Read how we came up with this grade.

Throughout the course of the 2012 election, the Consider the Source team will continue to write profiles about the major super PACs and nonprofits that are spending heavily on political advertising.

In addition to providing basic information about the origin of the organizations and their spending history, today we add a transparency grade to each group, indicating how much they reveal about their donors.

Super PACs, which are required to report donors to the Federal Election Commission, generally receive good grades. But they may be marked down if major donations come from shell corporations or nonprofits.

Nonprofit outside spending organizations, which are not required to report their donors, receive a "no disclosure" designation.

The grades are tabulated by the Consider the Source staff and are subjective. Any organization that would like to dispute its grade or provide a list of donors to the Center, please contact project director John Dunbar via email at jdunbar@publicintegrity.org. 

Transparency Test

FD (Full Disclosure): All donations of $200 or more are reported.

SD (Significant Disclosure): All donations of $200 or more are reported, but some large contributions come from nonprofits or mystery corporations.

PD (Partial Disclosure): A majority of donors of $200 or more are reported but a substantial percentage of funds come from nonprofits or mystery corporations.

ND (No Disclosure): The government generally does not require these organizations to publicly report their donors.

Transparency Grade: FD

• Revolution
• Santa Rita
• Americans for a Better Tomorrow, Tomorrow
• Cain Connections
• 9-9-9 Fund
• Red, White and Blue
• Leaders for Families
• Strong America Now
• Make Us Great Again
• Our Destiny
• Winning Our Future
• Endorse Liberty
• House Majority PAC
• Priorities USA Action

Transparency Grade: SD

• Restore Our Future
• Majority PAC
• American Crossroads
• American Bride 21st Century
• Ending Spending Action Fund

Transparency Grade: PD

• Citizens for a Working America
• FreedomWorks for America

Transparency Grade: ND

• Americans for Prosperity
• Americans for Tax Reform
• Crossroads GPS
• 60 Plus Association
• American Action Network
• American Commitment
• American Future Fund
• Ending Spending Inc.
• U.S. Chamber of Commerce

Read how we came up with this grade.

Read how we came up with this grade.

Read how we came up with this grade.

With less than two months to go before the Nov. 6th election, nearly $3 billion has been raised by all the presidential and congressional candidates, along with the parties and super PACs, a staggering figure.

Here is a rough tally at this moment in time, with help from OpenSecrets.org:

• All super PACs have raised about $350 million so far this cycle, with conservative groups bringing in the major share.
• All House candidates have raised about $784 million.
• All Senate candidates have raised about $445 million.
• And all presidential candidates have raised about $700 million. This figure includes $350 million by President Barack Obama and $194 million by Mitt Romney.
• In addition, the Democratic National Committee has raised $242 million and the Republican National Committee has raised $265 million. All these fundraising numbers are here on OpenSecrets.org.

And, each of these numbers will grow substantially in the next 54 days. The financial arms race at the presidential level is likely to be something of a draw by the time the final figures are counted, but the Republicans to date are at a distinct advantage with well-funded outside spending groups, which have blanketed the airwaves with mostly negative ads.

The 2012 presidential election will end up being the most expensive and least transparent presidential campaign of the modern era. Our year-long ‘Consider the Source’ project seeks to ‘out’ shadowy political organizations that have flourished in the wake of the Supreme Court’s Citizens United ruling. Turn to us through Election Day and beyond for the narrative behind the massive flow of money at federal and state levels. 

Bookmark these tools and resources:

The Daily Disclosure: From Federal Election Commission reports to YouTube postings and press releases, the Daily Disclosure provides an insider-look into super PACs’ and nonprofits’ reported campaign spending. Each day, we comb through the data to identify ads paid for by free-spending special interest groups.

Super PAC profiles: We’ve profiled 22 super PACs so far this election cycle. Each identifies the principals behind the PAC with brief bios, ideologies, money raised so far, and how it is being spent – mostly on attack ads as it turns out. 

Nonprofit donor profiles: Nonprofits can spend the same as super PACs but are not required to reveal their donors.  Our investigations have revealed details on 10 of these groups so far, including principals, ideology and finances wherever possible. 

Super donor profiles: Learn about the top 10 donors to super PACs and what they hope to get in return. Be sure to check out the trading-card versions of these all-stars here.

Citizens United – the back story: Need a primer on how we got here? In 2010, the courts reversed decades of legal precedent when they said it was OK for corporations and unions to spend as much as they want to put their favorite candidates in office. Our citizen’s guide explains what the courts ruled and why it matters.

It’s the tea party versus unions in the race to determine who will control Pennsylvania’s redrawn 12th Congressional District. Democratic Rep. Mark Critz, backed by union muscle, faces a challenge from attorney Keith Rothfus, a tea party favorite, in a race that has already seen $1.4 million in outside spending.

House races are especially vulnerable to outside spending because smaller districts and smaller campaign accounts mean less money is needed to make an impact.

The Service Employees International Union’s super PAC, SEIU PEA Federal, and its traditional PAC, SEIU COPE, dropped $277,000 on Thursday on ads and other campaign expenditures designed to help Critz stay in Congress, Federal Election Commission reports show. Critz has also gotten help from the AFL-CIO and its political committees and affiliates as well as the United Steelworkers and its PAC, according to the Center for Responsive Politics.

House Majority PAC, a Democratic super PAC, and the Democratic Congressional Campaign Committee have also supported his re-election with a combined $385,000 in spending.

Most of the outside spending in favor of Rothfus has come via the National Republican Congressional Committee, which has spent more than a half-million dollars in his favor. Rothfus also has financial support from the tea party-aligned super PAC FreedomWorks for America, headed up by former House Majority Leader Dick Armey, and Club for Growth, a free-market, conservative nonprofit.

The seat is considered a tossup.

Originally Republican-leaning, redistricting resulted in the 12th District incorporating the left-leaning Johnstown, Critz’s hometown, into the fold, The New York Times reported. Critz won the Democratic primary in a surprise outcome against another incumbent, Rep. Jason Altmire, who had represented two-thirds of the district beforehand, according to The Washington Post.

Labor began rallying around Critz during the primary, largely because of Critz's support for the Affordable Care Act (though he was elected after it passed), whereas Altmire at first voted against it, Politico reported. By April’s primary election, Critz had the endorsement of at least 20 labor groups.

Rothfus first ran for Congress in 2010 but was largely overlooked by the national Republican establishment. This year, with outside spending pouring in from the NRCC and a speaking slot at the Republican National Convention in Tampa, the Republican Party is fighting hard for him.

An endorsement from the Tea Party Express, FreedomWorks for America and Club for Growth has earned Rothfus a badge of acceptance from tea partiers across the state.

Outside ads’ criticisms of Rothfus have focused on alleged outsourcing to China (“Shanghai” from the DCCC), Medicare (“Not on Our Side” from SEIU COPE) and his legal representation of the bailed-out Bank of New York Mellon (“Problem” from House Majority PAC).

The Rothfus campaign released an ad Wednesday responding to the China allegations that says, “The attacks are wrong. The closest Keith Rothfus has been with China was when he has ordered takeout for his family.”

Rothfus also released a statement about Bank of New York Mellon arguing that it employs 7,500 people in the Pittsburgh area, and as such, it is unfair to call him a “millionaire Wall Street lawyer.” And as to Medicare, Rothfus opposes the Affordable Care Act and supports Rep. Paul Ryan’s “premium support” plan.

Critz for his part was hit by NRCC ads for his support of the Affordable Care Act (“20 Times”).

Rothfus’s campaign itself has raised $892,000 through the end of June, compared with Critz’s $1.8 million, and it has spent $273,000 compared with Critz’s $1.3 million, according to the most recent FEC reports.

In other outside spending news:

• SEIU PEA Federal, the super PAC, reported spending $865,000 on ads designed to help the Democratic candidates in several U.S. House and Senate races. SEIU COPE, the traditional PAC, spent an additional $869,000 on House and Senate races.
• House Majority PAC released “Strange,” saying Rep. Chip Cravaack, a Republican from Minnesota’s 8th District, came back from Washington with “strange ideas” like “ending the current Medicare system.” Former Rep. Rick Nolan, a Democrat, is challenging him for his seat. House Majority PAC also released "Choice," which supports Democratic Rep. Nick Rahall and opposes Republican state Rep. Rick Snuffer for U.S. House in West Virginia's 3rd District.
• "Buildings" from Majority PAC opposes former Wisconsin Gov. Tommy Thompson, who is running for U.S. Senate in Wisconsin against Democratic Rep. Tammy Baldwin.
• The American Federation of State, County and Municipal Employees union released “A Lot to Say,” an ad criticizing Rep. Denny Rehberg, R-Mont., who is running for U.S. Senate against Democratic Sen. Jon Tester.
• The conservative Republican Jewish Coalition placed billboards in Florida that read, “OBAMA…OY VEY!! Had enough?”
• “Insider” from the Democratic Congressional Campaign Committee hits Republican U.S. House candidate Rodney Davis for his support of Ryan’s Medicare plan. Davis, a congressional aide, faces physician Rodney Gill in Illinois’ 13th District.
• New super PACs: Transparency Now in Honolulu, Hawaii.

Thousands of doctors and other medical professionals have steadily billed higher rates for treating elderly patients on Medicare over the last decade — adding $11 billion or more to their fees and signaling a possible rise in medical billing abuse, an investigation by the Center for Public Integrity has found.

Medical groups argue that the fee hikes are justified because treating seniors has grown more complex and time-consuming, both due to new technology and declining health status. The rise in fees may also be a reaction, they say, to years of under-charging, and reflect more accurate billing. The fees are based on a system of billing codes that is structured to make higher payments for treatments that take more time and effort.

But the Center’s analysis of Medicare claims from 2001 through 2010 shows that over time, thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising.

While it’s impossible to know precisely why doctors and hospitals moved to better-paying codes in recent years, it’s likely that the trend in part reflects “upcoding,” — the practice of charging for more extensive and costly services than delivered, according to Medicare experts, analysis of the data and a review of government audits.

And Medicare regulators worry that the coding levels may be accelerating in part because of increased use of electronic health records, which make it easy to create detailed patient files with just a few mouse clicks.

Many health policy experts have long believed that billing errors and abuses, from confusion over how to pick proper payment codes to outright overcharges, are common in Medicare. But the Center’s year-long examination has outlined their scope in an unprecedented manner, uncovering a range of costly medical coding mistakes and abuses that have plagued the government-paid health care plan for years and are worsening amid lax federal oversight.

“This is an urgent problem,” said Dr. Mark McClellan, who directs the Engelberg Center for Health Care Reform at the Brookings Institution in Washington. McClellan, a former director of the Centers for Medicare and Medicaid Services, or CMS, said the agency must send a message that it “won’t stand by and do nothing … that they are paying attention to this.”

Among the investigation’s key findings:

• Doctors steadily billed Medicare for longer and more complex office visits between 2001 and the end of the decade even though there’s little hard evidence they spent more time with patients or that their patients were sicker and required more complicated — and time-consuming — care.  The higher codes for routine office visits alone cost taxpayers an estimated $6.6 billion over the decade.
• More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.
• The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.
• Medicare administrators have struggled for more than a decade to crack down on medical coding errors and abuses, often in the face of opposition from medical groups including the American Medical Association, which helped design, and now controls the codes. Whether they make honest mistakes or engage in willful misconduct, there’s little chance doctors who pad their charges will face any serious penalties.

CMS officials declined numerous interview requests. However, in an e-mail response to written questions, officials said while they believe most doctors and hospitals are “honest and try to bill Medicare correctly,” the agency also “is keenly aware that certain Medicare providers and suppliers seek to defraud the program.”

Dr. Robert Berenson, a former vice chairman of a federal commission that recommends Medicare payment strategies to Congress, called the Center’s findings “clearly significant,” and said they indicate an urgent need to revamp the pay scales.

“It is really time to deal with this issue. There are so many perverse outcomes, including spending for taxpayers,” Berenson said.

That so many doctors deviate widely from billing norms — and have done so for years with apparent impunity — spotlights Medicare’s chronic vulnerability to abuse and fraud, several experts said.

Thomas Scully, an architect of the Medicare pay scales during his White House days under the first President Bush, is now critical of the system. He said it was put in place in order to curb rising doctors’ fees, but Medicare’s pay hikes have been too small to match rising medical office expenses. Many doctors have responded by picking the highest codes possible, he said.

“You are going to pedal faster and code more aggressively,” said Scully, also a former director of the federal Medicare agency and now a Washington lobbyist with a range of health care clients. “I’m not sure it’s malicious. It’s a fact a life,” he said.

However, the U.S. Department of Health and Human Services inspector general in a May report stated that payments made under the doctor-visit codes rose 48 per cent between 2001 and 2010, from $22.7 billion to $33.5 billion. The report also noted that the coding system has been “vulnerable to fraud and abuse.”

And agency officials acknowledge that the surge in these billings has been driven at least partly by potentially illegal “upcoding” which the government has largely failed to stamp out through the years.

“We have some people who will use any excuse to get more money for the services they do,” said Jennifer Trussell, who heads the investigations unit for the HHS inspector general’s office. “They don’t see it as a crime.”

AMA president Jeremy A. Lazarus agreed that doctors have shifted toward billing higher priced codes. But the “contributing factors are unclear,” he said in a written statement. “There could be several possible reasons for this trend, but more analysis is needed,” Lazarus said.

Secret Code

The current billing scales, known as Evaluation and Management codes, were unveiled in 1992 as part of an unusual and secretive arrangement between Medicare officials and the AMA, the nation’s most influential doctors’ group.

The AMA wanted Medicare to reward doctors for the “thinking part” of medicine, or their skill in diagnosing and treating illness, as well as the time it takes. Medicare expected the pay scales to cut down on billing abuses and to save taxpayers money by setting measurable standards that all doctors would follow.

On paper, the process seems straightforward enough: the lowest of the five coding levels for an office visit, 99211, signifies a minimal health problem and five minutes either spent treating the patient or supervising a nurse or other health worker who does so.

That simple visit pays the doctor about $20 from Medicare.

The top code, 99215, requires much more effort. Doctors must do two of three things: a comprehensive examination, a detailed history of the patient’s health status, or make a medical decision of “high complexity.”

That typically requires 40 minutes of face-to-face contact between doctor and patient and pays about $140.

Medicare officials expect medical professionals to bill a range of the five fee codes because some patients require more time and effort to treat than others. The government trusts them to bill correctly and medical groups say the vast majority of America’s physicians follow the complex coding rules as best they can. Medicare pays for more than 200 million office visits each year.

However, doctors and hospitals have increasingly abandoned the lower-level codes for better paying ones. Medicare officials have largely failed to challenge these surges in billing across a broad spectrum of medicine, from doctors working in hospital emergency departments and nursing homes to family physicians and specialists seeing patients in their offices.

Government officials and medical data experts note that sharp spikes in billing strongly suggest some doctors and hospitals engage in “upcoding,” by finding ways to bill for higher codes than justified.

Medical groups counter that most doctors charge less than they deserve. The only way to tell for sure is to review patient records that support each of the 370 million such claims Medicare pays annually, which officials say is impractical and not cost-effective.

Physician groups don’t dispute that coding errors are commonplace in medicine or that a tiny fraction of doctors may exploit loose federal oversight to fatten up their fees.

But they argue that coding guidelines are vague and subjective and that just as many doctors undervalue their work by picking lower codes as might be tempted to bill too much.

The medical organizations also argue that more elderly patients over the past decade have been diagnosed with multiple health problems that require additional time and effort to treat, a contention undercut by much health care research.

And they cite growing use of computerized medical records and billing systems for enabling doctors to document the level of treatment they provide more easily than by hand, which pays off in higher codes. Federal officials are spending as much as $30 billion in economic stimulus money to help doctors and hospitals purchase the digital gear, and more than half the doctors billing Medicare are using it, with more expected to follow.

Dr. Thomas Weida, a family physician in Hershey, Pa., said that wiring up his office has boosted the amount of time spent face-to-face with a typical patient by five minutes or more, both from the amount of stored information he reviews and increased time writing and prescribing treatments. That alone could justify higher billing codes in many instances, he said.

“You’re having to do a lot more than you did before,” said Weida, a medical coding expert for the American Academy of Family Physicians.

But digital systems also can prompt doctors to “code at the highest possible level,” said Dr. David Kibbe, who has consulted with the family physicians’ group. Often, that means that with “the push of a button” doctors can create reams of documentation to support higher codes, Kibbe said.

Some doctors identified by the Center’s data analysis as disproportionately billing high codes for office visits cited the poor health condition of their patients as a key justification for doing so.

“I know they are high,” said Dr. Brantley B. Pace, who has practiced family medicine for more than a half century in Monticello, Miss., when asked about his billing practices, among the highest in the Medicare billing sample.

Pace said many of his longtime patients live with multiple infirmities that require his attention. “I rarely have a person who comes to me for a cold,” he said.

Data experts noted that some individual doctors may in fact be justified in billing much higher than their peers. But they stressed that the sheer numbers of physicians from a range of medical specialties who do suggests some degree of manipulation of the payment scales.

Billing Norms

The Center for Public Integrity analyzed a representative 5 percent sample of Medicare patients and their claims submitted by more than 400,000 medical practitioners and 7,000 hospitals and clinics, starting in 2001. The cost analysis projected the increase in Medicare costs as more doctors picked higher codes each year over the decade.

The added fees totaled at least $11 billion, adjusted for inflation — more than half of it from higher doctor fees for office visits and the rest from other services, including treatment in nursing homes and hospitals.

The investigation identified thousands of doctors, from a broad range of specialties and locales, who adjusted their billing patterns sharply upward and netted higher fees as a result. A 1979 federal court injunction in Florida bars HHS from publicly releasing doctors’ names and Medicare reimbursements.

The Center sued HHS to obtain the Medicare data but had to agree not to publish the names of individual doctors, unless they agreed to discuss their billing histories. Most who were contacted declined to do so.

From 1999 through 2008, the number of doctors who billed at least half of their office visits at one of the two most expensive codes more than doubled to at least 17,000 practitioners. Those who quit using the two least expensive codes rose 63 percent, climbing to more than 13,000 in 2008.

“Those are codes we see abused quite frequently,” said Trussell, of the HHS inspector general’s office.

In 2010 alone, Medicare paid for more than six million more visits at the second highest pay rate than the year before. That upsurge cost Medicare more than $1 billion, government records show.

Some doctors relied on the same code for nearly every patient visit despite Medicare guidelines calling for a balance because not all patients who see the doctor require the same degree of attention or time.

More than 750 doctors billed the two highest-paying codes exclusively for office visits, some for as long as seven years straight, for instance.

The changes in billing patterns vary sharply by region. For instance the Milwaukee area saw a steep jump in use of the two highest codes, from 19 percent at the start of the decade to 45 percent in 2008. The Phoenix and Salt Lake City areas also saw hefty jumps. By contrast, some major urban areas, including New York City and Los Angeles, decreased slightly over the decade.

Medicare has been paying for longer and more complex office visits despite annual surveys by the federal Centers for Disease Control and Prevention showing that the average time doctors spent with patients didn’t change much over the years.

Jerry Cromwell, a researcher with RTI International in North Carolina, in a 2006 study found the average Medicare doctor visit lasted about 18 minutes, or less. Yet Medicare billing records show a sharp rise in services over the decade that were supposed to take 25 minutes or longer in face-to-face contact with a patient.

Cromwell said it has been a “real challenge” for Medicare officials to verify how much time doctors typically spend with patients. He identified “upcoding” as one possible explanation for the discrepancy.

The Medicare billing data do not show that patients are getting more infirm; their reasons for visiting the doctor’s office were essentially unchanged over the decade. And the May report by the HHS inspector general said its review of 2010 Medicare claims found that many high-end billers tended to treat patients who were slightly younger than average.

Researchers also said there’s not much evidence that elderly people on Medicare have been getting sicker over time — certainly not enough to justify the sharp rise in more costly billings.

Eric Seiber, an Ohio State University researcher who has studied physician billing trends, said Medicare officials have yet to conduct studies to determine to what extent the pay scales are being manipulated.

“There is a lot of money there and we have almost no handle on it. It’s so hard to pin down,” Seiber said.

The Medicare billing data also lend little support to the argument that many doctors on average choose codes that are too low. In 2008, three times as many physicians were billing only the two top codes as picked the two lowest ones, for instance.

In addition, federal officials projected that Medicare overpaid nearly $658 million in 2010 as a result of wrongly coded bills for office visits at the second most expensive payment level. Officials found underpayments to be a tiny fraction of that amount, or about $6.1 million, according to government records.

Malcolm Sparrow, a health care fraud expert and professor at the John F. Kennedy School of Government at Harvard University, said: “If there are changes [in billing] over time costing the public billions of dollars, there should be an explanation.”

Coding Errors

Medicare manuals state that the government trusts doctors to bill accurately and pays bills “generally based solely on your representations” in the claim.

“When you submit a claim for services performed for a Medicare [patient], you are filing a bill with the federal government and certifying that you have earned the payment requested and complied with the billing requirements,” the manual reads.

Yet Medicare auditors through the years have repeatedly detailed high rates of doctor billing errors, though mostly in obscure audits which captured little public notice and spurred little government action.

In June 2000, Medicare officials identified incorrect coding as Medicare’s third most prominent error, triggering $1.7 billion in suspect payments. Much of the time, errors paid doctors too much, not too little.

“These improper payments, as in past years, could range from inadvertent mistakes to outright fraud and abuse. We cannot quantify what portion of the error rate is attributable to fraud,” auditors wrote.

In 2001, members of a government panel were so fed up with the payment scales that they recommended junking them. Two years later, Congress passed Medicare reform legislation that called for studies to consider alternatives to the pay scales.

But the law required Medicare officials to consult physicians’ groups before making any changes, a legacy of the decision to allow the AMA to develop the codes. Medical groups have since been able to block any reform effort, according to former government official Scully and other insiders.

Scully said it was a “big mistake” for the government to give the AMA such a prominent role in creating the doctor payment yardstick. “As a result the AMA has amassed enormous power,” he said.

Medicare officials deny the AMA and other medical groups have outsized influence over the payment system. But they concede that the system has been left in place for years because they could not reach an agreement on ways to improve it.

Most patients have no idea doctor pay scales exist because Medicare and other insurers don’t typically help people decipher them. As owner of the copyrights on the codes and their definitions, the AMA controls their publication and aggressively enforces its copyright.

Princeton University Professor Uwe E. Reinhardt, a prominent health care economist, said government officials could have paid the AMA a lump sum to develop the codes, simplified them and retained their ownership for taxpayers. Doing so would have opened up the process to public scrutiny and given patients a better understanding of health care finances. Other critics note that millions of seniors might help the government check on the veracity of medical bills if they knew the lingo and how to crack the codes.

“I wish I had some way to check up on the billing process,” said Judy Ryden, a retired community college teacher who is on Medicare and lives in Grants Pass, Ore. “Unless I had a degree in medical coding I have no idea what all that means. I can’t tell whether a charge is legitimate or not,” she said.

AMA president Lazarus in his statement noted that while the AMA provides “guidance for the appropriate use” of billing codes, it “does not profit in any way if physicians bill an insurer for a complex service rather than a simple service.”

Lazarus noted that the group “does not receive a single taxpayer dime” for its oversight of the codes. He said the system “saves taxpayers millions of dollars” by allowing medical information to be communicated efficiently and reliably.”

Without the system, “the transfer of vital information between physicians, hospitals and health plans would break down under an even greater burden of costly paperwork,” Lazarus said.

The payment system also has given rise to a cottage industry of coding experts and medical practice consultants who conduct seminars for doctors that often encourage higher coding — in some cases through Internet pitches that promise doctors significantly higher profits.

Medical organizations also teach their members ways to code at higher levels legitimately. In one 2009 article, the academy of family physicians noted that using the second-highest level for most office visits could put an additional $30,000 to $75,000 in a doctor’s pocket.

As a result, the billing codes intended to hold medical fees in check have instead contributed to spiraling Medicare costs.

Error Prone

Today, startlingly high rates of billing mistakes — many of them overcharges — persist, according to Medicare audits conducted in several states.

In May 2011, Medicare contractor Palmetto GBA notified more than 11,000 California doctors that it would begin auditing their claims for office visits after concluding that too many were being billed at high-level codes.

Another Medicare contractor called Trailblazer audited patient office visits in early 2010 in Virginia and found mistakes in half the records it reviewed. A similar audit in Colorado, New Mexico, Oklahoma and Texas reported a 91% error rate for billing for office visits.

Billy Quarles, a spokesman for BlueCross BlueShield of South Carolina, which owns both companies, said “inadequate documentation” was the primary reason for the high denial rates in the Trailblazer audit.

“In some cases the documentation available did not support the level of service billed, but more often, the documentation was not sufficient to determine medical necessity or evidence of a face-to-face encounter with the patient,” Quarles said.

A third Medicare contractor, WPS Medicare, conducted a similar review of doctors in Wisconsin, Illinois, Michigan and Minnesota after discovering unusually high levels of the second highest code, most of them coding errors on routine patient visits.

In both cases, the audits focused on family practice doctors and specialists in internal medicine. Doctors who failed to respond could face denials of their claims.

“Upcoding”

Deliberately inflating bills to boost profits can constitute health care fraud, but few offenders face any liability.

And chances of getting caught are very small because Medicare rarely audits closely and typically has no way of finding out unless someone on the inside comes forward and alerts them. Federal officials have recently stepped up efforts to use computers to detect abnormal billing patterns, however.

Many of the more than 50 “upcoding” court cases reviewed by the Center for Public Integrity resulted from whistleblower lawsuits, often filed by an employee who fears retribution after alerting superiors to the billing problems. They can share in money the government recoups, and most cases are settled with no admission of wrongdoing.

Minnesota family doctor David Lang offers an example. He sued his employer, the Apple Valley Medical Clinic in suburban Minneapolis, as a whistleblower after concluding that some of the 14 doctors working there were upcoding Medicare claims.

He also took his findings to federal officials, who joined the civil case.

In his suit, Lang said that when he brought up some “extraordinarily high” doctor billings to the clinic’s board, he faced threats and retaliation.

For instance, he said he was accused of seeing patients with “alcohol on his breath,” an allegation Lang refuted by demanding a test, which showed no liquor in his body, according to court filings.

The Apple Valley clinic’s managers denied wrongdoing, though they settled the suit by paying the government more than $180,000 in December 2010. The clinic did not respond to requests for comment. But Lang, a partner in the clinic, says it now bills properly.

“We’ve cleaned it up,” he said.

Lang said in an interview that he believes billing irregularities are “prevalent” in medical offices. He said some doctors overbill “consciously and without remorse,” while others may regard inflating a few service codes as a relatively harmless way to help defray rising office expenses — or to silently protest what they regard as stingy pay from Medicare.

According to Lang, Medicare officials should publicize these cases widely to limit what he called “robbing from the public.”

But that seldom happens.

Like many others, Lang’s lawsuit file was sealed by a federal court judge with only his initial allegations made public.

Even criminal prosecutions conducted in open court may not bring a significant penalty. Several criminal cases reviewed were settled with a plea bargain that not only kept the doctor out of jail, but also let him continue participating in Medicare.

Billing administrator Lynne Lewis helped trigger such a case after concluding that her boss, Massachusetts pain specialist Dr. Anil Kumar, was “upcoding” some bills.

When she confronted Kumar about his billing tactics, he testily told her that he did business that way “long before you came,” and would do so “while you are here” and “long after you are gone,” according to her lawsuit.

The tongue lashing didn’t deter Lewis. She filed a whistleblower lawsuit against the doctor and federal authorities charged Kumar with health care fraud.

Prosecutors accused Kumar of fraudulently billing every new patient visit as if it were a consultation referred by another doctor. At the time, Medicare paid more for consultations than for simple office visits.

In June 2010, Kumar agreed to pay the government $586,000 in a settlement deal in which he did not admit any wrongdoing. He still practices in Stoneham, Mass., and is in good standing with Medicare. He had no comment.

Growing Tensions

Though the Obama administration has made a significant commitment to cracking down on Medicare fraud and abuse, officials don’t appear to have an aggressive strategy for cutting down on medical coding abuses.

CMS acting Administrator Marilyn Tavenner earlier this year confirmed that the agency planned to contact as many as 5,000 doctors it identified as billing outside norms, but said the effort was “not intended to be punitive or sent as an indication of fraud.”

She said the agency would focus on the top ten high billers in each Medicare region as a first step, but that it might cost the agency more to investigate suspicious claims than it could collect.

The agency, Tavenner wrote in a letter published in the May IG report, “must take into account the respective return on investment of medical review activities.”

It is clear that CMS is meeting resistance to fraud-control audits from doctors’ groups — and threats that some physicians might dump Medicare patients if the government doesn’t back off.

In December of 2011, California Medical Association president Dr. James T. Hay fired off a letter to federal officials in Washington noting that audits of doctor billings have “created great consternation” among the state’s doctors and saddled them with what he deemed an “enormous administrative burden” on their office staffs.

“Clearly, physicians want their purposefully overbilling and illegally behaving peers to be found and stopped. We also want to be paid fairly,” Hay later wrote in a CMA publication.

Hay added a threat that targeting doctors for review unfairly “will only further induce physicians to decrease or stop their participation in the Medicare program.”

Asked about the controversy, Medicare officials said they didn’t believe the limited number of proposed audits would lead doctors to dump Medicare patients. Officials said they had responded to the letter by “conducting a telephone conference and additional discussions with [Medicare payment contractor] Palmetto,” but declined to offer details.

These sorts of clashes are likely to become more common. Several provisions in the health care reform law step up penalties for doctors and hospitals who fail to return any overpayments within 60 days, for instance.

In draft regulations, Medicare officials predicted the new policies would result in about 125,000 medical providers returning from three to five overpayments each during a typical year.

Many experts also predict an even sharper clash lies ahead over electronic health records, which Medicare officials are pushing doctors and hospitals to purchase, and also are widely marketed for their power to document higher billing codes — and thus boost the bottom line. More than half of doctors billing Medicare used the devices in 2011, and more are expected to do so.

Reinhardt, the health economist, said that government must be cautious to pay health professionals properly for their work, and that under the current coding system, fees often are too low, which in turn encourages higher coding.

“If it is a dishonest payment system, doctors will be dishonest,” Reinhardt said.

The “Cracking the Codes” stories are but the latest in a series of Center pieces that illuminate questionable Medicare practices and policies by marrying traditional shoe-leather reporting with rigorous data analysis.

The foundation of these pieces is the Center’s access to about two terabytes of Medicare claims data — data that was obtained by the Center in 2010 as the result of a settlement from litigation against the Centers for Medicare and Medicaid Services.   

Delving deeply into this data has now helped us expose one of medicine’s dirty little secrets: medical providers garnering extra Medicare fees by “upcoding,” or billing for more extensive care than had actually been delivered. But it wasn’t easy. “Cracking the Codes” is the result of almost 20 months of often-tedious work.

That work began in early 2011, with preliminary analysis by data editor David Donald that summarized changes in hundreds of codes used by doctors and hospitals to bill Medicare over much of the past decade. Center investigative reporter Fred Schulte spent hours sifting those findings for story ideas, and subsequently discovered sharp spikes in higher-cost Medicare billing codes for routine patient visits to doctors. The code patterns indicated that short office visits paying doctors modest amounts had dropped off precipitously, while lengthier and higher-paid visits were rising dramatically. The trends ran counter to much of the medical research; the differences were costing taxpayers billions of dollars. 

Under Donald’s direction, former Center data analyst Elizabeth Lucas then embarked on a six-month journey through millions of Medicare records to determine the extent of the billing anomalies and  quantify the cost to taxpayers. The database was daunting indeed, consisting of scores of tables and thousands of columns, totaling more than 700 million claims.

As the details of the data dive began rolling in during the latter months of 2011, Schulte and reporter Joe Eaton — also a veteran of the health care beat — dove into the “nuts and bolts” reporting, interviewing health care policy and health care fraud experts, while simultaneously combing through policy papers, Medicare audits, investigative reports and litigation case files.

Data analyst Lucas departed in April for a position at Investigative Reporters and Editors, but the Center then received pro-bono help from Palantir Technologies, a Silicon Valley software company specializing in integrating, visualizing and analyzing information.  Accommodating Palantir’s powerful servers required modification to the Center’s cooling facilities. Once those adjustments were completed, Palantir analysts Elizabeth Caudill, Daniel Tse and Lekan Wang — working at the Center and in Palo Alto — coordinated with Schulte, Eaton and Donald to marry further data analysis with more traditional reporting. Geographical analysis using the Palantir Gotham platform revealed the nationwide patterns of higher billing. Schulte then sketched the outlines of a three-part series, and the writing of the “Cracking the Codes” pieces began in the spring. Data editor Donald completed the data analysis in August.     

The Team:

Lead reporters: Fred Schulte and Joe Eaton

Fred Schulte, who joined the Center in 2011, has been exposing questionable health care practices for decades. Schulte, a four-time Pulitzer prize finalist, spent much of his career at the Baltimore Sun  and the South Florida Sun-Sentinel. He is the recipient of the George Polk Award, two Investigative Reporters and Editors awards, three Gerald Loeb awards for business writing and two Worth Bingham Prizes for investigative reporting .

Joe Eaton joined the Center in 2008. He previously served as a staff writer at the Washington City Paper and a reporter at The Roanoke Times.

Data Editor: David Donald

Data Analysis: Elizabeth Lucas, Elizabeth Caudill, Dan Tse, Lekan Wang

Web: Christine Montgomery, Sarah Whitmire

Graphics: Timothy Meko, Ajani Winston

Fact-checking: Peter Newbatt Smith

Project Editor: Gordon Witkin

Funding: “Cracking the Codes” pieces are generously supported by the Rita Allen Foundation, along with the Center for Public Integrity’s general supporters, including the Park Foundation, the John D. and Catherine T. MacArthur Foundation, and the Wyncote Foundation.   

For this series, the Center for Public Integrity and Palantir Technologies analyzed Medicare claims data obtained from the Centers for Medicare and Medicaid Services (CMS).

For privacy purposes and other reasons, the Center was limited to a 5 percent sample of national Medicare Part B data that contain claims for medical procedures, such as doctor office visits and emergency room procedures, and used mainly by researchers and consultants. Over and above the limitations of sampling, the data have only the quarter in which a procedure was performed, not actual dates. And a permanent federal injunction against the Department of Health and Human Services prevents data users from naming individual doctors who received payment for the claims. Some physicians subsequently contacted by the Center agreed to discuss their billing practices.

For the upcoding analysis, the Center and Palantir used a subset of the data submitted by physicians, hospitals and clinics from 1999 to 2008, the last year available at the time the data were acquired. The year 2002 was not included in the data, and any results for that year are imputed based on averaging 2001 and 2003 data. In addition, the Center and Palantir used CMS formulas for facility fees and co-payments, as CMS publishes formulas and modifier values to determine reimbursement amounts. Finally, Medicare Utilization reports published by CMS were used to look at specific billing codes for 2009 and 2010.

To calculate the possible taxpayer costs to upcoding, the Center and Palantir analyzed 14 sets of Current Procedure Terminology Evaluation and Management (E and M) codes published by the American Medical Association and used by most providers when filing their claims. Within each set are three to five billing codes requiring varying levels of Medicare reimbursement, based on the complexity of the treatment and the time spent by the doctor. We focused on a set of 84 million claims from office visits for established patients and five million emergency department visits in which  E and M codes were billed, as well as 12 other E and M categories. Denied claims were excluded from the analysis.

From those data subsets, we calculated costs from 2001 through 2008 for each code and compared trends within each of the 14 E and M groups. Data from 2009 and 2010 for some E and M code groups were added from the utilization reports. Using 2001 as a baseline, a percentage for each code from the total billing in each group was calculated, giving a decade-long trend line for a code in comparison with the other codes in its group. Then the 2001 ratio was applied to each subsequent year and dollar amounts adjusted for inflation. This allowed for comparisons of the actual trends to hypothetical trends if 2001 ratios had remained constant. The difference between the actual inflation-adjusted dollar amounts and the 2001-based projected dollar amounts were summed.

To look at trends in age among Medicare patients, the age at the time of a claim was averaged over geography, hospital or E and M code as needed. The CMS data only provided age ranges — under 65, 65-69, 70-74, 75-79, 80-84, and over 85 — in order to protect patient privacy. The under-65 age group typically represents exceptionally sick individuals with end-stage renal disease and was excluded from the analysis; the median values of the remaining age buckets (67, 72, 77, 82, and 87 for those over 85) were used to calculate the average age.

A geographical analysis revealed the nationwide trend of higher E and M billing. Claims were grouped by county and state, according to the beneficiary’s residence and visualized with heat maps to show geospatial and temporal trends of billing codes. A heat scale was applied with light red indicating a low percentage and a dark red indicating a high percentage of claims billed at the highest two codes for office visits emergency department visits.

In addition to the nationwide trends, hospitals, physicians, and counties with especially high rates of billing for the most expensive codes were examined in detail. E and M claims were aggregated by hospital, physician, or county, excluding those buckets that fell below a threshold for the minimum number of claims per year (50 claims per year for physicians, 100 for counties, and 100 for hospitals). Physicians who billed 50 percent, 75 percent, 90 percent, or 100 percent of claims at the highest two codes for a given year were analyzed for patterns of geography and specialty. Billing information was integrated with hospital affiliation, ownership, and electronic health-record use information to analyze patterns of billing within group practices and hospital chains.

Results from the 5 percent sample were multiplied by 20 to give a national scope to analyzed trends, an accepted survey research technique. However, even with a sample this large, it is impossible to account for all types of errors in the data. This means all calculations are estimates and rounded and must be considered imprecise. The Center and Palantir used accepted rounding practices. For analysis about specific doctors and some of their coding practices — not billing totals — sums were not multiplied by 20 and reported only as in the sample. When faced with a potential range of costs, we chose the smallest amount to keep estimates conservative. And dollar amounts were adjusted for inflation to prevent over-estimation so that the rising costs were indexed to 2001, the base year in the analysis.

There simply weren’t enough hours in the day to justify the fees Dr. Angel S. Martin collected from Medicare.

On fifty-three separate days, the Newton, Iowa, general surgeon billed the government health plan for the elderly and other insurers for medical services that would have taken him more than 24 hours to complete, according to federal prosecutors.

The hours made the case a slam dunk for prosecutors. But they weren’t Martin’s only problem. Many patients recalled the briefest of visits with the doctor, even though Martin routinely billed Medicare for long, complicated treatments.

Every year, Medicare pays doctors more than $30 billion for treating patients. For office visits, doctors must choose one of five escalating billing scales — called Evaluation and Management codes — that most closely reflect the complexity of the treatment and the time it takes. The fees range from about $20 to about $140.

Medical groups argue that most doctors take pains to bill accurately. If anything, doctors tend to pick codes that pay them less than they deserve out of concern that they might otherwise get audited and face financial penalties, these groups say.

But cases such as Martin’s reveal what can happen when doctors are tempted to game Medicare by “upcoding” — billing for more extensive care than actually delivered. Raising the code by a single level on two patients a day can increase a doctor’s income by more than $15,000 over the course of a year and is not likely to raise suspicions, experts said.

Upcoding “is a big problem,” said Charlene Frizzera, a consultant who spent three decades at the federal Centers for Medicare and Medicaid Services and served as its acting administrator in the early months of the Obama administration.

Indeed. A jury convicted Martin on 31 counts of health care fraud for manipulating the Medicare pay scales.

Martin, 64, spent six months in prison and was released in June. The doctor, who has surrendered his medical license, could not be reached for comment.

The Center for Public Integrity has documented widespread Medicare billing errors and abuses by doctors and hospitals that have cost taxpayers billions of dollars over the past decade. For instance, the investigation unmasked more than 7,500 doctors who were billing the top two highest codes for three out of four office visits in 2008. That’s a sharp rise from the start of the decade and significantly above the norms. Federal officials and fraud experts said the abnormally high billing patterns uncovered by the Center strongly suggest overcharges and possible upcoding.

“This has been one of the most common and garden variety fraud violations for years,” said William Mahon, a Virginia health care fraud expert. “This is the first time that anyone has quantified it.”

Yet unlike Martin, many doctors accused of inflating their bills don’t wind up in prison, according to a review of court filings.

Prosecutors argue that proving criminal fraud is difficult given the complexity and subjective nature of the codes — and the judgment calls doctors must routinely make in picking codes, or in hiring someone to do it for them.

The government often must hire coding experts who comb through reams of patient files to confirm the overbilling. And these experts can often disagree over which code to apply, potentially weakening a fraud prosecution.

As a result, authorities typically settle these cases — civil and criminal alike — with deals that keep the doctor out of jail and still entitled to treat Medicare patients. Some doctors agree to pay back suspected ill-gotten gains without admitting any wrongdoing or facing other serious consequences.

Cases such as Martin’s stand out because his alleged billing pattern appeared to be so extreme as to defy reasonable explanation.

At the doctor’s trial in late 2010, more than two dozen patients testified they had spent much less time at the doctor’s office than was reflected in their bills. Most recalled a “very short encounter” with the doctor, even though Martin had consistently billed for codes that reflected time-consuming and complex treatments, according to court filings.

Martin’s defense team argued that he had a “good faith belief that he was in fact applying the correct code,” according to court records.

Several other doctors accused of “upcoding” in criminal cases managed to avoid prison, according to court filings reviewed by the Center for Public Integrity.

Orthopedic surgeon Ezzat M. Soliman, for instance, almost always billed Medicare the maximum amount for patients treated at his clinic near Buffalo, N.Y., “without any regard to the level of service he actually provided,” prosecutors alleged.

Without admitting wrongdoing, Soliman agreed in December 2009 to repay the government $72,193.25 and complete a pretrial diversion program.

That ended the criminal case. He went on to practice at the Department of Veterans Affairs hospital in West Palm Beach, Fla., and retired last year, according to the hospital. He could not be reached for comment.

In some instances, highly-trained medical specialists may believe that because they treat people with serious illness any visit to the office justifies the highest fees.

“Specialists have a greater risk of over-coding because of the assumption that what they do is more complex,” said Lester Perling, a Florida lawyer who has represented doctors in payment disputes. “That couldn’t be further from the truth.”

Perling said that these risks may multiply as more doctors rely on electronic medical records and billing software to help them assign a billing code.

“Any practitioner that relies on software without a human verification is doing so at their own risk because I don’t think it’s that reliable yet,” Perling said.

Officials at CMS, the federal agency that oversees Medicare, said that the agency can take a number of steps short of prosecution, such as suspending payments to doctors it believes are ripping off the system. The agency also said it routinely refers cases of alleged fraud to law enforcement, but declined to give specifics.

Given the complexities of these cases, it’s no secret that prosecutors favor cases with a pile of highly incriminating evidence.

Jennifer Trussell, who directs investigations for the Department of Health and Human Services Office of Inspector General, discussed such a case at a Medicare Fraud Summit in Philadelphia in June 2011.

She told the audience (starting at 1:34) of discovering a psychiatrist who was billing for 12 hours of psychotherapy for 365 days a year. The prosecutor wouldn’t take the case until she could document the doctor billing for more than 24 hours in a single day. She did, and the case went to trial.

In another case, prosecutors allege that Arizona pain doctor Angelo Chirban overbilled for years before he came under scrutiny.

Authorities started investigating him in May 2008 when police found a suicide note near the body of a man who had worked for Chirban as a nurse practitioner.

In his suicide note, the man accused the doctor of running a dangerous pill mill. Chirban, he alleged, only saw a few patients a week, but billed as if he had seen hundreds of them, according to a search warrant application.

As the investigation proceeded, drug enforcement agents learned that ten of Chirban’s patients had died from overdoses between 2007 and 2009, the application stated. The doctor has not been charged in connection with any of these deaths.

However, Arizona health officials revoked his medical license last December, alleging “unprofessional conduct” in the care of a woman who fatally overdosed on drugs.

A federal grand jury indicted Chirban in December 2011 on 130 counts of submitting “false and fraudulent” bills to insurers, illegal prescribing of narcotics and money laundering. His case is set for trial in Phoenix in April of next year.

The indictment alleges that Chirban billed Medicare and Medicaid, the government health plan for the poor, for tens of thousands of patient visits, almost always using the two most lucrative billing codes.

The doctor billed more than 57,000 claims to Medicaid alone between September 2006 and April 2010. Prosecutors allege that most patients never saw the doctor.

One Medicare patient who said he had visited the clinic once a month for three years was unable to identify Chirban in a photo lineup. The man said he had always been treated by a female, even though Chirban had been paid more than $2,300 for the patient’s care from January 2007 to September 2009, according to the search warrant application.

Chirban’s lawyer, Ashley D. Adams of Scottsdale, said the doctor “was not involved in the coding aspect of the practice.”

Adams said that pain management “is a very difficult specialty area with very difficult clients,” and that the doctor “has helped many addicted patients get off of drugs, and has taken good care of countless others.”

She said Chirban “hopes to retire and move on with his life,” adding, “We are in the process of discussing resolution with the government."

U.S. counties in which doctors billed the highest percentage* of the two most expensive Medicare codes for established patients in 2008.

1. Santa Rosa County, Fla. (60%)
2. Escambia County, Fla. (57%)
3. Merrimack County, N.H. (56%)
4. Strafford County, N.H. (56%)
5. Washington County, Okla. (56%)
6. Colbert County, Ala. (55%)
7. Baldwin County, Ala. (55%)
8. Cumberland County, N.C. (55%)
9. Shelby County, Ala. (54%)
10. Whatcom County, Wash. (54%)
11. Limestone County, Ala. (53%)
12. Chittenden County, Vt. (53%)
13. Warren County, Ohio (52%)
14. Hunterdon County, N.J.  (51%)
15. York County, Maine (51%)
16. Clay County, Fla. (51%)
17. Arapahoe County, Colo. (50%)
18. Imperial County, Calif. (50%)
19. Adams County, Colo. (50%)
20. Duval County, Fla. (50%)

*For counties with at least 100 claims in the sample citing either or both of the top two billing codes

• Thousands of medical professionals have billed Medicare at progressively higher rates over a decade’s time, costing taxpayers at least $11 billion in inflated charges.
• A significant portion of the added charges is likely due to “upcoding” — charging for more extensive and costly services than actually delivered.
• Upcoding is facilitated by abuse of Medicare billing codes that reflect the range of care delivered and the time it takes. Many doctors have steadily billed the higher-level — and more lucrative — codes, while spurning those that pay less.
• Some of the most dramatic surges in higher-cost billing codes have occurred in hospital emergency rooms. Hospitals are permitted to set their own rules for billing outpatient charges and these payments are seldom audited by Medicare.
• The rise in costly coding and billing errors appears to be getting worse amid lax government oversight and the proliferation of electronic medical records systems, which critics say can facilitate abuse.

About this project | Methodology

MERIDIAN, Miss. — Lionel Townsend will turn 14 in September. And a few months after that he will be able to return to school, ending a year of exile.

Lionel admits he got into fights multiple times at Magnolia Middle School. When he was charged with vandalizing a school bus security camera, he was booted from school. He fought again in a community day program. The county Youth Court eventually put him on probation and ordered him to stay at home with an ankle monitor.

Nevertheless, the U.S. Justice Department’s Civil Rights Division is alleging the juvenile justice system here is so faulty that it amounts to a “school-to-prison pipeline.”

“If you do wrong, you got to pay,” insisted Lionel’s mother, Ella Townsend, speaking in the living room of the home she shares with her mother, Lionel and four of the boy’s siblings. Lionel listens quietly, a skinny boy, who grins when attention is turned to him, or he’s teased about the sparkly blue earring studded in his ear. “But “that was harsh punishment,” she said, “I feel like they were sort of out of order.”

Townsend says her son’s ankle monitor was so sensitive it went off if he went in the back yard. The young man is rid of it now, but not before he gouged off the speaker, causing what Townsend said the court assessed as $1,500 in damage.

She worries if Lionel makes another mistake, he will end up in prison with adults, where he will learn little more than how to be a criminal.

The Justice Department says it has probable cause to believe the city of Meridian and Lauderdale County routinely and  repeatedly incarcerate children for school disciplinary infractions, as outlined in an Aug. 10 open letter that was issued at the conclusion of an eight-month investigation. The department’s letter is addressed to the city and county, the county's two Youth Court judges, as well as the state Division of Youth Services, but not the Meridian school system.

The letter said infractions such as defiance, disrespect, dress code violations or cursing led to a police ride to the county Youth Court. City police in closed-door interviews called themselves a “taxi service” from school to jail, the DOJ writes.

“MPD officers may subjectively believe that they are acting appropriately,” reads the letter, but the DOJ argues the police are wrong to automatically arrest children referred by the schools, instead of investigating and determining probable cause themselves. The police, DOJ charges,  do not assess “whether the alleged conduct qualifies as an arrestable offense.”

Once in custody, the Youth Court fails to give children speedy hearings, the DOJ says, by holding court only two days per week, thus on weekends and holidays pushing some children over a 48-hour threshold. Furthermore, “children and their guardians consistently report that they are not always appointed an attorney for detention or adjuration hearings,” reads the letter, adding an allegation that the public defender in the court does not provide “meaningful or effective representation.”

In cases of probation, children are inappropriately signing probation contracts that they do not comprehend, says the DOJ, and there “is no evidence that Lauderdale County and DYS [Mississippi Division of Youth Services] ever provide constitutionally required probable cause hearings.”  DYS youth counselors — the DOJ calls them “probation officers” — in practice have “absolute discretion” to determine if there is a probation violation and what the consequence will be, according to allegations.

The federal agency also claims that African-American children are disproportionately suspended or expelled and that Meridian children who have disabilities are expelled or given long suspensions at a rate almost seven times higher than the state as a whole, though it does not quote detailed statistics.

The Justice Department said it sought Youth Court records to supplement site visits, and interviews with police, DYS staff and community members. They were denied access locally on privacy grounds. In a written comment, a Mississippi attorney general spokesperson explained, “We have said that the Administrative Office of the Courts (AOC) will cooperate in any lawful manner with the DOJ investigation.  However, state law, including Mississippi Code Section 43-21-261, prohibits the AOC from providing to DOJ copies of confidential youth court records without a court order.”

The city of Meridian and Lauderdale County reject the charges, accusing the federal agency of basing their allegations on only “a few” cases and “unsubstantiated” claims, in a letter they wrote to the DOJ, which was released in response to media queries to the police and the Youth Court.

The findings of the DOJ are “one-sided and reflect, in our opinion, the inexperience and unprofessionalism of your investigating representatives as to basic criminal procedure,” write Meridian City Attorney Ronnie Walton and attorney for Lauderdale County, J. Richard Barry. 

Youth Court judges Veldore Young and Frank Coleman “categorically deny any systematic violation of any child’s constitutional rights and have faithfully followed the laws of this State and will continue to protect the confidentiality of our children’s youth court records,” reads the attorneys’ Aug. 23 response.

They suggest the DOJ’s head civil rights lawyer is already biased against Meridian, accusing Assistant U.S. Attorney General Thomas Perez of running to the media instead of talking with judges; and of publicly criticizing Meridian schools.

They say the DOJ letter contains “outright untruths where it is stated that those judges would not cooperate” with the investigation by turning over juvenile court records. The attorneys say the judges do not have the legal right to hand over those papers.

After numerous requests for comment, a spokesperson from the Department of Justice wrote in an email that, “protecting the constitutional rights of youth is a top priority of the Justice Department. The department’s Civil Rights Division is tasked with ensuring and acting to protect the civil rights of children. If we find that a school district or juvenile justice system is depriving youth of their rights, we will not hesitate to act.

New school year

Last year, Alvin Taylor was hired as Meridian school superintendent after several rapid changes of leadership. Much of the top administration turned over at the same time, Taylor said, and his new team brought in new policies and procedures.

“I can’t speak on what happened before June 1, 2011,” said Taylor, referring to the day his work started.

Taylor’s 2011-2012 school year student handbooks lay out dozens of rule infractions and the punishments. Police only get involved, Taylor said, for three infractions named by Mississippi state law: weapons, drugs or serious violent acts.A schoolyard fight is not considered a serious violent act, Taylor said, but gang fights or assaulting a teacher for example, is.

When school staff determine that one of the three infractions requiring police action has occurred,  said Taylor, a call to police must first be approved by himself or the assistant superintendent of student services.

He said less than 1 percent of youth get arrested in a given year in his roughly 6,200-student system. There are also around 60 or so expulsions every year, he said. Taylor said that expulsion rate is lower than average, according to his research.

As for the DOJ allegations that children who have disabilities — including learning disabilities — are disproportionally ousted from school, Taylor said, “all those accusations stem from 2009. And I can’t speak on what they did back then. I can tell you that’s not the situation now.”

In 2009, Meridian High School enrolled 1,625 students, according to the latest figures available in a federal Department of Education database. The same database says that among 205 Meridian High School students who have disabilities, there were 145 instances of children getting more than one out-of-school suspension. The student population overall was 86.8 percent African-American, and black students represented 96 percent of all out-of-school suspensions and 100 percent of the 10 reported expulsions.

Long-smoldering fire

The DOJ received the very first complaints about Meridian in 2005 from NAACP activist Randle Jennings. He was surprised when the city cut funding to a baseball program for at-risk youth he ran. He started looking at schools and asked why more than 90 percent of the teachers were white, given that there were five historically black colleges or universities within one hundred miles, and more than 90 percent of Meridian's students were black?

“We realized something was going on,” said Jennings, now the county NAACP education chair.  “We smelled smoke,” but did not have an explanation for it, he said. He sent the data about teacher and student demographics to the DOJ, and admits he did not know what they might find.

Five years later, in May 2010, the Justice Department sent a letter to attorneys for Lauderdale County’s and Meridian, asking for records regarding school discipline and police involvement in schools. In the following months, DOJ officials, also participated in at least two public meetings where they asked area residents to come lodge their complaints about school discipline and the law.

 Jennings is sure a pipeline runs through Meridian. “We have a concern for our children, especially the next generation because we have seen two generations be destroyed … [we] systematically need a plan so our children aren’t shoved in that pipeline.”

Lauderdale County juvenile inmates used to land in a detention center on the edge of town. It’s closed now,  and since the beginning of 2012, minors have been bused to a center some 70 miles away in Rankin County. Lauderdale’s center had been the subject of a federal lawsuit brought by the Southern Poverty Law Center over conditions of incarceration.

Getting rid of the problem

The Love City Fellowship, a church in Meridian, hosted a public meeting on school discipline and the law in August 2010. The church, DOJ and the Southern Poverty Law Center invited parents to come to the afternoon meeting to talk about suspensions and arrests from city schools. Some church members are still collecting stories from friends and neighbors and urging parents to talk to Justice officials.

“Some of the rules that are in place do not put the child in mind first,” said Senior Pastor Lamorris Richardson. “Instead of having to deal with the problem and find a solution, it’s more ‘get rid of the problem.’ ”

The city school system is involved in a separately, related dispute with DOJ.  The school system is a party in a 1960s-era federal desegregation order. The DOJ reopened that case in 2010 in an effort to investigate the discipline complaints and other complaints alleging that the district was unfairly terminating African-American educators.

In that case, besides asking for data, the DOJ asked for access to visit schools and interview staff in 2010. The school district initially rejected those DOJ requests, and the DOJ responded by asking the federal court to order access and require that documents be released. According to court filings, the school argued the demand to visit and interview staff and law enforcement officers is too broad and amounts to “fishing” for information, as does a DOJ request to inspect databases and documents on site at schools. That battle over visits, interviews and inspections is ongoing in court and forms the background to the DOJ’s August letter and threat to sue the city and county.

Pastor Richardson said his city needs a school board picked by the community. The board is now  named by the mayor and confirmed by city council, though school district spokeswoman Elizabeth McDonald says , the board members each represent different areas of the city.. The board is currently made up of three whites and two blacks.

“This city has not moved in how many decades? … Five decades?” asked pastor Betty Alford, also of Love City Fellowship, comparing treatment of African-Americans now to the 1960s.

Richardson added, “No community, in 2012, should be still dealing with practices that [apply only] to a certain group, a certain community where kids rights are not being protected in school. We should be way past this kind of bias.”

But Meridian children like Lionel are out of Superintendent Taylor’s hands. Once a child is expelled, the child is not a “student” and the school board is not obligated to instruct him.

That could be changing. The schools, in partnership with the city and local groups, are inaugurating  a pilot program for expelled students that provides character and academic education, as well as technical options. It will have 18 slots and is set to start this month. That will be the only full-time educational opportunity for students expelled from school.

As for Lionel, Ella is teaching him at home until he goes back to school, though she said it is not enough. “I can do stuff from what I know, but I’m not a trained teacher,” she said. “He needs to eat his material, he needs to study and learn.” 

SANDAMALGAMA, Sri Lanka — In this tiny Sri Lankan village, rice farmer Wimal Rajaratna sits cross-legged on a wooden bed, peering out toward lush palm trees that surround his home. Listless and weak, the 46-year old father of two anxiously awaits word on whether his body can accept a kidney donation that offers his only chance of survival.

In Uddanam, India, a reed-thin farmer named Laxmi Narayna prepares for the grueling two-day journey he takes twice every week. For most of his 46 years, his job involved shimmying up palm trees to harvest coconuts at the top. He now spends most of his time negotiating the more than 100-mile bus trips he takes to receive the dialysis treatments that keep him alive.

Ten thousand miles away, in the Nicaraguan community of La Isla, Maudiel Martinez dreads returning to the rolling sugarcane fields where he spent most of his teenage years at work with a machete. Blood tests by the sugar company that employed him found that his kidneys were seriously damaged — and exertion beneath the tropical sun could tip the 20-year-old’s health into a lethal spiral.

In three countries on opposite ends of the world, these men face the same deadly mystery: their kidneys are failing, and no one knows why.

A mysterious form of chronic kidney disease — CKD — is afflicting thousands of people in rural, agricultural communities in Sri Lanka, India and Central America. The struggle to identify its causes is baffling researchers across multiple continents and posing a lethal puzzle worthy of Sherlock Holmes.

The three epidemics have crucial threads in common. The victims are relatively young and mostly farm workers, and few suffer from diabetes and high blood pressure, the usual risk factors for renal disease. They experience a rare form of kidney damage, known as tubulo-interstitial disease, consistent with severe dehydration and toxic poisoning.

Other common links offer clues to a possible cause. The epidemics affect sharply defined geographic areas that are stunningly fertile and swelteringly hot. The victims mostly perform heavy manual labor, have little formal education and lack easy access to medical care. Pesticides are used heavily, and communities drink local groundwater. In each case, the disease began surging in the 1990s.

Despite a decade of research in each affected region — and a potentially noteworthy discovery this year in Sri Lanka — scientists have yet to prove a chemical at fault or a means of exposure. Researchers are convinced that if they could identify the culprit, the outbreaks could be stopped and the death toll reversed.

“I absolutely think that it’s preventable,” said Daniel Brooks, an epidemiologist at Boston University who is leading a study in Nicaragua of the new form of CKD. “I’m very convinced that what is happening to individuals is from some sort of exposure.”

In a sense, researchers are waging a race against three parallel epidemics occurring across multiple continents. Yet the search for clues was slow to begin, with governments including the United States moving with little urgency despite warnings of the disease’s toll. And separate groups of researchers — each chasing clues to kidney epidemics across the globe — have not fully explored whether they are linked together.

The new form of CKD is not officially recognized in the Americas even though kidney disease has killed more people in El Salvador and Nicaragua than diabetes, HIV/AIDS and leukemia combined in the last five years on record, the Center for Public Integrity found.

In a disease not yet formally recognized, researchers cannot say how many have fallen ill. But the death toll reaches tens of thousands.

More than 16,000 men died of kidney failure in Central America from 2005 to 2009, with annual deaths increasing more than threefold since 1990, according to an analysis of World Health Organization data. In Sri Lanka, the WHO says at least 8,000 people suffer from chronic kidney disease of unknown cause, though other sources put the number more than double that. In the Indian state of Andhra Pradesh, more than 1,500 have been treated for the ailment since 2007.

“There’s a need to connect all the dots between these different outbreaks,” said Dr. Ajay Singh, a nephrologist at Harvard Medical School who is leading a study of the epidemic in India. “Our premise should be to first look for common causes.”

The response has been fragmented in part because wealthy countries and international institutions have been reluctant to recognize the problem. Most CKD is caused by diabetes, obesity or hypertension, all fast-growing problems in the developing world. Health officials have sometimes blamed the usual suspects of unhealthy diet and lifestyles for any increase in CKD in poor countries — a diagnosis that neglects the possibility of environmental exposure.

“Nephrologists and public health professionals from wealthy countries are mostly either unfamiliar with the problem or skeptical whether it even exists,” said Dr. Catharina Wesseling, the regional director for the Program on Work and Health (SALTRA) in Central America, which pioneered the initial studies of the region’s unsolved outbreak. “The response from the North and from international agencies must be much stronger.”

In the meantime, thousands of villagers are dying each year from an ailment triggering as many questions as answers. Are tainted agrochemicals to blame? Dehydration in the fields, aggravated by dangerous working conditions? Or could multiple culprits exist, with different causes in each region?

From Sri Lanka to India to Central America, all the victims know is that something in their lush, hauntingly beautiful surroundings is wasting away their lives. In one patch of rural Nicaragua, so many men have died the community is called “The Island of the Widows.” In the Indian region of Uddanam, a reverse trend has taken hold: Couples decline to marry at all.

In Sri Lanka, a Suspect Emerges

Wimal Rajaratna has worked in the rice paddies since he was 20. He enjoyed good health until December 2011, when he began suffering an alarming array of pains. His head pounded, his knees ached at the joints, and his appetite deserted him.

He traveled from his home in Sandamalgama — a village of 27 families — to the doctor in the nearby town of Horowpathana. Tests revealed that his levels of creatinine, a chemical in the blood that indicates kidney function, were an astronomical 9.45 mg/dL — more than seven times higher than normal. He had chronic kidney disease, advanced into its late stages.

Rajaratna’s illness is part of an epidemic sweeping northern Sri Lanka. The disease affects three provinces in the north central region of the country, and estimates of the number of patients range from 8,000 by the World Health Organization to nearly 19,000 in a tally based on hospital records compiled by independent researchers. Prevalence in the affected region is 15 percent, according to unpublished results from a three-year study by the Sri Lankan health ministry and WHO.

The government has even come up with a name for it: CKDu, chronic kidney disease of unknown etiology.

Since 2009, the health ministry and WHO have embarked on the world’s largest and most comprehensive study of CKDu. They have sampled patients’ blood and urine, tested the soil, water and food, and surveyed and mapped the population of the affected region. “We need to do full-blown research on this and then find out the causative agents,” said Dr. Palitha Mahipala, additional secretary of health for Sri Lanka and the leader of the official study.

Still, despite growing public pressure and repeated promises of definitive answers just months away from release, the official program maintained complete silence about its findings for three years.

Finally, in June 2012, the health ministry and WHO publicly identified chemicals they said were an essential cause of the disease. The culprits: The heavy metals cadmium and arsenic, through low-level exposure likely occurring through the food chain. “It’s not a mystery,” said Dr. Shanthi Mendis, the Coordinator and Senior Adviser of the WHO non-communicable disease program and the lead adviser of its efforts in Sri Lanka.

Cadmium and arsenic are both toxins with an array of human health effects that include kidney damage. Cadmium is often present in phosphate-based fertilizers, while arsenic has been detected in several Sri Lankan pesticides and also occurs naturally in some parts of South Asia.

The official findings in Sri Lanka represent a potential breakthrough, with implications in Central America and India. But the scientific program has not yet released any of its data behind its findings — leaving questions unanswered and lingering doubts about its conclusions.

In sufficient quantities, cadmium and arsenic cause the same rare type of kidney damage found in the disease’s victims. However, researchers Mahipala and Mendis said most of their patients’ tests and environmental samples showed these chemicals at levels below the exposure limits set by United Nations agencies.

“It has not exceeded the limits,” Mahipala said. “But now we are just thinking when somebody is exposed to these heavy metals over a long period of time,” damage to the kidney tissue could result.

Mahipala acknowledged that “we can’t really come to a conclusion” about the effects of specific exposures that remain within international limits. Neither he nor Mendis offered evidence to explain how these metals had entered the food chain or the bodies of victims at levels sufficient to cause CKD.

The WHO says it will release official study results in late October that will include hard data. The program is also embarking on research of dietary patterns in the affected region to better understand exposure levels.

Chemicals in Question: Big Business in Sri Lanka

Some evidence suggests that cadmium and arsenic have been disseminated through fertilizers and pesticides, whose import is financed by the Sri Lankan government. So, any definitive link between agrochemicals and public health failings would carry significant consequences.

Sri Lanka’s agrochemical industry disputes the notion that its products are at fault. “We can guarantee that pesticides produced by many multinationals and international companies, they follow all the WHO and FAO [Food and Agriculture Organization] guidelines,” said Rohitha Nanayakkara, secretary of Sri Lanka’s National Agribusiness Council. “We believe that those are not in harmful levels.”

In June 2011, Sri Lanka’s Registrar of Pesticides briefly banned several leading pesticides such as glyphosate and carbofuran after tests found they were contaminated with small amounts of arsenic. A few months later, it reversed the ban after concluding that the arsenic levels were too low to pose a serious threat.

The ban was overturned even as the WHO’s internal meeting notes in June 2011 called for stronger regulation of “nephrotoxic agrochemicals” — and warned that any delay would cause “further accumulation of toxic agents in the environment and result in cumulative damage to the health of the people living in these areas.”

As the fuller details of research remain undisclosed, Sri Lanka’s well-regarded health service struggles to meet the massive need in the affected area. Local doctors say that as few as one of every five patients that need dialysis are approved to receive it. Public hospitals offer kidney transplants if patients can find their own donors and pay a substantial portion of the costs of necessary medications.

In Rajaratna’s case, a friend of his family has offered to donate a kidney. As Rajaratna awaits the result of blood tests to determine if he is a match, he travels more than 60 miles twice a week to get dialysis, sleeping on the concrete floor of the hospital when his treatment goes too late for him to take the last bus home. He has no idea how he became so sick.

“That’s what I need to know,” he said. “What happened to me?”

In India, the Trouble in Uddanam

Laxmi Narayna’s village, Gonaputtuga, is part of a verdant rural belt along India’s eastern coast called Uddanam. Spanning less than 100 miles, this stretch of villages near the northern border of the Andhra Pradesh state has been suffering for two decades from a mysterious strain of CKD.

Healthy throughout his 46 years, Narayna began experiencing a painful series of ailments in late 2011. His body began to swell, he had difficulty urinating and he found blood in his stool. He visited a doctor in the closest major city, Visakhapatnam, where he learned he had CKD.

Unable to work after decades spent harvesting coconuts from the top of palm trees, Narayna spends his days resting and traveling back and forth from dialysis in Visakhapatnam. “Now, I do nothing,” he said. “I take medicines and be.”

India’s wave of CKD is smaller than the other outbreaks — but highly concentrated. Unpublished results from a study by Harvard Medical School found that 37% of the population in the hardest hit village, Akkupalli, had the disease. From 2007 to 2012, 1,520 patients from Uddanam received care for CKD from a state health insurance program for the poor. But this number significantly understates the burden of a disease that is latent until it reaches its advanced, deadly stages.

Unlike Sri Lanka and Central America, the illness affects men and women roughly equally, according to separate findings by researchers from Harvard and Stony Brook University. The gender equality and geographic concentration of the illness have focused concentration on potential contamination, particularly in the drinking water.

“This seemed to be an exposure to the community as a whole,” said Singh, of Harvard. Dr. Ravi Raju Tatapudi, a leading nephrologist in Andhra Pradesh and the other study director, said heavy metals and pesticides running off from the fields into the groundwater were the group’s primary suspects.

Despite years of attention to the disease, not one study has been published about Uddanam CKD. The Harvard group has conducted extensive tests of the groundwater and soil in the area, but the results have been delayed for months at a laboratory in Hyderabad.

For Laxmi Narayna, time is running out. At the Seven Hills Hospital, he smiles bravely and says he feels no pain, but his thin frame is dwarfed by the wide cot he rests on and the hulking hemodialysis machine attached by tubes to his arm.

“On dialysis people don’t do well,” said Narayna’s doctor, Ravi Shankar Machiraju. “Holding on for a year would be just about it.”

In Central America, the Science of Sweat

Maudiel Martinez started working in the cane fields at 14. His father had died of CKD two years before, and his family was struggling. After three years of work at the Ingenio San Antonio plantation, he was diagnosed with CKD at 17.

He continued to work — providing false identification to contractors who looked past the fact that his permit carried a woman’s name.

The epidemic in Central America spans six countries along a nearly 700-mile stretch of the Pacific coast. Across the region, kidney failure has killed more than 2,800 men each year from 2005 to 2009, according to an analysis of data from the WHO. In El Salvador, the kidney disease has become the second leading cause of death among adult men.

Groups of sick workers picket the gates of powerful sugar companies, demanding that the ailment be compensated as an occupational illness.

The Ingenio San Antonio sugar plantation is the epicenter of the fight. There, workers have been protesting for nearly a decade, alleging that the company’s pesticides and labor practices caused the disease. After the World Bank provided the Ingenio San Antonio with a $55 million loan in 2006, workers complained to the Bank’s ombudsman — leading to an agreement that the company fund the ongoing Boston University study.

The BU team has pinpointed evidence suggesting that heat stress and dehydration are key contributing factors. Workers who performed strenuous labor in the sun, such as cane cutters, suffered significantly more kidney damage over the course of a single harvest season than those with less arduous job responsibilities, the researchers found.

However, recent tests of adolescents found that many had markers of kidney damage without ever having entered the fields — suggesting a pre-existing exposure as well.

Brooks, the leader of the Boston University team, hypothesizes that a toxic exposure may render the population vulnerable but is not enough to trigger the disease by itself. “It doesn’t actually go to chronic kidney disease until you get what I would call the second hit, which would be the strenuous labor and the dehydration that may come from this difficult work,” he said.

Researchers in El Salvador have also uncovered intriguing clues. A study published in April found that low-lying, coastal communities that grew sugarcane and cotton were both swamped by the disease, while a sugarcane community at a higher altitude was barely affected — illustrating the vital role of geography. In Costa Rica, the government has launched a study that will seek to officially determine whether the illness is an occupational disease.

Workers like Martinez continue to place themselves at risk to support their families. At 20 years old, he is recently married and his wife is expecting a baby. “I feel like every day I work I’m taking away a little part of my life,” Martinez said.

“We work there because the company is the only option we have.”

Missed Opportunities

As the economic and human costs mount, governments have begun to fund studies and treatment programs. El Salvador has launched an initiative called NefroLempa that targets chronic kidney disease, the state of Andhra Pradesh has created a health insurance system for the poor and built new dialysis facilities, and Sri Lanka has worked closely with the WHO on research.

But international institutions and wealthy nations have repeatedly failed to connect the dots, let alone invest on a scale some experts say is necessary.

At a 2011 health summit in Mexico City, the United States beat back a proposal by Central American nations that would have listed CKD as a top priority for the Americas and adopted an official consensus that the Central American epidemic had distinct causes from most CKD.

“The idea was that to keep the focus on the key big risk factors that we could control and the major causes of death: heart disease, cancer and diabetes,” said David McQueen, a U.S. delegate from the Centers for Disease Control and Prevention who has since retired from the agency. “And we felt, the position we were taking, that CKD was included.”

McQueen’s comments reflect the widely held view that any CKD in developing countries stems from diabetes and other diet-related risk factors rather than a new form of illness.

For its part, the WHO has not made any connections between the studies it is supporting in El Salvador and in Sri Lanka. In Central America, it has neither adopted a formal name for the disease nor considered whether it is related to the illness that it recognizes as “CKDu” in Sri Lanka.

The WHO has not kept a record of outbreaks similar to CKDu — there have also been comparable reports in Egypt — and believes that it is premature to extrapolate findings from Sri Lanka onto other regions.

CKD researchers are beginning to study each other’s work independently. Scientists from Boston University, the Central American NGO SALTRA, and Sri Lanka have shared notes, and many will convene at a SALTRA-organized conference in Costa Rica in November. “We definitely need to see this as a global epidemic, but we must not forget that there may be important local causes and drivers,” said Wesseling, the SALTRA director in Central America.

But so far, none of the scientists have systematically compared the epidemics or joined forces across regions to explore the broader phenomenon. The teams from Harvard and Boston University, based half an hour apart, have never met.

The medical mystery is so difficult to solve in part because the pieces do not fit together easily. It is possible that each epidemic has a different cause: pesticides in one place, hard labor in another and an unexamined risk factor such as genetics in the third.

Yet most on-the-ground researchers believe they are connected.

“We’re talking about these outbreaks that are happening among poor agrarian residents of these countries, mainly among men … and that do not seem to be explained by diabetes or hypertension or any of the typical risk factors,” said Boston University’s Brooks. “So those things lead me to really think there’s a good chance they are in fact connected.”

Our investigation of unexplained CKD among rural workers began as a story about a single plantation in Nicaragua. Then, it became several plantations in the region; next, nearly the entire Pacific Coast of Central America; and most recently, Sri Lanka and India as well.

CKD among rural workers may be a broad international epidemic — and we need your help to figure out how widely it is occurring.

If you have information about another outbreak of mystery CKD, please take a moment to fill out the short form below.

Mystery in the Fields, a three-part series, explores how a rare form of kidney disease is killing laborers and crippling communities in three different regions, from Central America to Sri Lanka to India. As death tolls mount, researchers remain puzzled, unable to definitively uncover the disease’s causes.

The series is an outgrowth of an earlier investigation, “Island of the Widows,” published last December in the Center for Public Integrity and its International Consortium of Investigative Journalists. In that piece, reporter Sasha Chavkin exposed how chronic kidney disease was so prevalent in some regions of Central America it left communities filled with widows and scientists searching for answers.

Building from that research, Chavkin discovered that the disease had also developed in clusters in India and Sri Lanka. Over several months this year, he and video journalist Anna Barry-Jester traveled to the countries to tell the story from the ground, and pressed governments and leaders of the medical community for answers.

Their report is also being published or aired in news outlets including PRI’s The World, the BBC, The Sunday Times of Sri Lanka and The Week in India.

Project staff

Reporter: Sasha Chavkin

Photographer/videographer: Anna Barry-Jester

Web team: Christine Montgomery, Paul Williams, Sarah Whitmire

Fact-checking: Peter Newbatt Smith

Project Editor: Ronnie Greene