It’s never been easy to qualify for Social Security disability benefits. Christopher Tincher knows this firsthand.

Tincher began his working life in a coal mine in Aflex, Kentucky, as a teenager in the 1980s. As mines across the region shuttered, he turned to scraping grills at a Hardee’s, then cleaning office buildings at night, then stocking shelves and changing tires at a Walmart in Arkansas. Later, he was hired by a nearby town’s wastewater department. Often, he had to wade into sewage to fix equipment and clean out feces, needles and tampons entering the treatment facility.

In 2017, some of that liquid got into his work boots, which didn’t fit properly and had caused blisters to form. It soaked into his flesh, infecting his right foot all the way to the bone. Doctors cut his leg off below the knee so the infection wouldn’t spread.

Tincher was now a manual laborer on one leg, but he was denied disability benefits by the Social Security Administration the following year. On average, 65% of applicants are rejected, though some successfully appeal.

In Tincher’s case, it was partly because he was 48, and the agency’s rules give priority to disabled workers in their 50s, who are officially deemed to be nearing advanced age and therefore less able to switch careers or develop new skills.

Tincher got a prosthetic leg and went back to work, this time for a medical supplies delivery company. He did this for seven years, frequently in pain, he said. His other leg was almost always in a cast, due to further infected blisters and diabetic nerve damage, and his eyesight was rapidly deteriorating.

This February, he applied for disability again. He was desperate; he was in a wheelchair, and he’d had to move in with his son’s family in Cabot, Arkansas, because he couldn’t pay the rent on his trailer. And there just weren’t other, less physically demanding jobs available locally for someone with his experience: “About the best job I could’ve got would’ve been a door greeter at Walmart, but I don’t think they have those anymore,” he said.

Tincher is now 55, and reaching that age marker helped him qualify, in June, for just over $1,500 a month in Social Security Disability Insurance benefits. A three-time Donald Trump voter, he was approved just in the nick of time.

That’s because the Trump administration is rewriting the disability eligibility rules, ostensibly to modernize the program, in ways that will make it even harder for aging blue-collar workers like Tincher to get benefits. Hundreds of thousands just like him would become ineligible for aid.

These changes would fall disproportionately on some of Trump’s most loyal supporters in red states. Most affected would be 50- to 60-year-olds without a high school or college education who have, for decades, toiled in physically grueling jobs, including coal mining, logging, and factory and construction work. The five states where the highest proportions of people rely on these benefits are West Virginia, Arkansas, Kentucky, Mississippi and Alabama. Unlike New York, California and a few others, these states do not have their own disability insurance programs for workers to turn to amid federal cuts.

“The Trump administration does not think that simply being 50 years old is a disability,” said a senior administration official who would speak only on condition of anonymity. In the 1970s, when the current rules were written, the official said, many more jobs involved manual labor, but in the internet age that isn’t true anymore. Workers in their 50s with physical injuries are thus receiving disability benefits “when they don’t need to be,” given that they could get a more sedentary job in the modern economy.

The administration has also justified cuts like these on fiscal grounds: The federal budget deficit is massive, the Social Security retirement system could become insolvent in less than a decade and savings need to be found.

But the disability program is paid for, via payroll taxes, by its own trust fund, separate from the one for the retirement program. So reductions in disability payments would not help the retirement system stay afloat. Indeed, cutting eligibility for disability could result in more disabled workers claiming retirement benefits early, actuarial experts note, which would only increase pressure on the retirement system. Meanwhile, the money in the disability fund, which is projected to remain solvent through at least the end of this century, would just sit there, unused.

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The Trump administration’s upcoming proposed regulation would make two hugely consequential changes to the Social Security Administration’s disability system, according to four SSA officials with knowledge of the plans. First, it would modernize the job listings that Social Security’s disability adjudicators and judges use to decide if there’s work available in the U.S. economy that a manual laborer could do despite physical impairments — like a low-skilled desk job at a computer or driving for Uber or DoorDash. Second, the new rule would almost entirely remove age as a criterion, in most instances making a 50-plus-year-old like Tincher no more eligible for assistance than a 20-something.

Under the current system, eligibility for benefits ticks up at ages 50, 55 and 60, as workers become more medically vulnerable and less adaptable. Disability adjudicators use a series of grids that consider an applicant’s age, work experience and education level to determine whether they may have the skills to do another, less strenuous job. (The adjudicators make a yes-or-no decision on eligibility; each person who qualifies then receives a set amount based on their lifetime earnings. Once the person starts receiving Social Security retirement benefits, they no longer receive disability payments.)

The regulation that would undo this framework is slated to be formally proposed by December, according to a federal bulletin, although that deadline could push into next year, multiple officials said. The draft, which is based in large part on a plan that the first Trump administration tried to enact in 2020 before running out of time, still needs to be reviewed and edited by the White House’s Office of Management and Budget. After that, it will undergo the standard process of allowing the public to submit comments and objections.

But in its current form, the regulation would slash at least 830,000 people’s eligibility for disability benefits, according to an initial estimate from the Urban Institute, an economic policy think tank. As many as 1.5 million could lose eligibility over the next decade, including the widows and children of workers. Disability attorneys and experts familiar with who most relies on the program contend that the numbers could be considerably higher.

Separately, the Trump administration is preparing a proposed regulation that would eliminate or sharply cut the Supplemental Security Income benefits of roughly 400,000 extremely poor and disabled people. This second regulation would reduce support for adults and children with severe disabilities who are living in low-income households, as well as elderly people living with their adult children on tight budgets.

Barton Mackey, a spokesperson for the Social Security Administration, confirmed in a series of emailed statements that the Trump administration is working on what he called “improvements to the disability adjudication process.” These changes would ensure that the disability system “remains current” and can be more efficiently administered, Mackey said, while also promoting “dignity in work.” (Mackey did not respond to a question about the change to the SSI program.)

Further “speculation on any proposed rule prior to it being published,” he said, “only serves to misguide public discourse and stoke fear in those who rely on disability benefits for economic stability.”

White House spokesperson Kush Desai, in response to detailed questions, said that “President Trump will always protect and defend Social Security for American citizens” and pointed to Trump’s recent remarks commemorating the 90th anniversary of Social Security.

Retirement benefits — the largest and most popular of Social Security’s programs — would not be cut under the new regulation. But union leaders and advocates for older Americans said that the likely changes to disability eligibility for aging workers would undermine the financial and retirement security of working-class people and their families. Those who are denied benefits in their 50s would be forced to draw down any savings they have, which could lead them to apply for Social Security’s retirement benefits at age 62 instead of 67. That, in turn, would diminish their and their spouses’ monthly benefit amount by up to 30% until the day they die. Losing eligibility for disability would also block these workers’ access to Medicare, which they’re currently eligible for at their age precisely because they’re disabled.

Disability benefits frequently save recipients from bankruptcy, foreclosure and homelessness, according to research by University of Chicago economists and others.

George Piemonte, a former president of the National Organization of Social Security Claimants’ Representatives, has spent 30 years working on disability cases across the South. He emphasized that that’s where these disability cuts would be most acutely felt. “They call it modernizing the program, but that’s political speak,” Piemonte said. “This is a matter of life and death. If these workers don’t get their benefits, some of them are not even going to live to retirement.”

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Social Security officials under both Republican and Democratic administrations have long agreed that the disability program needs to be modernized in some practical ways.

For example, disability adjudicators continue to use a Dictionary of Occupational Titles, created in the 1930s and last updated in 1991, to determine whether there are jobs that exist in “significant” numbers in the national economy that an applicant with declining “residual functional capacity” could still do. The DOT, as it is called, is almost comically outdated: It includes “pneumatic tube operator” but not web designer. (Reporting by The Washington Post has helped bring attention to these issues in recent years.)

Under President Barack Obama, the Social Security Administration and the Bureau of Labor Statistics undertook a yearslong effort to replace the DOT with what would be called the Occupational Requirements Survey, an updated catalog of modern occupations as well as the levels of physical exertion and cognitive difficulty that each job can entail. Field economists surveyed employers across the country, asking how often their employees typically had to climb stairs or lift items of various weights and so on. That detailed dataset now exists, but it isn’t widely used yet; the new regulation would require its implementation.

“So, the technical part of all this has sort of already been accomplished,” said David Weaver, a former top Social Security Administration official who helped to develop the survey, known as the ORS, during the Obama years. (Weaver is now a professor of statistics at the University of South Carolina.)

“But,” he added, “conservative economist types want to also make it harder for certain workers to get disability benefits, which would be a policy choice.” The complexity of the potential changes — the draft of the Trump regulation is hundreds of pages long and has been called the “mega reg” by insiders — has helped to mask this, Weaver and others said.

“Simplifying and Modernizing the Disability Adjudication Process” is how Mark Warshawsky headlined his written remarks when he testified in 2023 before a congressional subcommittee examining the issue. Warshawsky, an architect of the disability overhaul during the first Trump administration as the deputy commissioner for retirement and disability policy at the Social Security Administration, testified that the current system wrongly “presumes a workforce with low levels of education which is largely involved in physical labor, works long hours, has little flexibility in work schedules, low adaptability, little access to assistive technology, never works from home, and retires early fairly often.” He also said that increasing eligibility starting at age 50 is not very scientific; for starters, it’s unfair to 49-year-olds. (Warshawsky, who is now a senior fellow at the American Enterprise Institute, declined an interview request from ProPublica.)

Warshawsky was unable to get the disability regulation across the finish line before Trump lost the 2020 election. But Russell Vought, the powerful head of Trump’s Office of Management and Budget and one of the originators of Project 2025, picked up on this first-term agenda item and has pursued it again this year.

The disability restructuring was “Russ Vought’s No. 1 priority for the Social Security Administration from Day 1,” said Leland Dudek, who was acting commissioner of the agency from February to May. In February, Dudek said, his staff met with Vought’s staff on multiple occasions; together, they “dug up what was done four years ago,” he said, indicating that the new proposed rule will be similar to a 2020 draft that was leaked to the press. (The senior Trump administration official said that Dudek is “disgruntled” and that the disability changes are no more of a priority for Vought than the rest of the administration’s “deregulatory agenda.” In the past, Vought has publicly pressed for fewer veterans and others to receive disability benefits.)

To opponents of the forthcoming regulation, including many still inside the Social Security Administration, Warshawsky and Vought’s conception of the modern economy neglects the fact that workers like Tincher grew up in a different world. They started their working lives at a time when most people didn’t have personal computers, when it wasn’t as common to get a high school education and when physical labor offered a path to eventual retirement security. To switch the rules now pulls the rug out from under them just as they’re reaching their most vulnerable years, officials and experts said.

“I believe disconnects occur when more highly educated policy people do not fully understand or appreciate what workers in physically demanding, labor-intensive occupations, such as longshoremen, have gone through,” said Steve Rollins, who was deputy associate commissioner of the Social Security Administration’s Office of Disability Policy during the latter years of the first Trump administration and associate commissioner through the Biden administration. Rollins oversaw the agency’s work on modernizing the disability program from 2019 to 2024.

What’s more, vocational experts said in interviews, even if 50- or 60-year-old former coal miners or factory workers are denied the disability benefits they say they need, they’re still likely to retire early, a finding backed by recent research. After all, if they try to get a desk job — assuming one is available in their rural or exurban community — they may feel they don’t have the education or training for it, and they may also be subject to age discrimination in the hiring process. As Michelle Aliff, a certified rehabilitation counselor who testifies at Social Security disability hearings nationwide as an impartial vocational expert, put it: “An oil field roustabout in his 50s isn’t going to just sit down at a computer for work without additional training.”

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The Trump administration’s plan to transform the U.S. disability system, once finalized, would interact with other cuts to the social safety net that the president and Republicans in Congress have already authored. For example, under legislation dubbed the One Big Beautiful Bill Act and signed into law by Trump, work requirements will be added to Medicaid; people with disabilities will largely be exempt, but the best way to establish eligibility for that exemption is to qualify for Social Security’s disability program, which would become harder under the new rule. A disabled worker could instead turn to Obamacare’s individual exchanges for insurance coverage, but Republicans are allowing the tax credit that makes those premiums affordable to expire.

Tincher feels lucky he applied when he did. Being approved for disability has meant his copays are covered, he can finally afford groceries and he has time to help watch over his grandkids. Still, he also feels a tinge of guilt. “I wish every day I could still work,” he said. His dad, a coal miner, once told him to work until the day he died. “Having to ask for help is hard especially for men to do, men of my generation.”

All Tincher would say to the officials pushing the changes to the disability program, he said, is “you don’t know until you’re here, at this point in a working life.”

The post Red State Workers Could Lose Out on Disability Benefits as Trump Administration Rewrites Eligibility Rules appeared first on ProPublica.

This post was originally published on ProPublica.

I’ve reported on Idaho’s anti-vaccination movement for the past 10 years, most recently for ProPublica. I’ve written about people moving to Idaho as self-described “refugees” from states where vaccines are required for school. After the COVID-19 pandemic arrived, I wrote about Idaho’s low COVID-19 vaccination rate and, later, how that contributed to deaths and the near-collapse of our hospitals.

As a journalist, the debate over vaccine policy and the rationales of the people behind the anti-vaccination movement fascinate me, even as the work comes with the weight of reporting on what can be, in some cases, life-or-death stakes. But I’m not just a journalist. I’m an Idahoan with a family, including a young child in school.

This week, I held both of those identities as I published a story about Idaho becoming the first state in the nation to ban vaccine mandates. The Idaho Medical Freedom Act makes it illegal to require almost anyone to take a vaccine, test or other “medical intervention.” The law’s author, Leslie Manookian, is a finance executive turned practitioner of homeopathy who became a leader in the “health freedom” movement.

Watch Leslie Manookian and Allies Celebrate Idaho Medical Freedom Act

I first heard Manookian’s name in the mid-2010s, when she was part of a group seeking to change Idaho’s school vaccination laws and rules, among other things. She went on to create the Health Freedom Defense Fund, which brought several lawsuits over vaccine and mask mandates during and after the COVID-19 pandemic. She lives in one of the few Idaho communities that wholeheartedly embraced COVID-19 precautions, and she has described feeling ostracized.

In our interview and follow-up calls, Manookian told me about her stance on vaccines, what she believes the role of public health should be and her longtime desire to pass the Idaho Medical Freedom Act.

In the background of our conversation: a national measles outbreak that is larger than the U.S. has seen in decades.

One big change with the Idaho Medical Freedom Act is how schools and day cares can respond if, or when, measles arrives. The law makes it illegal to send home kids who aren’t vaccinated, as long as they are “healthy.” That has important implications when it comes to measles, which can spread for days before the contagious person even realizes they’re sick.

As a person who lives here, I can’t help but think about this. My family is vaccinated, but what if a student at my child’s school can’t be immunized for some reason; what will their parents do if measles begins to spread? What about my friends with kids too young to be immunized, who still need to go to day care? Does the new law keep them from choosing what they believe is best for their child?

I posed that question to an ally of Manookian’s, Mary Holland, the CEO of Children’s Health Defense, a national organization that’s become one of the fiercest foes of childhood vaccines.

Holland said Idaho parents who want their kids to be in a learning environment with “herd immunity” levels of measles vaccination can start a private “association” — not a school, because schools can’t require vaccines — just as parents who don’t like vaccines have done in order to dodge requirements in states like California and New York.

Her answer underscored how this law isn’t just about policy. It is about flipping the script on what we’ve considered the norm for generations now: that if you’re going to be part of a community, you must help protect the other people in your community. The thinking behind the Idaho Medical Freedom Act not only rejects that norm when it comes to vaccines, it makes it illegal.

A week after my interview with Manookian, the duality of being a reporter covering vaccine policies and a parent of a school-aged child again came into sharp focus. I was standing outside my child’s school, chatting with the school nurse. She is in charge of many things, but in particular, knowing our school’s vaccination rates, fending off outbreaks and deciding if kids are too sick to be at school. As we talked, my phone buzzed with a call from Manookian to continue our conversation about the upcoming story.

It’s always my goal as a journalist to ensure accurate and fair coverage. I wanted to include Manookian’s voice because of how much influence she has over public health rules in Idaho. So I worked to faithfully describe her beliefs and how she arrived at them, but I also had a duty to spell out the wide array of scientific evidence to the contrary.

In our discussions, Manookian told me her driving goal is to keep people from being coerced into something they don’t believe is right, no matter what. It’s also her belief that vaccines are dangerous and that infectious diseases are beneficial. (That risk-benefit calculus is not supported by the overwhelming body of evidence, not even by studies the movement relies on.)

As an Idahoan, I pay close attention to what’s happening around me, so that I can make informed decisions. As a journalist, it’s my job to help readers understand the thinking behind changes to public policy and where those ideas come from.

As I reported this week, Manookian doesn’t just have her eyes on Idaho. She intends to take this law to other states and believes it can be a model for the country. I’ll have my eyes on that, too.

You can read my full story, which includes my interview with Manookian, for yourself here.

The post My State Banned Vaccine Mandates. Here’s How I Covered It as an Idaho Journalist. appeared first on ProPublica.

This post was originally published on ProPublica.

by Debbie Cenziper and Megan Rose

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They were the sort of disturbing discoveries that anyone taking generic medication would want to know.

At one Indian factory manufacturing drugs for the United States, pigeons infested a storage room and defecated on boxes of sterilized equipment. At another, pathogens contaminated purified water used to produce drugs. At a third, stagnant urine pooled on a bathroom floor not far from where injectable medication was made.

But when the Food and Drug Administration released the grim inspection reports and hundreds of others like them, the agency made a decision that undermined its mission to protect Americans from dangerous drugs.

Instead of sharing the names of the medications coming from the errant foreign factories, the FDA routinely blacked them out, keeping the information secret from the public. That decision prevented doctors, pharmacists and patients from knowing whether the drugs they counted on were tainted by manufacturing failures — and potentially ineffective or unsafe.

“Is there some quality issue? Is there a greater difference in potency than expected? Is there a contaminant? I don’t know,” said Dr. Donna Kirchoff, a pediatrician in Oregon who has spent hours trying to find out where certain drugs were made for patients reporting unexplained reactions.

There’s no specific requirement that the FDA block out drug names on inspection reports about foreign facilities. Still, the agency preemptively kept that information hidden, invoking a cautious interpretation of a law that requires the government to protect trade secrets.

It’s part of a decades-long pattern of discounting the interests of consumers who want to make informed choices about the drugs they take — even as 9 out of 10 prescriptions in the United States are filled with generics, many from India and China.

ProPublica previously disclosed that the FDA allowed some of the most troubled factories in India to ship drugs to U.S. consumers and kept the practice largely hidden from the public and from Congress. The agency did not proactively track whether people were being harmed as complaints poured in about pills with an abnormal taste or residue, or about patients who had experienced sudden and unexplained health concerns, including stomach pain and breathing problems.

The FDA told ProPublica that divulging drug names on its inspection reports would violate federal law that protects confidential commercial information. The agency said it only releases the information with approval from drug companies or in cases where companies have already made the details public.

Current and former officials said the restriction was imposed long ago by FDA lawyers who interpreted the law broadly because they feared being sued by drugmakers. No one could recall who made the initial decision to withhold the information or when it was made. The FDA did not respond to a request to make its general counsel available for an interview, and a half dozen former general counsels contacted by ProPublica declined to comment or did not return calls.

Officials with the generic drug lobbying group told ProPublica they have never weighed in on the redactions. A spokesperson from PhRMA, the trade group for brand-name drugmakers, did not answer a question about whether the organization had advocated for the redactions. She said that while appropriate transparency can promote public health, the FDA must protect sensitive manufacturing information.

Patient safety advocates said that should not include redacting drug names.

(Myriam Wares for ProPublica)

Just two and a half years ago, FDA inspectors visited a factory in western India and discovered that spore-forming organisms had contaminated the sterile manufacturing area. The plant went on to ship its drugs to the United States anyway.

Because the names of medications were redacted on the inspection report, where they ended up, who used them and whether they caused any harm remains a mystery, at least to the public.

“The whole thing is rendered impotent if you take out the most critical piece of information, which is, ‘What drug is it?’” said former FDA Associate Commissioner Dr. Peter Lurie, who left the agency in 2017. “You’re left with this kind of vague accusation on which nobody can act because nobody has enough information to be able to do anything.”

Dr. Janet Woodcock, the longtime head of drug safety at the FDA, said in an interview with ProPublica that she favors releasing drug names but also shrugged off the usefulness of inspection reports for members of the public.

“You guys think you are like citizen scientists and you can figure out what this means and it’s just not the case,” said Woodcock, who spent nearly four decades at the FDA before retiring early last year.

Even if the FDA opted to disclose the drug names in its reports, there’s still a significant hurdle that can prevent patients from knowing if their medicine was made in a deficient factory. Labels on pill bottles often don’t list the name of the manufacturer or include a factory address, a crucial detail.

Drug companies often have multiple plants, each with its own track record. If there are no specifics on the labels, pharmacists, patients and their doctors can’t trace a drug back to the factory or to FDA reports about a plant’s safety and quality practices.

For years, the FDA resisted calls from pharmacists, lawmakers and others to require that manufacturers disclose more details on labels. Woodcock said the agency didn’t want to police thousands of companies to ensure they were providing accurate information.

“What benefit would this give you and is it worth all the effort?” she said. “We didn’t think the juice was worth the squeeze.”

Now the agency has changed course. It has asked Congress to amend the law to clearly require that labels include the names and addresses of manufacturers as well as the companies that produced a drug’s key ingredients. The FDA suggested additional details could be listed on a website.

The FDA could do even more. Current and former officials acknowledge the agency knows where every drug approved for the U.S. market is made, but does not publish that information on its website.

Instead, the agency separates the information into two different lists: one that shows factory addresses without drug names and another that shows drug names without factory addresses. There’s no easy way to connect them.

Last year, ProPublica sued the FDA in federal court to get access to the internal list of drugs and the factories that made them. The agency ultimately provided much of the information but withheld more than 6,000 addresses, saying the companies had hired contractors to make their drugs and that those names and addresses were confidential. ProPublica’s lawsuit is ongoing.

The agency holds back other critical information on drug safety as well.

When a drug is potentially contaminated by bacteria or has other significant quality problems, manufacturers are required to submit a detailed report to the FDA within three days. The reports are meant to provide an early warning about possible safety threats, but the agency doesn’t post them to its website or issue regular alerts. The only way consumers would know about a problem is by requesting a report under the Freedom of Information Act — and getting it could take weeks or longer.

In 2023, the FDA stopped releasing complaints from doctors and others that linked specific cases of harm — including hospitalizations and deaths — to drug quality concerns. The FDA had included those reports in a public database of adverse events used by researchers, doctors and others trying to assess drug safety. The agency did not respond to questions about why it made the change.

“We’ve made it almost impossible for consumers to be their own best advocate,” said Lisa Salberg, founder of a nonprofit for people with hypertrophic cardiomyopathy, a disease that causes the heart muscles to thicken. “We want our food labels to tell us exactly how much carbohydrates are in them but the things we are taking to combat diseases, we literally know nothing about.”

(Myriam Wares for ProPublica) “Kind of Like a Black Hole”

One of the most widely prescribed drugs in the United States is the generic version of Lipitor, a blockbuster statin that lowers cholesterol and prevents heart attacks and strokes.

Lipitor generated billions in sales before Pfizer’s patent expired in 2011, opening the door to a patchwork of more than 20 mostly foreign drugmakers that supply their own generic, called atorvastatin.

But the boon to consumers and insurers clamoring for cheaper drugs had a little-known downside. FDA inspectors have found safety and quality violations over the years at about half of the plants that were approved to make atorvastatin, government records show.

Conditions were so worrisome at one plant in central India last year that the agency banned the factory from shipping its drugs to the United States. The FDA went on to give the plant an exemption that allowed the company to continue shipping atorvastatin here.

The millions of atorvastatin users in the U.S., however, essentially take their pills on faith, trusting the U.S. government to keep bad medicine out of the country.

Manufacturing failures can be life-threatening. Dirty equipment can contaminate drugs with glass, metal or bacteria. Poorly made drugs may not dissolve properly in the body or contain enough key ingredients. In the case of atorvastatin, the wrong dose could leave a patient with uncontrolled blood pressure.

When patients are prescribed generic drugs — typically because they are cheaper than brand names —pharmacies and insurance companies decide which ones they get. Someone taking a cancer drug, for example, could get a bottle of pills from a factory with a record of good inspections and a refill from a factory with mold, dirty water and rusted equipment.

The FDA doesn’t make it easy to know more.

In a statement, the agency said that it is reviewing the redaction process for inspection reports but did not provide specifics. One former FDA manager who dealt with the release of the reports for overseas factories said the redactions were made because revealing both the drug names and the details of what inspectors observed on production lines would give away confidential manufacturing practices.

As a result, the FDA for decades regularly defaulted to taking out all the drug names, said the former official, who did not want to be identified because they weren’t authorized to speak about agency policy by their former employer.

“It’s more important to leave what inspectors saw, so people can understand what was bad at the factory,” they said. “If you left the drug name in, you’d have to take out more of the observations.”

Woodcock and several inspectors, however, said the reports typically don’t include proprietary information about how drugs are made.

“They’re not talking about how much salt they have in there, or which buffer they use in a specific drug,” Woodcock said. “They’re talking about, ‘Did you do the test correctly? … Do you have mold in your dryer?’ That kind of thing.”

Legal experts told ProPublica that the wholesale removal of drug names was improper and that the redactions should have been made on a case-by-case basis.

In interviews, several former FDA officials now say they support releasing drug names. But Woodcock and others acknowledged they did not question the redactions while they held positions of power at the agency.

“If you’ve got lawyers telling you you can’t do this or this is putting the agency at risk or the agency will get sued and we will have our head handed to us on a platter by the courts, no one is going to say, ‘I’m willing to take that risk,’” said Dr. Mac Lumpkin, former deputy commissioner for international programs who spent more than two decades at the agency.

Meanwhile, the information that people already have ready access to — the labels on their pill bottles — can be misleading. Sometimes what appears to be the manufacturer is actually a repackager or distributor. The actual drugmaker and its factory, which is often not listed on the bottle, could be in India, China or another country.

For Kirchoff, the pediatrician in Oregon, knowing who actually makes the drugs that she prescribes would have saved five years of painstaking work. She started looking at labels when she grew worried that children with autism, anxiety and other conditions were too often declining after they switched from a brand name drug to a generic, or from one generic to another.

The labels, however, often directed her to a distributor and not to the drugmaker or factory. To this day, she said, she still doesn’t know where some drugs are coming from or whether the FDA has ever raised concerns about the factories that made them.

She now keeps a list of the drugs that she can trace to a specific manufacturer and relies on it when prescribing medication.

“Kids with neurodevelopmental disabilities can be exquisitely sensitive to little changes in medications,” Kirchoff said. “A different manufacturer can make all the difference.”

It’s not just a matter of knowing more about drug quality and safety. Pharmacists say the lack of information makes it harder for hospitals and pharmacies to keep their shelves stocked when a potential drug shortage looms.

As Hurricane Maria barreled toward Puerto Rico in 2017, ultimately causing widespread flooding and a monthslong blackout, University of Utah Hospital pharmacist Erin Fox raced to figure out which drugs were most at risk of running short. The island was home to dozens of factories that produced generic and brand-name medications.

“We know where the vulnerabilities are and we’re prioritizing,” then-FDA Commissioner Scott Gottlieb promised on Twitter at the time.

But the agency, citing confidentiality, wouldn’t release a list of drugs made in Puerto Rico, which meant Fox and others didn’t know which products to try to source from alternative suppliers.

“Nobody was ever able to get that specific list,” Fox said. “It’s kind of like a black hole.”

Ultimately, about 40 drugs were at risk of shortage after the storm.

(Myriam Wares for ProPublica) Information Denied

For more than a quarter of a century, as drugs from foreign factories flowed into the U.S. market, the FDA resisted calls for transparency.

In the early 2000s, Lumpkin and others tried to persuade the FDA to provide unredacted inspection reports to regulators in Switzerland. The plan was to share information with a trusted partner under a confidentiality agreement and, working with Swiss inspectors, boost the number of investigations at high-risk factories around the world.

But agency lawyers shut that effort down, saying the FDA could not release complete inspection reports, even to other governments.

“They didn’t want to do anything that would make the industry mad,” Lumpkin said. “It was not, ‘What do we need to do for public health?’ It was, ‘What do we need to do to keep the FDA out of court?’ that took precedence.”

The agency would wait until 2017 before launching these international partnerships, which it now has with the European Union, the United Kingdom and Switzerland.

Woodcock had also pushed for change in the early 2000s, instructing her team to start building a database of factory addresses for every drug approved for use in the United States. In some cases, the information had been languishing on paper records in a storage room and the agency had no way to easily determine which facilities were producing drugs for Americans or whether they had been inspected.

“There was no information,” Woodcock said. “It was terrible. It was a mess.”

In the two decades since the agency created that database, making it possible to easily share the information with the public, the FDA chose to release drug names and their manufacturers but not specific factory addresses.

Woodcock called it a “bandwidth issue” and said she believes that releasing the information would be a reasonable step.

Another effort around that time also fell short. As the Obama administration called for transparency in government, the FDA put a searchable database of inspection information online — a move meant to give the public more details about factory practices that could “jeopardize public health.”

But the agency ultimately undermined the gesture of transparency by redacting drug names from the reports.

In 2022, a committee established by the National Academies of Sciences, Engineering, and Medicine called on the FDA to require that manufacturers publicly disclose where drugs are made. Despite that call and the transparency efforts before it, nothing much has changed.

“You can have a medication in your hand and you can literally not know the company that made it and where it was made. That’s the life of a pharmacist,” said Fox, who was on the committee along with academics and industry experts. “It’s like shopping on Amazon and all you have is the price. You really have no other information.”

In July, newly named FDA Commissioner Marty Makary promised “radical transparency” and the agency released more information about why it had denied applications for new drugs and biological products.

Nearly seven months into his tenure, the agency has yet to release detailed information about where generic drugs are being made.

To conduct its research, ProPublica paid for access to Redica Systems, a quality and regulatory intelligence company with a vast collection of FDA inspection documents.

Brandon Roberts of ProPublica contributed data reporting, and Melissa Dai, Isaiah Steinberg and Aidan Johnstone of the Medill Investigative Lab contributed research.

This post was originally published on ProPublica.

by Debbie Cenziper and Megan Rose

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

ProPublica wanted to know something simple: Where a widely used generic drug was made and whether that factory had any quality problems. Instead, we found ourselves navigating a labyrinth of company names and complex databases that few regular consumers would even know exist.

And even after all that detective work, we hit a dead end.

Atorvastatin is a generic drug that treats high cholesterol and prevents heart attacks and strokes. It’s one of the most commonly prescribed medications in the United States, and many manufacturers make it.

We started with a label on a patient’s pill bottle. It shows the name of what appears to be the drug’s manufacturer: Quallent. The only addresses on the label are in Ohio and New Jersey and are for Express Scripts, a company that manages prescription benefits for insurers and employers.

(Myriam Wares for ProPublica)

So we went to DailyMed, an online database with labeling information for drugs. There we found 21 pages of atorvastatin generics. We looked for Quallent and found two listings for the company.

Both showed that Quallent, based in the Cayman Islands, was just the packager of the drug. So what company manufactured it?

One label noted that Quallent sourced its pills from a drugmaker in India, another said they came from a company headquartered in Canada. Nothing on the pill bottle told us which of the two made the pills. So we looked at the markings on our patient’s atorvastatin tablets and compared them to the pill descriptions in DailyMed. Turns out the ones in our bottle were manufactured by the Canadian company Apotex.

We were lucky to be able to find even this much. The information on DailyMed included the name of the drug’s manufacturer. That’s often not the case. DailyMed also provided a partial address in Toronto, home to the global headquarters of Apotex as well as several of its plants. But the information didn’t specifically tell us if the drug is actually made at a Toronto factory.

To learn more, we scrolled to the bottom of the DailyMed page to find what’s known as the ANDA number, which is assigned when a company applies for approval to make a drug. We took that number and went to another database called the Orange Book, where all drugs approved by the Food and Drug Administration are listed.

(Myriam Wares for ProPublica)

We put in our ANDA number and we were able to confirm that Apotex was the manufacturer and also learn that the company received approval to start making atorvastatin in 2012, which would guide our search for FDA inspection reports about the factory.

But alas the Orange Book doesn’t tell us where Apotex makes the drug. The company’s website says it has factories in Canada, Mexico and India, but it doesn’t say which drugs are made where.

If any consumer got this far, we’d be impressed. But here’s where the search got really complicated.

Even with our ANDA number and the name Apotex, we could not find the specific factory where our atorvastatin was made. The FDA has that information — it’s on the applications that companies turn in when they apply for new drug approvals — but the agency hasn’t made those addresses available to the public.

(Myriam Wares for ProPublica)

Last year, we filed a Freedom of Information Act request for those locations. Months passed and we eventually sued the FDA in federal court. Finally, the agency gave us some of the addresses, but not a complete list.

In the case of our atorvastatin, no luck. The agency didn’t give us that factory’s details, saying it held back addresses for drugmakers that hired other companies — contract manufacturers — to make their medications. So even though we had information that the public doesn’t have, we were still stuck.

We went to a private firm called Redica Systems and paid to use a database of reports written by FDA inspectors after visits to drug factories. We could see inspections for various Apotex factories in Canada and India that described problems over the years in the way drugs were made. The FDA, however, blacked out the names of the medications on those reports.

That’s where we hit a final dead end. After all that, we still don’t know where our atorvastatin was manufactured and whether the factory had a troubled record.

(Myriam Wares for ProPublica)

We reached out to Apotex to see if we could learn more but never heard back. On its website, the company says, “Patient safety and regulatory compliance guide every stage of our manufacturing process.”

Though the FDA has held back factory information for decades, agency officials recently asked Congress for the authority to require that manufacturers disclose where drugs are made on the labels of pill bottles.

Brandon Roberts of ProPublica contributed research.

This post was originally published on ProPublica.

by Audrey Dutton

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

Three women become choked up as they deliver news in a video posted to social media. “We did it, everybody,” says Leslie Manookian, the woman in the middle. She is a driving force in a campaign that has chipped away at the foundations of modern public health in Idaho. The group had just gotten lawmakers to pass what she called the first true “medical freedom” bill in the nation. “It’s literally landmark,” Manookian said. “It is changing everything.”

With Manookian in the video are two of her allies, the leaders of Health Freedom Idaho. It was April 4, hours after the governor signed the Idaho Medical Freedom Act into law.

Watch Leslie Manookian and Allies Celebrate Idaho Medical Freedom Act (Health Freedom Idaho via Rumble)

Watch video ➜

The act makes it illegal for state and local governments, private businesses, employers, schools and daycares to require anyone to take a vaccine or receive any other “medical intervention.”

Whether the law will actually alter day-to-day life in Idaho is an open question, because Idaho already made it easy to get around the few existing vaccination requirements.

But it could have a significant effect in other states, where rules aren’t already so relaxed. And it comes at a time when diseases once eradicated from the U.S. through vaccination are making a resurgence.

The law runs against one of the hallmarks of modern public health: that a person’s full participation in society depends on their willingness to follow certain rules. (Want to send your child to public school? They’ll need a measles vaccine. Want to work in a retirement community during flu season? You might have to wear a mask.)

The new Idaho law flips that on its head. It not only removes the obligation to follow such rules, it makes the rules themselves illegal.

The new law sets Idaho apart from even conservative-leaning South Carolina, where two schools recently quarantined more than 150 unvaccinated children after measles arrived.

A person can spread measles for four days before symptoms appear. During the South Carolina schools’ quarantine, five students began to show symptoms, but the quarantine kept them from spreading it, the health department said this month.

That precaution would now be illegal in Idaho.

Idaho’s law caught the attention of people who share Manookian’s belief that — contrary to hundreds of years of public health evidence and rigorous regulation in the U.S. — vaccines are worse than the diseases they prevent.

It also caught the attention of people like Jennifer Herricks, a pro-vaccine advocate in Louisiana and advocacy director for American Families for Vaccines.

Herricks and her counterparts in other states say that vaccine requirements have “done so much good for our kids and for our communities.”

An analysis published last year by the U.S. Centers for Disease Control and Prevention found that routine childhood vaccines prevented more than 1.1 million deaths and 32 million hospitalizations in the U.S. over three decades, saving $540 billion in direct costs and saving society about $2.7 trillion. The analysis was limited; it didn’t account for the lives and money saved by vaccines for flu or RSV, which kill and hospitalize babies and children each year.

Idaho’s move was “pretty concerning,” Herricks said, “especially seeing the direction that everything is headed at the federal government.”

The law is the culmination of a decade of anti-vaccine activism that got a boost from the pandemic.

It’s rooted in a belief system that distrusts institutions — government health agencies, vaccine makers, medical societies and others — on the premise that those institutions seek only money and control.

Manookian said in an interview that she believes one person should never be told to risk their health in “the theoretical” service of another.

Now, Manookian and her allies have a new goal in their sights: to make Idaho’s legislation a nationwide standard.

Idaho was already more permissive than other states when it came to vaccine rules. Parents since at least the 1990s could send unvaccinated children to school if they signed a form saying vaccination went against their religious or personal beliefs.

That wasn’t good enough for Idahoans who describe themselves as advocates for health freedom. They worked to shift the paradigm, bit by bit, so that it can be easier now for parents to get a vaccine exemption than to show the school their child is actually vaccinated.

In recent years, lawmakers ordered schools and daycare centers to tell parents about the exemptions allowed in Idaho whenever they communicate about immunizations.

The state also decided to let parents exempt their kids by writing a note, instead of having to fill out a form — one that, in the past, required them to acknowledge the risks of going unvaccinated.

(There is conflicting data on whether these changes truly affected vaccination rates or just led more parents to skip the trouble of handing in vaccine records. Starting in 2021, Idaho schools reported a steady drop in the share of kindergartners with documented vaccinations. Phone surveys of parents, by contrast, showed vaccination rates have been largely unchanged.)

An enduring backlash against Idaho’s short-lived COVID-19 mandates gave Manookian’s movement more momentum, culminating this year in what she considered the ultimate step in Idaho’s evolution.

Manookian had a previous career in finance in New York and London. She transitioned to work as a homeopath and advocate, ultimately returning to her home state of Idaho.

The bill she came up with said that almost nobody can be required to have a vaccine or take any test or medical procedure or treatment in order to go to school, get a job or go about life how they’d like to. In practice, that would mean schools couldn’t send unvaccinated kids home, even during a measles outbreak, and private businesses and daycares couldn’t require people on their property to follow public health guidance.

The state had just passed “the Coronavirus Stop Act” in 2023, which banned nearly all COVID-19 vaccine requirements. If lawmakers did that for COVID-19, Manookian reasoned, they could do the same for all communicable diseases and all medical decisions.

Leslie Manookian (Courtesy of Leslie Manookian)

Her theory was right, ultimately.

The bill she penned in the summer of 2024 made it through the Republican-controlled House and Senate in early 2025.

Manookian took to social media to rally support for the legislation as it sat on the desk of Gov. Brad Little.

But the governor vetoed it. In a letter, he explained that he saw the bill as government intrusion on “parents’ freedom to ensure their children stay healthy.” During an outbreak, he said, schools wouldn’t be able to send home students “with highly contagious conditions” like measles.

Manookian tried again days after the veto. In the next version of the bill, protections during a disease outbreak applied only to “healthy” people.

This time, Little signed it.

Weeks after the signing, Manookian joined like-minded advocates on a stage in Washington, D.C., for a launch event for the MAHA Institute, a group with strong ties to Robert F. Kennedy Jr. (MAHA stands for Make America Healthy Again.) The new Health and Human Services secretary had denounced vaccines for years before President Donald Trump appointed him.

At the gathering, Manookian announced her next mission: to make it “a societal norm and to codify it in law” that nobody can dictate any other person’s medical choices.

“We’re going to roll that out to other states, and we’re going to make America free again,” Manookian told the audience in May.

Manookian’s commitment to bring along the rest of the country has continued ever since.

U.S. Health and Human Services Secretary Robert F. Kennedy Jr. visited an Idaho farm with Leslie Manookian and several of her allies in the “health freedom” movement this past summer. (Screenshot by ProPublica)

Her nonprofit, the Health Freedom Defense Fund, is now distributing model legislation and a how-to guide, with talking points to persuade legislators. Manookian said in podcast interviews that she is working with the nonprofit Stand For Health Freedom to mobilize activists in every state.

In an interview with ProPublica, Manookian said her objective is for people to “understand and appreciate that the most basic and fundamental of human rights is the right to direct our own medical treatment — and to codify that in law in every state. Breaking that barrier in Idaho proves that it can be done, that Americans understand the importance of this, and the humanity of it, and that it should be done in other states.”

Her efforts were rewarded over the summer with a visit from none other than Kennedy, who visited Boise and toured a farm with Manookian and state lawmakers in tow.

“This state, more than any other state in the country” aligns with the MAHA campaign, Kennedy told reporters at a news conference where no one was allowed to ask questions. Kennedy called Idaho “the home of medical freedom.”

The Department of Health and Human Services did not respond to ProPublica’s request for comment from Kennedy or his staff on Idaho’s law and his visit to the state.

Children’s Health Defense, the organization Kennedy built into one of the fiercest foes of childhood vaccines, took interest in the Idaho bill early on.

The group promoted the bill as it sat on the governor’s desk, as he vetoed it, then as Manookian worked successfully to get a revived bill through the statehouse and signed into law.

The organization’s online video programming featured Manookian five times in late March and early April. One show’s host told viewers they could follow Idaho in its “very smart strategy” of taking a law against COVID-related mandates, “crossing out ‘COVID,’ making a few other tweaks, and you have an incredible health freedom bill after that.”

Children’s Health Defense CEO Mary Holland said she’s known Manookian for more than 15 years and pushed the national organization to publicize Manookian’s work. Holland introduced her at the Washington, D.C., event.

Whereas most states put the onus on unvaccinated people to show why they should opt out of a mandate, Idaho’s legislation made unvaccinated people the norm — shifting the burden of accommodation onto those who support vaccination.

Now, parents of infants too young for a measles vaccine can’t choose a daycare that requires immunization. Parents of immune-compromised students must decide whether to keep their children home from school during an outbreak of vaccine-preventable diseases, knowing unvaccinated children won’t be quarantined.

Holland said Idaho parents who want their kids to be in a learning environment with “herd immunity” levels of measles vaccination can start a private “association” — not a school, because schools can’t require vaccines — just as parents who don’t like vaccines have done in order to dodge requirements imposed by states like California and New York.

“I think you could certainly do that in Idaho.” Holland said. “It wouldn’t be a public school. It might be the Church of Vaccinia school.”

The Idaho Capitol building, before Gov. Brad Little’s press conference with Kennedy this past July. (Otto Kitsinger for ProPublica)

The day Idaho’s Medical Freedom Act was signed, a legislator in Louisiana brought forward the Louisiana Medical Freedom Act. In a hearing later, she pointed to Idaho as a model.

Louisiana followed Idaho once before in 2024, when it passed a law that requires schools to describe the exemptions available to parents whenever they communicate about immunizations. Idaho had passed an almost identical law three years earlier.

Herricks, the Louisiana pro-vaccine advocate, said she watched the Idaho Medical Freedom Act’s progress with “a lot of concern, seeing how much progress it was making.” Now it’s set a precedent, Herricks said.

Holland, the Children’s Health Defense CEO, said she looks forward to Idaho’s approach spreading.

She pointed to a September announcement by Florida Surgeon General Dr. Joseph Ladapo that he intends to rid his state of all vaccine mandates. Holland said she expects other Republican-controlled states to take a serious look at the Idaho law. (Ladapo’s office did not respond to requests for comment.)

“It’s a big change,” Holland said. “It’s not just related to vaccines. It’s a blow against the notion that there can be compulsory medicine.”

Some people support the more-than-century-old notion that compelling people to be vaccinated or masked will provide such enormous collective benefits that it outweighs any inconvenience or small incursion on personal liberty.

Others, like Holland and Manookian, do not.

At the heart of laws like Idaho’s is a sense of, “‘I’m going to do what I want to do for myself, and I don’t want anybody telling me what to do,’ which is in direct contrast to public health,” said Paul Offit, pediatrician and vaccinologist at the University of Pennsylvania and Children’s Hospital of Philadelphia.

Offit, who co-invented a vaccine against rotavirus, is a critic of Kennedy and was removed from a federal vaccine panel in September.

A more fundamental conflict is that some people believe vaccines and other tools to prevent the spread of illness, like masks, are harmful. That belief is at odds with the overwhelming consensus of scientists and health experts, including Kennedy’s own Department of Health and Human Services and the CDC.

Both tensions are at play in Idaho.

In April, Idaho Gov. Brad Little signed into law the Idaho Medical Freedom Act, which prohibits state and local governments, private businesses, employers, schools and daycares to require anyone to take a vaccine. (Otto Kitsinger for ProPublica)

As is the case nationally, Idaho’s “health freedom” movement has long pushed back against being labeled “anti-vaccine.” Idaho lawmakers and advocates have stressed that their goals are bodily autonomy and informed choice.

They do not take a stance on the bodily autonomy principle when it comes to abortion, however. Almost all state legislators who voted for the Idaho Medical Freedom Act also voted to ban abortion, if they were in office at both times.

“Every action has to be evaluated on its individual morality,” not on whether it does the most good for the most people, Manookian said.

But Manookian’s rejection of vaccine mandates goes beyond a libertarian philosophy.

Manookian has said publicly that she thinks vaccines are “poison for profit,” that continuing to let daycares require vaccination would “put our children on the chopping block,” that measles is “positive for the body,” that the virus protects against cancer, and that it can send people “into total remission” — an assertion she made on an Idaho wellness center’s podcast in April.

Manookian told ProPublica she believes infectious diseases have been made “the bogeyman.”

Against those claims, research has shown that having the measles suppresses immunity to other diseases, a phenomenon dubbed “immune amnesia” that can make children who have recovered from measles more susceptible to pneumonia and other bacterial and viral infections. About 20% of unvaccinated people who get measles will be hospitalized, and 1 to 3 of every 1,000 children who are infected will die from complications of the disease, according to the CDC.

And while researchers have studied using engineered measles viruses in a cancer treatment, those same researchers have written that they were “dismayed to learn” their research has been misconstrued by some who oppose vaccination. They said they “very strongly advise” giving children the measles vaccine, that there “is no evidence that measles infection can protect against cancer” and that measles is “a dangerous pathogen, not suitable for use as a cancer therapy.”

(Manookian said she believes she has evidence for her cancer remission claim but couldn’t readily produce it, adding that she may have been mistaken.)

The measles-mumps-rubella vaccine, meanwhile, is safe and highly effective, according to the American Academy of Pediatrics, the Infectious Diseases Society of America and the U.S. Centers for Disease Control and Prevention, among others. The CDC says the most common negative reactions are a sore arm, fever or mild rash. Two doses of the vaccine provide near total protection, according to the CDC.

Manookian said she doesn’t believe the research on vaccines has been adequate.

She will have another chance to spread her views from a prominent platform in November, when she’s scheduled to speak at the Children’s Health Defense 2025 conference in Austin, Texas.

She’ll share the stage with celebrities in the anti-vaccine movement: Del Bigtree, communications director for Kennedy’s past presidential campaign; actor Russell Brand; Kentucky Sen. Rand Paul and Wisconsin Sen. Ron Johnson; and Ladapo, the Florida surgeon general who made headlines for his push to end vaccine mandates in Florida, months after Idaho wrote that concept into law.

This post was originally published on ProPublica.

by Anna Clark

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

On the far east side of Michigan, the future of fluoride in drinking water — long an ordinary practice for preventing tooth decay — has suddenly provoked passionate debate.

Public meetings in St. Clair County, about an hour northeast of Detroit, have filled with people weighing in. One man waved his Fixodent denture cream before the county commissioners, suggesting that his own experience showed what would happen if local communities stopped treatment.

“I am an unfluoridated child,” he declared, “with a set of uppers and lowers.”

Another man, speaking to the county’s Advisory Board of Health, said that personal responsibility should be factored into the conversation. “I think there are some 3 Musketeer bars, Snicker bars that should be accounted for. Some Coca-Colas.”

And a young man used his time in the public comments to address not just fluoridation, but the county medical director who’s trying to get rid of it. He accused him of grandstanding to land a job with Robert F. Kennedy Jr., the U.S. health and human services secretary, by making moves that “lowered the quality of life for underserved people.”

The raucous arguments were spurred by a three-page memo sent in June to the Advisory Health Board by Dr. Remington Nevin, the medical director of St. Clair County’s Health Department. It urges the department to take steps to “prohibit the addition of fluoride” to public water systems because, he wrote in bold print, the additive is “a plausible developmental neurotoxicant” — a claim that runs counter to the assessment of many leading experts and health agencies, which have long celebrated fluoridation as a public health triumph.

Nevin recommended fluoride restrictions that would apply to any system located in the county and serving county residents. Potentially, that could include the Great Lakes Water Authority, which provides water to nearly 40% of the state’s population.

Drinking water fluoridation, which was pioneered in Michigan in 1945, led to a massive drop in tooth decay. Even with the rise of fluoride in toothpaste and other products, it’s credited with a 25% decrease in cavities. But skeptics increasingly hold sway in government, as ProPublica recently reported. Those opponents include Kennedy, the nation’s top health official, who has called fluoride “industrial waste.”

Now the Centers for Disease Control and Prevention and the Environmental Protection Agency are reviewing their approaches to fluoride in drinking water, and Utah and Florida became the first states to ban fluoridation.

Local communities, though, are on the front lines of the fluoride wars in most states, typically deciding whether or not to continue fluoridating their drinking water by council vote or community referendum. The public conversation in St. Clair County offers a vivid example of how contentious the issue can become. Advocates from well beyond its borders are getting involved, saying that what happens in the county has implications for the entire state.

Home to about 160,000 residents at the base of Michigan’s Thumb, St. Clair County shares a watery border with Canada. Some 67% of its voters chose President Donald Trump in the 2024 election. (Kennedy got under 1% of the vote.) About 110,000 residents receive fluoridated drinking water, according to the state’s environmental agency, while an additional 6,510 are served by water supplies with naturally occurring fluoride.

In his memo this summer, Nevin, who is a physician epidemiologist, cited a state-of-the-science report from the National Toxicology Program last year that described an association between higher levels of fluoride exposure and lower IQs in children. (The NTP is an interagency program within the Department of Health and Human Services that’s focused on toxicology research.)

Nevin also referenced a court decision in a case filed against the EPA by groups opposed to fluoridation, where a district judge relied, in part, on the NTP report in ruling that fluoride presented an “unreasonable risk.” Even as it appeals the decision, the EPA said its review of new science on fluoride in drinking water “is being done in coordination with Secretary Kennedy and HHS.”

Dr. Remington Nevin, medical director of St. Clair County’s Health Department, issued a three-page memo urging the county to take steps to prohibit the addition of fluoride to public water systems. (Nick Hagen for ProPublica)

The NTP report, though, is contested and based on limited studies involving fluoride levels that are more than twice the amount recommended by the federal government. Its own abstract says there isn’t enough information to link lower fluoride exposure with children’s IQ.

Nevin’s memo said that the EPA may take months or years to act on fluoride, but that didn’t mean local officials had to wait. “Across the Michigan Thumb, several townships have expressed a desire for similar measures,” he wrote, “and within St. Clair County, I have received a number of resident concerns related to this issue.” He recommended new regulations that would prohibit the addition of “any form of fluoride” to public water systems in the county that serve residents.

In Michigan, each community decides for itself if it will maintain fluoride in its drinking water system. But in an email to ProPublica, Nevin laid out a process where the St. Clair County Board of Commissioners could approve regulations that, in the name of public health, restrict the ability of suppliers to use the additive — in effect, enacting sweeping change throughout the region.

“Just as items manufactured in California are often subject to more stringent California environmental and health regulations, even if the majority are sold outside the state; so too could drinking water produced in St. Clair County be subject to more stringent county regulations, even if the majority is exported to other counties,” he wrote.

Whether or not this applies to any future fluoride regulations depends on the language that is adopted and approved, he added.

The state Department of Health and Human Services says it knows of no local health departments that have attempted such restrictions. In response to ProPublica’s queries, the Great Lakes Water Authority shared a May statement about fluoride, which says that the agency is required by its owner, the city of Detroit, to fluoridate its water supply. The current dosage is well below the maximum established by the Safe Drinking Water Act and the EPA, the statement said, and is in line with the recommended target for oral health benefits.

The water authority, which serves southeast Michigan, didn’t address the St. Clair County proposal. And it’s unclear whether the push for broad county regulations will gain traction.

As medical director, Nevin has an influential voice with county officials and shares guidance with Liz King, the county’s health officer-director. King, however, expressed reservations about Nevin’s proposal at a July meeting of the Advisory Health Board, according to the minutes.

In a statement to ProPublica, King said: “I do not support county-wide mandates to remove fluoride or actions that override the authority of local jurisdictions, unless there is an emergent or urgent public health need.”

Nevin was new to Michigan when he joined the Health Department in his part-time position about two years ago. He soon established that he would be an active force. He describes it in an email to ProPublica as “counter-activism,” adding: “I am largely working to counter the radical agendas of many past and current state public health officials.”

At the January meeting of the Advisory Health Board, Nevin provided members with a 2022 book by Kennedy — “A Letter to Liberals: Censorship and COVID: An Attack on Science and American Ideals” — that’s critical of the Democratic Party and government restrictions enacted during the COVID-19 pandemic. (To the notion that he wants to work for Kennedy, Nevin told ProPublica that it’s “baseless conjecture” and that he’s happy in St. Clair County.)

Less than a year into his tenure as HHS secretary, Kennedy’s approach was challenged by six former surgeons general who served under both Republicans and Democrats. In a recent op-ed, they said that Kennedy is “endangering the health of the nation.” His agency criticized their track records in office when contacted by ProPublica about the op-ed, saying they failed to improve public health.

Nevin has moved to make vaccine exemptions easier to get, saying in an April memo that it would “improve the public’s trust in public health.” Those efforts helped earn him a tribute signed by 10 Republican state legislators, which also highlights his fluoride recommendations. Nevin also successfully pushed for the department to wind down services at school health clinics, arguing, in part, that providing direct primary care isn’t a core function of public health.

Supporters point to his training in the military and at Johns Hopkins University. In addition to a medical degree, his CV lists a master’s degree and doctorate in public health. On his website, Nevin also highlights his ability to serve as an expert witness and consultant in legal cases that involve adverse effects from certain antimalarial drugs.

Nevin told ProPublica that past experience taught him that it can take years for neurotoxic effects of certain substances to be recognized. “I have every confidence that, in due course, fluoride will also be looked upon as a neurotoxicant that has no place being ingested,” he wrote in an email.

He added that the response he’s received to his proposal from the community “has been overwhelmingly positive.”

Dr. Randa Jundi-Samman, a recently retired dentist who worked in Port Huron, Michigan, for 30 years, has been a vocal opponent of removing fluoride from St. Clair County’s drinking water. (Nick Hagen for ProPublica)

But there’s been strong pushback. Dr. Randa Jundi-Samman, a recently retired dentist in St. Clair County, was one of the health professionals speaking in support of fluoridation at public meetings. She told ProPublica that dropping fluoridation would be a serious hit to community health.

“You’d 100% get more decay, especially in children in low-income communities that don’t get the chance to go to the dentist every six months,” Jundi-Samman said. “We certainly will see that. We already see it in people who don’t have fluoride in their water.”

Dr. Mert Aksu, president of the Michigan Oral Health Coalition’s board and dean of the University of Detroit Mercy’s dental school, said he’s hustling up to the public meetings in St. Clair County because it’s the duty of professionals “to make sure that the decisions that are being made within our communities are being made based upon scientific merit.”

Speaking broadly about the influence now wielded by fluoride skeptics, Aksu said, “We have opened ourselves up to opportunities from misinformed people who want to use this issue for political purposes.”

Dr. Mert Aksu, dean of the University of Detroit Mercy’s dental school, believes people are leveraging fluoride as an issue for political benefit. (Nick Hagen for ProPublica)

At an August meeting of the county commissioners, Kimberly Raleigh, interim executive director of the Michigan Oral Health Coalition, read a letter in support of fluoridation that was signed by the University of Michigan School of Dentistry, the Michigan Dental Association, the Indiana Dental Association, the Pennsylvania Coalition for Oral Health and dozens of others.

Nevin said in an email that the dental community “must recognize that community water fluoridation can no longer be relied upon to mask the dental problems created by our neglect of poor dietary choices.”

He argues that he has science on his side. “Scientific merit favors a recommendation to prohibit fluoride,” he wrote to ProPublica. “I have every confidence this will become much clearer in the coming months, as further federal guidance is inevitably released.”

Nevin’s recommendation is before the Advisory Health Board, which also was provided a fact sheet on fluoridation from the Health Department, submitted with Nevin’s approval. If the board endorses his proposal, King may then decide whether to propose regulations, which the Board of Commissioners would then weigh, according to the Health Department. Nevin estimated that the process could take six to 12 months.

Fluoride was on the agenda for the Advisory Health Board’s September meeting, which ended early because the members failed to reach a quorum. Nevin told ProPublica that he expects it to be discussed at this week’s meeting, and that he will present additional information then.

Meanwhile, Nevin has already influenced one of the county’s townships, Kimball, which receives treated water from Port Huron, the seat of St. Clair County.

At an August meeting, where Nevin spoke to the Board of Trustees, Kimball Township unanimously passed a resolution calling for Port Huron to discontinue fluoridation and direct any funds saved to support access to topical dental fluoride treatments.

Port Huron’s city manager declined to comment for this story, saying the township has not presented the city with any resolution or request. Nevin said in an email to ProPublica that he is “attempting to address every municipality in the county” with similar testimony.

After voting on the measure, one Kimball trustee made a point to show support for Nevin, saying “we’re blessed to have him making decisions.”

Nevin, he said, has had to overcome resistance from staff “pushing hard to make his life rather uncomfortable.”

“They’re not used to leadership,” the trustee said. “They’re not used to boldness. They’re not used to maybe some male energy that’s necessary to get things done.”

This post was originally published on ProPublica.