A July ruling by a three-judge panel of the 9th U.S. Circuit Court of Appeals upheld California’s right to mandate that every course doctors take to remain licensed must address how bias contributes to poorer health outcomes for racial and ethnic minorities. The ruling against the nonprofit and Los Angeles ophthalmologist Azadeh Khatibi amounts to a victory for California as it fights the Trump administration and right-leaning advocacy and legal groups’ attacks on perceived “wokeness.”

In August, the Pacific Legal Foundation, which represents Do No Harm and Khatibi, asked that a panel of 11 appellate judges reconsider what attorney Caleb Trotter characterized as a “very clearly wrong” decision. Trotter, a senior attorney for the Pacific Legal Foundation, expects the court’s response in October. If the appeal fails, he said, his firm would likely appeal to the U.S. Supreme Court. At stake, legal scholars say, is the latitude of states to prescribe educational content, including health equity training, for licensed professionals.

“The general recent tenor of the Supreme Court’s First Amendment jurisprudence has been very speech protective, so that we would like our odds with, of course, the understanding that any attempt to get the Supreme Court to take your case is a long shot,” Trotter said.

Erwin Chemerinsky, dean of the University of California-Berkeley law school, described the chances of the Supreme Court taking the case as “very unlikely” and the appellate ruling as “clearly correct” in affirming the state’s authority to impose course requirements.

California began requiring implicit-bias training for physicians in 2022. From 2019 through July 2022, enacted legislation mandating the training. California is the only state that requires it to be included in every course involving direct patient care.

In enacting the law, the legislature found that bias contributed to health care disparities and persisted regardless of other factors influencing care. Black women, for example, are often prescribed less pain medication than white women with the same complaints and are as white women to die of pregnancy-related causes.

Bias does influence clinical care and contribute to health care disparities, a concluded. Implicit-bias training, however, might have no impact and might even worsen care, the report noted.

and Khatibi alleged that violated their First Amendment rights. Khatibi acknowledges that unconscious bias might prejudice how clinicians treat patients. But the Los Angeles ophthalmologist does not believe she should be forced to carve out time to talk about it in a class she might teach on, for example, ocular tumors.

“The government is mandating doctors endorse a specific ideology or priority instead of science,” she said. “I believe government should not mandate or compel the speech of doctors.”

The three-judge appellate panel disagreed. No one is forcing Khatibi to teach state-accredited continuing education, the panel wrote in its a lower court’s decision that the state had the right to mandate the training. The judges found that the curriculum requirement constitutes government speech and, therefore, is not subject to free-speech protections.  

The does not dispute the state’s authority to require physicians to learn about unconscious prejudices. Instead, it argues the state has no right to demand that all teachers discuss bias in every continuing medical education class. California physicians must take at least 50 hours of continuing education every two years. Private institutions offer the courses, and physicians generally teach them.

Rep. Sydney Kamlager-Dove (D-Calif.), who wrote the bill when she was a member of the state Assembly, defended it. “By connecting every provider to consistent and evolving training, we can help close these gaps and provide more equitable care,” she said.

The Medical Board of California declined to comment.

Ashutosh Bhagwat, a UC Davis School of Law distinguished professor, said the state has a right to require implicit-bias training, although he disagrees that the training constitutes government speech. He sees it as private, but not compelled, speech because Khatibi and other instructors need only include a discussion of implicit bias if they want their classes to qualify for state licensing credit.

He likened the requirement to that of an accredited private school having to teach math. “Doesn’t matter if you don’t want to teach math. Doesn’t matter if you don’t believe in math,” he said. “You have to teach math.”

Bhagwat sees Khatibi’s case as “very weak.” But he said he could not predict anything the Supreme Court, with its six-justice conservative majority, might do.

“If Khatibi wins in the Supreme Court, or at any level, then chaos reigns because now every single requirement in any licensure that says you must teach this to qualify for continuing education is up for grabs,” he said.

Trotter fears the opposite outcome. If allowed to stand, the implicit-bias training mandate could be extended to continuing education for 50 trades and professions in California alone, he said. “Then all kinds of governments based on all kinds of views can start requiring private speakers to say all kinds of things that, depending on where you are, are going to be controversial in all different kinds of ways,” he said.

While Khatibi’s lawsuit and others like it have had little success in the courts, said Joan Williams, a distinguished professor emerita at UC Law-San Francisco, they have chilled the creation of laws deemed “woke” or those favoring diversity, equity, and inclusion, known as DEI.

“There’s been this huge attack on DEI, and it’s been extraordinarily effective in creating regulatory risk such that people are apprehensive and self-editing because they don’t want to put a target on their backs,” said Williams, who directs the .

Still, some supporters of bias training say California could refine its approach. Cristina Gonzalez, an internist and a New York University Grossman School of Medicine professor, designs and evaluates interventions to help recognize, prevent, and repair clinicians’ prejudices. She described implicit-bias training as “a science” and California’s approach as misguided because it requires all instructors, regardless of their knowledge of implicit bias, to teach the material.

Finger-wagging and blaming in implicit-bias training can lead doctors to become defensive and avoid patients, but done correctly, by experts, it does work, Gonzalez said. “The messaging has to be, ‘You’re not a bad person,’” she said.

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“I see you went popcorn-crazy this weekend,” Owens teased as she brushed kernels off the counter into a garbage can. Crooks, who relies on a walker or wheelchair, can steady herself against the counter while waiting for corn to pop. But back, knee, and foot problems have left the 77-year-old silver-haired retired teacher incapable of most food preparation and cleanup.

Like nearly 800,000 other Californians, Crooks depends on aides from In-Home Supportive Services, a program funded through Medi-Cal, California’s version of Medicaid. Owens has worked as Crooks’ aide for almost three years. In addition to cooking and cleaning, she helps her shower, shops for groceries, drives her to medical appointments, and runs other errands.

For more than 50 years, low-income seniors and disabled people have been able to stay in their California homes — and out of — with help from government-paid aides. But in their latest bid to renew President Donald Trump’s tax cuts, House Republicans released a plan on May 11 that would over 10 years from Medicaid, and could threaten funding for Owens and other In-Home Supportive Services workers.

While a major structural overhaul of Medicaid appears increasingly unlikely, with how to cut the budget. Several proposals would disproportionately target California, according to Larry Levitt, KFF’s executive vice president for health policy. Federal cuts, coupled with the state’s existing budget woes, could inflict a “double whammy for California and trigger reductions in Medi-Cal and other state programs,” he said. KFF is a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Although federal law compels states to offer certain services, such as nursing home care, they’re to cover home-based care for low-income seniors and disabled people like Crooks, leaving the in-home services program to cuts, said Amber Christ, managing director of health advocacy for the nonprofit legal group Justice in Aging.

In the wake of the Great Recession, California made a series of funding cuts to in-home support aides. Lawsuits temporarily stopped the bulk of the cuts, but a led to an 8% reduction in 2013 and an additional 7% cut in 2014.

Further reducing these services would inevitably force more people to move into nursing homes, Christ said. “It would be an enormous setback from the progress we have made to provide care in the home and the community to support older adults and their families,” she said. “I think it will cost people’s lives.”

Owens supports herself and her teenage son with what she earns working 136 hours a month for Crooks. She’s confident she can figure out another way to make a living, so she’s less worried about losing her $20-an-hour income than she is about Crooks’ losing her independence.

“I absolutely adore Carol,” said Owens, 36, as she chopped onions for Crooks’ breakfast. “I look at her as a grandma.”

From a makeshift desk where she’d been scrolling through emails, Crooks affectionately eyed Owens and announced, “You’re adopted.”

In his May 14 , Gov. Gavin Newsom trimmed funding for In-Home Supportive Services, most notably by putting weekly caps of 50 hours on provider overtime and travel, reinstating an asset limit, and eliminating the service for immigrant adults without legal status who aren’t already enrolled.

The proposed changes are unlikely to affect Crooks, but if congressional Republicans slash Medicaid spending, the Democratic governor , California could not afford to backfill all the proposed federal cuts. Almost two-thirds of the $28.3 billion California has budgeted for the in-home support program is supposed to come from endangered federal Medicaid funding. The state legislature must pass a balanced budget by June 15, regardless of the status of federal funding negotiations.

Owens delivered an omelet and a mug of coffee to Crooks. “I know these are politicians,” she said, “but they still have to understand the elders are our roots. And I’m sure they have to have some kind of heart.”

Crooks is less certain, more anxious. “If they start messing with my programs,” she said, “I’m in trouble.”

Burt Conell, 64, is also worried. A paraplegic, he’s been confined to a wheelchair for 30 years, since, despondent after his girlfriend left him, he jumped in front of a train. He relies on in-home aides to help him bathe and clean his San Francisco apartment.

When he heard the government might cut his funding, he imagined being unable to shower, getting rashes and bedsores, and having to move into a nursing home. Again, he contemplated suicide.

“It made me feel like I was using so much resources that I shouldn’t exist,” he said.

At an of San Francisco’s Disability and Aging Services Commission, Commissioner asked about the fate of In-Home Supportive Services, on which she relies. “We don’t know what’s going to happen,” Executive Director Kelly Dearman replied, adding that Medicaid cuts could result in a decrease in the number of hours San Francisco beneficiaries, like Conell and Bittner, who is quadriplegic with a speech disability, receive. “It’ll be dire,” Dearman concluded.

Every day, around 30 people contact California Advocates for Nursing Home Reform seeking advice on how to get in-home help, said Maura Gibney, the nonprofit’s executive director. These days, the group frequently hears from recipients who have achieved a semblance of normalcy in the aftermath of a major setback, such as a stroke, but fear they’ll lose their benefits, she said.

“It’s hard to really give people reassurance at this time because I don’t think any of us know what will happen,” Gibney said.

Lately, when she hears from people looking for in-home help for the first time, Gibney wonders if their efforts will end up being pointless. “It feels a little bit like trying to show somebody how to get into the building as the top floor is on fire,” she said.

Paul Dunaway, who directs Sonoma County’s Adult and Aging Division, described the dearth of information he and his staff have to offer older and disabled people about future services as “anxiety-provoking.”

“There’s a lot of chaos happening and not much to really grab onto yet about the funding on the federal level,” Dunaway said.

Uncertainty and fear about service cuts, coupled with weaning off pain medicine from a back surgery, left Crooks — who retired from teaching after being diagnosed with bipolar disorder — unable to sleep, she said, and she spiraled into her first manic episode in more than a decade.

Owens was sweeping the living room but stopped to listen as Crooks talked about being tired, worried, and feeling out of control. “I told her, ‘Regardless, I’m gonna always be here for you, no matter what,’” Owens said.

Crooks, wearing a T-shirt picturing the Statue of Liberty with her hands covering her face, nodded. “It helped a lot,” she said.

Nonetheless, without an in-home aide, Crooks said, she would have no choice but to move into a nursing home — a fate she cannot bear to consider.

“It wouldn’t be a home,” she said. “It’s where people go to die.”

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No one would say. “I asked like three times a day. It was brushed off,” Tomasek said, relaying her story by phone as she cradled Ezekiel, now 6 months old, in their San Jose apartment. She was told only that more tests were being run to ensure “everything’s good before you leave.”

She knew that her intensifying anger and fear about the holdup could raise her blood pressure, that Black pregnant women and new mothers are especially , and that it could kill her. Distraught, she called the person she most trusted to calm her, a caseworker for Santa Clara County’s Black Infant Health program.

“She really did help me to stay centered,” Tomasek said of the caseworker, who tracked her health throughout the pregnancy. “I felt a lot better.”

Since 2000, approximately 14,000 families have participated in Santa Clara County’s Black Infant Health program and related Perinatal Equity Initiative, both aimed at decreasing racial disparities in maternal and infant health. Enrolled mothers are assigned caseworkers and nurses who visit them at home to monitor blood pressure and other vital signs, help with breastfeeding, and screen infants for developmental delays. The mothers also attend support groups to learn skills to buffer the well-documented effects of .

The programs have measurably improved the health of enrolled women over the past decade, county , reducing rates of maternal hypertension — a leading cause of pregnancy-related deaths — by at least 30% and increasing screenings for other potentially life-threatening conditions.

Experts in the field and program participants stress that this work is urgent — in California, Black women are at least three times as likely as white women to die from pregnancy-related causes, and, nationally, Black infants have the highest rates of preterm birth and mortality.

While advocates for Black mothers laud the programs’ results as cause for optimism, they are concerned that the climate against diversity, equity, and inclusion, or DEI, initiatives could impede progress. Efforts to improve the health of this at-risk population have been targets of private lawsuits before, but since President Donald Trump took office, he has of all “‘equity-related’ grants” and against programs he claims illegally favor one racial group over another — even when they are designed to save lives, as is the case with the Santa Clara efforts.

Santa Clara County has received most of the $1 million-plus in federal funding it expects for Black Infant Health and the Perinatal Equity Initiative programs for the fiscal year ending in June. But county officials say it’s unclear how much, if any, of the remaining money — which comes from the federal health department’s Health Resources and Services Administration and Centers for Medicare & Medicaid Services — is at risk amid federal anti-DEI policies and the at the Department of Health and Human Services. The status on funding for the coming fiscal year is also unknown, county officials said.

Santa Clara stands to lose more than in public health funds due to the federal cuts, including money used to help deliver health services to underserved communities. A already terminated includes millions of dollars from at least three programs in other states focused on Black birth outcomes.

Any decrease in federal funding for these types of programs could have dire consequences, said Angela Aina, cofounder and executive director of . “We will likely see an increase in deaths,” she predicted.

Aina’s group pilots research and promotes public policy on behalf of 40 U.S. community-based organizations focused on Black maternal health. Member programs connect pregnant women to health care, counseling, and nutritional and breastfeeding advice, among other things.

If these services are cut, advocates fear, the progress made toward reducing racial disparities in birth outcomes could backslide. that eliminating such focused efforts could exacerbate the inequities, worsen the nation’s health, and increase health care costs overall.

“Our stakeholders are in a state of confusion right now because the federal workers that still have a job are not allowed to communicate, or there’s some kind of muzzle on their communication,” Aina said. “We don’t know — are we going to receive the rest of those grant funds?”

When asked how the state would respond to federal budget cuts to programs like Black Infant Health, Brian Micek, a California Department of Public Health spokesperson, said only that the agency remains “committed to protecting Californians’ access to the critical services and programs they need” and steadfast in its mission to “advance the health and well-being of California’s diverse people and communities.”

Requests for comment from the federal departments responsible for the grants funding Santa Clara’s programs went unanswered.

Communications directors from groups working on reducing racial disparities in birth outcomes declined to be interviewed for this article, citing fears of retribution.

Tonya Robinson, program manager for Black Infant Health, stands defiant in the face of these threats. She sees the federal government’s anti-DEI crusade as an invitation to practice the very skills they teach.

“Our program is working,” Robinson said. “And the way it’s working is by empowering women, giving women voices to help them stand up for what is right, and to recognize discrimination and the impact of structural racism on their bodies.”

The government’s antagonism toward her work inspires Robinson to soldier on calmly as a role model for the women she serves.

“We’re continuing to forge ahead,” Robinson said. “We want to make sure that we can be an example of how to manage stress at this time, in front of our clients.”

Evidence surfaced that childbirth was deadlier for African American women than white women more than a century ago. But the issue did not gain significant public attention until 2018, when and began airing their harrowing birth stories, highlighting the striking vulnerability of Black pregnant women and new mothers, even those with unlimited means.

In 2021, then-President Joe Biden proclaimed a week in April Black Maternal Health Week. A marking that week in 2024 read that “when Black women suffer from severe injuries or pregnancy complications or simply ask for assistance, they are often dismissed or ignored in the health care settings that are supposed to care for them.”

Eboni Tomasek certainly felt ignored.

Three days after giving birth in September — and after her Santa Clara caseworker reminded her she had a right to know why she wasn’t being released — a nurse finally explained that Tomasek’s blood pressure had been too high for the hospital to safely discharge her.

Had she been white, Tomasek believes, the staff would have informed her sooner. “I feel like they were being racist,” she said. She credited her training through Black Infant Health with her ability to calm herself and help lower her blood pressure, allowing her to leave that day with Ezekiel.

Jamila Perritt, president and CEO of Physicians for Reproductive Health, believes that the poor health outcomes Black women and infants face have historical roots and will change only with the help of programs that, like those in Santa Clara, address conditions facing Black women.

“What we’re seeing in terms of maternal mortality are race-bound conditions,” said Perritt, an obstetrician who co-chairs Washington, D.C.’s Maternal Mortality Review Committee. “Our policies cannot be race-blind if we’re attempting to address them.”

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She could have reached Plumas District Hospital, in Quincy, in just seven minutes. But it no longer delivers babies.

Local officials have a plan for a birth center in Quincy, where midwives could deliver babies with backup from on-call doctors and a standby perinatal unit at the hospital, but state health officials have yet to approve it.

That left Mazar to brave the long, winding road — one sometimes blocked by snow, floods, or forest fires — to have her baby. Women across California are facing similar ordeals as hospitals increasingly close money-losing maternity units, especially in rural areas.

Midwife-operated birth centers offer an alternative for women with low-risk pregnancies and can play a crucial role in filling the gap left by hospitals’ retreat from obstetrics, maternal health advocates say.

Declining birth rates, staffing shortages, and financial pressures have led — about 1 in 6 — to shutter maternity units over the past dozen years.

But midwives say California’s regulatory regime around birth centers is unnecessarily preventing new centers from opening and leading some existing facilities to close. Obtaining a license can take as long as four years.

“All they’ve essentially done is made it more dangerous to have a baby,” said Sacramento midwife “People have to drive two hours now because a birth center can’t open, so it’s more dangerous. People are going to be having babies in cars on the side of the road.”

Last month, state Assembly member Mia Bonta to streamline the regulatory process and fix what she calls “a broken system” for licensing birth centers.

“We know that alternative birth centers lead to often better outcomes, lower-risk births, more opportunity for children to be born healthy, and also to lower maternal mortality and morbidity,” she said.

The proposed bill would remove various bureaucratic requirements, though many details have yet to be finalized. Bonta introduced the bill in its current form as a jumping-off point for discussions about how to expedite licensing.

“It’s a starting place,” said Sandra Poole, health policy advocate for the Western Center on Law & Poverty, a co-sponsor of the legislation.

For now, birth centers struggle with a gantlet of rules, only some clearly connected to patient safety. Over the past decade, the number of licensed birth centers in California dropped from 12 to five, according to Bonta.

Plumas County officials are trying to address one key issue: how far a birth center can be from a hospital with a round-the-clock obstetrics unit. State regulations say it can be no more than a 30-minute drive, a distance set when many more hospitals had maternity units.

The first-of-its-kind “” aims to take advantage of flexibility provisions in the law to address the obstacle in a way that could potentially be replicated elsewhere in the state.

But the hospital’s application for a birth center and a perinatal unit has been “languishing” with the California Department of Public Health, which is “looking for cover from the legislature,” said Robert Moore, chief medical officer of Partnership HealthPlan of California, a Medi-Cal managed-care plan serving most of Northern California. Asked about the application, a CDPH spokesperson said only that it was under review.

The goal should be for all women to be within an hour’s drive of a hospital with an obstetrics unit, Moore said. Data shows the complication rate goes up after an hour and even higher after two hours, he said, while the benefit is less compelling between 30 and 60 minutes.

Numerous other regulations have made it difficult for birth centers to keep their doors open.

Since August, birth centers in and have had to stop operating because their heating ducts failed to meet licensing requirements. The facilities fall under the same state as primary care clinics, though birth centers see healthy families, not sick ones, and don’t need hospital-grade ventilation, said midwife Caroline Cusenza.

She had spent $50,000 remodeling the Monterey Birth & Wellness Center to include state-required items, such as nursing and hand-washing stations and a housekeeping closet. In the end, a requirement for galvanized steel heating vents, which would have required opening the ceiling at an unaffordable cost, prompted her heart-wrenching decision to close.

“We’re turning women away in tears,” said Sasaki, who owned Midtown Birth Center in Sacramento. She bought the building for $760,000 and spent $250,000 remodeling it in a way she believed met all licensing requirements. But regulators would not license it unless the heating system was redone. Sasaki estimated it would have cost an additional $50,000 to bring it into compliance — too much to keep operating.

She blamed her closure on “regulatory dysfunction.”

by Gov. Gavin Newsom last year could ease onerous building codes such as those governing Sasaki’s and Cusenza’s heating systems, said Poole, the health policy advocate.

The state has taken two to four years to issue birth center licenses, by the Osher Center for Integrative Health at the University of California-San Francisco. The state Department of Public Health “works tirelessly to ensure health facilities are able to be properly licensed and follow all applicable requirements within our authority before and during their operation,” spokesperson Mark Smith said.

Bonta, an Oakland Democrat who chairs the Assembly’s health committee, said she would consider increasing the allowable drive time between a birth center and a hospital maternity unit as part of her new legislation.

The state last updated birth center regulations more than a decade ago, before hospitals’ mass exodus from obstetrics. “The hurdle is the time and distance standards without compromising safety,” Poole said. “But where there’s nothing right now, we would say a birth center is certainly a better alternative to not having any maternal care.”

Moore noted that midwife-led births in homes and birth centers are the mainstay of obstetric care in Europe, where the infant mortality rate is than in the U.S. More than 98% of American babies are born .

Babies delivered by midwives are more likely to be born vaginally, less likely to require intensive care, and more likely to breastfeed, the has found. Midwife-led births also lead to fewer infant emergency room visits, hospitalizations, and neonatal deaths. And they cost far less: Birth centers generally charge one-quarter or less of the average cost of for a vaginal birth in a California hospital.

If they catered only to private-pay clients, Cusenza and Sasaki could have continued operating without licenses. They must be licensed, however, to receive payments from Medi-Cal and some private insurance companies, which they needed to remain in business. Medi-Cal, the state’s Medicaid health insurance program, which covers low-income residents, paid for about in 2022.

Bonta has heard reports from midwives that the key to getting licensed is hunting down the right state health department advocate. “I don’t believe that we should be building resources based on the model of ‘Where’s Waldo?’ in finding a champion inside CDPH,” she said.

, director of midwifery at Plumas District Hospital, believes the Plumas model can turn what’s become a maternity desert into an oasis. Jessie Mazar, whose son was born in September without complications at a Truckee hospital, would welcome the opportunity to deliver her planned second child in Quincy.

“That would be convenient,” she said. “We’re not holding our breath.”

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Five decades later, with in almost all circumstances, the University of California-San Francisco breast cancer surgeon has once again taken up the fight for women’s reproductive rights. Since 2021, when Texas prohibited most abortions, she the — a conference she had regularly attended, and frequently headlined, for 34 years.

“People are passing laws that are legislating what should be a medical decision,” she said. “And I am objecting in whatever way I can.”

and have urged their colleagues and medical societies to move all professional meetings out of states that criminalize abortion. Short of a move, they have called for boycotts of the events.

In November, Esserman expects 300 health providers and researchers to meet in San Francisco for an .

The effort to move annual conferences — which pump substantial revenue into local communities and attract many of the nation’s and other medical professionals looking to network, satisfy continuing education requirements, and learn about the latest developments in their fields — has led to some notable relocations.

The and an estimated 4,000 participants from New Orleans to Maryland in response to Louisiana’s abortion ban. An estimated 3,600 health care professionals attended the ’ conference in Chicago this year, after the group moved the meeting from its planned Phoenix location in response to Arizona’s restrictive abortion law.

“In addition to causing great physical and psychological harm to patients,” the association said in , abortion bans “threaten irreparable damage to the private and trusted relationship between medical professionals and their patients.”

Yet even doctors who agree about reproductive rights disagree about how to express dissent. it’s more important than ever to visit states where abortion has been outlawed, to learn about the issues surfacing because of the laws, and to help people organize against them.

“We cannot support penalizing communities that are already harmed by this legislation,” said obstetrician and gynecologist , president and CEO of Physicians for Reproductive Health. “As opposed to withdrawing support, what we’re calling for is actually flooding those folks with support.”

has been providing security for doctors targeted by anti-abortion activists, Perritt said, and training doctors to teach abortion care in abortion-restricting states and to testify to state legislatures about the need for abortion access.

“There is a lot to be gained by coming to these states, supporting us, seeing the reality, and bringing these conversations into your conference space so that you can better understand our reality, rather than just boycotting that state completely, which is not helpful,” said , chief medical officer for Planned Parenthood of Greater Ohio and a medical director for Planned Parenthood Gulf Coast in Texas and Louisiana.

Since the Supreme Court’s 2022 decision to overturn Roe and eliminate a federal constitutional right to abortion, all but nine states and Washington, D.C., have imposed abortion restrictions, according to the .

The San Antonio Breast Cancer Symposium continues to be held in Texas, where abortion is banned in almost all instances, and boycott calls do not appear to have slowed turnout. In fact, the number of in-person attendees increased from just under 8,000 in 2019 to 8,220 last year, organizers said.

Breast oncologist a University of Texas Health Science Center-San Antonio professor of medicine who co-directs the San Antonio symposium, plans to stay in Texas. She doesn’t believe in boycotts, though she does share boycott proponents’ concerns. Despite exceptions, such as the , doctors have by and large .

“I think the way to handle it is to talk to our elected officials, to go out and vote. Moving meetings from one place to another is not going to help,” Kaklamani said. “You stay and you fight for your patients.”

Esserman recognizes that boycott calls have not had significant impact, but she feels compelled to keep applying pressure anyway.

She can’t help but think about a patient who recently came to her San Francisco practice nine weeks pregnant and with an aggressive breast cancer. If she were to continue the pregnancy, she would be ineligible for the most effective treatment. “Where I live, she has a choice,” Esserman said. In some states, she would have no choice but to carry the pregnancy to term.

Cary Gross, a Yale School of Medicine professor who co-authored a JAMA Internal Medicine opinion piece last year advocating boycotts, cited three arguments: expressing the profession’s values, acting as an ethical consumer, and protecting the health of attendees. Women physicians of childbearing age have voiced fears about traveling to anti-abortion states, especially while pregnant.

“The legislators passing these laws are probably not going to change their stance,” Gross said. “But for the general population, the more you can do to alert people, to remind people there’s another way, you have to make your voice heard.”

Still, Gross, Esserman, and others pushing for boycotts can point to no evidence that their efforts have changed hearts and minds, let alone laws.

Instead of moving the American Society of Hematology’s 2022 meeting out of New Orleans after Louisiana imposed a trigger law to ban abortion, Jane Winter, the society’s president at the time, met with Louisiana’s then-governor, John Bel Edwards, and told him about women whose survival might depend on getting an abortion. They talked about her 22-year-old patient who had Hodgkin lymphoma and learned she was pregnant just before a planned stem cell transplant.

“Gov. Edwards was visibly moved by our clinical cases and shared that lawmakers had not considered the impact of abortion restrictions on the care of our patients,” in a column for The Hematologist.

Last year, the hematologists held their meeting in San Diego, and they will meet again in California, which has no post-Roe abortion restrictions, in December.

In an email, Winter said her conversation with Edwards changed nothing concrete, as far as she knows. But she added, “I do believe that telling the stories of specific individuals – in my case, those of my patients – is one way to begin to change minds.”

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UC-San Francisco’s renowned nursing school will graduate its final class of certified nurse-midwives next spring. Then the university will cancel its two-year master’s program in , along with other nursing disciplines, in favor of a three-year doctor of nursing practice, or DNP, degree. The change will pause UCSF’s nearly five decades-long training of nurse-midwives until at least 2025 and will more than double the cost to students.

State Assembly member Mia Bonta, who chairs the health committee, said she was “disheartened” to learn that UCSF was eliminating its master’s nurse-midwifery program and feared the additional time and costs to get a doctorate would deter potential applicants. “Instead of adding hurdles, we need to be building and expanding a pipeline of culturally and racially concordant providers to support improved birth outcomes, especially for Black and Latina birthing people,” she said in an email.

The switch to doctoral education is part of a national movement to require all advanced-practice registered nurses, including nurse-midwives and nurse practitioners, to earn doctoral degrees, Kristen Bole, a UCSF spokesperson, said in response to written questions. The doctoral training will feature additional classes in leadership and quality improvement.

But the movement, which dates to 2004, has not caught on the way the American Association of Colleges of Nursing envisioned when it called for doctorate-level education to be required for entry-level advanced nursing practice by 2015. That deadline came and went. Now, an acute need for maternal health practitioners has some universities moving in the other direction.

This year, Rutgers University reinstated the nurse-midwifery master’s training it had eliminated in 2016. The also restarted its master’s in nurse-midwifery program in 2022 after a 25-year hiatus. In addition, in Washington, D.C., in New Orleans, and the added master’s training in nurse-midwifery.

UCSF estimates tuition and fees will cost $152,000 for a three-year doctoral degree in midwifery, compared with $65,000 for a two-year master’s. that 71% of nursing master’s students and 74% of nursing doctoral students rely on student loans, and nurses with doctorates earn negligibly or no more than nurses with master’s degrees.

Kim Q. Dau, who ran UCSF’s nurse-midwifery program for a decade, resigned in June because she was uncomfortable with the elimination of the master’s in favor of a doctoral requirement, she said, which is at odds with the state’s workforce needs and unnecessary for clinical practice.

“They’ll be equally prepared clinically but at more expense to the student and with a greater time investment,” she said.

are registered nurses with graduate degrees in nurse-midwifery. Licensed in all 50 states, they work mostly in hospitals and can perform abortions and prescribe medications, though they are also trained in managing labor pain with showers, massage, and other natural means. Certified midwives, by contrast, study midwifery at the graduate level outside of nursing schools and are licensed only in some states. Certified professional midwives attend births outside of hospitals.

The California Nurse-Midwives Association also criticized UCSF’s program change, which comes amid a national maternal mortality crisis, a serious shortage of obstetric providers, and a growing reliance on midwives. According to the 2022 “” report, the U.S. has the highest maternal mortality rate of any developed nation and needs thousands more midwives and other women’s health providers to bridge the swelling gap.

, founder and CEO of Grow Midwives, a national consulting firm, likened UCSF’s switch from master’s to doctoral training to “an earthquake.”

“Why are we delaying the entry of essential-care providers by making them go to an additional year of school, which adds nothing to their clinical preparedness or safety to serve the community?” asked Breedlove, a past president of the American College of Nurse-Midwives. “Why they have chosen this during one of the worst workforce shortages combined with the worst maternal health crisis we have had in 50 years is beyond my imagination.”

A 2020 report published in failed to find that advanced-practice registered nurses with doctorates were more clinically proficient than those with master’s degrees. “Unfortunately, to date, the data are sparse,” it concluded.

The American College of Nurse-Midwives also , as have trade associations for , citing “the lack of scientific evidence that … doctoral-level education is beneficial to patients, practitioners, or society.”

There is no evidence that doctoral-level nurse-midwives will provide better care, Breedlove said.

“This is profit over purpose,” she added.

Bole disputed Breedlove’s accusation of a profit motive. Asked for reasons for the change, she offered broad statements: “The decision to upgrade our program was made to ensure that our graduates are prepared for the challenges they will face in the evolving health care landscape.”

Like Breedlove, , vice chair of the health policy committee for the , worries that UCSF’s switch to a doctoral degree will exacerbate the twin crises of maternal mortality and a shrinking obstetrics workforce across California and the nation.

On average, 10 to 12 nurse-midwives graduated from the UCSF master’s program each year over the past decade, Bole said. California’s remaining master’s program in nurse-midwifery is at , south of Los Angeles, and it graduated eight nurse-midwives last year and 11 this year.

More than half of rural counties in the U.S. lacked obstetric care in 2018, according to a .

In some parts of California, expectant mothers must drive two hours for care, said who runs Midtown Nurse Midwives, a Sacramento birth center. It has had to stop accepting new clients because it cannot find midwives.

Donnelly predicted the closure of UCSF’s midwifery program will significantly reduce the number of nurse-midwives entering the workforce and will inhibit people with fewer resources from attending the program. “Specifically, I think it’s going to reduce folks of color, people from rural communities, people from poor communities,” she said.

UCSF’s change will also likely undercut efforts to train providers from diverse backgrounds.

Natasha, a 37-year-old Afro-Puerto Rican mother of two, has spent a decade preparing to train as a nurse-midwife so she could help women like herself through pregnancy and childbirth. She asked to be identified only by her first name out of fear of reducing her chances of graduate school admission.

The UCSF program’s pause, plus the added time and expense to get a doctoral degree, has muddied her career path.

“The master’s was just the perfect program,” said Natasha, who lives in the Bay Area and cannot travel to the other end of the state to attend CSU-Fullerton. “I’m frustrated, and I feel deflated. I now have to find another career path.”

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Llano once tried to get on public assistance but couldn’t — something, he said, looking perplexed, about owing the state money — and he’d like to apply again.

But beginning next year, if he does, he’ll face a new city requirement that single adults with no dependents who receive cash benefits be screened for illegal drug use and, if deemed necessary, enter treatment. San Francisco’s voters approved the new mandate in March.

Llano has no objection to being screened. He said he uses cannabis, which is legal in California, though not federally, but does not use other drugs. Nonetheless, he said, “I suppose I would try recovery.”

Another man in the free-lunch line, Francis Farrell, 56, was far less agreeable. “You can screen me,” he said, raising his voice, “but I don’t think you should force me into your idea of treatment.”

No one will be forced to undergo substance abuse treatment, nor will anyone be subject to drug testing, San Francisco officials insist. Rather, starting in January 2025, San Francisco’s public assistance recipients who screen positive for addiction on a 10-question will be referred to treatment. Those who refuse or fail to show up for treatment will forfeit the $109 a month that the city grants to homeless adults who qualify for city shelters or supportive housing, or the $712 a month it grants to adults with home addresses.

The city famous for its tolerance is resorting to tough love.

, executive director of the San Francisco Human Services Agency, cited three reasons for the new measure, which was fashioned after similar policies in and : to incentivize people with a substance use disorder to enter treatment, to prevent taxpayer money from being used to buy illegal drugs, and to dissuade drug seekers from moving to San Francisco.

“We’re giving them the opportunity to engage in something, without requiring sobriety, to hopefully get on a path to recovery,” Rhorer told ºÚÁϳԹÏÍø News.

When introduced the ballot initiative known as in a last year, she called it an incentive to encourage drug-addicted recipients of public assistance to enter “into a program that will help save their life.” Accidental overdoses killed in San Francisco last year.

But in the eyes of many health care providers, researchers, and harm reduction advocates, the measure is neither an incentive nor an opportunity.

The policy was designed to have “a coercive, punitive effect” and could do more harm than good, said , president and chief executive of HealthRIGHT 360, San Francisco’s largest drug treatment provider.

“It would have been an interesting project, much more in the spirit of San Francisco as a hub of innovation, to figure out if we can identify people with substance use disorder. And if they go into treatment and stay for a period of time, they’ll get an increased benefit,” Eisen said.

in the city currently receive benefits from the County Adult Assistance Programs, or CAAP. Under Measure F, those who acknowledge drug abuse on the screening test but refuse treatment and live in city-provided shelter will lose their cash benefits but can maintain their shelter, Rhorer said. However, CAAP recipients who refuse treatment and depend on public assistance to pay their rent in private housing could lose their homes.

The city will give recipients three chances to show up for treatment and will pay rent directly to a landlord for one month, Rhorer said. Measure F came in response to the grim conditions on some San Francisco streets, where men and women lie on sidewalks, often blocking passersby with their arms and legs splayed, or stand bent over, frozen like statues. Many use fentanyl, a synthetic opioid that has turned a long-standing homelessness problem into a public health emergency.

About 12% of people who fatally overdosed in San Francisco last year were CAAP recipients, Rhorer said.

Compassion fatigue seems to have settled over this city known for its kindheartedness. Measure F proponents raised $667,000 — more than 17 times as much as opponents — largely from business executives and tech investors, according to the San Francisco Ethics Commission. Then in March, 58% of voters approved the measure.

Since fentanyl began replacing heroin around 2019, Rhorer said, “drug tourists” have flocked to San Francisco, where the opioid has been cheap and plentiful. Lenient law enforcement and relatively generous cash public assistance grants also have drawn people with addiction, he said, although police activity has increased since last spring.

A recent city report found that of the 718 people whom police cited for substance use over a 10-month period that ended in February said they lived in the city.

“People who live in San Francisco, who really need the most help, don’t get the help they need due to the influx of people coming from somewhere else,” said Cedric Akbar, who runs recovery programs and co-founded . “And should our tax dollars go to the ones in San Francisco, or are we going to take care of the whole country?”

Akbar began using heroin when he moved to San Francisco from Houston in the 1980s and has been in recovery for 31 years. He said he would have preferred even stricter requirements for eligibility for public assistance than those in Measure F but hopes the new mandate will at least help give people access to treatment.

The city’s capacity for treatment is also a concern. Eisen and others describe a dire shortage of behavioral health workers to staff treatment facilities and residential step-down units, which are crucial for housing those in recovery from drug addiction.

New programs funded by the recently approved Proposition 1 in California, which authorizes the state to spend $6.38 billion to build mental health treatment facilities and provide housing for homeless people, are meant to address the shortages.

, an addiction medicine physician and an assistant professor at the University of California-San Francisco, fears that pushing CAAP recipients into treatment could turn them off. When people “were stigmatized, or coerced, or told they would face consequences if they didn’t do a certain thing,” she said, “that pushed them away from the health system even further.”

Though evidence suggests compulsory treatment can provide short-term benefits, it also can lead to long-term harm, the said in an email.

“To achieve the best outcomes,” the email said, treatment should be “delivered without stigma or penalty.”

Almost everyone with a substance use disorder enters treatment under some kind of pressure, whether from a parent, a spouse, an employer, or the criminal justice system, said , a Stanford University psychiatry professor.

Nonetheless, he questioned the morality of requiring welfare recipients, as opposed to criminals, to get drug treatment.

“I would never start with people who are poor but not committing crimes,” he said. “I would start with people who are harming others.”

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Singleton, who is Black and has practiced for 50 years, sees calling doctors out for implicit bias as divisive, and argues the state cannot legally require her to teach the idea in her continuing education classes. She has sued the Medical Board of California, asserting a constitutional right not to teach something she doesn’t believe.

The way to address health care disparities is to target low-income people for better access to care, rather than “shaking your finger” at white doctors and crying “racist,” she said. “I find it an insult to my colleagues to imply that they won’t be a good doctor if a racially divergent patient is in front of them.”

The litigation is part of a national crusade by right-leaning advocacy and legal groups against diversity, equity, and inclusion, or DEI, initiatives in health care. The pushback is inspired in part by last year’s U.S. Supreme Court ruling barring affirmative action in higher education.

The California lawsuit does not dispute the state’s authority to require implicit-bias training. It questions only whether the state can require all teachers to discuss implicit bias in their continuing medical education courses. The suit’s outcome, however, could influence obligatory implicit-bias training for all licensed professionals.

Leading the charge is the Pacific Legal Foundation, a Sacramento-based organization that describes itself as a “national public interest law firm that defends Americans from government overreach and abuse.” Its clients include the activist group Do No Harm, founded in 2022 to fight affirmative action in medicine. The two groups have also joined forces to sue the Louisiana medical board and the Tennessee podiatry board for reserving board seats exclusively for racial minorities.

In their complaint against the California medical board, Singleton and Do No Harm, along with Los Angeles ophthalmologist , argue that the violates the First Amendment rights of doctors who teach continuing medical education courses by requiring them to discuss how unconscious bias based on race, ethnicity, gender identity, sexual orientation, age, socioeconomic status, or disability can alter treatment.

“It’s the government saying doctors must say things, and that’s not what our free nation stands for,” said Khatibi, who immigrated to the U.S. from Iran as a child. Unlike Singleton, Khatibi does believe implicit bias can unintentionally result in substandard care. But, she said, “on principle, I don’t believe in the government compelling speech.”

The lawsuit challenges the evidence of implicit bias in health care, saying there is no proof that efforts to reduce bias are effective. Interventions have thus far not demonstrated lasting effects,

In December, U.S. District Judge Dale S. Fischer dismissed the suit but allowed the Pacific Legal Foundation to file an amended complaint. A hearing is scheduled for March 11 in federal court in Los Angeles.

In enacting the training requirement, the California legislature found that physicians’ biased attitudes unconsciously contribute to health care disparities. It also found that racial and ethnic disparities in health care outcomes are “remarkably consistent” across a range of illnesses and persist even after adjusting for socioeconomic differences, whether patients are insured, and other factors influencing care.

Black women are three to four times as likely as white women to die of pregnancy-related causes, are often prescribed less pain medication than white patients with the same complaints, and are referred less frequently for advanced cardiovascular procedures,the legislature found.

It also noted that women treated by female doctors were more likely to survive heart attacks than those treated by men. This month, the California legislature’s Black Caucus requiring implicit-bias training for all maternal care providers in the state.

, who teaches an implicit-bias class for Massachusetts doctors, sees only the best intentions in her fellow physicians. “But we’re also human,” she said in an interview. “And to not acknowledge that we are just as susceptible to bias as anybody else in any other field is unfair to patients.”

Ennis offered an example of her own bias in a training session. Preparing to treat a patient in a hospital emergency room, she noticed a Confederate flag tattoo on his forearm.

“As a Black woman, I had to have a quick chat with myself,” she said. “I needed to ensure that I provided the same standard of care for him that I would for anyone else.”

Ennis’ class meets the requirements of a that physicians earn two hours of instruction in implicit bias to obtain or renew their licenses, as of 2022.

That same year, that all accredited continuing medical education courses involving direct patient care include discussion of implicit bias. The state mandates 50 hours of continuing education every two years for doctors to maintain their licenses. Private institutions offer courses on an array of topics, and physicians generally teach them.

Teachers may tell students they do not believe implicit bias drives health care disparities, Fischer wrote in her December ruling. But the state, which licenses doctors, has the right to decide what must be included in the classes, the judge wrote.

Professionals who elect to teach courses “must communicate the information that the legislature requires medical practitioners to have,” the judge wrote. “When they do so, they do not speak for themselves, but for the state.”

Whether they speak for themselves or for the state is a pivotal question. While the First Amendment protects private citizens’ right to free speech, that protection does not extend to government speech. The content of public school curricula, for example, is the speech of state government, not the speech of teachers, parents, or students, courts have said. In 1988, the that the First Amendment did not apply to student journalists when a principal censored articles they wrote as part of a school curriculum.

The Pacific Legal Foundation’s amended complaint aims to convince the judge that its clients teach as private citizens with First Amendment rights. If the judge again rules otherwise, lead attorney Caleb Trotter told ºÚÁϳԹÏÍø News, he plans to appeal the decision to the U.S. Court of Appeals for the 9th Circuit, and, if necessary, the Supreme Court.

“This is not government speech at all,” he said. “It’s private speech, and the First Amendment should apply.”

“Plaintiffs are plainly wrong,” lawyers for Rob Bonta, the state attorney general, responded in court papers. “There can be no dispute that the State shapes or controls the content of continuing medical education courses.”

The medical board declined to comment on the pending litigation.

From 2019 through July 2022, in addition to California and Massachusetts, enacted legislation requiring health care providers to be trained in implicit bias.

A landmark 2003 Institute of Medicine report, “,” found that limited access to care and other socioeconomic differences explain only part of racial and ethnic disparities in treatment outcomes. The expert panel concluded that clinicians’ prejudices could also contribute.

In the two decades since the report’s release, studies have documented that bias does influence clinical care and contribute to racial disparities, said.

But implicit-bias training might have no impact and might even worsen discriminatory care, the report found.

“There’s not really evidence that it works,” Khatibi said. “To me, addressing health care disparities is really important because lives are at stake. The question is, How do you want to achieve these ends?”

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The move comes at a time of rising alarm among researchers over the health effects of hair straighteners, products widely used by and heavily marketed to Black women. But advocates and scientists say the proposed regulation would do far too little, in addition to being far too late.

“The fact that formaldehyde is still allowed in hair care products is mind-blowing to me,” said , a former director of the National Institute of Environmental Health Sciences and the National Toxicology Program. “I don’t know what we’re waiting for.”

Asked why it’s taking so long to get the issue on the FDA’s agenda, , the regulatory agency’s chief scientist, told ºÚÁϳԹÏÍø News: “I think primarily the science has progressed.”

“Also,” she added, “the agency is always balancing multiple priorities. It is a priority for us now.”

The FDA’s glacial response to concerns about formaldehyde and other hazardous chemicals in hair straighteners partly reflects the agency’s limited powers when it comes to cosmetics and personal-care products, according to , a former assistant administrator for toxic substances at the Environmental Protection Agency. Under the law, she said, the FDA must consider all chemical ingredients “innocent until proven guilty.”

Critics say it also points to broader problems. “It’s a clear example of failure in public health protection,” said David Andrews, a senior scientist at the Environmental Working Group, which first petitioned the agency to ban formaldehyde in hair straighteners in 2011 and sued over the issue in 2016. “The public is still waiting for this response.”

Mounting evidence linking hair straighteners to hormone-driven cancers prompted Reps. Ayanna Pressley (D-Mass.) and Shontel Brown (D-Ohio) last year to to investigate straighteners and relaxers.

The FDA responded by proposing to do what many scientists say the agency should have done years ago — initiate a plan to eventually outlaw chemical straighteners that contain or emit formaldehyde.

Such a ban would be a crucial public health step but doesn’t go nearly far enough, scientists who study the issue said. The elevated risk of breast, ovarian, and uterine cancers that epidemiological studies have recently associated with hair straighteners is likely due to ingredients other than formaldehyde, they said.

Formaldehyde has been linked to an increased risk of upper respiratory tract cancer and myeloid leukemia, Bumpus of the proposed ban on X, formerly known as Twitter. But Kimberly Bertrand, an associate professor at the Boston University Chobanian & Avedisian School of Medicine, and other scientists said they were unaware of any studies linking formaldehyde to the hormone-driven, or reproductive, cancers that prompted recent calls for the FDA to act.

“It’s hard for me to imagine that removing formaldehyde will have an impact on the incidence of these reproductive cancers,” said Bertrand, an epidemiologist and lead author on , the second linking hair relaxers to an increased risk of uterine cancer.

Hair products targeted to African Americans contain a host of hazardous chemicals, said , an associate professor of epidemiology at the Harvard T.H. Chan School of Public Health who has studied the issue for 20 years.

Studies have shown that straightener ingredients include phthalates, parabens, and other that mimic the body’s hormones and have been linked to cancers as well as early puberty, fibroids, diabetes, and gestational high blood pressure, which is a key contributor to Black women’s outsize risk of maternal mortality, James-Todd said.

“We have to do a better job regulating ingredients that people are exposed to, particularly some of our most vulnerable in this country,” she said. “I mean, children are being exposed to these.”

The first study linking hair relaxers to uterine cancer, published in 2022, found that frequent use of chemical straighteners more than doubled a woman’s risk. It followed studies showing women who frequently used hair relaxers doubled their ovarian cancer risk and had a 31% higher risk of breast cancer.

Bumpus praised the studies as “scientifically sound” and said she would leave to epidemiologists and others questions about whether straightener ingredients besides formaldehyde might be contributing to an elevated risk of hormone-driven cancers.

She could not offer a timeline for a formaldehyde ban, except to say the agency was scheduled to initiate proceedings in April. The schedule could change, she said, and she did not know how long the process of finalizing a rule would take.

Brazilian Blowouts and similar hair-smoothing treatments sometimes use formaldehyde as a glue to hold the hair straight for months. Stylists usually seal the product into the hair with a flat iron. Heat converts liquid formaldehyde into a gas that creates fumes that can sicken salon workers and patrons.

In addition to cosmetics, formaldehyde is found in embalming fluid, medicines, fabric softeners, dishwashing liquid, paints, plywood, and particleboard. It irritates the throat, nose, eyes, and skin.

If there are opponents to a ban on formaldehyde in hair straighteners, they have not raised their voices. Even the Personal Care Products Council, which represents hair straightener manufacturers, supports a formaldehyde ban, spokesperson Stefanie Harrington said in an email. More than 10 years ago, she noted, a deemed hair products with formaldehyde unsafe when heated.

California and Maryland will ban formaldehyde from all personal-care products starting next year. And manufacturers already have curtailed their use of formaldehyde in hair care products. Reports to the California Department of Public Health’s show a tenfold drop in products containing formaldehyde from 2009 to 2022.

John Bailey, a former director of the FDA’s Office of Cosmetics and Colors, said the federal agency often waits for the industry to voluntarily remove hazardous ingredients.

Cheryl Morrow co-founded late last year to lobby on behalf of California Curl, a business she inherited from her father, a barber who started the company, and other Black hair care companies and salons. “Ban it,” she said of formaldehyde, “but please don’t mix it up culturally with what Black people are doing.”

She insisted the relaxers African Americans use contain no formaldehyde or other carcinogens and are safe.

found that hair products used primarily by Black women and children contained a host of hazardous ingredients. Investigators tested 18 products, from hot-oil treatments to anti-frizz polishes, conditioners, and relaxers. In each of the products they found at least four and as many as 30 endocrine-disrupting chemicals.

Racist beauty standards have long compelled girls and women with kinky hair to straighten it. Between 84% and 95% of Black women in the U.S. have reported using relaxers, studies show.

Black women’s often frequent and lifelong application of chemical relaxers to their hair and scalp might explain why hormone-related cancers kill more Black women than white women per capita, Bertrand and other epidemiologists say. Relaxers can be so habit-forming that users call them “creamy crack.”

As a public health educator, Astrid Williams, director of programs and initiatives at the California Black Health Network, has known the health risks associated with hair relaxers for years. Nonetheless, she used them from age 13 until two years ago, when she was 45.

“I felt I had to show up in a certain way,” she said.

A formaldehyde ban won’t make creamy crack safe, she said. “It’s not even a band-aid. The solution is to address all chemicals that pose risk.”

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Designed to counter the “” that researchers say leads a disproportionate number of African American mothers to die from childbirth, the project has provided 150 pregnant Black and Pacific Islander San Franciscans a $1,000 monthly stipend.

The money enabled Jones, 20, to pay for gas to drive to prenatal clinics, buy fresh fruits and vegetables for her toddler son and herself, and remain healthy as she prepared for the birth of her second child last year.

But the future of the Abundant Birth Project is clouded by alleging that the program, the first of its kind in the nation, illegally discriminates by giving the stipend only to people of a specific race. The lawsuit also targets San Francisco guaranteed-income programs , , and .

The litigation is part of a growing national effort by conservative groups to eliminate racial preferences in a wide range of institutions following a that found race-conscious admissions to colleges and universities to be unconstitutional.

In health care, legal actions threaten efforts to provide scholarships to minority medical school students and other initiatives to create a physician workforce that looks more like the nation.

The lawsuits also endanger other measures designed to reduce well-documented racial disparities. Black women are three to four times than white women to die in labor or from related complications in the U.S., and Black infants are twice as likely as white infants to be born prematurely and to die before their first birthdays. Racial and ethnic minorities also are to die from diabetes, high blood pressure, asthma, and heart disease than their white counterparts, according to the Centers for Disease Control and Prevention.

A handful of activist nonprofit groups and law firms are leading the charge. , a nonprofit formed in 2022, has sued , , and to try to stop them from choosing applicants based on race. Do No Harm claims more than 6,000 members worldwide and partners with nonprofit legal organizations, most notably the , which garnered national attention California’s same-sex marriage ban.

Another nonprofit, the , together with a Dallas-based law firm called the , filed the lawsuit against the city of San Francisco and the state of California over the Abundant Birth Project, alleging the program violates the equal protection clause of the Constitution’s 14th Amendment by granting money exclusively to Black and Pacific Islander women. The 14th Amendment was passed after the Civil War to give rights to formerly enslaved Black people.

The lawsuit calls public money used for the project and the three other guaranteed-income programs “discriminatory giveaways” that are “illegal, wasteful, and injurious.”

“The city and county of San Francisco crafted the Abundant Birth Project with the express intention of picking beneficiaries based on race,” Dan Morenoff, executive director of the American Civil Rights Project, said in a phone interview. “It’s unconstitutional. They can’t legally do it, and we are optimistic that the courts will not allow them to continue to do it.”

San Francisco and state officials declined to discuss the case because of the pending litigation, but the city defended the program in its initial response to the lawsuit. The Abundant Birth Project started in June 2021 and plans to make a second round of grants to pregnant mothers this fall, the response says.

The project strives to improve maternal and infant health outcomes by easing the economic stress on pregnant Black and Pacific Islander San Franciscans. People in those groups face some of the in the U.S., where as a result of pregnancy and childbirth than in other high-income nations. The state of California last year to expand the program to include Black mothers in four other counties.

But a Berkeley law professor and anthropologist who has talked to beneficiaries of the Abundant Birth Project but is not directly involved with it, said the Supreme Court ruling on college affirmative action could actually support the argument that the program is legal.

The court struck down affirmative action in part because the majority said Harvard and the University of North Carolina failed to show measurable outcomes justifying race consciousness in college admissions. While statistics on potential benefits from the Abundant Birth Project are not publicly available, Bridges and others familiar with the program expect researchers to demonstrate it saves and improves lives by comparing the health outcomes of families who received the stipend with those of families who did not. The outcomes could justify employing race to choose program participants, Bridges said.

Bridges also drew another distinction between the role of race in college admissions and the role of race in health disparities.

“If you don’t get into Harvard, there’s always Princeton or Columbia or Cornell,” she said. “Maternal death — the stakes are a little bit higher.”

In California, a voter initiative, Proposition 209, has prohibited race-based selection in public education and employment since 1996. California Assembly member (D-Oakland) has co-authored a that would amend the proposition to allow municipalities to grant benefits to specific groups of vulnerable people if they use research-based measures that can reduce health and other disparities.

Bonta, a law school graduate, told ºÚÁϳԹÏÍø News that the litigation against the Abundant Birth Project is the result of “conservative groups who want to exist in a world that doesn’t exist, where communities of color have not had to suffer the generational harm that comes from structural racism.”

Bonta has more than once been a victim of medical racism herself.

When she went to the hospital with a serious back injury, she was interrogated by a doctor who appeared to believe she was faking pain so she could obtain drugs.

“But for the intervention of my husband, who happened to be there and moved into health advocacy mode, I, as a Black Latina woman, would not have received the care that I needed,” she said. Bonta’s husband, Rob Bonta, is also a lawyer and is now California’s attorney general.

Briana Jones experiences racism every day, she said.

She was 15 when she gave birth to her first child in a San Francisco hospital. Terrified and in agonizing pain, she did what laboring mothers have always done and screamed.

A nurse ordered her to “shut up.”

In the U.S., Black women are far more likely than white women to report that health care providers scolded, threatened, or shouted at them during childbirth, . They also face of , including barriers to quality care and cumulative stress from lifelong discrimination.

Growing up Black in San Francisco has been a struggle for Jones. But, while carrying her second baby last year, she learned from her mother of the Abundant Birth Project, and within a month, her race and address in Bayview Hunters Point, where some of the city’s poorest residents live, qualified her as one of nearly 150 women to receive the $1,000 a month during her pregnancy and for six months postpartum.

“I really did feel like it was God helping me,” she said.

For Morenoff, though, it’s just another form of discrimination, and he says the city must either open the Abundant Birth Project to all pregnant women or close it down. “The whole point of the 14th Amendment is to require America to treat all Americans as Americans with the same equal rights,” he said.

Jones had high blood pressure, leading to swollen ankles and dizziness, during both her pregnancies. In her more recent one, the birth project stipend helped enable her to quit couch surfing and move into an apartment, and she gave birth to a healthy boy named Adonis.

“It’s known that people of color struggle way harder than other races,” Jones said. “Where I live, it’s nothing but struggle here, people trying to make ends meet.”

“For them to try to take this program away from us,” she said, “it’s wrong.”

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A July ruling by a three-judge panel of the 9th U.S. Circuit Court of Appeals upheld California’s right to mandate that every course doctors take to remain licensed must address how bias contributes to poorer health outcomes for racial and ethnic minorities. The ruling against the nonprofit and Los Angeles ophthalmologist Azadeh Khatibi amounts to a victory for California as it fights the Trump administration and right-leaning advocacy and legal groups’ attacks on perceived “wokeness.”

In August, the Pacific Legal Foundation, which represents Do No Harm and Khatibi, asked that a panel of 11 appellate judges reconsider what attorney Caleb Trotter characterized as a “very clearly wrong” decision. Trotter, a senior attorney for the Pacific Legal Foundation, expects the court’s response in October. If the appeal fails, he said, his firm would likely appeal to the U.S. Supreme Court. At stake, legal scholars say, is the latitude of states to prescribe educational content, including health equity training, for licensed professionals.

“The general recent tenor of the Supreme Court’s First Amendment jurisprudence has been very speech protective, so that we would like our odds with, of course, the understanding that any attempt to get the Supreme Court to take your case is a long shot,” Trotter said.

Erwin Chemerinsky, dean of the University of California-Berkeley law school, described the chances of the Supreme Court taking the case as “very unlikely” and the appellate ruling as “clearly correct” in affirming the state’s authority to impose course requirements.

California began requiring implicit-bias training for physicians in 2022. From 2019 through July 2022, enacted legislation mandating the training. California is the only state that requires it to be included in every course involving direct patient care.

In enacting the law, the legislature found that bias contributed to health care disparities and persisted regardless of other factors influencing care. Black women, for example, are often prescribed less pain medication than white women with the same complaints and are as white women to die of pregnancy-related causes.

Bias does influence clinical care and contribute to health care disparities, a concluded. Implicit-bias training, however, might have no impact and might even worsen care, the report noted.

and Khatibi alleged that violated their First Amendment rights. Khatibi acknowledges that unconscious bias might prejudice how clinicians treat patients. But the Los Angeles ophthalmologist does not believe she should be forced to carve out time to talk about it in a class she might teach on, for example, ocular tumors.

“The government is mandating doctors endorse a specific ideology or priority instead of science,” she said. “I believe government should not mandate or compel the speech of doctors.”

The three-judge appellate panel disagreed. No one is forcing Khatibi to teach state-accredited continuing education, the panel wrote in its a lower court’s decision that the state had the right to mandate the training. The judges found that the curriculum requirement constitutes government speech and, therefore, is not subject to free-speech protections.  

The does not dispute the state’s authority to require physicians to learn about unconscious prejudices. Instead, it argues the state has no right to demand that all teachers discuss bias in every continuing medical education class. California physicians must take at least 50 hours of continuing education every two years. Private institutions offer the courses, and physicians generally teach them.

Rep. Sydney Kamlager-Dove (D-Calif.), who wrote the bill when she was a member of the state Assembly, defended it. “By connecting every provider to consistent and evolving training, we can help close these gaps and provide more equitable care,” she said.

The Medical Board of California declined to comment.

Ashutosh Bhagwat, a UC Davis School of Law distinguished professor, said the state has a right to require implicit-bias training, although he disagrees that the training constitutes government speech. He sees it as private, but not compelled, speech because Khatibi and other instructors need only include a discussion of implicit bias if they want their classes to qualify for state licensing credit.

He likened the requirement to that of an accredited private school having to teach math. “Doesn’t matter if you don’t want to teach math. Doesn’t matter if you don’t believe in math,” he said. “You have to teach math.”

Bhagwat sees Khatibi’s case as “very weak.” But he said he could not predict anything the Supreme Court, with its six-justice conservative majority, might do.

“If Khatibi wins in the Supreme Court, or at any level, then chaos reigns because now every single requirement in any licensure that says you must teach this to qualify for continuing education is up for grabs,” he said.

Trotter fears the opposite outcome. If allowed to stand, the implicit-bias training mandate could be extended to continuing education for 50 trades and professions in California alone, he said. “Then all kinds of governments based on all kinds of views can start requiring private speakers to say all kinds of things that, depending on where you are, are going to be controversial in all different kinds of ways,” he said.

While Khatibi’s lawsuit and others like it have had little success in the courts, said Joan Williams, a distinguished professor emerita at UC Law-San Francisco, they have chilled the creation of laws deemed “woke” or those favoring diversity, equity, and inclusion, known as DEI.

“There’s been this huge attack on DEI, and it’s been extraordinarily effective in creating regulatory risk such that people are apprehensive and self-editing because they don’t want to put a target on their backs,” said Williams, who directs the .

Still, some supporters of bias training say California could refine its approach. Cristina Gonzalez, an internist and a New York University Grossman School of Medicine professor, designs and evaluates interventions to help recognize, prevent, and repair clinicians’ prejudices. She described implicit-bias training as “a science” and California’s approach as misguided because it requires all instructors, regardless of their knowledge of implicit bias, to teach the material.

Finger-wagging and blaming in implicit-bias training can lead doctors to become defensive and avoid patients, but done correctly, by experts, it does work, Gonzalez said. “The messaging has to be, ‘You’re not a bad person,’” she said.

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“I see you went popcorn-crazy this weekend,” Owens teased as she brushed kernels off the counter into a garbage can. Crooks, who relies on a walker or wheelchair, can steady herself against the counter while waiting for corn to pop. But back, knee, and foot problems have left the 77-year-old silver-haired retired teacher incapable of most food preparation and cleanup.

Like nearly 800,000 other Californians, Crooks depends on aides from In-Home Supportive Services, a program funded through Medi-Cal, California’s version of Medicaid. Owens has worked as Crooks’ aide for almost three years. In addition to cooking and cleaning, she helps her shower, shops for groceries, drives her to medical appointments, and runs other errands.

For more than 50 years, low-income seniors and disabled people have been able to stay in their California homes — and out of — with help from government-paid aides. But in their latest bid to renew President Donald Trump’s tax cuts, House Republicans released a plan on May 11 that would over 10 years from Medicaid, and could threaten funding for Owens and other In-Home Supportive Services workers.

While a major structural overhaul of Medicaid appears increasingly unlikely, with how to cut the budget. Several proposals would disproportionately target California, according to Larry Levitt, KFF’s executive vice president for health policy. Federal cuts, coupled with the state’s existing budget woes, could inflict a “double whammy for California and trigger reductions in Medi-Cal and other state programs,” he said. KFF is a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Although federal law compels states to offer certain services, such as nursing home care, they’re to cover home-based care for low-income seniors and disabled people like Crooks, leaving the in-home services program to cuts, said Amber Christ, managing director of health advocacy for the nonprofit legal group Justice in Aging.

In the wake of the Great Recession, California made a series of funding cuts to in-home support aides. Lawsuits temporarily stopped the bulk of the cuts, but a led to an 8% reduction in 2013 and an additional 7% cut in 2014.

Further reducing these services would inevitably force more people to move into nursing homes, Christ said. “It would be an enormous setback from the progress we have made to provide care in the home and the community to support older adults and their families,” she said. “I think it will cost people’s lives.”

Owens supports herself and her teenage son with what she earns working 136 hours a month for Crooks. She’s confident she can figure out another way to make a living, so she’s less worried about losing her $20-an-hour income than she is about Crooks’ losing her independence.

“I absolutely adore Carol,” said Owens, 36, as she chopped onions for Crooks’ breakfast. “I look at her as a grandma.”

From a makeshift desk where she’d been scrolling through emails, Crooks affectionately eyed Owens and announced, “You’re adopted.”

In his May 14 , Gov. Gavin Newsom trimmed funding for In-Home Supportive Services, most notably by putting weekly caps of 50 hours on provider overtime and travel, reinstating an asset limit, and eliminating the service for immigrant adults without legal status who aren’t already enrolled.

The proposed changes are unlikely to affect Crooks, but if congressional Republicans slash Medicaid spending, the Democratic governor , California could not afford to backfill all the proposed federal cuts. Almost two-thirds of the $28.3 billion California has budgeted for the in-home support program is supposed to come from endangered federal Medicaid funding. The state legislature must pass a balanced budget by June 15, regardless of the status of federal funding negotiations.

Owens delivered an omelet and a mug of coffee to Crooks. “I know these are politicians,” she said, “but they still have to understand the elders are our roots. And I’m sure they have to have some kind of heart.”

Crooks is less certain, more anxious. “If they start messing with my programs,” she said, “I’m in trouble.”

Burt Conell, 64, is also worried. A paraplegic, he’s been confined to a wheelchair for 30 years, since, despondent after his girlfriend left him, he jumped in front of a train. He relies on in-home aides to help him bathe and clean his San Francisco apartment.

When he heard the government might cut his funding, he imagined being unable to shower, getting rashes and bedsores, and having to move into a nursing home. Again, he contemplated suicide.

“It made me feel like I was using so much resources that I shouldn’t exist,” he said.

At an of San Francisco’s Disability and Aging Services Commission, Commissioner asked about the fate of In-Home Supportive Services, on which she relies. “We don’t know what’s going to happen,” Executive Director Kelly Dearman replied, adding that Medicaid cuts could result in a decrease in the number of hours San Francisco beneficiaries, like Conell and Bittner, who is quadriplegic with a speech disability, receive. “It’ll be dire,” Dearman concluded.

Every day, around 30 people contact California Advocates for Nursing Home Reform seeking advice on how to get in-home help, said Maura Gibney, the nonprofit’s executive director. These days, the group frequently hears from recipients who have achieved a semblance of normalcy in the aftermath of a major setback, such as a stroke, but fear they’ll lose their benefits, she said.

“It’s hard to really give people reassurance at this time because I don’t think any of us know what will happen,” Gibney said.

Lately, when she hears from people looking for in-home help for the first time, Gibney wonders if their efforts will end up being pointless. “It feels a little bit like trying to show somebody how to get into the building as the top floor is on fire,” she said.

Paul Dunaway, who directs Sonoma County’s Adult and Aging Division, described the dearth of information he and his staff have to offer older and disabled people about future services as “anxiety-provoking.”

“There’s a lot of chaos happening and not much to really grab onto yet about the funding on the federal level,” Dunaway said.

Uncertainty and fear about service cuts, coupled with weaning off pain medicine from a back surgery, left Crooks — who retired from teaching after being diagnosed with bipolar disorder — unable to sleep, she said, and she spiraled into her first manic episode in more than a decade.

Owens was sweeping the living room but stopped to listen as Crooks talked about being tired, worried, and feeling out of control. “I told her, ‘Regardless, I’m gonna always be here for you, no matter what,’” Owens said.

Crooks, wearing a T-shirt picturing the Statue of Liberty with her hands covering her face, nodded. “It helped a lot,” she said.

Nonetheless, without an in-home aide, Crooks said, she would have no choice but to move into a nursing home — a fate she cannot bear to consider.

“It wouldn’t be a home,” she said. “It’s where people go to die.”

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No one would say. “I asked like three times a day. It was brushed off,” Tomasek said, relaying her story by phone as she cradled Ezekiel, now 6 months old, in their San Jose apartment. She was told only that more tests were being run to ensure “everything’s good before you leave.”

She knew that her intensifying anger and fear about the holdup could raise her blood pressure, that Black pregnant women and new mothers are especially , and that it could kill her. Distraught, she called the person she most trusted to calm her, a caseworker for Santa Clara County’s Black Infant Health program.

“She really did help me to stay centered,” Tomasek said of the caseworker, who tracked her health throughout the pregnancy. “I felt a lot better.”

Since 2000, approximately 14,000 families have participated in Santa Clara County’s Black Infant Health program and related Perinatal Equity Initiative, both aimed at decreasing racial disparities in maternal and infant health. Enrolled mothers are assigned caseworkers and nurses who visit them at home to monitor blood pressure and other vital signs, help with breastfeeding, and screen infants for developmental delays. The mothers also attend support groups to learn skills to buffer the well-documented effects of .

The programs have measurably improved the health of enrolled women over the past decade, county , reducing rates of maternal hypertension — a leading cause of pregnancy-related deaths — by at least 30% and increasing screenings for other potentially life-threatening conditions.

Experts in the field and program participants stress that this work is urgent — in California, Black women are at least three times as likely as white women to die from pregnancy-related causes, and, nationally, Black infants have the highest rates of preterm birth and mortality.

While advocates for Black mothers laud the programs’ results as cause for optimism, they are concerned that the climate against diversity, equity, and inclusion, or DEI, initiatives could impede progress. Efforts to improve the health of this at-risk population have been targets of private lawsuits before, but since President Donald Trump took office, he has of all “‘equity-related’ grants” and against programs he claims illegally favor one racial group over another — even when they are designed to save lives, as is the case with the Santa Clara efforts.

Santa Clara County has received most of the $1 million-plus in federal funding it expects for Black Infant Health and the Perinatal Equity Initiative programs for the fiscal year ending in June. But county officials say it’s unclear how much, if any, of the remaining money — which comes from the federal health department’s Health Resources and Services Administration and Centers for Medicare & Medicaid Services — is at risk amid federal anti-DEI policies and the at the Department of Health and Human Services. The status on funding for the coming fiscal year is also unknown, county officials said.

Santa Clara stands to lose more than in public health funds due to the federal cuts, including money used to help deliver health services to underserved communities. A already terminated includes millions of dollars from at least three programs in other states focused on Black birth outcomes.

Any decrease in federal funding for these types of programs could have dire consequences, said Angela Aina, cofounder and executive director of . “We will likely see an increase in deaths,” she predicted.

Aina’s group pilots research and promotes public policy on behalf of 40 U.S. community-based organizations focused on Black maternal health. Member programs connect pregnant women to health care, counseling, and nutritional and breastfeeding advice, among other things.

If these services are cut, advocates fear, the progress made toward reducing racial disparities in birth outcomes could backslide. that eliminating such focused efforts could exacerbate the inequities, worsen the nation’s health, and increase health care costs overall.

“Our stakeholders are in a state of confusion right now because the federal workers that still have a job are not allowed to communicate, or there’s some kind of muzzle on their communication,” Aina said. “We don’t know — are we going to receive the rest of those grant funds?”

When asked how the state would respond to federal budget cuts to programs like Black Infant Health, Brian Micek, a California Department of Public Health spokesperson, said only that the agency remains “committed to protecting Californians’ access to the critical services and programs they need” and steadfast in its mission to “advance the health and well-being of California’s diverse people and communities.”

Requests for comment from the federal departments responsible for the grants funding Santa Clara’s programs went unanswered.

Communications directors from groups working on reducing racial disparities in birth outcomes declined to be interviewed for this article, citing fears of retribution.

Tonya Robinson, program manager for Black Infant Health, stands defiant in the face of these threats. She sees the federal government’s anti-DEI crusade as an invitation to practice the very skills they teach.

“Our program is working,” Robinson said. “And the way it’s working is by empowering women, giving women voices to help them stand up for what is right, and to recognize discrimination and the impact of structural racism on their bodies.”

The government’s antagonism toward her work inspires Robinson to soldier on calmly as a role model for the women she serves.

“We’re continuing to forge ahead,” Robinson said. “We want to make sure that we can be an example of how to manage stress at this time, in front of our clients.”

Evidence surfaced that childbirth was deadlier for African American women than white women more than a century ago. But the issue did not gain significant public attention until 2018, when and began airing their harrowing birth stories, highlighting the striking vulnerability of Black pregnant women and new mothers, even those with unlimited means.

In 2021, then-President Joe Biden proclaimed a week in April Black Maternal Health Week. A marking that week in 2024 read that “when Black women suffer from severe injuries or pregnancy complications or simply ask for assistance, they are often dismissed or ignored in the health care settings that are supposed to care for them.”

Eboni Tomasek certainly felt ignored.

Three days after giving birth in September — and after her Santa Clara caseworker reminded her she had a right to know why she wasn’t being released — a nurse finally explained that Tomasek’s blood pressure had been too high for the hospital to safely discharge her.

Had she been white, Tomasek believes, the staff would have informed her sooner. “I feel like they were being racist,” she said. She credited her training through Black Infant Health with her ability to calm herself and help lower her blood pressure, allowing her to leave that day with Ezekiel.

Jamila Perritt, president and CEO of Physicians for Reproductive Health, believes that the poor health outcomes Black women and infants face have historical roots and will change only with the help of programs that, like those in Santa Clara, address conditions facing Black women.

“What we’re seeing in terms of maternal mortality are race-bound conditions,” said Perritt, an obstetrician who co-chairs Washington, D.C.’s Maternal Mortality Review Committee. “Our policies cannot be race-blind if we’re attempting to address them.”

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She could have reached Plumas District Hospital, in Quincy, in just seven minutes. But it no longer delivers babies.

Local officials have a plan for a birth center in Quincy, where midwives could deliver babies with backup from on-call doctors and a standby perinatal unit at the hospital, but state health officials have yet to approve it.

That left Mazar to brave the long, winding road — one sometimes blocked by snow, floods, or forest fires — to have her baby. Women across California are facing similar ordeals as hospitals increasingly close money-losing maternity units, especially in rural areas.

Midwife-operated birth centers offer an alternative for women with low-risk pregnancies and can play a crucial role in filling the gap left by hospitals’ retreat from obstetrics, maternal health advocates say.

Declining birth rates, staffing shortages, and financial pressures have led — about 1 in 6 — to shutter maternity units over the past dozen years.

But midwives say California’s regulatory regime around birth centers is unnecessarily preventing new centers from opening and leading some existing facilities to close. Obtaining a license can take as long as four years.

“All they’ve essentially done is made it more dangerous to have a baby,” said Sacramento midwife “People have to drive two hours now because a birth center can’t open, so it’s more dangerous. People are going to be having babies in cars on the side of the road.”

Last month, state Assembly member Mia Bonta to streamline the regulatory process and fix what she calls “a broken system” for licensing birth centers.

“We know that alternative birth centers lead to often better outcomes, lower-risk births, more opportunity for children to be born healthy, and also to lower maternal mortality and morbidity,” she said.

The proposed bill would remove various bureaucratic requirements, though many details have yet to be finalized. Bonta introduced the bill in its current form as a jumping-off point for discussions about how to expedite licensing.

“It’s a starting place,” said Sandra Poole, health policy advocate for the Western Center on Law & Poverty, a co-sponsor of the legislation.

For now, birth centers struggle with a gantlet of rules, only some clearly connected to patient safety. Over the past decade, the number of licensed birth centers in California dropped from 12 to five, according to Bonta.

Plumas County officials are trying to address one key issue: how far a birth center can be from a hospital with a round-the-clock obstetrics unit. State regulations say it can be no more than a 30-minute drive, a distance set when many more hospitals had maternity units.

The first-of-its-kind “” aims to take advantage of flexibility provisions in the law to address the obstacle in a way that could potentially be replicated elsewhere in the state.

But the hospital’s application for a birth center and a perinatal unit has been “languishing” with the California Department of Public Health, which is “looking for cover from the legislature,” said Robert Moore, chief medical officer of Partnership HealthPlan of California, a Medi-Cal managed-care plan serving most of Northern California. Asked about the application, a CDPH spokesperson said only that it was under review.

The goal should be for all women to be within an hour’s drive of a hospital with an obstetrics unit, Moore said. Data shows the complication rate goes up after an hour and even higher after two hours, he said, while the benefit is less compelling between 30 and 60 minutes.

Numerous other regulations have made it difficult for birth centers to keep their doors open.

Since August, birth centers in and have had to stop operating because their heating ducts failed to meet licensing requirements. The facilities fall under the same state as primary care clinics, though birth centers see healthy families, not sick ones, and don’t need hospital-grade ventilation, said midwife Caroline Cusenza.

She had spent $50,000 remodeling the Monterey Birth & Wellness Center to include state-required items, such as nursing and hand-washing stations and a housekeeping closet. In the end, a requirement for galvanized steel heating vents, which would have required opening the ceiling at an unaffordable cost, prompted her heart-wrenching decision to close.

“We’re turning women away in tears,” said Sasaki, who owned Midtown Birth Center in Sacramento. She bought the building for $760,000 and spent $250,000 remodeling it in a way she believed met all licensing requirements. But regulators would not license it unless the heating system was redone. Sasaki estimated it would have cost an additional $50,000 to bring it into compliance — too much to keep operating.

She blamed her closure on “regulatory dysfunction.”

by Gov. Gavin Newsom last year could ease onerous building codes such as those governing Sasaki’s and Cusenza’s heating systems, said Poole, the health policy advocate.

The state has taken two to four years to issue birth center licenses, by the Osher Center for Integrative Health at the University of California-San Francisco. The state Department of Public Health “works tirelessly to ensure health facilities are able to be properly licensed and follow all applicable requirements within our authority before and during their operation,” spokesperson Mark Smith said.

Bonta, an Oakland Democrat who chairs the Assembly’s health committee, said she would consider increasing the allowable drive time between a birth center and a hospital maternity unit as part of her new legislation.

The state last updated birth center regulations more than a decade ago, before hospitals’ mass exodus from obstetrics. “The hurdle is the time and distance standards without compromising safety,” Poole said. “But where there’s nothing right now, we would say a birth center is certainly a better alternative to not having any maternal care.”

Moore noted that midwife-led births in homes and birth centers are the mainstay of obstetric care in Europe, where the infant mortality rate is than in the U.S. More than 98% of American babies are born .

Babies delivered by midwives are more likely to be born vaginally, less likely to require intensive care, and more likely to breastfeed, the has found. Midwife-led births also lead to fewer infant emergency room visits, hospitalizations, and neonatal deaths. And they cost far less: Birth centers generally charge one-quarter or less of the average cost of for a vaginal birth in a California hospital.

If they catered only to private-pay clients, Cusenza and Sasaki could have continued operating without licenses. They must be licensed, however, to receive payments from Medi-Cal and some private insurance companies, which they needed to remain in business. Medi-Cal, the state’s Medicaid health insurance program, which covers low-income residents, paid for about in 2022.

Bonta has heard reports from midwives that the key to getting licensed is hunting down the right state health department advocate. “I don’t believe that we should be building resources based on the model of ‘Where’s Waldo?’ in finding a champion inside CDPH,” she said.

, director of midwifery at Plumas District Hospital, believes the Plumas model can turn what’s become a maternity desert into an oasis. Jessie Mazar, whose son was born in September without complications at a Truckee hospital, would welcome the opportunity to deliver her planned second child in Quincy.

“That would be convenient,” she said. “We’re not holding our breath.”

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Five decades later, with in almost all circumstances, the University of California-San Francisco breast cancer surgeon has once again taken up the fight for women’s reproductive rights. Since 2021, when Texas prohibited most abortions, she the — a conference she had regularly attended, and frequently headlined, for 34 years.

“People are passing laws that are legislating what should be a medical decision,” she said. “And I am objecting in whatever way I can.”

and have urged their colleagues and medical societies to move all professional meetings out of states that criminalize abortion. Short of a move, they have called for boycotts of the events.

In November, Esserman expects 300 health providers and researchers to meet in San Francisco for an .

The effort to move annual conferences — which pump substantial revenue into local communities and attract many of the nation’s and other medical professionals looking to network, satisfy continuing education requirements, and learn about the latest developments in their fields — has led to some notable relocations.

The and an estimated 4,000 participants from New Orleans to Maryland in response to Louisiana’s abortion ban. An estimated 3,600 health care professionals attended the ’ conference in Chicago this year, after the group moved the meeting from its planned Phoenix location in response to Arizona’s restrictive abortion law.

“In addition to causing great physical and psychological harm to patients,” the association said in , abortion bans “threaten irreparable damage to the private and trusted relationship between medical professionals and their patients.”

Yet even doctors who agree about reproductive rights disagree about how to express dissent. it’s more important than ever to visit states where abortion has been outlawed, to learn about the issues surfacing because of the laws, and to help people organize against them.

“We cannot support penalizing communities that are already harmed by this legislation,” said obstetrician and gynecologist , president and CEO of Physicians for Reproductive Health. “As opposed to withdrawing support, what we’re calling for is actually flooding those folks with support.”

has been providing security for doctors targeted by anti-abortion activists, Perritt said, and training doctors to teach abortion care in abortion-restricting states and to testify to state legislatures about the need for abortion access.

“There is a lot to be gained by coming to these states, supporting us, seeing the reality, and bringing these conversations into your conference space so that you can better understand our reality, rather than just boycotting that state completely, which is not helpful,” said , chief medical officer for Planned Parenthood of Greater Ohio and a medical director for Planned Parenthood Gulf Coast in Texas and Louisiana.

Since the Supreme Court’s 2022 decision to overturn Roe and eliminate a federal constitutional right to abortion, all but nine states and Washington, D.C., have imposed abortion restrictions, according to the .

The San Antonio Breast Cancer Symposium continues to be held in Texas, where abortion is banned in almost all instances, and boycott calls do not appear to have slowed turnout. In fact, the number of in-person attendees increased from just under 8,000 in 2019 to 8,220 last year, organizers said.

Breast oncologist a University of Texas Health Science Center-San Antonio professor of medicine who co-directs the San Antonio symposium, plans to stay in Texas. She doesn’t believe in boycotts, though she does share boycott proponents’ concerns. Despite exceptions, such as the , doctors have by and large .

“I think the way to handle it is to talk to our elected officials, to go out and vote. Moving meetings from one place to another is not going to help,” Kaklamani said. “You stay and you fight for your patients.”

Esserman recognizes that boycott calls have not had significant impact, but she feels compelled to keep applying pressure anyway.

She can’t help but think about a patient who recently came to her San Francisco practice nine weeks pregnant and with an aggressive breast cancer. If she were to continue the pregnancy, she would be ineligible for the most effective treatment. “Where I live, she has a choice,” Esserman said. In some states, she would have no choice but to carry the pregnancy to term.

Cary Gross, a Yale School of Medicine professor who co-authored a JAMA Internal Medicine opinion piece last year advocating boycotts, cited three arguments: expressing the profession’s values, acting as an ethical consumer, and protecting the health of attendees. Women physicians of childbearing age have voiced fears about traveling to anti-abortion states, especially while pregnant.

“The legislators passing these laws are probably not going to change their stance,” Gross said. “But for the general population, the more you can do to alert people, to remind people there’s another way, you have to make your voice heard.”

Still, Gross, Esserman, and others pushing for boycotts can point to no evidence that their efforts have changed hearts and minds, let alone laws.

Instead of moving the American Society of Hematology’s 2022 meeting out of New Orleans after Louisiana imposed a trigger law to ban abortion, Jane Winter, the society’s president at the time, met with Louisiana’s then-governor, John Bel Edwards, and told him about women whose survival might depend on getting an abortion. They talked about her 22-year-old patient who had Hodgkin lymphoma and learned she was pregnant just before a planned stem cell transplant.

“Gov. Edwards was visibly moved by our clinical cases and shared that lawmakers had not considered the impact of abortion restrictions on the care of our patients,” in a column for The Hematologist.

Last year, the hematologists held their meeting in San Diego, and they will meet again in California, which has no post-Roe abortion restrictions, in December.

In an email, Winter said her conversation with Edwards changed nothing concrete, as far as she knows. But she added, “I do believe that telling the stories of specific individuals – in my case, those of my patients – is one way to begin to change minds.”

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UC-San Francisco’s renowned nursing school will graduate its final class of certified nurse-midwives next spring. Then the university will cancel its two-year master’s program in , along with other nursing disciplines, in favor of a three-year doctor of nursing practice, or DNP, degree. The change will pause UCSF’s nearly five decades-long training of nurse-midwives until at least 2025 and will more than double the cost to students.

State Assembly member Mia Bonta, who chairs the health committee, said she was “disheartened” to learn that UCSF was eliminating its master’s nurse-midwifery program and feared the additional time and costs to get a doctorate would deter potential applicants. “Instead of adding hurdles, we need to be building and expanding a pipeline of culturally and racially concordant providers to support improved birth outcomes, especially for Black and Latina birthing people,” she said in an email.

The switch to doctoral education is part of a national movement to require all advanced-practice registered nurses, including nurse-midwives and nurse practitioners, to earn doctoral degrees, Kristen Bole, a UCSF spokesperson, said in response to written questions. The doctoral training will feature additional classes in leadership and quality improvement.

But the movement, which dates to 2004, has not caught on the way the American Association of Colleges of Nursing envisioned when it called for doctorate-level education to be required for entry-level advanced nursing practice by 2015. That deadline came and went. Now, an acute need for maternal health practitioners has some universities moving in the other direction.

This year, Rutgers University reinstated the nurse-midwifery master’s training it had eliminated in 2016. The also restarted its master’s in nurse-midwifery program in 2022 after a 25-year hiatus. In addition, in Washington, D.C., in New Orleans, and the added master’s training in nurse-midwifery.

UCSF estimates tuition and fees will cost $152,000 for a three-year doctoral degree in midwifery, compared with $65,000 for a two-year master’s. that 71% of nursing master’s students and 74% of nursing doctoral students rely on student loans, and nurses with doctorates earn negligibly or no more than nurses with master’s degrees.

Kim Q. Dau, who ran UCSF’s nurse-midwifery program for a decade, resigned in June because she was uncomfortable with the elimination of the master’s in favor of a doctoral requirement, she said, which is at odds with the state’s workforce needs and unnecessary for clinical practice.

“They’ll be equally prepared clinically but at more expense to the student and with a greater time investment,” she said.

are registered nurses with graduate degrees in nurse-midwifery. Licensed in all 50 states, they work mostly in hospitals and can perform abortions and prescribe medications, though they are also trained in managing labor pain with showers, massage, and other natural means. Certified midwives, by contrast, study midwifery at the graduate level outside of nursing schools and are licensed only in some states. Certified professional midwives attend births outside of hospitals.

The California Nurse-Midwives Association also criticized UCSF’s program change, which comes amid a national maternal mortality crisis, a serious shortage of obstetric providers, and a growing reliance on midwives. According to the 2022 “” report, the U.S. has the highest maternal mortality rate of any developed nation and needs thousands more midwives and other women’s health providers to bridge the swelling gap.

, founder and CEO of Grow Midwives, a national consulting firm, likened UCSF’s switch from master’s to doctoral training to “an earthquake.”

“Why are we delaying the entry of essential-care providers by making them go to an additional year of school, which adds nothing to their clinical preparedness or safety to serve the community?” asked Breedlove, a past president of the American College of Nurse-Midwives. “Why they have chosen this during one of the worst workforce shortages combined with the worst maternal health crisis we have had in 50 years is beyond my imagination.”

A 2020 report published in failed to find that advanced-practice registered nurses with doctorates were more clinically proficient than those with master’s degrees. “Unfortunately, to date, the data are sparse,” it concluded.

The American College of Nurse-Midwives also , as have trade associations for , citing “the lack of scientific evidence that … doctoral-level education is beneficial to patients, practitioners, or society.”

There is no evidence that doctoral-level nurse-midwives will provide better care, Breedlove said.

“This is profit over purpose,” she added.

Bole disputed Breedlove’s accusation of a profit motive. Asked for reasons for the change, she offered broad statements: “The decision to upgrade our program was made to ensure that our graduates are prepared for the challenges they will face in the evolving health care landscape.”

Like Breedlove, , vice chair of the health policy committee for the , worries that UCSF’s switch to a doctoral degree will exacerbate the twin crises of maternal mortality and a shrinking obstetrics workforce across California and the nation.

On average, 10 to 12 nurse-midwives graduated from the UCSF master’s program each year over the past decade, Bole said. California’s remaining master’s program in nurse-midwifery is at , south of Los Angeles, and it graduated eight nurse-midwives last year and 11 this year.

More than half of rural counties in the U.S. lacked obstetric care in 2018, according to a .

In some parts of California, expectant mothers must drive two hours for care, said who runs Midtown Nurse Midwives, a Sacramento birth center. It has had to stop accepting new clients because it cannot find midwives.

Donnelly predicted the closure of UCSF’s midwifery program will significantly reduce the number of nurse-midwives entering the workforce and will inhibit people with fewer resources from attending the program. “Specifically, I think it’s going to reduce folks of color, people from rural communities, people from poor communities,” she said.

UCSF’s change will also likely undercut efforts to train providers from diverse backgrounds.

Natasha, a 37-year-old Afro-Puerto Rican mother of two, has spent a decade preparing to train as a nurse-midwife so she could help women like herself through pregnancy and childbirth. She asked to be identified only by her first name out of fear of reducing her chances of graduate school admission.

The UCSF program’s pause, plus the added time and expense to get a doctoral degree, has muddied her career path.

“The master’s was just the perfect program,” said Natasha, who lives in the Bay Area and cannot travel to the other end of the state to attend CSU-Fullerton. “I’m frustrated, and I feel deflated. I now have to find another career path.”

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Llano once tried to get on public assistance but couldn’t — something, he said, looking perplexed, about owing the state money — and he’d like to apply again.

But beginning next year, if he does, he’ll face a new city requirement that single adults with no dependents who receive cash benefits be screened for illegal drug use and, if deemed necessary, enter treatment. San Francisco’s voters approved the new mandate in March.

Llano has no objection to being screened. He said he uses cannabis, which is legal in California, though not federally, but does not use other drugs. Nonetheless, he said, “I suppose I would try recovery.”

Another man in the free-lunch line, Francis Farrell, 56, was far less agreeable. “You can screen me,” he said, raising his voice, “but I don’t think you should force me into your idea of treatment.”

No one will be forced to undergo substance abuse treatment, nor will anyone be subject to drug testing, San Francisco officials insist. Rather, starting in January 2025, San Francisco’s public assistance recipients who screen positive for addiction on a 10-question will be referred to treatment. Those who refuse or fail to show up for treatment will forfeit the $109 a month that the city grants to homeless adults who qualify for city shelters or supportive housing, or the $712 a month it grants to adults with home addresses.

The city famous for its tolerance is resorting to tough love.

, executive director of the San Francisco Human Services Agency, cited three reasons for the new measure, which was fashioned after similar policies in and : to incentivize people with a substance use disorder to enter treatment, to prevent taxpayer money from being used to buy illegal drugs, and to dissuade drug seekers from moving to San Francisco.

“We’re giving them the opportunity to engage in something, without requiring sobriety, to hopefully get on a path to recovery,” Rhorer told ºÚÁϳԹÏÍø News.

When introduced the ballot initiative known as in a last year, she called it an incentive to encourage drug-addicted recipients of public assistance to enter “into a program that will help save their life.” Accidental overdoses killed in San Francisco last year.

But in the eyes of many health care providers, researchers, and harm reduction advocates, the measure is neither an incentive nor an opportunity.

The policy was designed to have “a coercive, punitive effect” and could do more harm than good, said , president and chief executive of HealthRIGHT 360, San Francisco’s largest drug treatment provider.

“It would have been an interesting project, much more in the spirit of San Francisco as a hub of innovation, to figure out if we can identify people with substance use disorder. And if they go into treatment and stay for a period of time, they’ll get an increased benefit,” Eisen said.

in the city currently receive benefits from the County Adult Assistance Programs, or CAAP. Under Measure F, those who acknowledge drug abuse on the screening test but refuse treatment and live in city-provided shelter will lose their cash benefits but can maintain their shelter, Rhorer said. However, CAAP recipients who refuse treatment and depend on public assistance to pay their rent in private housing could lose their homes.

The city will give recipients three chances to show up for treatment and will pay rent directly to a landlord for one month, Rhorer said. Measure F came in response to the grim conditions on some San Francisco streets, where men and women lie on sidewalks, often blocking passersby with their arms and legs splayed, or stand bent over, frozen like statues. Many use fentanyl, a synthetic opioid that has turned a long-standing homelessness problem into a public health emergency.

About 12% of people who fatally overdosed in San Francisco last year were CAAP recipients, Rhorer said.

Compassion fatigue seems to have settled over this city known for its kindheartedness. Measure F proponents raised $667,000 — more than 17 times as much as opponents — largely from business executives and tech investors, according to the San Francisco Ethics Commission. Then in March, 58% of voters approved the measure.

Since fentanyl began replacing heroin around 2019, Rhorer said, “drug tourists” have flocked to San Francisco, where the opioid has been cheap and plentiful. Lenient law enforcement and relatively generous cash public assistance grants also have drawn people with addiction, he said, although police activity has increased since last spring.

A recent city report found that of the 718 people whom police cited for substance use over a 10-month period that ended in February said they lived in the city.

“People who live in San Francisco, who really need the most help, don’t get the help they need due to the influx of people coming from somewhere else,” said Cedric Akbar, who runs recovery programs and co-founded . “And should our tax dollars go to the ones in San Francisco, or are we going to take care of the whole country?”

Akbar began using heroin when he moved to San Francisco from Houston in the 1980s and has been in recovery for 31 years. He said he would have preferred even stricter requirements for eligibility for public assistance than those in Measure F but hopes the new mandate will at least help give people access to treatment.

The city’s capacity for treatment is also a concern. Eisen and others describe a dire shortage of behavioral health workers to staff treatment facilities and residential step-down units, which are crucial for housing those in recovery from drug addiction.

New programs funded by the recently approved Proposition 1 in California, which authorizes the state to spend $6.38 billion to build mental health treatment facilities and provide housing for homeless people, are meant to address the shortages.

, an addiction medicine physician and an assistant professor at the University of California-San Francisco, fears that pushing CAAP recipients into treatment could turn them off. When people “were stigmatized, or coerced, or told they would face consequences if they didn’t do a certain thing,” she said, “that pushed them away from the health system even further.”

Though evidence suggests compulsory treatment can provide short-term benefits, it also can lead to long-term harm, the said in an email.

“To achieve the best outcomes,” the email said, treatment should be “delivered without stigma or penalty.”

Almost everyone with a substance use disorder enters treatment under some kind of pressure, whether from a parent, a spouse, an employer, or the criminal justice system, said , a Stanford University psychiatry professor.

Nonetheless, he questioned the morality of requiring welfare recipients, as opposed to criminals, to get drug treatment.

“I would never start with people who are poor but not committing crimes,” he said. “I would start with people who are harming others.”

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Singleton, who is Black and has practiced for 50 years, sees calling doctors out for implicit bias as divisive, and argues the state cannot legally require her to teach the idea in her continuing education classes. She has sued the Medical Board of California, asserting a constitutional right not to teach something she doesn’t believe.

The way to address health care disparities is to target low-income people for better access to care, rather than “shaking your finger” at white doctors and crying “racist,” she said. “I find it an insult to my colleagues to imply that they won’t be a good doctor if a racially divergent patient is in front of them.”

The litigation is part of a national crusade by right-leaning advocacy and legal groups against diversity, equity, and inclusion, or DEI, initiatives in health care. The pushback is inspired in part by last year’s U.S. Supreme Court ruling barring affirmative action in higher education.

The California lawsuit does not dispute the state’s authority to require implicit-bias training. It questions only whether the state can require all teachers to discuss implicit bias in their continuing medical education courses. The suit’s outcome, however, could influence obligatory implicit-bias training for all licensed professionals.

Leading the charge is the Pacific Legal Foundation, a Sacramento-based organization that describes itself as a “national public interest law firm that defends Americans from government overreach and abuse.” Its clients include the activist group Do No Harm, founded in 2022 to fight affirmative action in medicine. The two groups have also joined forces to sue the Louisiana medical board and the Tennessee podiatry board for reserving board seats exclusively for racial minorities.

In their complaint against the California medical board, Singleton and Do No Harm, along with Los Angeles ophthalmologist , argue that the violates the First Amendment rights of doctors who teach continuing medical education courses by requiring them to discuss how unconscious bias based on race, ethnicity, gender identity, sexual orientation, age, socioeconomic status, or disability can alter treatment.

“It’s the government saying doctors must say things, and that’s not what our free nation stands for,” said Khatibi, who immigrated to the U.S. from Iran as a child. Unlike Singleton, Khatibi does believe implicit bias can unintentionally result in substandard care. But, she said, “on principle, I don’t believe in the government compelling speech.”

The lawsuit challenges the evidence of implicit bias in health care, saying there is no proof that efforts to reduce bias are effective. Interventions have thus far not demonstrated lasting effects,

In December, U.S. District Judge Dale S. Fischer dismissed the suit but allowed the Pacific Legal Foundation to file an amended complaint. A hearing is scheduled for March 11 in federal court in Los Angeles.

In enacting the training requirement, the California legislature found that physicians’ biased attitudes unconsciously contribute to health care disparities. It also found that racial and ethnic disparities in health care outcomes are “remarkably consistent” across a range of illnesses and persist even after adjusting for socioeconomic differences, whether patients are insured, and other factors influencing care.

Black women are three to four times as likely as white women to die of pregnancy-related causes, are often prescribed less pain medication than white patients with the same complaints, and are referred less frequently for advanced cardiovascular procedures,the legislature found.

It also noted that women treated by female doctors were more likely to survive heart attacks than those treated by men. This month, the California legislature’s Black Caucus requiring implicit-bias training for all maternal care providers in the state.

, who teaches an implicit-bias class for Massachusetts doctors, sees only the best intentions in her fellow physicians. “But we’re also human,” she said in an interview. “And to not acknowledge that we are just as susceptible to bias as anybody else in any other field is unfair to patients.”

Ennis offered an example of her own bias in a training session. Preparing to treat a patient in a hospital emergency room, she noticed a Confederate flag tattoo on his forearm.

“As a Black woman, I had to have a quick chat with myself,” she said. “I needed to ensure that I provided the same standard of care for him that I would for anyone else.”

Ennis’ class meets the requirements of a that physicians earn two hours of instruction in implicit bias to obtain or renew their licenses, as of 2022.

That same year, that all accredited continuing medical education courses involving direct patient care include discussion of implicit bias. The state mandates 50 hours of continuing education every two years for doctors to maintain their licenses. Private institutions offer courses on an array of topics, and physicians generally teach them.

Teachers may tell students they do not believe implicit bias drives health care disparities, Fischer wrote in her December ruling. But the state, which licenses doctors, has the right to decide what must be included in the classes, the judge wrote.

Professionals who elect to teach courses “must communicate the information that the legislature requires medical practitioners to have,” the judge wrote. “When they do so, they do not speak for themselves, but for the state.”

Whether they speak for themselves or for the state is a pivotal question. While the First Amendment protects private citizens’ right to free speech, that protection does not extend to government speech. The content of public school curricula, for example, is the speech of state government, not the speech of teachers, parents, or students, courts have said. In 1988, the that the First Amendment did not apply to student journalists when a principal censored articles they wrote as part of a school curriculum.

The Pacific Legal Foundation’s amended complaint aims to convince the judge that its clients teach as private citizens with First Amendment rights. If the judge again rules otherwise, lead attorney Caleb Trotter told ºÚÁϳԹÏÍø News, he plans to appeal the decision to the U.S. Court of Appeals for the 9th Circuit, and, if necessary, the Supreme Court.

“This is not government speech at all,” he said. “It’s private speech, and the First Amendment should apply.”

“Plaintiffs are plainly wrong,” lawyers for Rob Bonta, the state attorney general, responded in court papers. “There can be no dispute that the State shapes or controls the content of continuing medical education courses.”

The medical board declined to comment on the pending litigation.

From 2019 through July 2022, in addition to California and Massachusetts, enacted legislation requiring health care providers to be trained in implicit bias.

A landmark 2003 Institute of Medicine report, “,” found that limited access to care and other socioeconomic differences explain only part of racial and ethnic disparities in treatment outcomes. The expert panel concluded that clinicians’ prejudices could also contribute.

In the two decades since the report’s release, studies have documented that bias does influence clinical care and contribute to racial disparities, said.

But implicit-bias training might have no impact and might even worsen discriminatory care, the report found.

“There’s not really evidence that it works,” Khatibi said. “To me, addressing health care disparities is really important because lives are at stake. The question is, How do you want to achieve these ends?”

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The move comes at a time of rising alarm among researchers over the health effects of hair straighteners, products widely used by and heavily marketed to Black women. But advocates and scientists say the proposed regulation would do far too little, in addition to being far too late.

“The fact that formaldehyde is still allowed in hair care products is mind-blowing to me,” said , a former director of the National Institute of Environmental Health Sciences and the National Toxicology Program. “I don’t know what we’re waiting for.”

Asked why it’s taking so long to get the issue on the FDA’s agenda, , the regulatory agency’s chief scientist, told ºÚÁϳԹÏÍø News: “I think primarily the science has progressed.”

“Also,” she added, “the agency is always balancing multiple priorities. It is a priority for us now.”

The FDA’s glacial response to concerns about formaldehyde and other hazardous chemicals in hair straighteners partly reflects the agency’s limited powers when it comes to cosmetics and personal-care products, according to , a former assistant administrator for toxic substances at the Environmental Protection Agency. Under the law, she said, the FDA must consider all chemical ingredients “innocent until proven guilty.”

Critics say it also points to broader problems. “It’s a clear example of failure in public health protection,” said David Andrews, a senior scientist at the Environmental Working Group, which first petitioned the agency to ban formaldehyde in hair straighteners in 2011 and sued over the issue in 2016. “The public is still waiting for this response.”

Mounting evidence linking hair straighteners to hormone-driven cancers prompted Reps. Ayanna Pressley (D-Mass.) and Shontel Brown (D-Ohio) last year to to investigate straighteners and relaxers.

The FDA responded by proposing to do what many scientists say the agency should have done years ago — initiate a plan to eventually outlaw chemical straighteners that contain or emit formaldehyde.

Such a ban would be a crucial public health step but doesn’t go nearly far enough, scientists who study the issue said. The elevated risk of breast, ovarian, and uterine cancers that epidemiological studies have recently associated with hair straighteners is likely due to ingredients other than formaldehyde, they said.

Formaldehyde has been linked to an increased risk of upper respiratory tract cancer and myeloid leukemia, Bumpus of the proposed ban on X, formerly known as Twitter. But Kimberly Bertrand, an associate professor at the Boston University Chobanian & Avedisian School of Medicine, and other scientists said they were unaware of any studies linking formaldehyde to the hormone-driven, or reproductive, cancers that prompted recent calls for the FDA to act.

“It’s hard for me to imagine that removing formaldehyde will have an impact on the incidence of these reproductive cancers,” said Bertrand, an epidemiologist and lead author on , the second linking hair relaxers to an increased risk of uterine cancer.

Hair products targeted to African Americans contain a host of hazardous chemicals, said , an associate professor of epidemiology at the Harvard T.H. Chan School of Public Health who has studied the issue for 20 years.

Studies have shown that straightener ingredients include phthalates, parabens, and other that mimic the body’s hormones and have been linked to cancers as well as early puberty, fibroids, diabetes, and gestational high blood pressure, which is a key contributor to Black women’s outsize risk of maternal mortality, James-Todd said.

“We have to do a better job regulating ingredients that people are exposed to, particularly some of our most vulnerable in this country,” she said. “I mean, children are being exposed to these.”

The first study linking hair relaxers to uterine cancer, published in 2022, found that frequent use of chemical straighteners more than doubled a woman’s risk. It followed studies showing women who frequently used hair relaxers doubled their ovarian cancer risk and had a 31% higher risk of breast cancer.

Bumpus praised the studies as “scientifically sound” and said she would leave to epidemiologists and others questions about whether straightener ingredients besides formaldehyde might be contributing to an elevated risk of hormone-driven cancers.

She could not offer a timeline for a formaldehyde ban, except to say the agency was scheduled to initiate proceedings in April. The schedule could change, she said, and she did not know how long the process of finalizing a rule would take.

Brazilian Blowouts and similar hair-smoothing treatments sometimes use formaldehyde as a glue to hold the hair straight for months. Stylists usually seal the product into the hair with a flat iron. Heat converts liquid formaldehyde into a gas that creates fumes that can sicken salon workers and patrons.

In addition to cosmetics, formaldehyde is found in embalming fluid, medicines, fabric softeners, dishwashing liquid, paints, plywood, and particleboard. It irritates the throat, nose, eyes, and skin.

If there are opponents to a ban on formaldehyde in hair straighteners, they have not raised their voices. Even the Personal Care Products Council, which represents hair straightener manufacturers, supports a formaldehyde ban, spokesperson Stefanie Harrington said in an email. More than 10 years ago, she noted, a deemed hair products with formaldehyde unsafe when heated.

California and Maryland will ban formaldehyde from all personal-care products starting next year. And manufacturers already have curtailed their use of formaldehyde in hair care products. Reports to the California Department of Public Health’s show a tenfold drop in products containing formaldehyde from 2009 to 2022.

John Bailey, a former director of the FDA’s Office of Cosmetics and Colors, said the federal agency often waits for the industry to voluntarily remove hazardous ingredients.

Cheryl Morrow co-founded late last year to lobby on behalf of California Curl, a business she inherited from her father, a barber who started the company, and other Black hair care companies and salons. “Ban it,” she said of formaldehyde, “but please don’t mix it up culturally with what Black people are doing.”

She insisted the relaxers African Americans use contain no formaldehyde or other carcinogens and are safe.

found that hair products used primarily by Black women and children contained a host of hazardous ingredients. Investigators tested 18 products, from hot-oil treatments to anti-frizz polishes, conditioners, and relaxers. In each of the products they found at least four and as many as 30 endocrine-disrupting chemicals.

Racist beauty standards have long compelled girls and women with kinky hair to straighten it. Between 84% and 95% of Black women in the U.S. have reported using relaxers, studies show.

Black women’s often frequent and lifelong application of chemical relaxers to their hair and scalp might explain why hormone-related cancers kill more Black women than white women per capita, Bertrand and other epidemiologists say. Relaxers can be so habit-forming that users call them “creamy crack.”

As a public health educator, Astrid Williams, director of programs and initiatives at the California Black Health Network, has known the health risks associated with hair relaxers for years. Nonetheless, she used them from age 13 until two years ago, when she was 45.

“I felt I had to show up in a certain way,” she said.

A formaldehyde ban won’t make creamy crack safe, she said. “It’s not even a band-aid. The solution is to address all chemicals that pose risk.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/health-industry/hair-relaxers-straighteners-formaldehyde-carcinogen-fda/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Designed to counter the “” that researchers say leads a disproportionate number of African American mothers to die from childbirth, the project has provided 150 pregnant Black and Pacific Islander San Franciscans a $1,000 monthly stipend.

The money enabled Jones, 20, to pay for gas to drive to prenatal clinics, buy fresh fruits and vegetables for her toddler son and herself, and remain healthy as she prepared for the birth of her second child last year.

But the future of the Abundant Birth Project is clouded by alleging that the program, the first of its kind in the nation, illegally discriminates by giving the stipend only to people of a specific race. The lawsuit also targets San Francisco guaranteed-income programs , , and .

The litigation is part of a growing national effort by conservative groups to eliminate racial preferences in a wide range of institutions following a that found race-conscious admissions to colleges and universities to be unconstitutional.

In health care, legal actions threaten efforts to provide scholarships to minority medical school students and other initiatives to create a physician workforce that looks more like the nation.

The lawsuits also endanger other measures designed to reduce well-documented racial disparities. Black women are three to four times than white women to die in labor or from related complications in the U.S., and Black infants are twice as likely as white infants to be born prematurely and to die before their first birthdays. Racial and ethnic minorities also are to die from diabetes, high blood pressure, asthma, and heart disease than their white counterparts, according to the Centers for Disease Control and Prevention.

A handful of activist nonprofit groups and law firms are leading the charge. , a nonprofit formed in 2022, has sued , , and to try to stop them from choosing applicants based on race. Do No Harm claims more than 6,000 members worldwide and partners with nonprofit legal organizations, most notably the , which garnered national attention California’s same-sex marriage ban.

Another nonprofit, the , together with a Dallas-based law firm called the , filed the lawsuit against the city of San Francisco and the state of California over the Abundant Birth Project, alleging the program violates the equal protection clause of the Constitution’s 14th Amendment by granting money exclusively to Black and Pacific Islander women. The 14th Amendment was passed after the Civil War to give rights to formerly enslaved Black people.

The lawsuit calls public money used for the project and the three other guaranteed-income programs “discriminatory giveaways” that are “illegal, wasteful, and injurious.”

“The city and county of San Francisco crafted the Abundant Birth Project with the express intention of picking beneficiaries based on race,” Dan Morenoff, executive director of the American Civil Rights Project, said in a phone interview. “It’s unconstitutional. They can’t legally do it, and we are optimistic that the courts will not allow them to continue to do it.”

San Francisco and state officials declined to discuss the case because of the pending litigation, but the city defended the program in its initial response to the lawsuit. The Abundant Birth Project started in June 2021 and plans to make a second round of grants to pregnant mothers this fall, the response says.

The project strives to improve maternal and infant health outcomes by easing the economic stress on pregnant Black and Pacific Islander San Franciscans. People in those groups face some of the in the U.S., where as a result of pregnancy and childbirth than in other high-income nations. The state of California last year to expand the program to include Black mothers in four other counties.

But a Berkeley law professor and anthropologist who has talked to beneficiaries of the Abundant Birth Project but is not directly involved with it, said the Supreme Court ruling on college affirmative action could actually support the argument that the program is legal.

The court struck down affirmative action in part because the majority said Harvard and the University of North Carolina failed to show measurable outcomes justifying race consciousness in college admissions. While statistics on potential benefits from the Abundant Birth Project are not publicly available, Bridges and others familiar with the program expect researchers to demonstrate it saves and improves lives by comparing the health outcomes of families who received the stipend with those of families who did not. The outcomes could justify employing race to choose program participants, Bridges said.

Bridges also drew another distinction between the role of race in college admissions and the role of race in health disparities.

“If you don’t get into Harvard, there’s always Princeton or Columbia or Cornell,” she said. “Maternal death — the stakes are a little bit higher.”

In California, a voter initiative, Proposition 209, has prohibited race-based selection in public education and employment since 1996. California Assembly member (D-Oakland) has co-authored a that would amend the proposition to allow municipalities to grant benefits to specific groups of vulnerable people if they use research-based measures that can reduce health and other disparities.

Bonta, a law school graduate, told ºÚÁϳԹÏÍø News that the litigation against the Abundant Birth Project is the result of “conservative groups who want to exist in a world that doesn’t exist, where communities of color have not had to suffer the generational harm that comes from structural racism.”

Bonta has more than once been a victim of medical racism herself.

When she went to the hospital with a serious back injury, she was interrogated by a doctor who appeared to believe she was faking pain so she could obtain drugs.

“But for the intervention of my husband, who happened to be there and moved into health advocacy mode, I, as a Black Latina woman, would not have received the care that I needed,” she said. Bonta’s husband, Rob Bonta, is also a lawyer and is now California’s attorney general.

Briana Jones experiences racism every day, she said.

She was 15 when she gave birth to her first child in a San Francisco hospital. Terrified and in agonizing pain, she did what laboring mothers have always done and screamed.

A nurse ordered her to “shut up.”

In the U.S., Black women are far more likely than white women to report that health care providers scolded, threatened, or shouted at them during childbirth, . They also face of , including barriers to quality care and cumulative stress from lifelong discrimination.

Growing up Black in San Francisco has been a struggle for Jones. But, while carrying her second baby last year, she learned from her mother of the Abundant Birth Project, and within a month, her race and address in Bayview Hunters Point, where some of the city’s poorest residents live, qualified her as one of nearly 150 women to receive the $1,000 a month during her pregnancy and for six months postpartum.

“I really did feel like it was God helping me,” she said.

For Morenoff, though, it’s just another form of discrimination, and he says the city must either open the Abundant Birth Project to all pregnant women or close it down. “The whole point of the 14th Amendment is to require America to treat all Americans as Americans with the same equal rights,” he said.

Jones had high blood pressure, leading to swollen ankles and dizziness, during both her pregnancies. In her more recent one, the birth project stipend helped enable her to quit couch surfing and move into an apartment, and she gave birth to a healthy boy named Adonis.

“It’s known that people of color struggle way harder than other races,” Jones said. “Where I live, it’s nothing but struggle here, people trying to make ends meet.”

“For them to try to take this program away from us,” she said, “it’s wrong.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This <a target="_blank" href="/race-and-health/pregnant-black-mothers-guaranteed-income-affirmative-action/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">