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

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

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.

by Jessica Schreifels, The Salt Lake Tribune

This article was produced for ProPublica’s Local Reporting Network in partnership with The Salt Lake Tribune. Sign up for Dispatches to get our stories in your inbox every week.

The patients kept coming to the Utah oral surgeon’s office — one after another, year after year — with dental work that the surgeon said had gone wrong. He later recounted in a letter to state licensors that he had seen dental implants that had been the wrong size, patients with chronic sinus infections and one person whose implant had become lost inside their sinus cavity. These patients, he said, had all been worked on by the same dentist: Dr. Nicholas LaFeber.

The surgeon, a 30-year veteran, wrote the letter in November 2022 after Utah’s licensing division asked for his opinion of work done by LaFeber, whose license was on probation after the agency determined he had provided substandard care to more than a dozen patients. His warning was blunt: He believed LaFeber wouldn’t improve as a dentist and should not be performing dental implant procedures. He had seen LaFeber make the same mistakes in patients for years, he wrote, causing “severe” and sometimes life-changing complications.

“I believe that he is not competent to place implants,” the oral surgeon, Dr. Creed Haymond, concluded. “I give this opinion with soberness and sadness, but I feel I have a duty to aid the board in protecting the public from what appears to be an incompetent practitioner.”

His assessment of LaFeber’s skills in restorative dentistry was also mentioned in a February 2023 order regarding agency action on LaFeber’s license. Haymond did not respond to interview requests.

This was the second letter that Utah’s Division of Professional Licensing had received recommending that LaFeber be stopped or limited from practicing after more than a decade of dentistry in Utah, according to records obtained by The Salt Lake Tribune and ProPublica. The agency licenses Utah dentists and other professionals and investigates allegations of misconduct.

Two years prior, another dentist who had considered buying one of LaFeber’s practices recommended LaFeber’s license be revoked after looking through patient files: “As I started going through charts, as well as seeing the previous work, I began to realize how poor he treated these individuals,” wrote Dr. Brandon McKee. “Patients with failed implants are put on antibiotics and told to wait while the implant is continuing to heal. Some of these are for nine months.”

This letter was discussed in a September 2020 public dentistry board meeting. McKee did not respond to interview requests.

The licensing division’s dentistry board — whose members are mostly dentists and hygienists — recommended to Utah licensing director Mark Steinagel in December 2022 that LaFeber’s license be revoked after reviewing additional evidence suggesting his skills had not improved.

But despite this recommendation and the letters of warning from his colleagues, Steinagel reinstated LaFeber’s license in May 2023 after the dentist completed three years of probation, which included taking remedial classes.

Mark Steinagel, director of the state agency that licenses Utah professionals, reinstated Nicholas LaFeber’s license even though the agency’s dentistry board recommended that it be revoked. (Rick Egan/The Salt Lake Tribune)

Since LaFeber’s license was reinstated, new patients say they’ve been hurt. The Tribune and ProPublica spoke with two patients who say they saw the dentist within the last year for what they believed would be routine cavity fillings. Instead, they say they left in pain that became prolonged and ultimately required the procedures to be redone by other dentists. Neither knew when they sought dental care that LaFeber had nearly lost his license after regulators determined his work fell below the standard of care.

“I had never had this done before, so I didn’t know what’s normal,” said one patient, Michelle Lipsey. “I was just like, ‘He’s an adult, male dentist. He probably knows what he’s doing.’”

Lipsey filed a complaint against LaFeber with licensors in July detailing her experience, but the agency closed the case a month later and took no disciplinary action.

LaFeber said he would not discuss individual patients because they did not grant him permission to do so. He told The Tribune and ProPublica that he has always tried to keep his patients’ best interests in mind. “I had a few outcomes from dental work that had complications and needed further treatment,” he wrote in an email in response to questions.

“I assume every dentist encounters some percentage of negative patient outcomes and I have no reason to believe that my practice had a higher percentage than others.”

Melanie Hall, a spokesperson for Steinagel and the Division of Professional Licensing, said in response to questions that the division only revokes someone’s license when their conduct has been “especially egregious” because doing so “ends a career.”

The agency’s top priority, she said, is keeping Utahns safe — but she added that it also wants to ensure that licensees have a chance at “professional rehabilitation” and, when appropriate, can continue to work and earn money.

The state has revoked two dental licenses since June 2015, according to a Tribune and ProPublica examination of a decade’s worth of publicly available licensing division records.

Hall said that LaFeber’s license was reinstated despite the dental board’s recommendation because the dentist had finished the remedial courses that the board required him to take and his probationary period was ending. She noted that no other patients filed a complaint during that three-year period and that the dental board’s role was to only make recommendations to Steinagel and his staff.

That decision bothered some of those who served on the dental board during that time. Two former board members told The Tribune and ProPublica that they were frustrated state licensing division leaders did not listen to them and that they felt LaFeber should not practice dentistry given his record. Both spoke on the condition of anonymity because of potential professional repercussions.

“You hate to take somebody’s livelihood away from them when they’ve gone through years of dental school and had a practice,” one of the former board members said. “But the board’s job is to protect the public.”

In LaFeber’s case, the former board member said, “the public was not well-served.”

LaFeber, without knowing the identities of the board members, suggested that some might have been biased against him.

“Every One of These Cases Was Alarming”

LaFeber said in public dentistry board meetings that he came to the attention of the licensing division in late 2019 after one of his former employees filed a complaint. He said the employee, who he said he had previously fired, directed licensors to more than a dozen cases in which he admitted during a board meeting that he had provided “poor patient care.”

State licensing officials could have suspended or revoked LaFeber’s license, but instead, in early 2020, they struck an agreement with LaFeber — a common outcome in license discipline cases. According to the agreement, investigators found that some of the patients in those cases had had root canals that resulted in infections or needed to be redone. Licensors also determined that LaFeber had improperly placed permanent replacement teeth in other patients, including one whose implant extended into the sinus cavity, the document said.

LaFeber agreed to spend three years on professional probation, during which he would be under the supervision of another dentist whose time he was required to pay for. He was still allowed to perform dental work during that period, according to the stipulation, but agreed not to do implant procedures or root canals.

He was not required to tell his current or future patients about this discipline. Like most other states, Utah has no law requiring patient disclosure when a licensed professional is disciplined, and a review of more than 3,200 filings from the licensing division’s website shows the state has rarely required disclosure of unprofessional conduct to patients.

The Utah regulators who discipline licensed professionals act only when someone files a complaint, like what happened in LaFeber’s case. “We don’t have manpower or staffing for proactive investigations,” Larry Marx, the state’s health care licensing bureau manager, explained to the dental board in a 2020 public meeting.

Once LaFeber was on probation, oversight of his progress moved to the dental board, an advisory group whose role it is to interview probationers in quarterly public meetings and make recommendations to Steinagel about whether the professionals completed their probation and if they should have their licenses reinstated.

In these interviews with the dental board, LaFeber admitted his mistakes. He blamed bad outcomes on being burned out from owning four dental clinics, and he said he had done procedures on friends and acquaintances who actually needed more specialized care but didn’t have the money.

“Some of it I will just admit was a poor, poor choice on my part,” he told the board, according to a recording of the meeting. “And I can also say for some of them, they are very dear friends of mine, that I have either coached their kids or helped them in Scouts or something else, single moms, and trying to help them out.”

Dr. Nicholas LaFeber’s profile on the website of his practice, Sandy Center Dental (Screenshot by ProPublica)

In addition to the problems that the former employee initially reported to the state licensing division, one dental board member, Dr. Ruedi Tillmann, looked at more than a dozen other files of LaFeber’s during the first few months of his probation and found other cases in which Tillmann saw indications that patients had poor outcomes, according to a December 2020 board meeting.

Tillmann, a dentist, said during the online meeting that he saw “a number of cases” where LaFeber did four or five implants on a single patient and none of them properly integrated into the patient’s jawbone. “Poor margins, open margins, implant crowns not sitting on implants correctly,” he said about patient files he reviewed. “I’m sorry to be harsh. It’s just that every one of these cases was alarming to me.”

Dr. Daniel Poulson, another dentist on the board, questioned why LaFeber would do substandard work on his patients, including people he said he knew and cared about.

“With 30 cases, what that communicates to me is you didn’t learn. You just kept doing it,” Poulson said during the same meeting. “And to blame that on being stressed or overworked — we’re all stressed. Dentistry is an incredibly stressful profession. But that shouldn’t, in my mind, make an excuse for ill-treating a patient. Using a lot of antibiotics to cover infections that last years is just out of bounds.”

LaFeber told the board during this meeting that he was confident he could improve his dentistry by taking continuing education courses and by being more selective about patients and referring them more often to specialists instead of trying to do the work himself.

He also downsized to just one clinic, Sandy Center Dental, a wood-trimmed office suite in a large, tan stucco building located in a Salt Lake City suburb at the base of the Wasatch Mountains.

“They Were So Disgusted With All the Problems”

LaFeber met with the dental board 11 times during his probation in public meetings that were often conducted on video calls because of the coronavirus pandemic. He was cheerful and agreeable during meetings, even at times when board members asked him pointed, critical questions about his work.

His polite nature was noted several times in records reviewed by The Tribune and ProPublica. For example, McKee, the dentist who had considered buying LaFeber’s practice, wrote in his letter to the board that LaFeber came across as a “humble,” “very nice guy” who patients trusted. A dentist who leads a dental examination agency wrote in his summary of an exam that LaFeber took that he was “overly pleasant to the extreme.”

Members of the dental board remarked during public meetings about how “unique” LaFeber’s case was, and they questioned what the right metric would be to determine whether his dentistry had improved and he was safe to work with patients.

Utah licensors rarely discipline dentists over whether they are competent to do their jobs, an analysis by The Tribune and ProPublica found. A review of disciplinary records from the last decade shows dentists most often getting in trouble for drug or alcohol use or for overprescribing or diverting prescriptions.

Hall, the licensing division spokesperson, said the agency does not track how many standard-of-care complaints it receives, but acknowledged that proving those types of cases tends to be difficult.

“As a result, they are less likely to lead to disciplinary actions compared to cases involving drug use, unlawful behavior, or practicing outside one’s scope of practice,” she said.

But tension was growing between LaFeber and the dental board: While LaFeber had taken a few online, self-paced courses, board members felt he needed more intensive, hands-on classes to improve.

A breaking point between LaFeber and the board occurred near the end of LaFeber’s probation. At the December 2022 dental board meeting, LaFeber peppered members with questions about the board’s role governing probationers and implied that a board member had acted improperly by soliciting complaints about him.

The board seemed equally frustrated; LaFeber still hadn’t enrolled in the hands-on courses they had required him to take, programs that could have cost up to $50,000. LaFeber had instead taken a licensure exam and failed several sections, according to a copy of the exam results obtained by The Tribune and ProPublica, which was also referenced in the 2023 agency order.

LaFeber did not respond on the record to questions about these test results.

Given the test results, Poulson, who had become board chair, said in the public meeting that he worried whether LaFeber would be able to practice dentistry safely by the following February, when his probation period would end.

“I have two doctors that once tried to buy your practice. They gave it back because they were so disgusted with all the problems they were having with patients,” Tillmann, one of the board members, said in that same meeting, recalling previous conversations he had.

LaFeber’s practice, Sandy Center Dental. LeFeber was not required to tell his current or future patients about his probation. (Francisco Kjolseth/The Salt Lake Tribune)

Poulson suggested that the group make a motion recommending that the state licensing division either revoke or suspend LaFeber’s license, saying that the action would be “protecting the public from inferior care.” The board unanimously voted to recommend revocation.

A few months later, Marx issued the agency order stating that LaFeber’s license should be suspended until he could demonstrate he could practice dentistry “with reasonable skill and safety.”

LaFeber, though, had one more chance to respond before the suspension would take effect. Soon after the agency order, LaFeber enrolled in and completed his remedial training. He also hired an attorney who signaled his intent to fight the agency’s action, according to public records.

In response, Marx requested that the agency’s move to suspend LaFeber’s license be dismissed, noting that LaFeber said he had delayed complying with the dental board’s requirement that he complete further training because of “financial limitations.” Then, Steinagel reinstated LaFeber’s license.

By this point, Steinagel’s agency knew not only about the reports of patients with improper tooth implants and the failed root canals that led to LaFeber’s probation, it also knew the state dental board had recommended that LaFeber’s license be revoked.

In addition, the agency was aware LaFeber had been sued three times for medical malpractice — including by a patient who alleged he had implants placed in his sinuses, which caused sepsis, and another patient who said in her lawsuit that, after months of painful infections, she went to another dentist who found a broken dental instrument lodged in her gums. (LaFeber told The Tribune and ProPublica these lawsuits were settled by his medical malpractice insurance carrier and there was never any determination made that his treatment fell below the standard of care.)

LaFeber said in response to questions that he was not aware of any recommendation from the board to revoke his license — though according to recordings and minutes of the public dentistry board meetings, he was present when the dentistry board took its vote. The board’s revocation recommendation is also referenced in the agency order he received, which The Tribune and ProPublica obtained through a public records request.

The dentist said he felt he was treated fairly by licensors and most members of the dentistry board, but added that he felt one board member did not disclose a conflict of interest and had a “personal vendetta” against him. LaFeber did not respond on the record to follow-up questions asking for further details. He said he complied with every request by licensors and its dentistry board and “even went above and beyond” by taking additional continuing education. He noted that he passed the remediation courses and related tests that the board had requested.

“I also worked with a supervising dentist, at significant expense, who reviewed my work and provided mentoring for 3 years between 2020 and 2023,” LaFeber wrote.

After taking these courses, he said, he has been able to incorporate new technology in his practices that has improved patient outcomes. “Dentistry is an area that is constantly evolving with so much new technology,” he said, “and I welcome all information sources that can help me improve my practice.”

The Tribune and ProPublica asked the two former board members who spoke to the news organizations whether their vote to recommend LaFeber’s license be revoked would have changed if they had the opportunity to weigh in again after he had completed his remedial training.

One former board member said they didn’t think the training completed to satisfy the state was enough to overcome years of poor dentistry. Another said that nothing seems to have changed given new patient complaints. Three board members who were involved in LaFeber’s case declined to comment for this story, and four others could not be reached.

New Patients Say They Were Harmed

With his license restored, LaFeber started to once again grow his business. Public records show he still owns Sandy Center Dental, and in July 2024 he got a business license for a second clinic about 10 miles to the west. (An online ad this summer indicated LaFeber was trying to sell his second practice.)

LaFeber is referenced as the sole dentist on websites for both of these businesses. In his response to The Tribune and ProPublica, he said he owns and operates a single office, Sandy Center Dental, where he works four days a week. A Sept. 23 search of public business records show he is still listed as the registered agent and principal for both practices. LaFeber said he helped start the second office, Parkway Smile Center, but said it is now “entirely owned and managed by another dentist.” The new owner could not be reached for comment.

In the nearly two years since LaFeber’s full return to practice, at least two more patients have publicly complained they were harmed under his care, both of whom The Tribune and ProPublica contacted after they left negative online reviews.

Michelle Lipsey had been a patient at Sandy Center Dental for nearly eight years, but she said in an interview that she hadn’t been to the dentist for a couple years after her second child was born. She said LaFeber told her during an October 2024 appointment that she needed five cavities filled. She returned a week later for the procedures.

For weeks after, Lipsey was in pain, and she returned to Sandy Center Dental later that month, complaining that she couldn’t sleep and was only able to eat soft food, according to her medical records. LaFeber redid some of the fillings, medical records show, but Lipsey said the pain persisted. She said a second dentist told her that LaFeber hadn’t properly sealed the fillings and had drilled far deeper than he needed to.

LaFeber noted in her medical records that he tried to call and text Lipsey after she left a negative review online. “Remember patient was very nervous,” her patient file reads. “We tried our best to help calm but at no point had the appointment gone as she described in the post.”

Haley Stafford described a similar experience earlier this year. She said that, based on what LeFeber told her, she was expecting to have two cavities filled during a March appointment; instead, he put fillings in seven teeth. She recalled in an interview that his hands shook when he gave her numbing shots. (The testing exam results reviewed by The Tribune and ProPublica also noted LaFeber’s unsteady hands.)

“That was the first time he actually did work on me,” she said. “And it was completely botched.”

She’s been in near-daily pain since, she said, and has needed more dental work on her affected teeth, including two root canals. Stafford found a new dentist, but the repair work has cost her thousands of dollars.

Both Stafford and Lipsey said LaFeber contacted them about refunding their money.

LaFeber said he doesn’t recall refunding money to any patients after a complaint. He said he could not comment on specific cases to protect patient privacy, but said that sensitivity and pain can happen after a treatment.

“We try to do all we can to minimize it,” he said. “The presence of pain does not demonstrate treatment that fell below the standard of care.”

Lipsey filed a complaint with licensors in late July and said she was interviewed by an investigator and shared X-rays from before and after LaFeber filled her cavities.

Licensors sent Lipsey an email in late August saying that they were closing the case and that “appropriate action was taken,” according to a screenshot of the email Lipsey shared with The Tribune and ProPublica. They would not tell her what that action was, saying the investigative record was considered private under Utah law. Licensing officials declined to comment on the outcome of Lipsey’s complaint.

If licensors had disciplined LaFeber, it would be considered a public record. The agency has the option to address a complaint informally by giving a verbal warning to a licensed professional or writing a letter of concern. Those measures typically are not disclosed to the public.

LaFeber told The Tribune and ProPublica that Lipsey’s complaint was dismissed and he did not receive any warnings or a letter of concern. Licensors “investigated it thoroughly and found it to be meritless,” he said.

LaFeber’s license remains in good standing, according to the state’s licensing database in September.

Stafford hasn’t filed a complaint with the state and said she had no idea LaFeber had nearly lost his license until a reporter reached out to her.

How does a dentist nearly “lose their license and get it back,” she asked, “and patients are not aware of that?”

This post was originally published on ProPublica.