Kaiser Health News
Epidemic: Do You Know Dutta?
by
Tue, 01 Aug 2023 09:00:00 +0000
By the mid-1970s, India’s smallpox eradication campaign had been grinding for over a decade. But the virus was still spreading beyond control. It was time to take a new, more targeted approach.
This strategy was called “search and containment.” Teams of eradication workers visited communities across India to track down active cases of smallpox. Whenever they found a case, health workers would isolate the infected person then vaccinate anyone that individual might have come in contact with.
Search and containment looked great on paper. Implementing it on the ground took the leadership of someone who knew the ins and outs of public health in India.
Episode 2 of “Eradicating Smallpox” tells the story of Mahendra Dutta, an Indian physician and public health worker who used his political savvy and local knowledge to pave the way to eradication. Dutta’s contributions were vital to the eradication campaign, but his story has rarely been told outside India. To conclude the episode, host Céline Gounder and epidemiologist Madhukar Pai discuss “decolonizing public health,” a movement to put leaders from the most affected communities in the driver’s seat to make decisions about global health.
The Host:
Céline Gounder
Senior fellow & editor-at-large for public health, KFF Health News
Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.
In Conversation With Céline Gounder:
Madhukar Pai
Community medicine physician, professor of epidemiology and global health at McGill University in Montreal
Voices From the Episode:
Bill Foege
Smallpox eradication worker, former director of the Centers for Disease Control and Prevention
Yogesh Parashar
Pediatrician living in Delhi
Mahendra Dutta
Smallpox eradication worker, former health commissioner of New Delhi, India
Click to open the transcript
Transcript: Do You Know Dutta?
Podcast Transcript Epidemic: “Eradicating Smallpox” Season 2, Episode 2: Do You Know Dutta? Air date: Aug. 1, 2023
Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.
TRANSCRIPT
Céline Gounder:
This season, the “Epidemic” podcast is about the eradication of smallpox in South Asia. And to understand the breakout public health strategy that ultimately made eradication possible, we’re taking a quick detour … to West Africa.
[Nigerian music begins to play.]
Céline Gounder: It was 1966 — and Bill Foege found himself in Nigeria. The young physician and epidemiologist from Iowa was a long way from home — but in good company as part of a team of health workers sent to the region by the CDC [the Centers for Disease Control and Prevention]. Their mission was to vaccinate as many people as possible to stop smallpox.
They traveled from one remote location to the next on electric bikes. [Electric bikes whir.] To coordinate the work and respond quickly to each new outbreak, they had two-way radios. [Radio static crackles.]
[Music fades to silence.]
Bill Foege: On Dec. 4, 1966, I got a message saying, “I think we have smallpox. Could you come and look?”
We went to the place, 8 miles off of a road, and it was immediately clear that the first person I saw had smallpox. And so, we started looking at: What did we have in the way of vaccine?
Ordinarily, you would’ve done a mass vaccination campaign around the area.
Céline Gounder: At the time, the standard procedure was to vaccinate every single person in the region. But there was a problem: There wasn’t enough vaccine. Bill was still waiting on a big shipment. Without enough doses to vaccinate everyone, his team had to break protocol and get creative.
Bill Foege: We knew what we should do, but we couldn’t. So, at 7 o’clock that night, with maps in front of me, I divided the area and sent runners to the villages to see if they had smallpox. Twenty-four hours later, we got back on the radio [radio static], and now I could pinpoint the exact villages where there was smallpox. And we used the rest of our vaccine on those areas.
[Music begins.]
Bill Foege: Much to our surprise, smallpox simply stopped in weeks. We just were so fortunate — so lucky that with our limited vaccine, we were able to hit the right people. And by July, we were working on the last outbreak in all of eastern Nigeria.
Céline Gounder: The health workers began to wonder: Could this approach also work in other parts of the world? The new vaccine strategy — the innovation that Bill and his team stumbled upon, out of necessity — came to be known as “search and containment.”
That meant …
First searching for anyone with an active case of smallpox.
Then isolating the infected person.
And finally, tracking down and vaccinating everyone that person had come into contact with.
It worked in West Africa. Could it work in South Asia?
[Music fades to silence.]
Céline Gounder: Getting locals there to adopt search and containment was going to take an ally, a leader with a big personality who knew the ins and outs of public health in India. Someone who could make things happen. Someone whose story you’ve probably never heard.
Yogesh Parashar: Things look very rosy and very nice in a textbook. You never get the feel of what actually happened, how much sweat it entailed, what blood it entailed.
Céline Gounder: I’m Dr. Céline Gounder and this is “Epidemic.”
[“Epidemic” theme music plays then fades to silence.]
[Music begins.]
Céline Gounder: By 1973, countries from Nigeria to Brazil to Indonesia had recorded their final cases of smallpox. But in India, the campaign to end the disease was still grinding along. The population was roughly 600 million people — and the goal to vaccinate every single person in the country was daunting.
Epidemiologist Bill Foege was older now — in his late 30s — and leading the CDC’s global program to eradicate smallpox.
He turned his attention to Bihar, a state in eastern India. It was the biggest smallpox hot spot in the world. There, Bill found an ally and a good friend in another physician, a man named Mahendra Dutta. Mahendra was in charge of the smallpox eradication program in Bihar.
[Music fades to silence.]
Yogesh Parashar: He had a booming, loud voice.
Céline Gounder: That’s his son Yogesh Parashar, a pediatrician living in Delhi.
Yogesh Parashar: My father was known for his honesty. He would help people. He had that nature.
Céline Gounder: Mahendra Dutta died a few years ago. And Yogesh was just a boy during the eradication campaign. But his father shared stories from his years in the trenches fighting smallpox. And there was no battle bigger — or more lifesaving — than persuading the vaccinators to change their way of doing things.
After a decade of mass vaccination, smallpox raged on. Yogesh says his father could see that the strategy wasn’t working quickly enough to stop the virus.
Yogesh Parashar: The standard way of doing things is not going to get us anywhere. Being nice, doing the right way, is not going to get the disease away.
Céline Gounder: It was time to try something new. But getting India to adopt search and containment would prove challenging.
Yogesh Parashar: People who were trained in the previous school of thought could never believe that smallpox could be got rid of in this strategy.
Céline Gounder: Luckily, Mahendra could be very persuasive.
Yogesh Parashar: My father did all the dirty work. He got enemies also in the process, I’m sure he did, but that is what he did.
[Music begins.]
Céline Gounder: Mahendra Dutta was a gifted political strategist who built relationships with magistrates and commissioners throughout his work in public health. He was an insider who moved comfortably through the halls of power in India.
Once, over dinner and a glass of whisky — Chivas Regal, to be specific — a senior official told Mahendra to come to him in the future if he ever needed a favor. Later, when it was time to build support for search and containment, Mahendra knew exactly how to cash in on that promise.
Yogesh Parashar: My father gifted him the Chivas Regal.
“Now do you remember? You had told me that if I need any help, I should come to you. And here I am asking for help now.” This is how he did it.
Céline Gounder: You might call it “Dutta diplomacy.”
[Music fades to silence.]
Céline Gounder: Using charm and his extensive personal network, Mahendra recruited a staff of workers dedicated to the new strategy of search and containment — instead of trying to change the minds of people invested in the old ways of doing things.
Yogesh Parashar: So, practically, a parallel health system was set up.
Céline Gounder: The stakes were high.
Yogesh Parashar: Any outbreak was an emergency, because if you don’t move within hours and contain it, you do not know how many contacts will be there, how much it would spread, and your work would increase exponentially.
[Suspenseful music begins.]
Céline Gounder: Instead of waiting for smallpox cases to be reported, the workers headed out into the community to look for them.
Bill Foege: At first, we went and we talked to the village headmen, the teachers, and some children. And gradually, we went from that to actually going house by house in every village.
Céline Gounder: But some cases were still falling through the cracks.
Bill Foege: And so, we developed secondary surveillance teams who would go around to the markets with a smallpox identification card.
Yogesh Parashar: There were WHO [World Health Organization] cards, which had photographs of cases of smallpox, their face, their body, and so on. So, the people would go out and ask the students, ask the people in the market, “Have you seen such a person with this kind of an illness?” This was one way of actively searching.
Céline Gounder: Everyone was willing to help.
Yogesh Parashar: The vehicle driver would also ask. Why would the foreign epidemiologist ask? The vehicle driver will talk in the local language: “OK, I’m looking for this.” They will tell him, “Yes, this is here.”
Céline Gounder: And, as soon as a case was identified, a team of containment workers would spring into action, isolating the patient, tracking down their recent contacts, and vaccinating anyone they could have transmitted the virus to.
[Suspenseful music fades to silence.]
Céline Gounder: By 1974, the scale of the smallpox surveillance operation was gigantic. Over 100 million households across India were visited every single month in the search for active cases. Over 130,000 field workers were mobilized.
Bill Foege: At that point, we were having 1,500 new cases of smallpox a day in Bihar.
Céline Gounder: To manage all these moving pieces, the workers documented their efforts meticulously.
Bill Foege: I mean, you can’t imagine the millions of forms that we had. We had forms for everything. Forms for the containment team, forms for the assessors, forms for the watch guards.
I often said, “We’ve just buried smallpox in forms.”
Céline Gounder: Search and containment was working in Bihar. Mahendra and Bill could finally see a path to eradication.
Then, they hit a very public stumbling block that threatened to derail their work.
[Sound of bomb exploding.] Céline Gounder: In May 1974, journalists from all over the world flooded into the country to cover a major news event.
Here are a few lines from a New York Times article from that time.
[Voice actor reading a headline from the May 20, 1974, edition of The New York Times. An audio filter gives it a grainy ’70s newscaster’s sound. Typewriter sound effects play.]
Newscaster: India conducted today her first successful test of a powerful nuclear device. The surprise announcement means that India is the sixth nation to have exploded a nuclear device.
Céline Gounder: The code name for the nuclear bomb test was Operation Smiling Buddha. And with it, the country joined a short list of superpowers. All eyes were on India.
[Dramatic music begins playing.]
Céline Gounder: And … those international journalists on the hunt for interesting things to report came across another big story: Smallpox cases appeared to be exploding.
Bill Foege: And then suddenly the newspaper articles come out saying, here’s India working on nuclear weapons and they can’t even control smallpox.
Céline Gounder: In actuality, the new search-and-containment strategy was just a lot better at uncovering cases of smallpox.
But those glaring headlines — accurate or not — put the eradication program in the spotlight.
[Dramatic music fades to silence.]
Céline Gounder: Indian health officials were worried. And they threatened to pull their support for search and containment.
The famous Dutta diplomacy was about to be put to the test …
Bill Foege: The minister of health for all of India came to Patna, and Mahendra Dutta went to the airport to meet him.
Yogesh Parashar: He said, “I have to address a meeting, and it would be difficult to talk to you separately. So why don’t you get into my car?”
Céline Gounder: During the ride, the minister of health told Mahendra that he was on his way to a press conference to announce that the smallpox program would switch back to the strategy of mass vaccination.
To Mahendra, giving up on search and containment meant giving up on their best shot at eradication.
Bill Foege: And that’s when Mahendra Dutta said, “Before you do that, you have one more thing to do.” And he said, “What’s that?” He said, “You have to fire me.”
Yogesh Parashar: My father tells the minister that “if we are going to follow vaccinating everyone, then I think I should give you my resignation.”
Bill Foege: And the minister was irate. He said, “Do you know who you’re talking to?” And he said, “I do. And that’s how important this is.”
Céline Gounder: Mahendra told him the latest figures. He explained how the team was finally slowing the virus — that things were coming under control.
And the health minister listened.
Yogesh Parashar: And, within a few minutes, when they had reached the venue, the health minister was addressing the other officials, and he said, “OK, we have a new strategy of search and containment, which is very successful, has been tried in a number of countries, and we will bring forward this strategy and get rid of the disease.”
[Triumphant music begins playing.]
Bill Foege: All he did was praise the smallpox workers for what they had done, never said a word about switching back to mass vaccination.
That’s how close we came, I think, to losing the program in India. And, of course, if we lost it in India, we lost it everyplace.
Céline Gounder: If India, with its population of over 600 million people, failed to stop smallpox, then the virus would have remained a threat to the entire world.
Yogesh Parashar: My father has done the dirty job of saying what is to be said and got away with it.
He diplomatically bought time, allowed the search and containment to go on and get “smallpox zero.”
[Triumphant music fades to silence.]
Céline Gounder: While some of his American collaborators have been celebrated around the world for their work to end smallpox, Mahendra Dutta’s story — and his contributions — aren’t well known outside of India.
But we managed to find this recording of his voice …
[Brief pause.]
Mahendra Dutta: In public health, community approach, your conviction, your devotion, and team effort, that’s what matters the most.
Céline Gounder: That’s Mahendra Dutta in 2008, when he was in his late 70s. He and Bill Foege sat down together to reminisce about the history of smallpox eradication as part of a CDC event.
The two old friends reflected on what they’d learned together.
Bill Foege: I think that’s the lesson of smallpox in India, that the team worked as a unit. It was a coalition in truth.
Mahendra Dutta: Devoted efforts, team efforts always matter in community health work.
[Music begins playing.] Céline Gounder: Search and containment was one of the public health innovations that made eradication possible — that, and the collaboration among international health workers and local public health leaders.
Here, we followed the story of Mahendra Dutta, but there were many names — thousands — working together toward a common goal.
[Music begins.]
Céline Gounder: I have a friend who thinks about that a lot. Madhukar Pai is a community medicine physician, an epidemiologist — and he teaches global health.
His big thing is he wants rich countries to stop trying to use their own lens to solve health problems around the world. He says that just doesn’t work.
He’s calling for a “radical shift.” But …
Madhu Pai: It is hard to give up on power and privilege. No powerful person wants to ever give it up.
Céline Gounder: More from Madhu after the break.
[Music fades to silence.]
Céline Gounder: Wiping out smallpox nearly 50 years ago required the skill of thousands of local people who are largely unrecognized in any history book — or podcast.
Putting locals in the driver’s seat is one part of a growing movement to “decolonize” public health.
That term might sound wonky. But Madhukar Pai, a professor of epidemiology and global health at McGill University [in Montreal], says decolonizing public health is exactly what’s needed to get to health equity around the world.
But Madhu is frankly pretty pessimistic about the current system.
Madhu Pai: I sometimes wonder how the hell did we eradicate smallpox. I mean, today, I don’t think we would have. Honestly, if there was a virus like smallpox today, there’s zero chance of eradicating it.
Céline Gounder: So what was it about smallpox eradication that allowed us to do it?
Madhu Pai: I think those were simpler days, right? And then WHO said, you know what? Let’s just get all together and just help end this disease. That collaboration was unprecedented in smallpox.
But I think it was, in the end, remarkable numbers of people, you know, essentially armies of community health workers, vaccinators, front-line staff, field workers. And that was a mobilization kind of an effort that I think we definitely tried to do during covid. But probably not as unified as we could have been.
Céline Gounder: We did try to do something like that. It was called COVAX.
It was an alphabet soup of international groups — from Gavi to the WHO — that wanted to pool buying power and scientific resources.
COVAX was an attempt to make sure that there was covid vaccine for the whole world.
So … why did COVAX fail?
Madhu Pai: First of all, I think COVAX was conceived by “global north” white people, and it was conceived with all good intent, but essentially the “global south” was left behind even in the design of COVAX. Now that in essence is global health, right? That is, privileged people in the global north are constantly making decisions, thinking that we know best.
Céline Gounder: In case our audience isn’t familiar with that term, when Madhu says “global north,” that’s a shorthand for talking about wealthy industrialized nations.
Madhu Pai: Relying on the global north time and time and time again is doomed as an idea because we’ve seen there is no end to our greed and myopia and self-centeredness.
Céline Gounder: What would that have looked like? Centering international efforts to provide vaccines to low-income countries?
Madhu Pai: To me, centering on them rather than us and saying, “What do you need from us to succeed in your plan?” Right? “How can we be allies to you?” We need to get behind that and respect the desires and the aspirations of global south countries.
If there is a new pandemic and there’s a new vaccine or medicine, that technology should be transferred very quickly.
That’s what allyship genuinely is about. And that’s what our country should have done. We could … should have been allies as countries, right? We should have given the vaccine recipe. We should have helped out way better with the vaccine donation — the opportunity of a lifetime to be good allies. But we left it on the table.
Céline Gounder: If you had to give a grade to our global health response to covid, what would it be and why?
Madhu Pai: I would probably give it a “D” because I think, as humankind, we genuinely failed. There’s no reason at all so many people should have died. That’s inexcusable. The fact that 2.3 billion people, mostly in low-income countries, middle-income countries have not received even one dose is a very telling statement on how this all unfolded. That’s political failure. It’s got nothing to do with science, technology, or availability, or money.
Céline Gounder: So let’s say another pandemic hits us tomorrow. How is that gonna play out, then?
Madhu Pai: Exactly like it played out in covid, I do not expect anything different, honestly. Which is bloody sad, really.
Céline Gounder: You said before that the big global health programs have good intentions. So, what should they be doing differently?
Madhu Pai: Global health, as you know, is full of these examples where the global north person always gets the, you know, the shining credit and the medal on the wall.
We need to kind of flip the switch and re-center global health away from this, what I call default settings in global health, to the front lines. Right? People on the ground. People who are Black, Indigenous. People who are in communities. People who are actually dealing with the disease burden. People who are dying of it, right? People who have actually lived experience of these diseases that we are talking about, right? Having them run it is the most radical way of reimagining and shifting power and global health.
Céline Gounder: As Madhu and I were talking, he reminded me about Bill Foege. He’s the American eradication worker from Iowa we already met in this episode. The one who worked closely with local partners like Mahendra Dutta.
But near the end … he stepped out of the spotlight.
I asked Bill about this:
Céline Gounder: You left India before smallpox was declared eradicated. And as I understand it, that was important to you to no longer be in the country at the time. Why is that?
Bill Foege: I had the feeling that it should be an Indian victory. That foreigners should be happy and pleased that they had a chance to be part of it but don’t get carried away with being celebrated.
Madhu Pai: People like Foege are the exception in global health and not the norm. Finding ways to completely disappear and then center on people who really matter, I think is a, is a great gift.
The ability to do Dr. Foege’s ego-suppression work, uh, allyship work, that’s where the next frontier lies. And I’m not sure if we are ready for it, right? Because it is hard to give up on power and privilege, right? No powerful person ever wants to give it up.
Céline Gounder: So if you had a call to arms to your colleagues about preparing for the next pandemic, what would you say?
Madhu Pai: Yeah, I would say, anything that is led by global south, anything that is led by communities, must be on top of the agenda because that is how this is all gonna work.
So I don’t think climate change, or conflicts, or covid will be magically solved by global north institutions or individuals. So, de-center, de-center, de-center away from us, and be good allies to the global south.
Everybody’s agreed that we gotta do better, you know, we’ve got to decolonize global health. But it isn’t meaningfully moving the needle in the right direction. Because when rubber hits the road, our allyship only goes so far as just talking about it, which is not allyship at all in the first place.
[“Epidemic” theme music begins playing.]
Next time on “Epidemic” …
Bhakti Dastane: We have to achieve “zeropox,” so it was our motto: “zeropox.”
CREDITS
Céline Gounder: “Eradicating Smallpox,” our latest season of “Epidemic,” is a co-production of KFF Health News and Just Human Productions.
Additional support provided by the Sloan Foundation.
This episode was produced by Taylor Cook, Zach Dyer, Jenny Gold, and me.
Our translator and local reporting partner in India was Swagata Yadavar.
Taunya English is our managing editor.
Oona Tempest is our graphics and photo editor.
The show was engineered by Justin Gerrish.
We had extra support from Viki Merrick.
Music in this episode is from the Blue Dot Sessions and Soundstripe.
Audio of Mahendra Dutta via the Global Health Chronicles recorded at the David J. Sencer CDC Museum at the U.S. Centers for Disease Control and Prevention.
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If you enjoyed the show, please tell a friend. And leave us a review on Apple Podcasts. It helps more people find the show.
Follow KFF Health News on Twitter, Instagram, and TikTok.
And find me on Twitter @celinegounder. On our socials, there’s more about the ideas we’re exploring on the podcasts.
And subscribe to our newsletters at KFFHealthNews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news.
I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.”
[“Epidemic” theme music fades to silence.]
Bill Foege: It was great to work with you then, and it’s great to hear you reminisce now.
Mahendra Dutta: I’m also pleased that I’d worked with you.
Credits
Taunya English
Managing editor
Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects.
Zach Dyer
Senior producer
Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production.
Taylor Cook
Associate producer
Taylor is associate audio producer for Season 2 of “Epidemic.” She researches, writes, and fact-checks scripts for the podcast.
Oona Tempest
Photo editing, design, logo art
Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.
Additional Newsroom Support
Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Gabe Brison-Trezise, deputy copy chiefChris Lee, senior communications officer
Additional Reporting Support
Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh
“Epidemic” is a co-production of KFF Health News and Just Human Productions.
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Title: Epidemic: Do You Know Dutta?
Sourced From: kffhealthnews.org/news/podcast/epidemic-season-2-episode-2-do-you-know-dutta/
Published Date: Tue, 01 Aug 2023 09:00:00 +0000
Kaiser Health News
US Judge Names Receiver To Take Over California Prisons’ Mental Health Program
SACRAMENTO, Calif. — A judge has initiated a federal court takeover of California’s troubled prison mental health system by naming the former head of the Federal Bureau of Prisons to serve as receiver, giving her four months to craft a plan to provide adequate care for tens of thousands of prisoners with serious mental illness.
Senior U.S. District Judge Kimberly Mueller issued her order March 19, identifying Colette Peters as the nominated receiver. Peters, who was Oregon’s first female corrections director and known as a reformer, ran the scandal-plagued federal prison system for 30 months until President Donald Trump took office in January. During her tenure, she closed a women’s prison in Dublin, east of Oakland, that had become known as the “rape club.”
Michael Bien, who represents prisoners with mental illness in the long-running prison lawsuit, said Peters is a good choice. Bien said Peters’ time in Oregon and Washington, D.C., showed that she “kind of buys into the fact that there are things we can do better in the American system.”
“We took strong objection to many things that happened under her tenure at the BOP, but I do think that this is a different job and she’s capable of doing it,” said Bien, whose firm also represents women who were housed at the shuttered federal women’s prison.
California corrections officials called Peters “highly qualified” in a statement, while Gov. Gavin Newsom’s office did not immediately comment. Mueller gave the parties until March 28 to show cause why Peters should not be appointed.
Peters is not talking to the media at this time, Bien said. The judge said Peters is to be paid $400,000 a year, prorated for the four-month period.
About 34,000 people incarcerated in California prisons have been diagnosed with serious mental illnesses, representing more than a third of California’s prison population, who face harm because of the state’s noncompliance, Mueller said.
Appointing a receiver is a rare step taken when federal judges feel they have exhausted other options. A receiver took control of Alabama’s correctional system in 1976, and they have otherwise been used to govern prisons and jails only about a dozen times, mostly to combat poor conditions caused by overcrowding. Attorneys representing inmates in Arizona have asked a judge to take over prison health care there.
Mueller’s appointment of a receiver comes nearly 20 years after a different federal judge seized control of California’s prison medical system and installed a receiver, currently J. Clark Kelso, with broad powers to hire, fire, and spend the state’s money.
California officials initially said in August that they would not oppose a receivership for the mental health program provided that the receiver was also Kelso, saying then that federal control “has successfully transformed medical care” in California prisons. But Kelso withdrew from consideration in September, as did two subsequent candidates. Kelso said he could not act “zealously and with fidelity as receiver in both cases.”
Both cases have been running for so long that they are now overseen by a second generation of judges. The original federal judges, in a legal battle that reached the U.S. Supreme Court, more than a decade ago forced California to significantly reduce prison crowding in a bid to improve medical and mental health care for incarcerated people.
State officials in court filings defended their improvements over the decades. Prisoners’ attorneys countered that treatment remains poor, as evidenced in part by the system’s record-high suicide rate, topping 31 suicides per 100,000 prisoners, nearly double that in federal prisons.
“More than a quarter of the 30 class-members who died by suicide in 2023 received inadequate care because of understaffing,” prisoners’ attorneys wrote in January, citing the prison system’s own analysis. One prisoner did not receive mental health appointments for seven months “before he hanged himself with a bedsheet.”
They argued that the November passage of a ballot measure increasing criminal penalties for some drug and theft crimes is likely to increase the prison population and worsen staffing shortages.
California officials argued in January that Mueller isn’t legally justified in appointing a receiver because “progress has been slow at times but it has not stalled.”
Mueller has countered that she had no choice but to appoint an outside professional to run the prisons’ mental health program, given officials’ intransigence even after she held top officials in contempt of court and levied fines topping $110 million in June. Those extreme actions, she said, only triggered more delays.
The 9th U.S. Circuit Court of Appeals on March 19 upheld Mueller’s contempt ruling but said she didn’t sufficiently justify calculating the fines by doubling the state’s monthly salary savings from understaffing prisons. It upheld the fines to the extent that they reflect the state’s actual salary savings but sent the case back to Mueller to justify any higher penalty.
Mueller had been set to begin additional civil contempt proceedings against state officials for their failure to meet two other court requirements: adequately staffing the prison system’s psychiatric inpatient program and improving suicide prevention measures. Those could bring additional fines topping tens of millions of dollars.
But she said her initial contempt order has not had the intended effect of compelling compliance. Mueller wrote as far back as July that additional contempt rulings would also be likely to be ineffective as state officials continued to appeal and seek delays, leading “to even more unending litigation, litigation, litigation.”
She went on to foreshadow her latest order naming a receiver in a preliminary order: “There is one step the court has taken great pains to avoid. But at this point,” Mueller wrote, “the court concludes the only way to achieve full compliance in this action is for the court to appoint its own receiver.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
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Kaiser Health News
Amid Plummeting Diversity at Medical Schools, a Warning of DEI Crackdown’s ‘Chilling Effect’
The Trump administration’s crackdown on DEI programs could exacerbate an unexpectedly steep drop in diversity among medical school students, even in states like California, where public universities have been navigating bans on affirmative action for decades. Education and health experts warn that, ultimately, this could harm patient care.
Since taking office, President Donald Trump has issued a handful of executive orders aimed at terminating all diversity, equity, and inclusion, or DEI, initiatives in federally funded programs. And in his March 4 address to Congress, he described the Supreme Court’s 2023 decision banning the consideration of race in college and university admissions as “brave and very powerful.”
Last month, the Education Department’s Office for Civil Rights — which lost about 50% of its staff in mid-March — directed schools, including postsecondary institutions, to end race-based programs or risk losing federal funding. The “Dear Colleague” letter cited the Supreme Court’s decision.
Paulette Granberry Russell, president and CEO of the National Association of Diversity Officers in Higher Education, said that “every utterance of ‘diversity’ is now being viewed as a violation or considered unlawful or illegal.” Her organization filed a lawsuit challenging Trump’s anti-DEI executive orders.
While California and eight other states — Arizona, Florida, Idaho, Michigan, Nebraska, New Hampshire, Oklahoma, and Washington — had already implemented bans of varying degrees on race-based admissions policies well before the Supreme Court decision, schools bolstered diversity in their ranks with equity initiatives such as targeted scholarships, trainings, and recruitment programs.
But the court’s decision and the subsequent state-level backlash — 29 states have since introduced bills to curb diversity initiatives, according to data published by the Chronicle of Higher Education — have tamped down these efforts and led to the recent declines in diversity numbers, education experts said.
After the Supreme Court’s ruling, the numbers of Black and Hispanic medical school enrollees fell by double-digit percentages in the 2024-25 school year compared with the previous year, according to the Association of American Medical Colleges. Black enrollees declined 11.6%, while the number of new students of Hispanic origin fell 10.8%. The decline in enrollment of American Indian or Alaska Native students was even more dramatic, at 22.1%. New Native Hawaiian or other Pacific Islander enrollment declined 4.3%.
“We knew this would happen,” said Norma Poll-Hunter, AAMC’s senior director of workforce diversity. “But it was double digits — much larger than what we anticipated.”
The fear among educators is the numbers will decline even more under the new administration.
At the end of February, the Education Department launched an online portal encouraging people to “report illegal discriminatory practices at institutions of learning,” stating that students should have “learning free of divisive ideologies and indoctrination.” The agency later issued a “Frequently Asked Questions” document about its new policies, clarifying that it was acceptable to observe events like Black History Month but warning schools that they “must consider whether any school programming discourages members of all races from attending.”
“It definitely has a chilling effect,” Poll-Hunter said. “There is a lot of fear that could cause institutions to limit their efforts.”
Numerous requests for comment from medical schools about the impact of the anti-DEI actions went unreturned. University presidents are staying mum on the issue to protect their institutions, according to reporting from The New York Times.
Utibe Essien, a physician and UCLA assistant professor, said he has heard from some students who fear they won’t be considered for admission under the new policies. Essien, who co-authored a study on the effect of affirmative action bans on medical schools, also said students are worried medical schools will not be as supportive toward students of color as in the past.
“Both of these fears have the risk of limiting the options of schools folks apply to and potentially those who consider medicine as an option at all,” Essien said, adding that the “lawsuits around equity policies and just the climate of anti-diversity have brought institutions to this place where they feel uncomfortable.”
In early February, the Pacific Legal Foundation filed a lawsuit against the University of California-San Francisco’s Benioff Children’s Hospital Oakland over an internship program designed to introduce “underrepresented minority high school students to health professions.”
Attorney Andrew Quinio filed the suit, which argues that its plaintiff, a white teenager, was not accepted to the program after disclosing in an interview that she identified as white.
“From a legal standpoint, the issue that comes about from all this is: How do you choose diversity without running afoul of the Constitution?” Quinio said. “For those who want diversity as a goal, it cannot be a goal that is achieved with discrimination.”
UC Health spokesperson Heather Harper declined to comment on the suit on behalf of the hospital system.
Another lawsuit filed in February accuses the University of California of favoring Black and Latino students over Asian American and white applicants in its undergraduate admissions. Specifically, the complaint states that UC officials pushed campuses to use a “holistic” approach to admissions and “move away from objective criteria towards more subjective assessments of the overall appeal of individual candidates.”
The scrutiny of that approach to admissions could threaten diversity at the UC-Davis School of Medicine, which for years has employed a “race-neutral, holistic admissions model” that reportedly tripled enrollment of Black, Latino, and Native American students.
“How do you define diversity? Does it now include the way we consider how someone’s lived experience may be influenced by how they grew up? The type of school, the income of their family? All of those are diversity,” said Granberry Russell, of the National Association of Diversity Officers in Higher Education. “What might they view as an unlawful proxy for diversity equity and inclusion? That’s what we’re confronted with.”
California Attorney General Rob Bonta, a Democrat, recently joined other state attorneys general to issue guidance urging that schools continue their DEI programs despite the federal messaging, saying that legal precedent allows for the activities. California is also among several states suing the administration over its deep cuts to the Education Department.
If the recent decline in diversity among newly enrolled students holds or gets worse, it could have long-term consequences for patient care, academic experts said, pointing toward the vast racial disparities in health outcomes in the U.S., particularly for Black people.
A higher proportion of Black primary care doctors is associated with longer life expectancy and lower mortality rates among Black people, according to a 2023 study published by the JAMA Network.
Physicians of color are also more likely to build their careers in medically underserved communities, studies have shown, which is increasingly important as the AAMC projects a shortage of up to 40,400 primary care doctors by 2036.
“The physician shortage persists, and it’s dire in rural communities,” Poll-Hunter said. “We know that diversity efforts are really about improving access for everyone. More diversity leads to greater access to care — everyone is benefiting from it.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
The post Amid Plummeting Diversity at Medical Schools, a Warning of DEI Crackdown’s ‘Chilling Effect’ appeared first on kffhealthnews.org
Kaiser Health News
Tribal Health Leaders Say Medicaid Cuts Would Decimate Health Programs
As Congress mulls potentially massive cuts to federal Medicaid funding, health centers that serve Native American communities, such as the Oneida Community Health Center near Green Bay, Wisconsin, are bracing for catastrophe.
That’s because more than 40% of the about 15,000 patients the center serves are enrolled in Medicaid. Cuts to the program would be detrimental to those patients and the facility, said Debra Danforth, the director of the Oneida Comprehensive Health Division and a citizen of the Oneida Nation.
“It would be a tremendous hit,” she said.
The facility provides a range of services to most of the Oneida Nation’s 17,000 people, including ambulatory care, internal medicine, family practice, and obstetrics. The tribe is one of two in Wisconsin that have an “open-door policy,” Danforth said, which means that the facility is open to members of any federally recognized tribe.
But Danforth and many other tribal health officials say Medicaid cuts would cause service reductions at health facilities that serve Native Americans.
Indian Country has a unique relationship to Medicaid, because the program helps tribes cover chronic funding shortfalls from the Indian Health Service, the federal agency responsible for providing health care to Native Americans.
Medicaid has accounted for about two-thirds of third-party revenue for tribal health providers, creating financial stability and helping facilities pay operational costs. More than a million Native Americans enrolled in Medicaid or the closely related Children’s Health Insurance Program also rely on the insurance to pay for care outside of tribal health facilities without going into significant medical debt. Tribal leaders are calling on Congress to exempt tribes from cuts and are preparing to fight to preserve their access.
“Medicaid is one of the ways in which the federal government meets its trust and treaty obligations to provide health care to us,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, a nonprofit policy advocacy organization for 33 tribes spanning from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.
“So we view any disruption or cut to Medicaid as an abrogation of that responsibility,” she said.
Tribes face an arduous task in providing care to a population that experiences severe health disparities, a high incidence of chronic illness, and, at least in western states, a life expectancy of 64 years — the lowest of any demographic group in the U.S. Yet, in recent years, some tribes have expanded access to care for their communities by adding health services and providers, enabled in part by Medicaid reimbursements.
During the last two fiscal years, five urban Indian organizations in Montana saw funding growth of nearly $3 million, said Lisa James, director of development for the Montana Consortium for Urban Indian Health, during a webinar in February organized by the Georgetown University Center for Children and Families and the National Council of Urban Indian Health.
The increased revenue was “instrumental,” James said, allowing clinics in the state to add services that previously had not been available unless referred out for, including behavioral health services. Clinics were also able to expand operating hours and staffing.
Montana’s five urban Indian clinics, in Missoula, Helena, Butte, Great Falls, and Billings, serve 30,000 people, including some who are not Native American or enrolled in a tribe. The clinics provide a wide range of services, including primary care, dental care, disease prevention, health education, and substance use prevention.
James said Medicaid cuts would require Montana’s urban Indian health organizations to cut services and limit their ability to address health disparities.
American Indian and Alaska Native people under age 65 are more likely to be uninsured than white people under 65, but 30% rely on Medicaid compared with 15% of their white counterparts, according to KFF data for 2017 to 2021. More than 40% of American Indian and Alaska Native children are enrolled in Medicaid or CHIP, which provides health insurance to kids whose families are not eligible for Medicaid. KFF is a health information nonprofit that includes KFF Health News.
A Georgetown Center for Children and Families report from January found the share of residents enrolled in Medicaid was higher in counties with a significant Native American presence. The proportion on Medicaid in small-town or rural counties that are mostly within tribal statistical areas, tribal subdivisions, reservations, and other Native-designated lands was 28.7%, compared with 22.7% in other small-town or rural counties. About 50% of children in those Native areas were enrolled in Medicaid.
The federal government has already exempted tribes from some of Trump’s executive orders. In late February, Department of Health and Human Services acting general counsel Sean Keveney clarified that tribal health programs would not be affected by an executive order that diversity, equity, and inclusion government programs be terminated, but that the Indian Health Service is expected to discontinue diversity and inclusion hiring efforts established under an Obama-era rule.
HHS Secretary Robert F. Kennedy Jr. also rescinded the layoffs of more than 900 IHS employees in February just hours after they’d received termination notices. During Kennedy’s Senate confirmation hearings, he said he would appoint a Native American as an assistant HHS secretary. The National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for tribes, in December endorsed elevating the director of the Indian Health Service to assistant secretary of HHS.
Jessica Schubel, a senior health care official in Joe Biden’s White House, said exemptions won’t be enough.
“Just because Native Americans are exempt doesn’t mean that they won’t feel the impact of cuts that are made throughout the rest of the program,” she said.
State leaders are also calling for federal Medicaid spending to be spared because cuts to the program would shift costs onto their budgets. Without sustained federal funding, which can cover more than 70% of costs, state lawmakers face decisions such as whether to change eligibility requirements to slim Medicaid rolls, which could cause some Native Americans to lose their health coverage.
Tribal leaders noted that state governments do not have the same responsibility to them as the federal government, yet they face large variations in how they interact with Medicaid depending on their state programs.
President Donald Trump has made seemingly conflicting statements about Medicaid cuts, saying in an interview on Fox News in February that Medicaid and Medicare wouldn’t be touched. In a social media post the same week, Trump expressed strong support for a House budget resolution that would likely require Medicaid cuts.
The budget proposal, which the House approved in late February, requires lawmakers to cut spending to offset tax breaks. The House Committee on Energy and Commerce, which oversees spending on Medicaid and Medicare, is instructed to slash $880 billion over the next decade. The possibility of cuts to the program that, together with CHIP, provides insurance to 79 million people has drawn opposition from national and state organizations.
The federal government reimburses IHS and tribal health facilities 100% of billed costs for American Indian and Alaska Native patients, shielding state budgets from the costs.
Because Medicaid is already a stopgap fix for Native American health programs, tribal leaders said it won’t be a matter of replacing the money but operating with less.
“When you’re talking about somewhere between 30% to 60% of a facility’s budget is made up by Medicaid dollars, that’s a very difficult hole to try and backfill,” said Winn Davis, congressional relations director for the National Indian Health Board.
Congress isn’t required to consult tribes during the budget process, Davis added. Only after changes are made by the Centers for Medicare & Medicaid Services and state agencies are tribes able to engage with them on implementation.
The amount the federal government spends funding the Native American health system is a much smaller portion of its budget than Medicaid. The IHS projected billing Medicaid about $1.3 billion this fiscal year, which represents less than half of 1% of overall federal spending on Medicaid.
“We are saving more lives,” Malerba said of the additional services Medicaid covers in tribal health care. “It brings us closer to a level of 21st century care that we should all have access to but don’t always.”
This article was published with the support of the Journalism & Women Symposium (JAWS) Health Journalism Fellowship, assisted by grants from The Commonwealth Fund.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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