a gang member who, using obscene and threatening language, asked if Diego was also in a gang. Diego said he tried to walk past the boys, one of whom appeared to have a gun.
“I didn’t know how to fire a gun,” Diego said. “I just wanted them to get away.”
In news accounts of the shooting, witnesses said they heard five gunshots. “The only thing I remember is the sound of the shots,” Diego said. “Everything else was going in slow motion.”
Diego had shot two of the boys in the legs. The girl ran one way, and he ran another. Police arrested Diego at home a few hours later. He was tried as an adult, convicted of two counts of attempted homicide, and sentenced to 12 years.
A Second Chance
In the past two decades, the justice system has made major changes in the way it treats children.
Youth arrests for violent crime plummeted 67% from 2006 to 2020, and 40 states have made it harder to charge minors as adults. States also are adopting alternatives to incarceration, such as group homes that allow teens to remain in their communities, while providing treatment to help them change their behavior.
Because Diego was 17 when he was sentenced, he was sent to a juvenile facility, where he received therapy for the first time.
Diego finished high school while behind bars and went on to earn an associate’s degree from a community college. He and other young inmates went on field trips to theaters and the aquarium — places he had never been. The detention center director asked Diego to accompany her to events about juvenile justice reform, where he was invited to tell his story.
Those were eye-opening experiences for Diego, who realized he had seen very little of Chicago, even though he had spent his life there.
“Growing up, the only thing you see is your community,” said Diego, who was released after four years in detention, when the governor commuted his sentence. “You assume that is what the whole world is like.”
KHN data editor Holly K. Hacker and researcher Megan Kalata contributed to this report.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
USE OUR CONTENT
This story can be republished for free (details).