After 50 days, Gaza European Hospital, one of the few trauma centers serving the Gaza strip, reopened, according to the Gaza Health Ministry. The hospital has been a vital part of the crumbling medical infrastructure in the region. It reopened earlier this month.

In August, I told the story of two medical students who worked at Gaza European Hospital before it was shuttered and forcibly evacuated on July 1st. The medical center remained closed amid bombardment in the area for over a month. Each student told me harrowing stories of their time suddenly propelled to the job of full-time doctors amid the devastation of the medical system in Gaza.  

You can read the full piece, here:

Related

Inside One of the Last Hospitals in Gaza

Now, the students are back to work. Hasan Ali Abu Ghalyoon, a dental student I interviewed via WhatsApp in August, returned to European Hospital on September 9th. He said things are different there now. 

Before the July evacuation, he slept at the hospital. Now, he commutes back and forth from his family’s tent in Deir al-Balah, a trip that takes him three or four hours a day. It is only about a seven-mile journey. But in Gaza, it can be treacherous.

Normally, he takes a hospital-provided bus to work. Last Friday, though, “I was a little late for the bus and I was forced to go by car,” he said. On his journey, he passed a destroyed World Health Organization warehouse, a torched mosque, and innumerable teetering husks of buildings and dust-covered tents. “I took three cars on my way to get from my tent to the hospital and I walked through many destroyed streets on foot.” 

In some areas of eastern Gaza, there are no cars at all. The trip, he said, cost him 25 shekels, or about eight dollars, thanks to the lack of fuel entering Gaza. Before the war, transportation wouldn’t cost a thing. 

Nermeen Ziyad Abo Mostafa, another student volunteer, hears the zanana—Gazan slang for the incessant buzzing of drones overhead—on her way to the hospital. “It was not easy to reopen it, because all the hospital’s property was stolen,” she said. The hospital is still not fully equipped, she explained, but medical teams are doing their best to work with what they have. 

Once the students arrive, they see “mostly burns and fractures,” Abu Ghalyoon said. Every day, there are patients requiring skin grafts. 

Another change: there are now fewer international delegations than before. The flow of international medics into the Gaza strip has slowed to a trickle. The Israeli military has hit international aid workers like those from World Central Kitchen, after a vehicle from the group was bombed in April, and UN workers, like those from the World Food Program, whose vehicles were struck in August. Supply shortages are ongoing. As Abu Ghalyoon put it: “There is a very, very severe shortage of all medicines. The medical equipment is old and sometimes works and sometimes doesn’t.”

On September 12th, the World Health Organization released a report estimating that over 22,500 people in Gaza have suffered “life-changing injuries” since Israel’s offensive in Gaza began. Most of these injuries—about 13,000 to 17,000—are what the WHO report calls “severe limb injuries,” and at least 3,000 are amputations.

“The huge surge in rehabilitation needs occurs in parallel with the ongoing decimation of the health system,” said Dr. Richard Peeperkorn, WHO Representative in the occupied Palestinian territory. “Patients can’t get the care they need. Acute rehabilitation services are severely disrupted and specialized care for complex injuries is not available, placing patients’ lives at risk. Immediate and long-term support is urgently needed to address the enormous rehabilitation needs.” 

Vice President Kamala Harris has lost no time blaming former President Donald Trump for the death of a single mother in Georgia after hospital doctors, working under the constraints of an abortion ban, delayed treating her catastrophic infection.

The story of Amber Nicole Thurman’s death in August 2022—and its connection to the six-week abortion ban enacted in Georgia the month before she died—was first reported by ProPublica’s Kavitha Surana. While doctors, patients, and reproductive justice advocates have long warned that abortion bans were causing profound disruptions and delays in healthcare for pregnant women, Thurman’s is the first death to come to public attention.

“This young mother should be alive, raising her son, and pursuing her dream of attending nursing school,” Harris said in a statement reported by the Associated Press. “Women are bleeding out in parking lots, turned away from emergency rooms, losing their ability to ever have children again. Survivors of rape and incest are being told they cannot make decisions about what happens next to their bodies. And now women are dying.”

“These are the consequences of Donald Trump’s actions,” Harris added.

Later on Tuesday, during a interview moderated by the National Association of Black Journalists and WHYY public radio station in Philadelphia, Harris once again drew a link between Thurman’s death and Trump. “Over 20 states have passed what I call ‘Trump abortion bans,’ because I understand how we got here,” Harris told an audience of journalism students from historically Black colleges and universities. “The former president handpicked three members of the United States Supreme Court with the intention they would undo the protections of Roe v. Wade. They did as he intended, and in state after state, laws have been passed criminalizing health care providers.”

The doctors who delayed Thurman’s care were operating under these laws, Harris pointed out. “It appears the people who should have given her health care were afraid they’d be criminalized after the Dobbs decision came down,” she said.

According to ProPublica, Georgia’s ban on abortions after six weeks affected Thurman in multiple ways. When Thurman discovered she was pregnant with twins in July 2022, she was just over the gestational limit. Because the 28-year-old medical assistant could not get an abortion near where she lived, she had to drive four hours with a friend to North Carolina. Then, stuck in traffic, she missed her appointment for a surgical abortion using a technique called dilation and curettage (D&C), so the clinic instead gave her medication to end her pregnancy and sent her home. The distance meant that days later, when Thurman began experiencing a rare complication from the medication abortion—her body hadn’t expelled all the fetal tissue, putting her at risk of a dangerous infection—she couldn’t go back to the provider for a free D&C. Only when her condition deteriorated did she end up going to a hospital outside Atlanta.

There, her blood pressure falling and organs failing, Thurman was diagnosed with “acute severe sepsis.” But physicians waited 20 hours to operate. The hospital and doctors did not respond to ProPublica’s requests for comment. But the delays mirror many other stories about abortion bans leading to dangerous disruptions in pregnancy care since the Supreme Court overturned Roe. Physicians afraid of being prosecuted have raised alarms about the laws’ hard-to-interpret exceptions: How close to death does a pregnant patient have to be in order for them to perform emergency abortion?

Thurman ultimately died in the operating room. A Georgia state committee tasked with reviewing maternal deaths found that the delay in providing the D&C had a “large” impact on her death, and they deemed it “preventable,” according to ProPublica.

Harris’ attention to Thurman’s story is no surprise given her reputation as a forceful defender of abortion rights on the campaign trail and in her debate against Trump. But her attention to pregnancy-related deaths—which are far more common in the United States than in other high-income countries—dates back years. In the Senate, Harris focused on reducing maternal mortality for Black women like Thurman, who are 2.6 times more likely to die of pregnancy-related causes than white women, according to 2022 CDC data. In 2018, she sponsored a resolution recognizing “Black Maternal Health Week” and introduced the Maternal CARE Act to create a grant program to address racial bias in obstetrics and gynecology. As vice president, she pushed efforts to expand postpartum Medicaid coverage from 60 days to 12 months.

“For years, I have worked to make sure our country treats maternal mortality as the national crisis it is,” Harris wrote in 2022, prefacing a 50-point plan to use government agencies to lower maternal deaths. “I am proud to lead our Administration’s efforts to address this issue.”

Reproductive justice advocates have been warning for more than two years that the end of Roe v. Wade would lead to surge in maternal mortality among patients denied abortion care—and that the increase was likely to be greatest among low-income women of color. Now, a new report by ProPublica has uncovered the first such verified death. A 28-year-old medical assistant and Black single mother in Georgia died from a severe infection after a hospital delayed a routine medical procedure that had been outlawed under that state’s six-week abortion ban.

Amber Nicole Thurman’s death, in August 2022, was officially deemed “preventable” by a state committee tasked with reviewing pregnancy-related deaths. Thurman’s case is the first time a preventable abortion-related death has come to public attention since the Supreme Court overturned Roe, ProPublica‘s Kavitha Surana reported.

Now, “we actually have the substantiated proof of something we already knew—that abortion bans kill people,” said Mini Timmaraju, president of the abortion-rights group Reproductive Freedom for All, during a call with media. “It cannot go on.”

Thurman is almost certainly not the only person to have died as a consequence of an abortion ban, even if her case is the first to be officially confirmed. As ProPublica noted, that’s because investigations of maternal deaths often don’t happen until years later:

Committees like the one in Georgia, set up in each state, often operate with a two-year lag behind the cases they examine, meaning that experts are only now beginning to delve into deaths that took place after the Supreme Court overturned the federal right to abortion.

Earlier this year, the New Yorker reported on the story of Yeniifer Alvarez-Estrada Glick, a 29-year-old woman in Texas who died in July 2022 from complications of a high-risk pregnancy. In that case, medical records did “not suggest any discussion of the fact that an abortion could have alleviated the additional strain that the pregnancy placed on her heart,” the New Yorker reported.

According to ProPublica, Thurman had decided to get an abortion after learning she was pregnant with twins. But the very day she passed the six-week mark of her pregnancy, Georgia implemented a ban forbidding abortion after six weeks’ gestation—as the Supreme Court allowed states to do when it overturned Roe earlier that summer. So Thurman traveled four hours to an abortion clinic in North Carolina, where abortions were then allowed past 20 weeks. There she was given mifepristone and misoprostol, a two-drug regimen used to end pregnancies.

A few days after she took the pills, Thurman’s pain became excruciating, and she was bleeding through a pad every hour. Complications from abortion pills are rare, but sometimes patients require a procedure called dilation and curettage, or D&C, to remove remaining fetal tissue from the uterus that could lead to life-threatening sepsis. The North Carolina clinic would have performed the D&C for free if Thurman lived closer, ProPublica said. Instead, after vomiting blood and passing out at home, Thurman was brought to the hospital in the Atlanta suburbs, where doctors noted signs of an infection. According to ProPublica,

The standard treatment of sepsis is to start antibiotics and immediately seek and remove the source of the infection. For a septic abortion, that would include removing any remaining tissue from the uterus. One of the hospital network’s own practices describes a D&C as a “fairly common, minor surgical procedure” to be used after a miscarriage to remove fetal tissue.

But because D&Cs can be used to perform abortions, physicians operating under an abortion ban can be slow to provide them even for miscarriages and other emergency situations, as illustrated in a recent report on post-Roe disruptions to pregnancy care in Louisiana. Not until 2 p.m. the day after Thruman entered the hospital was she brought for surgery. She died in the operating room. The Georgia maternal mortality review committee found that if a D&C had been performed earlier, there was a “good chance” her death could have been prevented, ProPublica reports.

“These devastating bans did not only block Amber, and many others, from accessing abortion care in her state, they also delayed the routine life-saving care she later needed, leaving her to suffer and die,” Timmaraju said during the press call on Monday.

While every state abortion ban contains exceptions to save the life of the pregnant person, uncertainty among medical providers over exactly when doctors can step in without fear of being prosecuted has led to delays in medical care for pregnant woman across the country, with devastating consequences.

On the call with reporters, leaders of reproductive justice organizations pointed to the way bans and delays in emergency medical care for pregnant people disproportionately impact Black women. Black women are about 2.6 times more likely to die from a pregnancy-related cause than white women, according to the Centers for Disease Control and Prevention.

“Reproductive justice is not just about abortion access, but also about the broader right to quality, comprehensive, full-range, culturally humble care, life saving health care for all of us,” said KR Redman, executive director of SPARK, a reproductive justice group in Georgia. “Amber’s case is just an example of the ongoing systemic negligence that continues to claim the lives of Black folks.”

More than two years since the overturn of Roe v Wade, legal battles over abortion laws are as chaotic as ever. But occasionally, the challenges playing out state by state result in a string of good news for abortion rights. That was the case this week, with a cluster of court decisions that will expand abortion access in Nevada and North Dakota, and allow Missouri and Nebraska voters to weigh in on the issue in November.

On Thursday, District Court Judge Bruce Romanick in Bismarck, North Dakota, issued a powerful opinion siding with abortion providers who challenged a state law that had deemed their practice a felony.

In his order, which takes effect in two weeks, Rominick ruled that the North Dakota constitution’s protections for life, liberty, and the right to pursue happiness include the right to choose abortion. “A woman’s choice of whether or not to carry a pregnancy to term shapes the very nature and future course of her life, on nearly every possible level,” he wrote. “The Court finds that such a choice, at least pre-viability, must belong to the individual woman and not to the government.” He also struck down the ban for its vagueness, concluding that, at present, North Dakota doctors could be prosecuted if other physicians second-guessed their decision to provide an emergency abortion.

Virtually all abortions have been illegal in North Dakota since April 2023, when Republican Gov. Doug Burgum signed a ban with exceptions only to save the life of the pregnant person, or for rape and incest survivors within the first six weeks of pregnancy. North Dakota’s only abortion clinic moved across the state line to Minnesota in 2022, soon after the Supreme Court overturned Roe v. Wade, meaning most people seeking to end a pregnancy will have to leave the state.

But Romnick’s decision should make it easier for doctors to provide emergency abortions to patients with severe pregnancy complications—care that that is often withheld in abortion-ban states, with dire consequences. “It is now much safer to be pregnant in North Dakota,” Center for Reproductive Rights lawyer Meetra Mehdizadeh said in a statement on Friday.

Also on Thursday, a Nevada court order requiring the state Medicaid program to cover abortion became final after the state government declined to appeal an earlier ruling. Nevada will become the 18th state to allow Medicaid funds to cover abortion, the Associated Press reported.

That ruling is the result of a challenge brought under Nevada’s Equal Rights Amendment, which added language banning sex discrimination, along with many other types of discrimination, to the state constitution. Voters there supported the ERA by a nearly 18-point margin in 2022.

In their lawsuit, a Nevada abortion fund and the ACLU argued that the ban on Medicaid coverage amounted to sex discrimination because it denied low-income Nevadans who can become pregnant the ability to make decisions about their future. Back in March, a Clark County District Judge Erika Ballou had agreed—though her decision didn’t become final until this week.

“The court made clear that the state cannot withhold coverage for essential, sex-linked health care from low-income Nevadans,” ACLU Reproductive Freedom Project staff attorney Rebecca Chan explained in a statement. “As a result of this decision, Nevadans who have Medicaid as their health insurance will no longer need to fear that they will be forced to carry a pregnancy against their will.”

In November, voters in New York will decide whether to enshrine an ERA of their own—one of 10 states with abortion-related initiatives slated for the 2024 ballot. Yet initiatives in two of those states were in jeopardy until courts came to their rescue this week. On Tuesday, the Missouri Supreme Court threw out a last-minute claim arguing that the text of an abortion-rights initiative petition had omitted details required by state law; it ordered the anti-abortion secretary of state to certify the initiative for the ballot.

On Friday, the Nebraska Supreme Court ruled that dueling initiatives can appear on the ballot in that state, where current law bans abortion after 12 weeks. One of the initiatives, titled “Protect the Right to Abortion,” would create a state constitutional right for Nebraskans to get an abortion prior to “viability” (the hard-to-pinpoint moment in pregnancy when a fetus is able to survive outside the uterus). The other, titled “Protect Women and Children” would enshrine the current 12-week abortion ban in the state constitution.

If both pass, the one with the most votes prevails. But anti-abortion advocates had tried to kill the pro-abortion rights measure altogether by arguing that by regulating abortion before and after viability differently, it dealt with more than one subject, according to the Nebraska Examiner. Friday’s state Supreme Court ruling tossed that challenge, and ensures the vote on both questions will proceed.

Now, with 52 days left before voters will decide whether to add abortion protections to their state constitutions, the opinion from North Dakota’s Judge Rominick could offer some guidance.

“If we can learn anything from examining the history and prior traditions surrounding women’s rights, women’s health, and abortion in North Dakota, the Court hopes that we would learn this: that there was a time when we got it wrong and when women did not have a voice,” Rominick wrote. “This does not need to continue for all time, and the sentiments of the past, alone, need not rule the present for all time.”

In front of a packed room at a Senate hearing on Thursday, longtime nurse Ellen MacInnis recounted working at a Massachusetts hospital owned by Steward Health Care, the nation’s largest for-profit hospital provider. Her voice broke as she remembered the many times she and her colleagues couldn’t give their patients the very best care because Steward insisted on saving money: by laying off staff, cutting resources, and leaving medical supply bills unpaid.

During one shift, MacInnis remembered, there were 95 patients in the emergency room and only 11 nurses; that day, she said, an elderly man awaiting chemotherapy treatment suddenly died in the ER. Another day, a patient in mental health crisis arrived in the emergency room. Without enough staff, they couldn’t allocate someone to watch him continuously, as is standard procedure. That patient went into distress and died.

The veteran nurse told this story in front of the Senate Committee on Health, Education, Labor, and Pensions (HELP), which held a charged hearing on the abuses of Steward and its investor owners. In response to testimony from MacInnis and others about the abysmal patient treatment they witnessed thanks to Steward’s extractive business model, lawmakers from both sides of the aisle assailed the company and promised to work on legislation to prevent Wall Street firms from looting hospital systems, amid a growing trend of private equity investment in health care.

“Private equity firms have bought up hundreds of hospitals, thousands of nursings homes, and tens of thousands of medical practices,” said Sen. Bernie Sanders (I-Vt.) in kicking off the hearing. “The collapse of Steward Health Care is just one extreme example of the damaging role that private equity is having, in my view, on our health care system.”

Steward declared bankruptcy in May, and has come under fire this year as details have emerged about the many ways the company prioritized enriching its top brass and investors at the expense of patient care, eventually running the chain into financial ruin. The company, which operates hospitals in eight states, was formed when private equity firm Cerberus bought a Massachusetts Catholic hospital chain in 2010, and is now owned by a publicly traded real estate investment trust (REIT) called Medical Properties Trust.

A recent Boston Globe investigation revealed that Steward’s disinvestment in patient care led to at least 15 deaths over the past 14 years. At the same time, top executives at Steward earned enormous sums while cutting costs at their hospitals, placing strain on health care providers trying to do their jobs and leading to subpar care for patients. In particular, Steward CEO Ralph de la Torre—who bought a $40 million yacht and a $15 million luxury fishing boat, uses two private jets Steward purchased for a combined $95 million, and who received a $100 million dividend when he engineered the sale of Steward to MPT—has drawn sharp criticism from the likes of Sanders and Sen. Elizabeth Warren (D-Mass.).

De la Torre was subpoenaed to appear before the Senate HELP Committee in July. About a week ago, his attorneys informed the committee that he was planning to defy the subpoena. On Thursday, committee members announced they would file resolutions to hold de la Torre in contempt for refusing to show. If he is prosecuted and convicted of criminal contempt, de la Torre could face a fine of up to $100,000 and jail time.

At Thursday’s hearing, nurse Audra Sprague recounted how the beds at her hospital would not be repaired when they broke. Staff then rented beds to fill in the gap. But Steward stopped paying the rental bed vendor, forcing Sprague and her colleagues to transfer patients to other hospitals because they didn’t have a physical place for them to lie. Her hospital, which served a rural population in central Massachusetts, closed abruptly last month due to Steward’s bankruptcy. It was licensed for 57 beds, but Sprague said that by the time it closed there were only 18 working ones left.

MacInnis added that Steward’s habit of understaffing their hospitals, as well as failing to pay many vendors, led to preventable patient harm and death. “The immediate and most debilitating impact of the ownership of Steward was Steward’s tendency to understaff units whenever and wherever they can,” she said. “The corporatization and commodification of hospital care has led to horrific harm and suffering to our patients.”

Throughout the hearing, lawmakers asked witnesses what sort of regulation they believed would help prevent more Stewards in the future. The mayor of West Monroe, Louisiana, Staci Mitchell, agreed that greater transparency into the opaque actions and finances of private equity and REIT hospital owners could have helped prevent some of the harms that unfolded at the Steward hospital in her community, Glenwood Medical Center, which included a major reduction in emergency services, layoffs of hundreds of medical staff, and strain on small businesses in the community who were owed tens of thousands by Steward for work.

After the hearing, Sen. Ed Markey (D-Mass.) held a press conference where he shed further light on lawmakers’ plans to try to regulate private equity purchases of hospitals with the Health Over Wealth Act. Introduced this summer, the bill would require that private equity–owned health care providers publicly report their debt, executive pay, health care costs charged to patients, and any reductions in services to patients or to staff pay—the kind of transparency that might help spot the sort of drastic cost-cutting that Steward Health Care engaged in for years.

The bill “will ensure transparency, accountability, protections for patients and providers, and guarantee access to care for every community in the country,” Markey said in a statement. “I am committed to preventing Steward’s failures from becoming America’s health care standard.”

More than two years since the overturn of Roe v Wade, legal battles over abortion laws are as chaotic as ever. But occasionally, the challenges playing out state by state result in a string of good news for abortion rights. That was the case this week, with a cluster of court decisions that will expand abortion access in Nevada and North Dakota, and allow Missouri and Nebraska voters to weigh in on the issue in November.

On Thursday, District Court Judge Bruce Romanick in Bismarck, North Dakota, issued a powerful opinion siding with abortion providers who challenged a state law that had deemed their practice a felony.

In his order, which takes effect in two weeks, Rominick ruled that the North Dakota constitution’s protections for life, liberty, and the right to pursue happiness include the right to choose abortion. “A woman’s choice of whether or not to carry a pregnancy to term shapes the very nature and future course of her life, on nearly every possible level,” he wrote. “The Court finds that such a choice, at least pre-viability, must belong to the individual woman and not to the government.” He also struck down the ban for its vagueness, concluding that, at present, North Dakota doctors could be prosecuted if other physicians second-guessed their decision to provide an emergency abortion.

Virtually all abortions have been illegal in North Dakota since April 2023, when Republican Gov. Doug Burgum signed a ban with exceptions only to save the life of the pregnant person, or for rape and incest survivors within the first six weeks of pregnancy. North Dakota’s only abortion clinic moved across the state line to Minnesota in 2022, soon after the Supreme Court overturned Roe v. Wade, meaning most people seeking to end a pregnancy will have to leave the state.

But Romnick’s decision should make it easier for doctors to provide emergency abortions to patients with severe pregnancy complications—care that that is often withheld in abortion-ban states, with dire consequences. “It is now much safer to be pregnant in North Dakota,” Center for Reproductive Rights lawyer Meetra Mehdizadeh said in a statement on Friday.

Also on Thursday, a Nevada court order requiring the state Medicaid program to cover abortion became final after the state government declined to appeal an earlier ruling. Nevada will become the 18th state to allow Medicaid funds to cover abortion, the Associated Press reported.

That ruling is the result of a challenge brought under Nevada’s Equal Rights Amendment, which added language banning sex discrimination, along with many other types of discrimination, to the state constitution. Voters there supported the ERA by a nearly 18-point margin in 2022.

In their lawsuit, a Nevada abortion fund and the ACLU argued that the ban on Medicaid coverage amounted to sex discrimination because it denied low-income Nevadans who can become pregnant the ability to make decisions about their future. Back in March, a Clark County District Judge Erika Ballou had agreed—though her decision didn’t become final until this week.

“The court made clear that the state cannot withhold coverage for essential, sex-linked health care from low-income Nevadans,” ACLU Reproductive Freedom Project staff attorney Rebecca Chan explained in a statement. “As a result of this decision, Nevadans who have Medicaid as their health insurance will no longer need to fear that they will be forced to carry a pregnancy against their will.”

In November, voters in New York will decide whether to enshrine an ERA of their own—one of 10 states with abortion-related initiatives slated for the 2024 ballot. Yet initiatives in two of those states were in jeopardy until courts came to their rescue this week. On Tuesday, the Missouri Supreme Court threw out a last-minute claim arguing that the text of an abortion-rights initiative petition had omitted details required by state law; it ordered the anti-abortion secretary of state to certify the initiative for the ballot.

On Friday, the Nebraska Supreme Court ruled that dueling initiatives can appear on the ballot in that state, where current law bans abortion after 12 weeks. One of the initiatives, titled “Protect the Right to Abortion,” would create a state constitutional right for Nebraskans to get an abortion prior to “viability” (the hard-to-pinpoint moment in pregnancy when a fetus is able to survive outside the uterus). The other, titled “Protect Women and Children” would enshrine the current 12-week abortion ban in the state constitution.

If both pass, the one with the most votes prevails. But anti-abortion advocates had tried to kill the pro-abortion rights measure altogether by arguing that by regulating abortion before and after viability differently, it dealt with more than one subject, according to the Nebraska Examiner. Friday’s state Supreme Court ruling tossed that challenge, and ensures the vote on both questions will proceed.

Now, with 52 days left before voters will decide whether to add abortion protections to their state constitutions, the opinion from North Dakota’s Judge Rominick could offer some guidance.

“If we can learn anything from examining the history and prior traditions surrounding women’s rights, women’s health, and abortion in North Dakota, the Court hopes that we would learn this: that there was a time when we got it wrong and when women did not have a voice,” Rominick wrote. “This does not need to continue for all time, and the sentiments of the past, alone, need not rule the present for all time.”

In front of a packed room at a Senate hearing on Thursday, longtime nurse Ellen MacInnis recounted working at a Massachusetts hospital owned by Steward Health Care, the nation’s largest for-profit hospital provider. Her voice broke as she remembered the many times she and her colleagues couldn’t give their patients the very best care because Steward insisted on saving money: by laying off staff, cutting resources, and leaving medical supply bills unpaid.

During one shift, MacInnis remembered, there were 95 patients in the emergency room and only 11 nurses; that day, she said, an elderly man awaiting chemotherapy treatment suddenly died in the ER. Another day, a patient in mental health crisis arrived in the emergency room. Without enough staff, they couldn’t allocate someone to watch him continuously, as is standard procedure. That patient went into distress and died.

The veteran nurse told this story in front of the Senate Committee on Health, Education, Labor, and Pensions (HELP), which held a charged hearing on the abuses of Steward and its investor owners. In response to testimony from MacInnis and others about the abysmal patient treatment they witnessed thanks to Steward’s extractive business model, lawmakers from both sides of the aisle assailed the company and promised to work on legislation to prevent Wall Street firms from looting hospital systems, amid a growing trend of private equity investment in health care.

“Private equity firms have bought up hundreds of hospitals, thousands of nursings homes, and tens of thousands of medical practices,” said Sen. Bernie Sanders (I-Vt.) in kicking off the hearing. “The collapse of Steward Health Care is just one extreme example of the damaging role that private equity is having, in my view, on our health care system.”

Steward declared bankruptcy in May, and has come under fire this year as details have emerged about the many ways the company prioritized enriching its top brass and investors at the expense of patient care, eventually running the chain into financial ruin. The company, which operates hospitals in eight states, was formed when private equity firm Cerberus bought a Massachusetts Catholic hospital chain in 2010, and is now owned by a publicly traded real estate investment trust (REIT) called Medical Properties Trust.

A recent Boston Globe investigation revealed that Steward’s disinvestment in patient care led to at least 15 deaths over the past 14 years. At the same time, top executives at Steward earned enormous sums while cutting costs at their hospitals, placing strain on health care providers trying to do their jobs and leading to subpar care for patients. In particular, Steward CEO Ralph de la Torre—who bought a $40 million yacht and a $15 million luxury fishing boat, uses two private jets Steward purchased for a combined $95 million, and who received a $100 million dividend when he engineered the sale of Steward to MPT—has drawn sharp criticism from the likes of Sanders and Sen. Elizabeth Warren (D-Mass.).

De la Torre was subpoenaed to appear before the Senate HELP Committee in July. About a week ago, his attorneys informed the committee that he was planning to defy the subpoena. On Thursday, committee members announced they would file resolutions to hold de la Torre in contempt for refusing to show. If he is prosecuted and convicted of criminal contempt, de la Torre could face a fine of up to $100,000 and jail time.

At Thursday’s hearing, nurse Audra Sprague recounted how the beds at her hospital would not be repaired when they broke. Staff then rented beds to fill in the gap. But Steward stopped paying the rental bed vendor, forcing Sprague and her colleagues to transfer patients to other hospitals because they didn’t have a physical place for them to lie. Her hospital, which served a rural population in central Massachusetts, closed abruptly last month due to Steward’s bankruptcy. It was licensed for 57 beds, but Sprague said that by the time it closed there were only 18 working ones left.

MacInnis added that Steward’s habit of understaffing their hospitals, as well as failing to pay many vendors, led to preventable patient harm and death. “The immediate and most debilitating impact of the ownership of Steward was Steward’s tendency to understaff units whenever and wherever they can,” she said. “The corporatization and commodification of hospital care has led to horrific harm and suffering to our patients.”

Throughout the hearing, lawmakers asked witnesses what sort of regulation they believed would help prevent more Stewards in the future. The mayor of West Monroe, Louisiana, Staci Mitchell, agreed that greater transparency into the opaque actions and finances of private equity and REIT hospital owners could have helped prevent some of the harms that unfolded at the Steward hospital in her community, Glenwood Medical Center, which included a major reduction in emergency services, layoffs of hundreds of medical staff, and strain on small businesses in the community who were owed tens of thousands by Steward for work.

After the hearing, Sen. Ed Markey (D-Mass.) held a press conference where he shed further light on lawmakers’ plans to try to regulate private equity purchases of hospitals with the Health Over Wealth Act. Introduced this summer, the bill would require that private equity–owned health care providers publicly report their debt, executive pay, health care costs charged to patients, and any reductions in services to patients or to staff pay—the kind of transparency that might help spot the sort of drastic cost-cutting that Steward Health Care engaged in for years.

The bill “will ensure transparency, accountability, protections for patients and providers, and guarantee access to care for every community in the country,” Markey said in a statement. “I am committed to preventing Steward’s failures from becoming America’s health care standard.”

Former President Donald Trump has “concepts of a plan” to replace the Affordable Care Act, also known as Obamacare. At least that’s what he claimed during his debate against Vice President Kamala Harris in Philadelphia tonight. Having access to affordable health care remains a key issue for Americans, according to Pew Research Center.

Moderator Linsey Davis of ABC News asked Trump if he had plans to get rid of the Affordable Care Act, something he vowed and failed to do during his presidency. Recently, Trump walked back this claim, saying he would keep the Affordable Care Act, unless he was able to find a good replacement. Trump, in his response, was very vague, concerning an issue as serious as health care—except he knew Democrats were to blame for any problems.

“Obamacare was lousy. It’s not very good today. And what I said that if we come up with something…we’re going to do it and we’re going to replace it. But remember this, I inherited Obamacare because Democrats wouldn’t change it. They wouldn’t vote for it. They were unanimous. They wouldn’t vote to change it. If they would have done that, we would have had a much better plan than Obama’s.”

Davis followed up, asking if he had a plan in mind to replace it. Trump seemed unable to remember that during his time as president, he had the opportunity to create a new health care program, but was unable to do so. Today, he still can’t seem to provide a coherent answer, saying,

“I have concepts of a plan. I’m not President right now, but if we come up with something, I would only change it if we come up with something that’s better and less expensive. And there are concepts and options we have to do that, and you’ll be hearing about it in the not too distant future.”

This article was published in partnership with The Marshall Project, a nonprofit news organization covering the US criminal justice system, Reveal, and USA Today. Sign up for The Marshall Project’s newsletters, and follow them on Instagram,  TikTok, Reddit, and Facebook.

Susan Horton had been a stay-at-home mom for almost 20 years, and now—pregnant with her fifth child—she felt a hard-won confidence in herself as a mother.

Then she ate a salad from Costco. 

It was her final meal before going to Kaiser Permanente hospital in Santa Rosa, in Northern California, to give birth in August 2022. It had been an exhausting pregnancy. Her family had just moved houses, and Horton was still breastfeeding her toddler. Because of her teenage son’s heart condition, she remained wary of Covid-19 and avoided crowded places, even doctor’s offices. Now, already experiencing the clawing pangs of contractions, she pulled out a frozen pizza and a salad with creamy everything dressing, savoring the hush that fell over the house, the satisfying crunch of the poppy seeds as she ate. 

Horton didn’t realize that she would be drug-tested before her child’s birth. Or that the poppy seeds in her salad could trigger a positive result on a urine drug screen, the quick test that hospitals often use to check pregnant patients for illicit drugs. Many common foods and medications—from antacids to blood pressure and cold medicines—can prompt erroneous results.

The morning after Horton delivered her daughter, a nurse told her she had tested positive for opiates. Horton was shocked. She hadn’t requested an epidural or any narcotic pain medication during labor—she didn’t even like taking Advil. “You’re sure it was mine?” she asked the nurse.

If Horton had been tested under different circumstances—for example, if she was a government employee and required to be tested as part of her job—she would have been entitled to a more advanced test and to a review from a specially trained doctor to confirm the initial result. 

But as a mother giving birth, Horton had no such protections. The hospital quickly reported her to child welfare, and the next day, a social worker arrived to take baby Halle into protective custody.  

Kaiser Permanente declined to comment on Horton’s care. A spokesperson said the Santa Rosa hospital typically gets consent to drug-test patients for medical reasons, and as a mandated reporter under state law, it refers potential exposures of newborns to illicit drugs to child welfare authorities. 

The Sonoma County Human Services Department said, in a statement, that it evaluates all referrals using “evidence- and research-based” methods, and if a report is deemed valid, it has a duty under state law to investigate.

Horton said the experience made her feel powerless and terrified.

“They had a singular piece of evidence that I had taken something,” she said, “and it was wrong.” 

For decades, state and federal laws have required hospitals across the country to identify newborns affected by drugs in the womb and to refer such cases to child protective services for possible investigation. To comply, hospitals often use urine drug screens that are inexpensive (as little as $10 per test), simple to administer (the patient pees in a cup), and provide results within minutes. 

But urine drug screens are easily misinterpreted and often wrong, with false positive rates as high as 50 percent, according to some studies. Without confirmation testing and additional review, false positive results can lead hospitals to wrongly accuse parents of illicit drug use and report babies to child welfare agencies—which may separate newborns from their families, an investigation by The Marshall Project and Reveal has found.

It’s unclear how many of the nation’s 3.6 million births every year involve drug testing, but health care experts said urine screening is ubiquitous. Tens of thousands of infants are reported annually to authorities for in utero drug exposure, with no guarantee that the underlying tests are accurate, our analysis of federal data shows.

To report this story, The Marshall Project interviewed dozens of patients, medical providers, toxicologists, and other experts, and collected information on more than 50 mothers in 22 states who faced reports and investigations over positive drug tests that were likely wrong. We also pored over thousands of pages of policy documents from every state child welfare agency in the country. 

Problems with drug screens are well known, especially in workplace testing. But there’s been little investigation of how easily false positives can occur inside labor and delivery units, and how quickly families can get trapped inside a system of surveillance and punishment.

Hospitals reported women for positive drug tests after they ate everything bagels and lemon poppy seed muffins, or used medications including the acid reducer Zantac, the antidepressant Zoloft, and labetalol, one of the most commonly prescribed blood pressure treatments for pregnant women. 

After a California mother had a false positive for meth and PCP, authorities took her newborn, then dispatched two sheriff’s deputies to also remove her toddler from her custody, court records show. In New York, hospital administrators refused to retract a child welfare report based on a false positive result, and instead offered the mother counseling for her trauma, according to a recording of the conversation. And when a Pennsylvania woman tested positive for opioids after eating pasta salad, the hearing officer in her case yelled at her to “buck up, get a backbone, and stop crying,” court records show. It took three months to get her newborn back from foster care. 

Federal officials have known for decades that urine screens are not reliable. Poppy seeds—which come from the same plant used to make heroin—are so notorious for causing positives for opiates that last year the Department of Defense directed service members to stop eating them. At hospitals, test results often come with warnings about false positives and direct clinicians to confirm the findings with more definitive tests. 

Yet state policies and many hospitals tend to treat drug screens as unassailable evidence of illicit use, The Marshall Project found. Hospitals across the country routinely report cases to authorities without ordering confirmation tests or waiting to receive the results. 

At least 27 states explicitly require hospitals to alert child welfare agencies after a positive screen or potential exposure, according to a review of state laws and policies by The Marshall Project. But, not a single state requires hospitals to confirm test results before reporting them. At least 25 states do not require child welfare workers to confirm positive test results, either. 

While parents often lack protections, most of the caseworkers who investigate them are entitled to confirmation testing and a review if they test positive for drugs on the job, our analysis found. 

Health care providers say there are medical reasons to test labor and delivery patients for drugs, including alerting doctors to watch a newborn for withdrawal symptoms. They also cite concerns about criminal and legal liability if they fail to report positive test results. 

Even when a doctor refutes a positive result and vouches for their patient, hospitals may report the incorrect data anyway to child welfare agencies.

“It’s almost like a gut punch. You come to the hospital and you see a social work note on your patient’s chart,” said Dr. Yashica Robinson, an OB/GYN in Huntsville, Alabama, who has tried and failed several times to halt child welfare reports and investigations of patients with false positive results. “Once that ball is rolling, it’s hard to stop it,” Robinson said.

No government agency collects comprehensive data on false positive results or on how many pregnant patients are tested. And confidentiality laws that shield medical and child welfare records make it difficult for the public to understand how many families are affected. 

In 2016, Congress mandated states to submit the number of “substance-affected” infants to the U.S. Department of Health and Human Services. Not all states track every case, but from fiscal years 2018 through 2022, medical professionals reported at least 170,000 infants to child welfare agencies for exposure to substances, according to an analysis by The Marshall Project. In 2022 alone, more than 35,000 such cases were reported, and authorities removed more than 6,000 infants from their families, our analysis found. 

The harms of drug testing fall disproportionately on low-income, Black, Hispanic, and Native American women, who studies have found are more likely to be tested when they give birth, more likely to be investigated, and less likely to reunite with their children after they’ve been removed. 

But the false positive cases The Marshall Project identified include parents of all socioeconomic classes and occupations—from a lawyer to a school librarian to a nurse who drug-tests other people for a living. 

“People should be concerned,” said Dr. Stephen Patrick, a leading neonatal researcher who chairs the Department of Health Policy and Management at the Rollins School of Public Health in Atlanta. “This could happen to any one of us.”

Drug screens are more guesswork than exact science. Chemicals in the tests quickly cross-react with urine, flagging anything that looks like it could be an illicit substance. The tests are like fishing nets that are cast wide and pick up anything and everything that fits, said Dr. Gwen McMillin, a professor at the University of Utah School of Medicine and medical director of a drug-testing lab. The problem is that nets also ensnare fish that aren’t being targeted: compounds that are closely related to illicit substances or merely look similar. 

“Drug testing results need to be confirmed before they go to CPS,” McMillin said. “Actions should not be taken based on a single drug testing result. Period.” 

But sometimes, even confirmation tests can be misinterpreted, as Susan Horton found. At first, Horton was puzzled by her positive test result. She wondered if her urine might have been mixed up with another patient’s. Then—“ding ding ding!”—her last meal popped into her head. She told a nurse about the poppy seeds in her salad, sure that this would resolve her doctors’ concerns. 

Horton’s records show Kaiser ran her urine sample through a second test, and this time it came back positive for one opiate in particular: codeine. That shouldn’t have been surprising—poppy seeds, like the ones in Horton’s salad, are derived from the opium poppy plant and contain codeine. 

To differentiate between salad dressing or bagels and illicit drugs, toxicologists have long recommended testing urine for the presence of a compound called thebaine, which is found in poppy seeds but not in heroin. There’s no indication that the hospital performed or even knew about the thebaine test, leaving providers with no way to prove or disprove Horton’s claims.

“Mom and dad insistent that a Costco salad with poppyseed dressing is responsible,” a doctor wrote in her notes. Another doctor wrote: “We are unable to verify whether this could result in a positive test.”

Soon, multiple doctors and nurses filed into Horton’s room. They said hospital policy dictated that Halle remain there for five days to be monitored for possible drug withdrawal symptoms—“for baby’s safety,” a doctor told Horton.

Unlike most other states that require hospitals to report positive drug tests, California law says a positive test alone “is not in and of itself a sufficient basis for reporting child abuse or neglect.” But because of Covid-19 and her son’s heart condition, Horton had also missed some prenatal appointments, which many providers see as a red flag for drug use. A hospital social worker noted the missed appointments and decided to file a report.

In a statement about its practices in general, Kaiser said it always conducts a “multi-faceted assessment” prior to filing a report to CPS, which is responsible for reviewing the information and investigating. 

Horton insisted that keeping her baby at the hospital was unnecessary. “I’m not a drug addict,” she said she pleaded. Desperate for help, her husband called the police, who declined to oppose hospital directives, records show. 

When the caseworker arrived, the couple refused to sign a safety plan or allow the person to interview their children and inspect their home. So the caseworker immediately obtained a judge’s order and placed baby Halle into temporary custody in the hospital, before discharging her to her grandparents, who were ordered to supervise Horton with her child. 

A few days later, Horton stood silently in court, dressed in pants that clung uncomfortably to her still-healing body, feeling as if her motherhood was on trial. A caseworker told the judge it would be dangerous to release Halle to her parents, and Horton agreed to another drug test. A worker followed her to the bathroom and watched her urinate in a cup.

By then, caseworkers and doctors had privately acknowledged that poppy seeds could have caused Horton’s positive test result. But in court the caseworker didn’t mention that. Instead, she argued that Horton’s purported drug use had “caused serious physical harm” to her child. 

The agency said under state law it can’t comment on individual cases. Speaking generally, it said a single positive drug test, false or otherwise, doesn’t warrant an investigation, and that there needs to be “a reported observation of impact to the child.”

When workplace drug testing was introduced in the 1980s, unions and civil rights groups decried the error rates of drug screens and how companies were firing workers over false positive results. In response, federal authorities mandated safeguards for employees, including requiring confirmation tests and a review from a specially trained doctor to determine whether a food or medication could have caused a positive result. 

A federal medical advisory committee in 1993 urged health care providers who drug-test pregnant patients to adopt the same rigorous standards. But amid the “crack baby” panic, the idea of protecting mothers did not catch on. 

Hospital drug testing policies vary widely. Many facilities, such as Kaiser in Santa Rosa, test every labor-and-delivery patient. Other hospitals flag only certain people, such as those with limited prenatal care, high blood pressure, even bad teeth, experts say. At many hospitals, the decision is up to doctors and nurses, who may view a mother’s tattoos, disheveled clothing, or stressed demeanor with suspicion. Studies have found that the decision to test is rife with class and race bias.

“Those who look like they have less resources, people might say, ‘Well, they look more likely to use drugs,’” said Dr. Cresta Jones, an associate professor and maternal-fetal medicine specialist at the University of Minnesota Medical School.

Hospitals often have full discretion over whether to screen for drugs, but once a positive result is in hand, the decision to report becomes more complicated. Laws and policies in at least 12 states explicitly require hospitals to send screen results to child welfare agencies, even if they are not confirmed, according to The Marshall Project’s review. 

For hospitals, cost is also an issue. While urine screens are cheap, the equipment needed to run a confirmation test costs hundreds of thousands of dollars, in addition to the cost of expert personnel and lab certification. Some hospitals contract out confirmation testing—a lower-cost alternative—but getting results can take days, long after many families are ready to go home.

Doctors, nurses, and hospital social workers face an uncomfortable predicament: Do they send the baby home to what they believe could be an unsafe environment, or do they call authorities?

“God forbid the baby goes home, withdraws and dies, we’re going to be held liable for that,” said Dr. Adi Davidov, an obstetrician at Staten Island University Hospital, which drug-tests every birthing patient.

State mandatory reporting laws add to the pressure on doctors and nurses. These laws impose criminal liability on providers who fail to report, while also protecting physicians who report “in good faith”—insulating hospitals from lawsuits if test results are wrong. 

Even when doctors have the ability to order a confirmation test, they don’t always do so. Many misinterpret positive screens as definitive evidence of drug use.

When Grace Smith had her fourth child in 2021 at St. Luke’s University Hospital, an hour north of Philadelphia, she was taking prescribed marijuana and Vyvanse, a medication for attention deficit hyperactivity disorder. The medicine contains amphetamine, but the hospital’s drug screen results did not differentiate between meth and amphetamine, according to medical records. The day after Smith delivered her son, a doctor told her that she and her baby had tested positive for meth and that the hospital had notified child protective services.

Smith’s husband, Michael, asked the doctor to review his wife’s medical records to confirm her prescription, according to the doctor’s notes. The doctor argued that wasn’t her role. “I explained that our responsibility as healthcare workers was to report the case” to child welfare authorities, she wrote, adding that the agency “would conduct any investigation that was necessary.”

When Michael Smith told the doctor they were leaving with their baby, the hospital called the police. An officer escorted the parents out, without their newborn, a police report shows. The Smiths said the police told them they would be arrested if they returned.

A spokesperson for St. Luke’s University Health Network declined to answer questions from The Marshall Project, saying in an email that the hospital “complies with all rules and regulations regarding drug testing and reporting” and that the newborn’s welfare “is always our primary concern.”

Four days after the Smiths’ son was born, Monroe County Children and Youth Services told the hospital it was okay to release the baby to his parents. But the investigation remained open. It wasn’t until the Smiths paid more than $3,500 for a lawyer—and nearly $300 for a confirmation drug test that came back negative—that the agency closed their case. The agency declined to comment.

The Smiths filed a lawsuit in 2022 against St. Luke’s. In its response, the hospital acknowledged that it had not given Grace a confirmation test, but denied violating the Smiths’ privacy or civil rights. A judge dismissed the suit in 2023, saying in part that the Smiths did not sufficiently argue their claims.

Many providers erroneously assume that child welfare agencies verify a parent’s drug use. But government caseworkers typically lack the expertise to accurately interpret drug test results. State policy manuals seldom mention the possibility of false positives. It often falls on parents to prove their own innocence.

As a nurse in South Carolina, Ashley Riley said she regularly drug-tested patients in an addiction treatment program, flagged faulty tests, and sent out positive screens for confirmation. But when she herself screened positive for opiates after delivering her son in 2023, Riley said the hospital declined to order a confirmation test, then reported her to authorities.

Riley and her husband, Jeffrey, insisted the positive result was from lemon poppy seed muffins that she had eaten throughout her pregnancy. As proof, Jeffrey Riley texted the investigator a receipt for the muffins, studies on false positives caused by poppy seeds, and the 2023 memo from the Department of Defense urging service members to avoid poppy seeds.

“At no point in time was there anybody in there that was even trying to advocate for my wife, except for me,” he recalled.

At first, he thought his efforts were working. The caseworker acknowledged in his notes having seen the poppy seeds and noted that the report “could be falsified.” 

But the caseworker still insisted the couple sign a safety plan, advising them that their two children would be placed in foster care unless they assigned a “protector”—a responsible adult who would supervise them with their children at all times. This continued for 45 days before the case was closed as unfounded. 

“We were guilty until proven innocent,” Ashley Riley said. 

The hospital even charged $424 for the problematic urine test. Hospital officials did not respond to multiple interview requests.

Will Batchelor, a spokesperson for the South Carolina Department of Social Services, wrote in a statement that the agency has a duty to investigate once a hospital has filed a report and that it “exercised appropriate restraint” by not removing the child from the home.

“Because the safety of a child is at stake, DSS has to continue its investigation beyond seeing a receipt for poppy seed muffins,” Batchelor wrote.

Even when a parent has a confirmation test and her own doctor’s word attesting to a false positive result, authorities may keep investigating.

When Melissa Robinson, an elementary school librarian in Huntsville, Alabama, screened pos​​itive for cocaine in early 2024, the news shocked her and her doctors. Robinson had avoided anything during her pregnancy that could be risky, even cold cuts—which may carry bacteria—and had no history of drug use. Because of the positive test, staff told Robinson she was not allowed to breastfeed her daughter, hospital records show, and they reported her to Alabama’s child welfare agency, the Department of Human Resources. Robinson said a caseworker told her that she probably wouldn’t be allowed to be alone with her baby—her husband would have to supervise.

A few days later, a confirmation test came back negative for any substances. With proof that she had not used cocaine, Robinson assumed the case would be closed. Instead, the agency continued to investigate, inspecting her home and even requiring her husband to take a drug test, she said.

A spokesperson for Alabama’s child welfare agency said they are required to respond immediately to a hospital report and “make safety decisions relying on current and most accessible information.”

When the baby was two weeks old, the agency closed the case, citing insufficient evidence. But the allegations will remain on Robinson’s record for at least five years.

“To have such a beautiful experience tainted by something like that, it’s difficult,” Robinson recalled. “Truthfully, it’s turned me into somebody different.” 

Some medical groups and providers have taken steps to reduce unnecessary child welfare reports. The American College of Obstetricians and Gynecologists advises hospitals to use a screening questionnaire rather than drug tests to identify people who may have substance abuse problems. The organization also recommends that hospitals obtain consent from patients, explaining the potential consequences of a positive result—including if the hospital is required to report it to authorities. A number of large hospitals have adopted some version of those recommendations. 

After a study at Staten Island University Hospital in New York found a high rate of false positives, administrators brought the confirmation testing in-house. They said results come back within a day or two, rather than the week that is typical for outside tests, which allows providers to wait before contacting child welfare.

“Any time you act on a test that’s not 100 percent, you run the risk of causing more harm than good,” said the hospital’s Dr. Davidov. “If you are going to get CPS involved with a mother who did nothing wrong and is a good citizen, that’s harming her. It’s harming her experience, it’s harming her ability to take care of her newborn.”

In recent years, advocacy groups have filed lawsuits against hospitals for testing without explicit consent, which has led some state officials and lawmakers to speak out against the testing. But in most of the United States, it remains common practice to report families based on unconfirmed positive screens. Most of the women interviewed by The Marshall Project signed general consent forms at the hospital but said they were never informed explicitly they would be drug-tested, nor that a positive result could be reported to authorities.

For Susan Horton, her family’s ordeal has created an undercurrent of fear that courses through her daily life. 

After the court hearing in August 2022, child welfare workers took the baby to Horton’s elderly in-laws and barred Horton and her husband from being alone with their newborn while the agency investigated. Finally, almost two weeks after their daughter was born, the agency withdrew its petition and a judge dismissed the case, allowing the Hortons to bring baby Halle home.

One afternoon last spring, Horton took her daughter, now a toddler, outside. Halle giggled as her mother chased her around the front yard, her little feet splashing in a small mud hole. This was the life Horton had envisioned years ago—a quiet place in the California countryside where her children could delight in the world around them. And yet, Horton couldn’t help but remember the investigation that destroyed her family’s peace of mind—and her self-esteem.

“I had a lot of confidence in how I mother and how I parent,” she said. “Now in my head, I’m always questioning my choices.” She wondered aloud what neighbors would say if they saw her daughter playing in the mud, if someone might accuse her of being a bad parent.

“I just always have that looming feeling that at any moment CPS could come knocking and take my children away.” 

Marshall Project reporters Weihua Li, Andrew Rodriguez Calderón, Nakylah Carter, and Catherine Odom contributed to this story.

This article was published in partnership with The Marshall Project, a nonprofit news organization covering the US criminal justice system, Reveal, and USA Today. Sign up for The Marshall Project’s newsletters, and follow them on Instagram,  TikTok, Reddit, and Facebook.

Susan Horton had been a stay-at-home mom for almost 20 years, and now—pregnant with her fifth child—she felt a hard-won confidence in herself as a mother.

Then she ate a salad from Costco. 

It was her final meal before going to Kaiser Permanente hospital in Santa Rosa, in Northern California, to give birth in August 2022. It had been an exhausting pregnancy. Her family had just moved houses, and Horton was still breastfeeding her toddler. Because of her teenage son’s heart condition, she remained wary of Covid-19 and avoided crowded places, even doctor’s offices. Now, already experiencing the clawing pangs of contractions, she pulled out a frozen pizza and a salad with creamy everything dressing, savoring the hush that fell over the house, the satisfying crunch of the poppy seeds as she ate. 

Horton didn’t realize that she would be drug-tested before her child’s birth. Or that the poppy seeds in her salad could trigger a positive result on a urine drug screen, the quick test that hospitals often use to check pregnant patients for illicit drugs. Many common foods and medications—from antacids to blood pressure and cold medicines—can prompt erroneous results.

The morning after Horton delivered her daughter, a nurse told her she had tested positive for opiates. Horton was shocked. She hadn’t requested an epidural or any narcotic pain medication during labor—she didn’t even like taking Advil. “You’re sure it was mine?” she asked the nurse.

If Horton had been tested under different circumstances—for example, if she was a government employee and required to be tested as part of her job—she would have been entitled to a more advanced test and to a review from a specially trained doctor to confirm the initial result. 

But as a mother giving birth, Horton had no such protections. The hospital quickly reported her to child welfare, and the next day, a social worker arrived to take baby Halle into protective custody.  

Kaiser Permanente declined to comment on Horton’s care. A spokesperson said the Santa Rosa hospital typically gets consent to drug-test patients for medical reasons, and as a mandated reporter under state law, it refers potential exposures of newborns to illicit drugs to child welfare authorities. 

The Sonoma County Human Services Department said, in a statement, that it evaluates all referrals using “evidence- and research-based” methods, and if a report is deemed valid, it has a duty under state law to investigate.

Horton said the experience made her feel powerless and terrified.

“They had a singular piece of evidence that I had taken something,” she said, “and it was wrong.” 

For decades, state and federal laws have required hospitals across the country to identify newborns affected by drugs in the womb and to refer such cases to child protective services for possible investigation. To comply, hospitals often use urine drug screens that are inexpensive (as little as $10 per test), simple to administer (the patient pees in a cup), and provide results within minutes. 

But urine drug screens are easily misinterpreted and often wrong, with false positive rates as high as 50 percent, according to some studies. Without confirmation testing and additional review, false positive results can lead hospitals to wrongly accuse parents of illicit drug use and report babies to child welfare agencies—which may separate newborns from their families, an investigation by The Marshall Project and Reveal has found.

It’s unclear how many of the nation’s 3.6 million births every year involve drug testing, but health care experts said urine screening is ubiquitous. Tens of thousands of infants are reported annually to authorities for in utero drug exposure, with no guarantee that the underlying tests are accurate, our analysis of federal data shows.

To report this story, The Marshall Project interviewed dozens of patients, medical providers, toxicologists, and other experts, and collected information on more than 50 mothers in 22 states who faced reports and investigations over positive drug tests that were likely wrong. We also pored over thousands of pages of policy documents from every state child welfare agency in the country. 

Problems with drug screens are well known, especially in workplace testing. But there’s been little investigation of how easily false positives can occur inside labor and delivery units, and how quickly families can get trapped inside a system of surveillance and punishment.

Hospitals reported women for positive drug tests after they ate everything bagels and lemon poppy seed muffins, or used medications including the acid reducer Zantac, the antidepressant Zoloft, and labetalol, one of the most commonly prescribed blood pressure treatments for pregnant women. 

After a California mother had a false positive for meth and PCP, authorities took her newborn, then dispatched two sheriff’s deputies to also remove her toddler from her custody, court records show. In New York, hospital administrators refused to retract a child welfare report based on a false positive result, and instead offered the mother counseling for her trauma, according to a recording of the conversation. And when a Pennsylvania woman tested positive for opioids after eating pasta salad, the hearing officer in her case yelled at her to “buck up, get a backbone, and stop crying,” court records show. It took three months to get her newborn back from foster care. 

Federal officials have known for decades that urine screens are not reliable. Poppy seeds—which come from the same plant used to make heroin—are so notorious for causing positives for opiates that last year the Department of Defense directed service members to stop eating them. At hospitals, test results often come with warnings about false positives and direct clinicians to confirm the findings with more definitive tests. 

Yet state policies and many hospitals tend to treat drug screens as unassailable evidence of illicit use, The Marshall Project found. Hospitals across the country routinely report cases to authorities without ordering confirmation tests or waiting to receive the results. 

At least 27 states explicitly require hospitals to alert child welfare agencies after a positive screen or potential exposure, according to a review of state laws and policies by The Marshall Project. But, not a single state requires hospitals to confirm test results before reporting them. At least 25 states do not require child welfare workers to confirm positive test results, either. 

While parents often lack protections, most of the caseworkers who investigate them are entitled to confirmation testing and a review if they test positive for drugs on the job, our analysis found. 

Health care providers say there are medical reasons to test labor and delivery patients for drugs, including alerting doctors to watch a newborn for withdrawal symptoms. They also cite concerns about criminal and legal liability if they fail to report positive test results. 

Even when a doctor refutes a positive result and vouches for their patient, hospitals may report the incorrect data anyway to child welfare agencies.

“It’s almost like a gut punch. You come to the hospital and you see a social work note on your patient’s chart,” said Dr. Yashica Robinson, an OB/GYN in Huntsville, Alabama, who has tried and failed several times to halt child welfare reports and investigations of patients with false positive results. “Once that ball is rolling, it’s hard to stop it,” Robinson said.

No government agency collects comprehensive data on false positive results or on how many pregnant patients are tested. And confidentiality laws that shield medical and child welfare records make it difficult for the public to understand how many families are affected. 

In 2016, Congress mandated states to submit the number of “substance-affected” infants to the U.S. Department of Health and Human Services. Not all states track every case, but from fiscal years 2018 through 2022, medical professionals reported at least 170,000 infants to child welfare agencies for exposure to substances, according to an analysis by The Marshall Project. In 2022 alone, more than 35,000 such cases were reported, and authorities removed more than 6,000 infants from their families, our analysis found. 

The harms of drug testing fall disproportionately on low-income, Black, Hispanic, and Native American women, who studies have found are more likely to be tested when they give birth, more likely to be investigated, and less likely to reunite with their children after they’ve been removed. 

But the false positive cases The Marshall Project identified include parents of all socioeconomic classes and occupations—from a lawyer to a school librarian to a nurse who drug-tests other people for a living. 

“People should be concerned,” said Dr. Stephen Patrick, a leading neonatal researcher who chairs the Department of Health Policy and Management at the Rollins School of Public Health in Atlanta. “This could happen to any one of us.”

Drug screens are more guesswork than exact science. Chemicals in the tests quickly cross-react with urine, flagging anything that looks like it could be an illicit substance. The tests are like fishing nets that are cast wide and pick up anything and everything that fits, said Dr. Gwen McMillin, a professor at the University of Utah School of Medicine and medical director of a drug-testing lab. The problem is that nets also ensnare fish that aren’t being targeted: compounds that are closely related to illicit substances or merely look similar. 

“Drug testing results need to be confirmed before they go to CPS,” McMillin said. “Actions should not be taken based on a single drug testing result. Period.” 

But sometimes, even confirmation tests can be misinterpreted, as Susan Horton found. At first, Horton was puzzled by her positive test result. She wondered if her urine might have been mixed up with another patient’s. Then—“ding ding ding!”—her last meal popped into her head. She told a nurse about the poppy seeds in her salad, sure that this would resolve her doctors’ concerns. 

Horton’s records show Kaiser ran her urine sample through a second test, and this time it came back positive for one opiate in particular: codeine. That shouldn’t have been surprising—poppy seeds, like the ones in Horton’s salad, are derived from the opium poppy plant and contain codeine. 

To differentiate between salad dressing or bagels and illicit drugs, toxicologists have long recommended testing urine for the presence of a compound called thebaine, which is found in poppy seeds but not in heroin. There’s no indication that the hospital performed or even knew about the thebaine test, leaving providers with no way to prove or disprove Horton’s claims.

“Mom and dad insistent that a Costco salad with poppyseed dressing is responsible,” a doctor wrote in her notes. Another doctor wrote: “We are unable to verify whether this could result in a positive test.”

Soon, multiple doctors and nurses filed into Horton’s room. They said hospital policy dictated that Halle remain there for five days to be monitored for possible drug withdrawal symptoms—“for baby’s safety,” a doctor told Horton.

Unlike most other states that require hospitals to report positive drug tests, California law says a positive test alone “is not in and of itself a sufficient basis for reporting child abuse or neglect.” But because of Covid-19 and her son’s heart condition, Horton had also missed some prenatal appointments, which many providers see as a red flag for drug use. A hospital social worker noted the missed appointments and decided to file a report.

In a statement about its practices in general, Kaiser said it always conducts a “multi-faceted assessment” prior to filing a report to CPS, which is responsible for reviewing the information and investigating. 

Horton insisted that keeping her baby at the hospital was unnecessary. “I’m not a drug addict,” she said she pleaded. Desperate for help, her husband called the police, who declined to oppose hospital directives, records show. 

When the caseworker arrived, the couple refused to sign a safety plan or allow the person to interview their children and inspect their home. So the caseworker immediately obtained a judge’s order and placed baby Halle into temporary custody in the hospital, before discharging her to her grandparents, who were ordered to supervise Horton with her child. 

A few days later, Horton stood silently in court, dressed in pants that clung uncomfortably to her still-healing body, feeling as if her motherhood was on trial. A caseworker told the judge it would be dangerous to release Halle to her parents, and Horton agreed to another drug test. A worker followed her to the bathroom and watched her urinate in a cup.

By then, caseworkers and doctors had privately acknowledged that poppy seeds could have caused Horton’s positive test result. But in court the caseworker didn’t mention that. Instead, she argued that Horton’s purported drug use had “caused serious physical harm” to her child. 

The agency said under state law it can’t comment on individual cases. Speaking generally, it said a single positive drug test, false or otherwise, doesn’t warrant an investigation, and that there needs to be “a reported observation of impact to the child.”

When workplace drug testing was introduced in the 1980s, unions and civil rights groups decried the error rates of drug screens and how companies were firing workers over false positive results. In response, federal authorities mandated safeguards for employees, including requiring confirmation tests and a review from a specially trained doctor to determine whether a food or medication could have caused a positive result. 

A federal medical advisory committee in 1993 urged health care providers who drug-test pregnant patients to adopt the same rigorous standards. But amid the “crack baby” panic, the idea of protecting mothers did not catch on. 

Hospital drug testing policies vary widely. Many facilities, such as Kaiser in Santa Rosa, test every labor-and-delivery patient. Other hospitals flag only certain people, such as those with limited prenatal care, high blood pressure, even bad teeth, experts say. At many hospitals, the decision is up to doctors and nurses, who may view a mother’s tattoos, disheveled clothing, or stressed demeanor with suspicion. Studies have found that the decision to test is rife with class and race bias.

“Those who look like they have less resources, people might say, ‘Well, they look more likely to use drugs,’” said Dr. Cresta Jones, an associate professor and maternal-fetal medicine specialist at the University of Minnesota Medical School.

Hospitals often have full discretion over whether to screen for drugs, but once a positive result is in hand, the decision to report becomes more complicated. Laws and policies in at least 12 states explicitly require hospitals to send screen results to child welfare agencies, even if they are not confirmed, according to The Marshall Project’s review. 

For hospitals, cost is also an issue. While urine screens are cheap, the equipment needed to run a confirmation test costs hundreds of thousands of dollars, in addition to the cost of expert personnel and lab certification. Some hospitals contract out confirmation testing—a lower-cost alternative—but getting results can take days, long after many families are ready to go home.

Doctors, nurses, and hospital social workers face an uncomfortable predicament: Do they send the baby home to what they believe could be an unsafe environment, or do they call authorities?

“God forbid the baby goes home, withdraws and dies, we’re going to be held liable for that,” said Dr. Adi Davidov, an obstetrician at Staten Island University Hospital, which drug-tests every birthing patient.

State mandatory reporting laws add to the pressure on doctors and nurses. These laws impose criminal liability on providers who fail to report, while also protecting physicians who report “in good faith”—insulating hospitals from lawsuits if test results are wrong. 

Even when doctors have the ability to order a confirmation test, they don’t always do so. Many misinterpret positive screens as definitive evidence of drug use.

When Grace Smith had her fourth child in 2021 at St. Luke’s University Hospital, an hour north of Philadelphia, she was taking prescribed marijuana and Vyvanse, a medication for attention deficit hyperactivity disorder. The medicine contains amphetamine, but the hospital’s drug screen results did not differentiate between meth and amphetamine, according to medical records. The day after Smith delivered her son, a doctor told her that she and her baby had tested positive for meth and that the hospital had notified child protective services.

Smith’s husband, Michael, asked the doctor to review his wife’s medical records to confirm her prescription, according to the doctor’s notes. The doctor argued that wasn’t her role. “I explained that our responsibility as healthcare workers was to report the case” to child welfare authorities, she wrote, adding that the agency “would conduct any investigation that was necessary.”

When Michael Smith told the doctor they were leaving with their baby, the hospital called the police. An officer escorted the parents out, without their newborn, a police report shows. The Smiths said the police told them they would be arrested if they returned.

A spokesperson for St. Luke’s University Health Network declined to answer questions from The Marshall Project, saying in an email that the hospital “complies with all rules and regulations regarding drug testing and reporting” and that the newborn’s welfare “is always our primary concern.”

Four days after the Smiths’ son was born, Monroe County Children and Youth Services told the hospital it was okay to release the baby to his parents. But the investigation remained open. It wasn’t until the Smiths paid more than $3,500 for a lawyer—and nearly $300 for a confirmation drug test that came back negative—that the agency closed their case. The agency declined to comment.

The Smiths filed a lawsuit in 2022 against St. Luke’s. In its response, the hospital acknowledged that it had not given Grace a confirmation test, but denied violating the Smiths’ privacy or civil rights. A judge dismissed the suit in 2023, saying in part that the Smiths did not sufficiently argue their claims.

Many providers erroneously assume that child welfare agencies verify a parent’s drug use. But government caseworkers typically lack the expertise to accurately interpret drug test results. State policy manuals seldom mention the possibility of false positives. It often falls on parents to prove their own innocence.

As a nurse in South Carolina, Ashley Riley said she regularly drug-tested patients in an addiction treatment program, flagged faulty tests, and sent out positive screens for confirmation. But when she herself screened positive for opiates after delivering her son in 2023, Riley said the hospital declined to order a confirmation test, then reported her to authorities.

Riley and her husband, Jeffrey, insisted the positive result was from lemon poppy seed muffins that she had eaten throughout her pregnancy. As proof, Jeffrey Riley texted the investigator a receipt for the muffins, studies on false positives caused by poppy seeds, and the 2023 memo from the Department of Defense urging service members to avoid poppy seeds.

“At no point in time was there anybody in there that was even trying to advocate for my wife, except for me,” he recalled.

At first, he thought his efforts were working. The caseworker acknowledged in his notes having seen the poppy seeds and noted that the report “could be falsified.” 

But the caseworker still insisted the couple sign a safety plan, advising them that their two children would be placed in foster care unless they assigned a “protector”—a responsible adult who would supervise them with their children at all times. This continued for 45 days before the case was closed as unfounded. 

“We were guilty until proven innocent,” Ashley Riley said. 

The hospital even charged $424 for the problematic urine test. Hospital officials did not respond to multiple interview requests.

Will Batchelor, a spokesperson for the South Carolina Department of Social Services, wrote in a statement that the agency has a duty to investigate once a hospital has filed a report and that it “exercised appropriate restraint” by not removing the child from the home.

“Because the safety of a child is at stake, DSS has to continue its investigation beyond seeing a receipt for poppy seed muffins,” Batchelor wrote.

Even when a parent has a confirmation test and her own doctor’s word attesting to a false positive result, authorities may keep investigating.

When Melissa Robinson, an elementary school librarian in Huntsville, Alabama, screened pos​​itive for cocaine in early 2024, the news shocked her and her doctors. Robinson had avoided anything during her pregnancy that could be risky, even cold cuts—which may carry bacteria—and had no history of drug use. Because of the positive test, staff told Robinson she was not allowed to breastfeed her daughter, hospital records show, and they reported her to Alabama’s child welfare agency, the Department of Human Resources. Robinson said a caseworker told her that she probably wouldn’t be allowed to be alone with her baby—her husband would have to supervise.

A few days later, a confirmation test came back negative for any substances. With proof that she had not used cocaine, Robinson assumed the case would be closed. Instead, the agency continued to investigate, inspecting her home and even requiring her husband to take a drug test, she said.

A spokesperson for Alabama’s child welfare agency said they are required to respond immediately to a hospital report and “make safety decisions relying on current and most accessible information.”

When the baby was two weeks old, the agency closed the case, citing insufficient evidence. But the allegations will remain on Robinson’s record for at least five years.

“To have such a beautiful experience tainted by something like that, it’s difficult,” Robinson recalled. “Truthfully, it’s turned me into somebody different.” 

Some medical groups and providers have taken steps to reduce unnecessary child welfare reports. The American College of Obstetricians and Gynecologists advises hospitals to use a screening questionnaire rather than drug tests to identify people who may have substance abuse problems. The organization also recommends that hospitals obtain consent from patients, explaining the potential consequences of a positive result—including if the hospital is required to report it to authorities. A number of large hospitals have adopted some version of those recommendations. 

After a study at Staten Island University Hospital in New York found a high rate of false positives, administrators brought the confirmation testing in-house. They said results come back within a day or two, rather than the week that is typical for outside tests, which allows providers to wait before contacting child welfare.

“Any time you act on a test that’s not 100 percent, you run the risk of causing more harm than good,” said the hospital’s Dr. Davidov. “If you are going to get CPS involved with a mother who did nothing wrong and is a good citizen, that’s harming her. It’s harming her experience, it’s harming her ability to take care of her newborn.”

In recent years, advocacy groups have filed lawsuits against hospitals for testing without explicit consent, which has led some state officials and lawmakers to speak out against the testing. But in most of the United States, it remains common practice to report families based on unconfirmed positive screens. Most of the women interviewed by The Marshall Project signed general consent forms at the hospital but said they were never informed explicitly they would be drug-tested, nor that a positive result could be reported to authorities.

For Susan Horton, her family’s ordeal has created an undercurrent of fear that courses through her daily life. 

After the court hearing in August 2022, child welfare workers took the baby to Horton’s elderly in-laws and barred Horton and her husband from being alone with their newborn while the agency investigated. Finally, almost two weeks after their daughter was born, the agency withdrew its petition and a judge dismissed the case, allowing the Hortons to bring baby Halle home.

One afternoon last spring, Horton took her daughter, now a toddler, outside. Halle giggled as her mother chased her around the front yard, her little feet splashing in a small mud hole. This was the life Horton had envisioned years ago—a quiet place in the California countryside where her children could delight in the world around them. And yet, Horton couldn’t help but remember the investigation that destroyed her family’s peace of mind—and her self-esteem.

“I had a lot of confidence in how I mother and how I parent,” she said. “Now in my head, I’m always questioning my choices.” She wondered aloud what neighbors would say if they saw her daughter playing in the mud, if someone might accuse her of being a bad parent.

“I just always have that looming feeling that at any moment CPS could come knocking and take my children away.” 

Marshall Project reporters Weihua Li, Andrew Rodriguez Calderón, Nakylah Carter, and Catherine Odom contributed to this story.

Jade Dass was taking medication to treat her addiction to opioids before she became pregnant—which scientific studies and the Centers for Disease Control and Prevention recommend. But after Dass delivered a healthy daughter, the hospital reported her to the Arizona Department of Child Safety.

Even as medications like Suboxone help pregnant women safely treat addiction, taking them can trigger investigations by child welfare agencies that separate parents from their newborns. Why are women like Dass being investigated for using addiction-treatment medications during pregnancy?

To understand the scope of the dragnet, the Center for Investigative Reporting’s Shoshana Walter and Melissa Lewis, with a team of researchers and lawyers, filed 100 public records requests, putting together the first-ever tally of how often women are reported to child welfare agencies for taking prescription drugs during pregnancy. 

This week on Reveal, in an episode first aired in July 2023, follow Dass as she grapples with losing custody of her baby—and makes one last desperate attempt to keep her family together.

For more about Dass and other mothers facing investigation for taking medication-assisted treatment, read Shoshana Walter’s investigation in collaboration with the New York Times Magazine.

On June 6, the Rahma Worldwide international medical delegation arrived at Gaza European Hospital in Khan Younis. The humanitarian volunteers noticed something immediately: Some of the medical staff welcoming them—with the best food available, an assortment of cucumbers, hummus, and french fries—appeared remarkably young to be doctors.

Before the delegation could ask any questions, an airstrike hit the neighborhood. The walls of Gaza European Hospital—then one of the only functioning medical centers in the region—shook.

“Within the first 15 minutes that we were here,” Dr. Mohammed Mustafa, an emergency specialist from Australia, recalled, “nine people came in an ambulance, already dead.”

This, the doctors learned, was typical of the day-to-day life in Gaza. It was only later the international doctors would come to find out that many of the staff were not fully credentialed doctors, but student volunteers. Dr. Bing Li, another member of the Rahma delegation—a team of a dozen doctors from different countries, there to provide support to Gaza’s depleted health system—estimated that half of the people working in European Hospital’s emergency department in June were students or trainees from Gaza’s two medical schools.

“The health care system’s on the verge of collapsing,” Salman Dasti, an anesthesiologist who worked in Gazan hospitals both before and during this war, said. “It’s being propped up because of students.”

Mustafa found the students’ ability to keep the hospital functioning remarkable. “We were getting patients moving and getting them treated. It was pretty amazing to see,” he recalled, “especially since you can see how broken they are physically, emotionally.”

On the first day, Li recalled meeting one of the volunteers keeping Gaza’s hospitals running. A patient was brought in and losing blood quickly from a blast injury to his leg. Li worked with a volunteer to stabilize the man; the volunteer then pulled Li aside and introduced herself excitedly in English: Her name was Nermeen Ziyad Abo Mostafa, and she was 20 years old.

“I had this impression she was this very friendly person, and she asked me if I wanted help with translation and seeing other patients,” Li said. The foreign doctor appreciated the aid. Earlier that day, Li, an emergency specialist from Arizona, had already had a heartbreaking experience. “We evaluated one patient that was maybe three or four years old,” she recalled. “Half his head was basically blown off.” (It ended up being “just one of many similar cases,” Li said; other doctors who have returned from Gaza say the Israeli military regularly targets children.)

As Nermeen showed Li around, another doctor noticed who the American was talking to and pulled her aside. Li was told Nermeen had a friend die earlier that same day in the blast that sent a raft of critically injured patients to the hospital.

“She was keeping this brave face despite learning that she lost somebody,” Li remembers.

Nermeen always wanted to be a doctor. As a young child, she said, she “had doctor’s tools in the form of toys.” As she grew older, she watched medical school graduation videos online, transfixed by the celebrations. She imagined herself as a cardiovascular specialist, or perhaps a pediatrician; she was overjoyed when, in 2021, she was finally able to enroll at her dream school: Al-Azhar University-Gaza. (For this article, I interviewed Nermeen using WhatsApp text messages and voice memos. Her internet and data access in Gaza is not good enough for phone calls of length.)

By October 7, 2023, Nermeen had made it through two and a half years of medical school. (In Gaza, students’ medical training starts immediately after high school, when they begin a six-year program of study.) Her tuition was expensive, and the hourlong bus ride to school from her home in Abasan Al-Kabira, a small city east of Khan Younis, made her carsick. But she was happy to be learning.

Then, the war came. In early November, Israeli warplanes destroyed Nermeen’s campus. By mid-January, Israeli bombardment had reduced every university in Gaza to rubble. Nermeen moved constantly. She evacuated from place to place four times in the first six months of the war. Eighty-four percent of Gaza is now under evacuation order. She watched classmates, professors, and friends die nearly every week. “In this war, I lost many of my colleagues and friends from school,” she told me. “I lost four members of my family.”

In April, Nermeen started volunteering at the hospital. It was the “one positive amid all of this,” she said. A third-year student would not ordinarily be actively treating patients. But her clinical phase began early. “I was learning from the doctors and helping them,” she said.

Many of those working and volunteering at the hospital had shifts lasting 24 hours—and no one I spoke with had received payment from the hospital since October. Anything shorter than a 24-hour shift would mean more trips on treacherous roads, made nearly impassable by millions of pounds of debris and sewage overflows from broken sanitation systems.

On a normal day, Nermeen began her shift early in the morning, connecting to the internet and trying to download lectures and readings from the website of her bombed university, before beginning to see the injured, “standing with doctors, talking to patients.”

As a volunteer, she cleaned wounds, translated for foreign doctors, and made treatment plans. “There were days when…the work was a lot, due to the arrival of large numbers of martyrs, and injured,” she said. “But the thing I loved to do most was stitches in the emergency department.” 

This was made difficult by short supplies. The sutures in Gaza hospitals were labeled “not for use on humans,” Mohammed Mustafa, the ER doctor from Australia, recalled. Still, he helped Nermeen with her suture technique; he noticed that she was particularly careful in caring for patients during the process. Nermeen did her best to stitch in a way that would minimize scarring.  

Conditions were hard. There were no beds, only rigid metal frames. Rooms were cramped and hot. Even the chairs in the hospital were occupied by patients, leaving little room for their caregivers to rest. The complex smelled of rot, and flies landed in patients’ wounds just as Nermeen finished disinfecting them. Even the suture needle was less sharp than it should be. 

“It would take you maybe three, four attempts to pierce the skin with the suture,” Mustafa said. “And you can imagine trying to do that with very limited anesthetic, [on] children as well.” 

Beyond the shortage of goods, there was also a shortage of personnel. Students did their best to fill in. One 22-year-old student who spoke to Mother Jones, Hasan Ali Abu Ghalyoon, was in his third year of dental school before the war. He was initially told he’d be working as a porter, then a translator. He spent four months volunteering at European Hospital, unable to see his family in Deir al-Balah after the Israeli army took over the area between the hospital and his family’s tent.

“I slept in the office of the International Committee of the Red Cross at the hospital for four months,” he said. ‘There was a broken bed that does not move from its place,” which was not used except for emergencies. When it was unoccupied by patients—and when he wasn’t being called to translate for a surgeon in the middle of the night—he got that bed.

As he spent more time in the hospital, he learned “there was a severe shortage of dentists specializing in maxillofacial surgery,” so he quickly found himself assisting with those surgeries, too. “It is difficult to talk to patients with burns or fractures,” he said, “some of whom lost a loved one with the same injury minutes before.”

Sometimes, the patients the students cared for were people they recognized. On the mid-June day when Nermeen met Bing Li, she wasn’t supposed to be at work. She was at her family’s tent, taking a rest day, when she felt a bomb detonate nearby. “We saw the smoke of the bombing, and a large number of ambulances,” she recalled. Without internet access, Nermeen worried her own relatives might be among the dead.

Nermeen decided to go to the hospital on her day off. “I put on the uniform and walked to the road.” A man with a car offered her a ride when he saw her medical uniform. His family lived in the area that had just been bombed, Nermeen remembered, and he was headed to the hospital, too. Once there, she opened her phone to scroll through the names of the dead. “My friend’s name was among the names of the martyrs of this massacre.” She rushed to the emergency room in hopes that the news was wrong. “But it was true.”

Most of her friend’s family had been killed. She found her friend’s younger sister, Samar, waiting alone, with wounds all over her body. Nermeen monitored her vital signs, stitched up a deep gash in her left foot, and patched up two wounds on her leg.

Samar was later transferred to a different department, where her head wounds were treated. “She remained in care for several days,” Nermeen remembered. Then, Samar was discharged, but “she was still in a state of shock, and would not speak.” At the end of July, Nermeen received word that Samar had been killed, too: “She joined the rest of her family.”

Gaza’s medical system has been painfully constricted for decades. This is partially due to the longstanding Israeli policy of blocking “dual-use items” at the border—medical devices that could, allegedly, be used as weapons. Those items have included crutches, hearing aid batteries, thermometers, and incubators. This means the doctors of Gaza must make do.

Dasti, the anaesthesiologist from San Francisco, visited Gaza multiple times as part of a medical mission group with the Palestinian Children’s Relief Fund before 2023. “I was fairly impressed with the robustness of the health care system,” he said. “I mean, it still lacked resources, but I was pretty impressed with the training that the physicians there had.”

There were 36 fully functioning hospitals in Gaza prior to the war. By mid-August, according to the World Health Organization, only 16 of those 36 hospitals were even partially operational. These 16 hospitals have treated patients far beyond their capacity. Staff is low: The UN Human Rights Office reported that more than 500 medical workers have been killed in Gaza since October 7. And an NBC News investigation recently suggested Israel has targeted doctors for kidnapping and taken them to torture camps. Hanan Balkhy, Eastern Mediterranean regional director for the World Health Organization, said that as of early August, WHO has been able to verify more than 500 attacks on medical personnel in Gaza.

This leaves a staggering hole for those in need of care. The WHO estimates that nearly 93,000 people in Gaza are injured. Among those 16 remaining hospitals, there are fewer than 1,500 hospital beds—about one for every 60 injured people. And those numbers don’t account for those who would ordinarily require hospital beds even in peacetime: diabetic patients requiring dialysis, cancer patients, and pregnant women needing somewhere to give birth.

“The remaining students are now basically frontline doctors, because of just the lack of personnel,” Dasti said. Students spent their days at European Hospital “functioning as essentially an attending physician, while not getting paid and working long arduous hours with little sleep.” 

Balkhy, of WHO, said the students are exhibiting “more resilience than anyone should need to have.” Nermeen and her classmates dream of continuing their education—perhaps leaving and studying elsewhere if the borders reopen—but, as Balkhy said, it is “a race against time and circumstance.”

Conditions in Gaza, meanwhile, are only worsening. WHO confirmed the first case of polio in Gaza in 25 years on August 22: “Health workers have been digging graves for patients they know they are not able to save because they don’t have the resources needed.”

Forty-five international doctors who spent time in Gaza published a letter on July 25 addressed to President Joe Biden and Vice President Kamala Harris. Bing Li and Salman Dasti were among the signatories. They detailed the injuries they’d seen—preteens deliberately shot in the head, healthy babies dying of preventable diseases—and noted their “acute awareness” that Gaza’s medical professionals have been targeted. The doctors begged the president for an arms embargo, and for “unfettered aid delivery” of antibiotics, painkillers, and sutures.

On August 1, 300 days into the destruction of Gaza, Nermeen turned 21 in a white tent, as temperatures soared above 90 degrees. As she sent me WhatsApp voice notes, warplanes buzzed overhead and her siblings chattered in the background.

She had been away from the hospital for a month. It was evacuated on July 1. Patients left, or were carried out by hand, over a chaotic 24 hours. “There’s really no roads because they’ve all been destroyed,” Dasti remembered. Taking a patient a couple of miles to the nearest hospital took at least an hour. Even in the United States, under the best of conditions, it is hard to move a patient from the ICU down the hall to the operating room safely. “I think some of them died on the way,” Dasti said.

Hasan, the dental student, evacuated too. He has spent the past two months sharing an 8-by-20-foot tent with four families in Deir al-Balah refugee camp, not far from the site of the Al-Tabin School bombing, in which the Israel Defense Forces used US-made bombs to hit a school building and kill nearly 100 people. He spends time making videos about his work in the hospital, which the international doctors he met have been sharing at conferences back home.

Hasan has been trying to return to European Hospital to see if he could help if it reopens—and perhaps find a path to continuing his studies. (World Health Organization officials told Mother Jones that they are partnering with the Gaza Ministry of Health to restore emergency services at the hospital, though the timeline has been postponed amid heavy bombing.) On WhatsApp, Hasan showed me a map outlining the route he planned to take, with red danger zones highlighted. When he tried to make the journey, “the people on the road told me to go back [because] the army is on the road.” He turned around and returned to Deir al-Balah.

When we messaged last week, Hasan said he had heard a system of buses organized by the International Committee of the Red Cross might be able to bring him back to Khan Younis. But a day after we spoke, Israeli forces once again ordered the evacuation of large portions of Khan Younis—and bombed portions of Deir al-Balah, where Hasan now lives. But he hasn’t given up. “I will try again,” he said.

Nermeen faces similar obstacles. “I am impatiently waiting for the hospital to reopen, because I miss helping and learning new things,” she said. While she heard that administrative work on reopening the hospital began in mid-August, she doesn’t know when it will reopen fully. And returning to the hospital might be dangerous: “Sudden bombing could occur on the road.” So, instead, she has returned to her studies, when the intermittent-at-best internet allows, and when the “terrifying” noises of artillery shells pause long enough to let her focus. One day, Nermeen announced proudly that she’d managed to turn in her endocrinology exam online, to a virtual classroom run by professors from a university that, physically, no longer exists.

“All of this losing makes my heart broken,” Nermeen said. “I hope I can be strong, because my dreams wait [for] me, and many people…I want to help them.” 

Enlarge / Hospital staff and community members held a protest in front of Carney Hospital in Boston on August 5 as Steward has announced it will close the hospital. "Ralph" refers to Steward's CEO, Ralph de la Torre, who owns a yacht. (credit: Getty | Suzanne Kreiter)

As the more than 30 hospitals in the Steward Health Care System scrounged for cash to cover supplies, shuttered pediatric and neonatal units, closed maternity wards, laid off hundreds of health care workers, and put patients in danger, the system paid out at least $250 million to its CEO and his companies, according to a report by The Wall Street Journal.

The newly revealed financial details bring yet more scrutiny to Steward CEO Ralph de la Torre, a Harvard University-trained cardiac surgeon who, in 2020, took over majority ownership of Steward from the private equity firm Cerberus. De la Torre and his companies were reportedly paid at least $250 million since that takeover. In May, Steward, which has hospitals in eight states, filed for Chapter 11 bankruptcy.

Critics—including members of the Senate Committee on Health, Education, Labor, and Pensions (HELP)—allege that de la Torre stripped the system's hospitals of assets, siphoned payments from them, and loaded them with debt, all while reaping huge payouts that made him obscenely wealthy.

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On Thursday, the Biden administration announced that it had negotiated down the cost of the 10 most costly drugs covered by Medicare in a landmark deal. Once the reduced prices are enacted, in 2026, patients are expected to spend billions less out of pocket—as is the US government.

Meanwhile, Kamala Harris is speaking in North Carolina and elsewhere to push a new slate of economic policies, including aggressive action on price gouging, medical expenses, and the rising cost of living. What are the natural next steps for Democrats to build on the momentum of the White House’s Medicare deal?

They’ve got a lot of options. Even among generic drugs, prescriptions cost around three times as much in the US as they do in other countries. Americans across political parties also agree that the federal government negotiating drug costs down is a good thing, according to KFF and other polls.

There are at least four paths the government can take to keep cutting prescription drug costs that are likely to meet with similar public support—so people don’t have to forgo prescriptions they need.

Negotiate Rare Disease Drugs Under Medicare

Rare disease drugs—also known as orphan disease drugs–can cost a pretty penny. In 2019, nearly 7 million Americans on Medicare had a rare disease, alongside some 20 million or more rare disease patients without Medicare coverage. But even with Medicare, these medications and treatments can still cost individuals thousands of dollars out of pocket each year.

Thomas Waldrop, a healthcare policy fellow with The Century Foundation, says going after the cost of rare disease drugs could have a meaningful impact on out-of-pocket costs.

“These more niche drugs for these rare diseases,” Waldrop said, “might have an outsized impact on disabled communities or chronically ill patients, who might have had disproportionately high health spending.”

Unfortunately for rare disease patients hard-pressed by medical bills, rare disease drugs are currently exempt from negotiations under the Inflation Reduction Act, partly thanks to arguments that the exemption encourages pharmaceutical companies to invest in relevant research.

Pass the Savings to Private Insurers

Nearly two-thirds of Americans under the age of 65 are on employer-sponsored health insurance, according to KFF. Given that the average annual premium is around $8,000 for such plans, people without Medicare’s protections can be hit with large prescription cost bills, especially at the beginning of the year. It doesn’t have to be this way.

“If these same prices were available to employer-sponsored insurers, there would be these even bigger savings,” Waldrop said.

One current roadblock, as a Center for American Progress report highlights, is that “individual employers have limited ability to negotiate lower prices for their insurance plans.” That’s where a governmental response may be more fruitful.

Tackle Overpriced Treatments for Chronic Illness

We know it’s possible for expensive drugs that treat chronic illnesses to be made cheaper. For example, more Americans can now get a month’s supply of insulin for $35, a significant reduction for a lifesaving treatment long marked by price gouging. But it can still be challenging for uninsured and underinsured people to secure affordable insulin, especially if they are insulin-dependent but don’t have Type I diabetes.

The federal government could fight—including through sustained public pressure—to get pharmaceutical companies to bring high prices for inexpensively made drugs in line with actual production costs. Those costs can pose a burden to chronically ill young people in particular, says Generation Patient CEO Sneha Dave, as they may have unstable health insurance for the first time in their lives.

Dave would look to “the impact that the Inflation Reduction Act can have on state drug pricing, for example, with prescription drug affordability boards that affect patients of all ages.”

Fight for Patent Reform

In July, the Affordable Prescriptions for Patients Act unanimously passed the Senate. The Act tries to clamp down on pharmaceutical companies’ practice of applying for (and receiving) multiple patents for nominally different uses or formulations of the same drug, which keeps cheaper generics off the market.

“Lowering drug prices requires comprehensive reform,” Dave says, including to the way medical patents are regulated, “to ensure affordability for the current and next generation of patients.”

Enacting the APPA, currently waiting to be heard in the House of Representatives, would be another move in the right direction.

On Thursday, the Biden administration announced that it had negotiated down the cost of the 10 most costly drugs covered by Medicare in a landmark deal. Once the reduced prices are enacted, in 2026, patients are expected to spend billions less out of pocket—as is the US government.

Meanwhile, Kamala Harris is speaking in North Carolina and elsewhere to push a new slate of economic policies, including aggressive action on price gouging, medical expenses, and the rising cost of living. What are the natural next steps for Democrats to build on the momentum of the White House’s Medicare deal?

They’ve got a lot of options. Even among generic drugs, prescriptions cost around three times as much in the US as they do in other countries. Americans across political parties also agree that the federal government negotiating drug costs down is a good thing, according to KFF and other polls.

There are at least four paths the government can take to keep cutting prescription drug costs that are likely to meet with similar public support—so people don’t have to forgo prescriptions they need.

Negotiate Rare Disease Drugs Under Medicare

Rare disease drugs—also known as orphan disease drugs–can cost a pretty penny. In 2019, nearly 7 million Americans on Medicare had a rare disease, alongside some 20 million or more rare disease patients without Medicare coverage. But even with Medicare, these medications and treatments can still cost individuals thousands of dollars out of pocket each year.

Thomas Waldrop, a healthcare policy fellow with The Century Foundation, says going after the cost of rare disease drugs could have a meaningful impact on out-of-pocket costs.

“These more niche drugs for these rare diseases,” Waldrop said, “might have an outsized impact on disabled communities or chronically ill patients, who might have had disproportionately high health spending.”

Unfortunately for rare disease patients hard-pressed by medical bills, rare disease drugs are currently exempt from negotiations under the Inflation Reduction Act, partly thanks to arguments that the exemption encourages pharmaceutical companies to invest in relevant research.

Pass the Savings to Private Insurers

Nearly two-thirds of Americans under the age of 65 are on employer-sponsored health insurance, according to KFF. Given that the average annual premium is around $8,000 for such plans, people without Medicare’s protections can be hit with large prescription cost bills, especially at the beginning of the year. It doesn’t have to be this way.

“If these same prices were available to employer-sponsored insurers, there would be these even bigger savings,” Waldrop said.

One current roadblock, as a Center for American Progress report highlights, is that “individual employers have limited ability to negotiate lower prices for their insurance plans.” That’s where a governmental response may be more fruitful.

Tackle Overpriced Treatments for Chronic Illness

We know it’s possible for expensive drugs that treat chronic illnesses to be made cheaper. For example, more Americans can now get a month’s supply of insulin for $35, a significant reduction for a lifesaving treatment long marked by price gouging. But it can still be challenging for uninsured and underinsured people to secure affordable insulin, especially if they are insulin-dependent but don’t have Type I diabetes.

The federal government could fight—including through sustained public pressure—to get pharmaceutical companies to bring high prices for inexpensively made drugs in line with actual production costs. Those costs can pose a burden to chronically ill young people in particular, says Generation Patient CEO Sneha Dave, as they may have unstable health insurance for the first time in their lives.

Dave would look to “the impact that the Inflation Reduction Act can have on state drug pricing, for example, with prescription drug affordability boards that affect patients of all ages.”

Fight for Patent Reform

In July, the Affordable Prescriptions for Patients Act unanimously passed the Senate. The Act tries to clamp down on pharmaceutical companies’ practice of applying for (and receiving) multiple patents for nominally different uses or formulations of the same drug, which keeps cheaper generics off the market.

“Lowering drug prices requires comprehensive reform,” Dave says, including to the way medical patents are regulated, “to ensure affordability for the current and next generation of patients.”

Enacting the APPA, currently waiting to be heard in the House of Representatives, would be another move in the right direction.

On Thursday, the Biden administration announced that—after months of negotiations—it had finally struck a deal with prescription drug companies to slash the prices of some of Medicare’s most expensive medications, prescriptions for which currently cost the federal government some $56 billion last year.

“It’s a relief for the millions of seniors that take these drugs to treat everything from heart failure, blood clots, diabetes, arthritis, Crohn’s disease, and more—and it’s a relief for American taxpayers,” President Biden said in a statement. 

“Kamala and I both get it. We know it isn’t just about health care,” he added, appearing alongside Vice President Kamala Harris for their first joint event since she gained the Democratic presidential nomination. “It’s about your dignity.”

Starting in 2026, ten prescriptions for ailments ranging from diabetes to blood cancer will have their costs drastically lowered—by up to 79 percent of their manufacturers’ list price. These cuts will save taxpayers $6 billion and seniors and beneficiaries alone more than $1.5 billion, according to the Center for Medicare and Medicaid Services.

The action was reportedly made possible by the 2022 passage of the Inflation Reduction Act, which opened the door for changes to Medicare with the aim of “expanding benefits, lowering drug costs, and improving sustainability.” The deal is only phase one of the administration’s plan to make Medicare more affordable: The Department of Health and Human Services will be allowed to select another set of 15 drugs for price negotiations next year.

In late April, New York Democratic Gov. Kathy Hochul and state lawmakers finalized a $233 billion budget for the next fiscal year. One item in its 144-page official summary has sparked fear among disability advocates: dramatic changes to a vital home health aid program that may push more people into nursing homes.

A quarter of a million New Yorkers currently use CDPAP, a widely popular program launched in 1995, which facilitates Medicaid funding for home carers chosen by patients themselves at hours they arrange. Participants spoke to Mother Jones about how the program allows them to remain in their communities, rather than being institutionalized—a cause central to disability rights activism. Without access to workers who understand their needs, like assisting people with spinal cord injuries with toileting, those participants risk hospitalization, placement in restrictive long-term care, or both.

The program is run through “fiscal intermediaries,” which provide financial and administrative oversight; some specialize in helping certain groups, such as the Bengali immigrant community. Hochul’s plan would make the program an administrative monopoly: by October, one middleman—potentially an out-of-state, for-profit firm—will hold a $40 billion contract covering all 250,000 participants in the state. Currently, those intermediaries are subject to oversight by New York’s chief fiscal officer; under Hochul’s system, the new middleman wouldn’t be. In late July, some current intermediaries sued New York’s Department of Health over the changes.

“This was a backroom deal that happened days before the budget was finalized,” said Kendra Scalia, a disabled public policy analyst and board president of the Consumer Directed Personal Assistance Association of New York State, which supports both CDPAP providers and recipients. “It was never discussed with disabled communities.”

Hochul has been incredibly critical of CDPAP, calling it a “racket” and “one of the most abused programs in the entire history of the state of New York.” But 2022 audits by the state’s Medicaid Inspector General reviewed $37 million in claims—and found that 99 percent were accurate. Of $46,000 in documented overpayments, $41,000 was recollected. Hochul’s office did not respond to a request for evidence that the program has been abused.

It can already be difficult to get care through CDPAP. For Laura Mauldin, a graduate student when she applied in 2010, it took nine months—and an initial rejection—to get her partner, who had been sick with cancer for four years, approved for support.

“There was not an option to check for CDPAP” in home care applications at the time, said Mauldin. The request for around-the-clock care was eventually approved—allowing Mauldin to leave her apartment, with her partner in a worker’s care—but so late that Mauldin’s partner was only able to use it for three months before passing away.

Critics like Hochul see the potential for corruption in the fact that disabled people can hire family members—something Kendra Scalia first did by hiring her sister when she was in college.

“I felt really vulnerable to hiring strangers or welcoming strangers into my dorm room where there’s no oversight,” Scalia said. Her brother now has worked as her assistant for the past decade.

Some care workers feel they’ve been left in limbo on how Hochul’s changes will impact them. For the past 25 years, Tara Murphy has worked as a home care provider through CDPAP, after working as a certified nursing assistant in a nursing home. As a home carer, Murphy felt she’d be able to serve people better.

“I saw all the horrendous things and lack of care and neglect that were happening,” said Murphy, who is based in Troy, New York. “I knew I couldn’t change it, and I didn’t want to be part of the medical mafia.”

Now, Murphy is panicked over the impending changes to the program that helps employ her. She doesn’t know whether she’d be hired under the new monopoly, or whether her pay will be cut. “I’m sitting here every day,” Murphy said, “like, ‘Am I going to have a place to live? Am I going to be able to eat?’ 

1199SEIU, New York’s main health care workers’ union, has been critical of for-profits’ growing role in the program. Helen Schaub, the union’s interim political director, said that administrative costs have ballooned since a 2012 jump in the number of for-profit intermediaries. One of New York’s largest home care intermediaries, Schaub points out, is being run by embattled insurance giant Anthem.

Some users of the program who spoke with Mother Jones also expressed concerns that pay cuts could force their aides to look elsewhere for work, leaving both patients and workers in a difficult position. 

Lacey Tompkins, who works in advertising in New York City, says that CDPAP makes it possible for her to maintain a partly remote job as a disabled worker, with help getting to work despite hours that can change from week to week. “I can make my decisions and not [have] a standard set of hours,” Tompkins said.

Advocates with differing views agree on one thing: Hochul’s six-month timeline to transform the program is unreasonable and impractical. “Any serious company who is bidding on the work also believes that, because it’s a very daunting task,” said Schaub, of SEIU. “Privately, people in the [Hochul] administration have said, ‘We know that it can’t happen on that scale.’”

Update, August 13: This article has been updated to detail the current and proposed roles of the New York State Comptroller in reviewing the state’s CDPAP program.

Lots of people seem to dislike the views of Sen. JD Vance (R-Ohio) these days: Jennifer Aniston, Congressional Republicans, and…maybe even Donald Trump?

Now hundreds of medical professionals from Vance’s home state of Ohio have also joined that list. On Tuesday, more than 260 doctors from the Ohio Physicians for Reproductive Rights—a nonpartisan group whose members initiated and helped draft the state’s ballot measure securing the constitutional right to abortion in Ohio last year—condemned Trump’s selection of Vance as his running mate, citing Vance’s lengthy anti-abortion record. A letter from the group—signed by physicians who practice a variety of specialties, not just OB/GYNs who perform abortions, including pediatrics, family and internal medicine, and child and adolescent psychology—outlined the dangers of what it calls “the Trump-Vance anti-reproductive freedom agenda.”

“Ohio proved to America last year that voters will not stand by as politicians such as J.D. Vance threaten our rights and freedoms,” says the letter, which Mother Jones is the first to report. “This coming November, millions of Americans across the country are going to join us in firmly declaring that we will not give JD Vance any further opportunities to strip away our rights.”

The letter comes as Trump’s campaign has dodged calls to define his stance on abortion, an evasion tactic that has seen him land all over the map on the issue, from his pledge to leave abortion rights “to the states”—after appointing three of the five Supreme Court justices who overruled Roe—to Vance trying to walk back his prior calls for a national abortion ban. But despite Trump’s efforts to avoid clarifying questions about his position on threats to abortion access via the Comstock Act and fetal personhood, there are a lot of reasons to believe the GOP would, indeed, try to ban abortion nationwide if Trump is re-elected. Tuesday’s letter cited some of these indicators and Vance’s support for them, including:

• Vance’s support for Project 2025, an initiative led by dozens of conservative groups and spearheaded by the Heritage Foundation, that outlines plans for a second Trump term—including recommending the Department of Justice use the Comstock Act to prosecute providers who mail abortion pills to patients (Vance also went on record last year stating his support for this proposal) and recommending the Department of Health and Human Services be replaced with a “Department of Life” in order to reject “the notion that abortion is health care.”
• Vance’s prior comments against rape and incest exceptions for abortion bans, in which he dismissed those traumatic assaults as “inconveniences,” adding, “I think two wrongs don’t make a right.” (Trump, for his part, claims to support exceptions for “rape, incest and life of the mother”—despite appointing three of the five Supreme Court justices who overruled Roe, allowing states to ban abortion without exceptions if they so choose.)

Dr. Lauren Beene, a pediatrician who signed the letter and is a co-founder and executive director of Ohio Physicians for Reproductive Rights, told me that she sees Vance as a bigger threat to abortion rights than Trump because he has been consistent in his opposition to them: “Of all people to have second in command to Donald Trump, who is trying his best to pretend that he is more supportive of reproductive freedom than he is, to choose JD Vance is very telling as far as the true goals of their presidential mission.”

“Both Trump and JD Vance are huge risks [to abortion rights],” she added, “but the combination of the two is just terrible.”

The letter also pointed to Vance’s opposition to Ohio’s abortion rights ballot measure. After it passed in November, he called it a “gut punch…politically dumb and morally repugnant.” (As my colleagues Madison Pauly and Ari Berman chronicled last year, anti-abortion Republicans went to great lengths to prevent the measure from passing last year—and from even coming up for a vote.) And while the measure’s passage was a major win for Ohioans, allowing access to abortion up until the point of fetal viability and allowing abortions later in pregnancy when necessary to protect the patient’s life or health, the letter notes that barriers to abortion access remain: “Threats abound from Ohio’s gerrymandered State Legislature, State and National Supreme Courts, and now, with J.D. Vance joining the presidential race alongside Donald Trump, our patients’ access to necessary and lifesaving reproductive healthcare is at grave risk.” Plus, Beene added, “obstructionist laws” remain on the books in the state—including a 24-hour waiting period mandated before obtaining an abortion, which is currently being challenged in court.

In response to a request for comment on the letter, William Martin, a spokesperson for Vance, told Mother Jones that Vance “agrees with President Trump’s view that abortion policy should be decided by the states,” adding that Vance also “supports reasonable exceptions for rape, incest and life of the mother.”

Martin added: “These desperate smear tactics won’t change the fact that Kamala Harris has no record to run on except for the failure and destruction of the current Administration and been flip-flopping on every single issue possible since she became the de facto nominee. The American people, and particularly the great State of Ohio, are going to soundly reject her weak, failed and dangerously liberal agenda come November.”

A public condemnation from hundreds of doctors over Vance’s anti-abortion views comes as poll after poll shows most Americans disapprove of the Dobbs decision and support abortion access in all or most cases.

As the letter states: “Vance’s extremist views are objectively out of touch with his own Ohio voters, and with the American people.”

The fate of gender-affirming care for transgender youth in Ohio will soon rest in one person’s hands. For the past week, Franklin County Judge Michael Holbrook has heard a case challenging a recent state law that includes a ban on the use of puberty blockers and hormones for trans youth. Now, it’s up to him to decide whether to turn a temporary block on the law into a permanent one—which would make Ohio just the third state to do so as a growing body of anti-trans laws moves through the courts.

From his chambers on the fifth floor of a downtown Columbus courthouse, the judge has heard pleas from the parents of trans children whose lives have been saved by gender-affirming care, physicians from the state’s children’s hospitals, and national experts in trans care. He’s also heard the state’s sharp defense of its law, featuring what is being framed as the “expert” testimony of nationally prominent anti-trans activists who made dubious claims about the efficacy and risks of puberty blockers, hormones, and other gender-affirming medical treatment.

Ohio’s sweeping law, dubbed the “Saving Adolescents from Experimentation” or “SAFE” Act, doesn’t just block the use of puberty blockers and hormones in trans youth (while allowing such medical interventions for cisgender children who may need them for precocious puberty or polycystic ovary syndrome). Passed by a GOP supermajority in January over Republican Gov. Mike DeWine’s veto, it also prohibits trans girls and women from playing women’s sports, including college athletics. The ACLU of Ohio is challenging the entire law as a violation of the state’s single-subject rule for legislation, which requires that bills must pertain to one topic. The state says that topic is “addressing gender transition in children,” but the trial mainly focused on what the families of two trans girls have argued is the discriminatory, life-threatening impact of the ban on gender-affirming care.

Ohio is among the 25 states with laws on the books restricting gender-affirming care, according to the Kaiser Family Foundation, and 39 percent of trans youth live in states with such policies. While most bans have been challenged—and several temporarily blocked, like Ohio’s—the vast majority remain in effect. Only policies in Florida and Arkansas have been permanently enjoined, while the US Supreme Court has agreed to hear a case this coming term about the constitutionality of trans care bans.

On Monday, the mother of a 12-year-old trans girl testified that when her daughter began publicly identifying as a girl, her anxiety “melted away.” The daughter, going by the alias “Grace Goe,” has received gender-affirming mental health care for seven years and hopes to medically suppress puberty at its onset. The prospect of not being able to access that medical care has caused immense distress for Goe and her family. “She laid down and wept in my bed,” her mother said of Goe learning of the ban. “She is carrying looming anxiety and deep sadness surrounding this law.”

The state of Ohio showcased its line of experts, including Jamie Reed, a self-identified “whistleblower,” whose claims about a Missouri gender clinic have been widely disputed by families of the clinic’s current and former patients. Another Ohio witness was James Cantor, a Canadian sex researcher who has testified in support of gender-affirming care bans in trials across the country.

Cantor, a PhD who has never diagnosed a child with gender dysphoria or served on a child’s gender-affirming care team, claimed US studies on gender-affirming care are “sloppy” and that such care causes “sterility in children.” While hormones are known to cause temporary infertility, the long-term effects are unknown—which is why the World Professional Association for Transgender Health (WPATH), the leading professional organization for gender-affirming care providers, recommends providers and patients extensively discuss fertility impacts and options before initiating such treatments. (Some forms of gender-affirming surgery do cause permanent infertility, but for years the Ohio Children’s Hospital Association has assured lawmakers it is not being offered to trans youth in Ohio.)

And as my colleague Madison Pauly revealed last year, it’s not medical professionals or swaths of people who have stopped gender-affirming care proposing these bans to state legislators; many are conservative Christian organizations that believe transness is something to be “cured.”

As the trial wraps up on Friday, it bears repeating what actual experts testified: Dr. Sarah Corathers, an endocrinologist at Cincinnati Children’s Hospital who has served on care teams for about 300 trans youth over the past decade, said she’s seen patients’ quality of life improve under her care. “When medically indicated, gender-affirming medical treatment is safe, effective, and well-established,” she said. Dr. Jack Turban, the director of the University of California, San Francisco’s Gender Psychiatry program, explained the widely accepted protocols clinicians in Ohio and elsewhere use for offering such care to trans youth, including using a multidisciplinary team of providers, offering comprehensive mental health support, and making every decision in concert with the trans child and their parents. He noted that every major medical organization opposes bans on gender-affirming care.