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. Ìý

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 with how to cut the budget. Several proposals would disproportionately target California, according to Larry Levitt, Â鶹ŮÓÅ’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. Â鶹ŮÓÅ is a health information nonprofit that includes Â鶹ŮÓÅ Health 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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La prestigiosa escuela de enfermería de la UC-San Francisco graduará a su última promoción de enfermeras parteras la próxima primavera.

Luego, la universidad cancelará su programa de máster de dos años en , junto con otras disciplinas de enfermería, en favor de un doctorado en enfermería de tres años, o DNP.

El cambio pondrá entre paréntesis la formación de enfermeras parteras que la UCSF ha impartido durante casi cinco décadas, al menos hasta 2025, y duplicará con creces el costo para los estudiantes.

Mia Bonta, legisladora de la Asamblea Estatal que preside el comité de salud, dijo que estaba “descorazonada” al saber que la UCSF cancelaba su programa de maestría en enfermería obstétrica y temía que el tiempo y los costos adicionales para obtener un doctorado disuadieran a futuros postulantes.

“En lugar de agregar obstáculos, tenemos que construir y ampliar un canal de proveedores cultural y racialmente competentes para apoyar la mejora de los resultados del parto, especialmente para las parturientas afroamericanas y latinas”, expresó Bonta en un correo electrónico.

El cambio a la formación doctoral forma parte de un movimiento nacional que exige que todas las enfermeras registradas de práctica avanzada, incluidas las enfermeras parteras y las especializadas, obtengan títulos de doctorado, según declaró Kristen Bole, vocera de la UCSF. La formación doctoral incluirá clases adicionales sobre liderazgo y mejora de la calidad en la atención.

Sin embargo, este movimiento, que se remonta a 2004, no se desarrolló de la forma que imaginó la Asociación Estadounidense de Facultades de Enfermería cuando pidió que, para 2015, tener un doctorado fuera obligatorio para practicar la enfermería especializada. Ese plazo se cumplió.

Ahora, la acuciante necesidad de profesionales de salud materna hace que algunas universidades se muevan en otra dirección.

Este año, la Universidad Rutgers restableció la formación de máster en enfermería obstétrica que había eliminado en 2016. La también reinició su programa de máster en enfermería obstétrica en 2022, tras un paréntesis de 25 años. Además, la de Washington, DC, la de Nueva Orleans y la agregaron formación de máster en enfermería obstétrica.

La UCSF calcula que la matrícula y las tasas costarán $152,000 por un doctorado de tres años en obstetricia, frente a los $65,000 de un máster de dos años. Los que el 71% de los estudiantes de máster en enfermería y el 74% de los estudiantes de doctorado en enfermería dependen de préstamos estudiantiles, y las enfermeras con doctorado ganan igual o poco más que las que tienen un máster.

Kim Q. Dau, que dirigió el programa de enfermería obstétrica de la UCSF durante una década, dimitió en junio porque se sentía incómoda con la eliminación del máster en favor de un requisito de doctorado que, según dijo, contradice las necesidades de mano de obra del estado y es innecesario para la práctica clínica.

“Estarán igualmente preparadas clínicamente, pero a un costo mayor para el estudiante y con una mayor inversión de tiempo”, expresó Dau.

Las son enfermeras tituladas en enfermería obstétrica. Con licencia en los 50 estados, trabajan especialmente en hospitales y pueden practicar abortos y recetar medicamentos, aunque también están capacitadas para tratar el dolor del parto con duchas, masajes y otros medios naturales. En cambio, las parteras o comadronas tituladas estudian obstetricia a nivel de postgrado fuera de las escuelas de enfermería y sólo están autorizadas en algunos estados. Las parteras profesionales tituladas atienden partos fuera de los hospitales.

La Asociación de Enfermeras Obstetras de California también criticó el cambio de programa de la UCSF, que se produce en medio de una crisis nacional de mortalidad materna, una grave escasez de proveedores de obstetricia y una creciente dependencia de las parteras.

Según el informe (Plan de la Casa Blanca para abordar la crisis de salud materna) de 2022, Estados Unidos tiene la tasa de mortalidad materna más alta de todos los países desarrollados y necesita miles de parteras más y otros proveedores de salud para la mujer que reduzcan la creciente brecha.

, fundadora y CEO de Grow Midwives, una consultora nacional, comparó el cambio de la UCSF de la formación de máster a la de doctorado con “un terremoto”.

“¿Por qué estamos retrasando la entrada de proveedores de cuidados esenciales haciéndoles cursar un año más de estudios, que no agrega nada a su preparación clínica ni a su seguridad para servir a la comunidad?”, se preguntó Breedlove, ex presidenta del American College of Nurse-Midwives (ACNM, Colegio Profesional de Enfermeras Parteras). “Resulta incomprensible que hayan elegido hacer esto durante la peor escasez de mano de obra combinada con la peor crisis de salud materna que hemos tenido en 50 años”.

Un informe de 2020 publicado en no encontró que las enfermeras registradas de práctica avanzada con doctorados fueran más competentes clínicamente que las que tenían maestrías. “Por desgracia, hasta la fecha, los datos son escasos”, concluyó el informe.

El ACNM también denunció el , al igual que las , citando “la falta de pruebas científicas de que… la formación a nivel de doctorado sea beneficiosa para los pacientes, los profesionales o la sociedad”.

Según Breedlove, no hay pruebas de que las enfermeras obstétricas con doctorado proporcionen mejores cuidados.

“Se busca beneficio económico, no un mejor resultado”, agregó.

Bole rebatió la acusación de lucro hecha por Breedlove. Consultada por las razones del cambio, ofreció declaraciones generales: “La decisión de actualizar nuestro programa se tomó para garantizar que nuestros graduados estén preparados para los retos a los que se enfrentarán en el cambiante campo de la salud”.

Al igual que Breedlove, , vicepresidenta del comité de políticas de salud de la , teme que el cambio de la UCSF a un título de doctorado agrave la doble crisis de la mortalidad materna y la disminución del personal de obstetricia en California y en el país.

En promedio, de 10 a 12 enfermeras obstetras se han graduado del programa de maestría de la UCSF cada año durante la última década, según Bole. El programa de máster en enfermería obstétrica que queda en California está en la , (CSU-Fullerton), al sur de Los Angeles, en donde se graduaron ocho enfermeras obstétricas el año pasado, y 11 este año.

Más de la mitad de los condados rurales de Estados Unidos carecieron de atención obstétrica en 2018, según un informe de la

En algunas áreas de California, las futuras madres deben conducir dos horas para recibir atención, señaló , quien dirige Midtown Nurse Midwives, un centro de nacimientos en Sacramento que ha tenido que dejar de aceptar nuevas pacientes porque no encuentra comadronas.

Donnelly predijo que el cierre del programa de la UCSF reducirá significativamente el número de enfermeras parteras que se incorporen al mercado laboral, e impedirá que las personas con menos recursos asistan al programa. “En concreto, creo que se reducirá el número de personas de color, de comunidades rurales y de comunidades pobres”, afirmó.

El cambio de la UCSF también afectará con toda probabilidad los esfuerzos por formar a proveedores con una herencia diversa.

Natasha, afropuertorriqueña, de 37 años y madre de dos hijos, lleva una década preparándose para ser enfermera partera y poder ayudar a mujeres como ella durante el embarazo y el parto. Pidió que sólo se la identificara por su nombre de pila por miedo a reducir sus posibilidades de ser admitida en una escuela de posgrado.

La pausa del programa de la UCSF, más el tiempo y los gastos que se suman para obtener un doctorado, han enturbiado su trayectoria profesional.

“El máster era el programa perfecto”, afirmó Natasha, que vive en la zona de la Bahía de San Francisco y no puede viajar al otro extremo del estado para asistir a CSU-Fullerton. “Estoy frustrada y me siento desmoralizada. Ahora tengo que buscar otra carrera”.

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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 Â鶹ŮÓÅ Health 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 Â鶹ŮÓÅ Health 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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La medida llega en un momento en que investigadores están cada vez más preocupados por los riesgos de estos productos para la salud, que se promocionan principalmente entre mujeres negras. Pero defensores y científicos dicen que la norma haría muy poco y que, además, llega demasiado tarde.

“Me resulta increíble que todavía se permita el formaldehído en los productos para el cuidado del cabello”, dijo , ex directora del Instituto Nacional de Ciencias de la Salud Ambiental y del Programa Nacional de Toxicología. “No sé qué estamos esperando”.

A la pregunta de por qué la FDA está tardando tanto en abordar el tema, , jefa científica de la agencia reguladora, contestó a Â鶹ŮÓÅ Health News: “En primer lugar, me parece que la ciencia ha avanzado. La agencia siempre está evaluando varias prioridades a la vez. En este momento esto es una prioridad para nosotros”.

La lentitud de la FDA para actuar sobre el formaldehído y otras sustancias químicas peligrosas en los alisadores de cabello, refleja en parte sus limitaciones cuando se trata de cosméticos y productos de cuidado personal, opinó , ex administradora adjunta de sustancias tóxicas de la Agencia de Protección Ambiental de Estados Unidos. Según la ley, dijo, la FDA debe asumir que las sustancias químicas son “inocentes hasta que se demuestre lo contrario”.

Críticos dicen que esto revela problemas más amplios. “Es un claro ejemplo del fracaso de proteger la salud pública”, dijo David Andrews, científico principal de Environmental Working Group. La organización le pidió a la FDA que prohibiera el formaldehído en alisadores de cabello por primera vez en 2011, y presentó una demanda en 2016. “El público sigue esperando una respuesta”.

Cada vez hay más evidencia que vincula a los alisadores de cabello con ciertos tipos de cáncer relacionados con hormonas. Por eso, el año pasado, las representantes Ayanna Pressley (demócrata de Massachusetts) y Shontel Brown (demócrata de Ohio) a que investigara estos productos.

La agencia respondió haciendo lo que, según científicos, debería haber hecho hace años: lanzando un plan que eventualmente prohíba los alisadores químicos que contienen o emiten formaldehído.

Sería una medida fundamental para la salud pública, pero no tiene gran alcance, apuntaron estudiosos del tema. El riesgo elevado de cáncer de mama, ovario y útero asociado con los alisadores de cabello, según estudios epidemiológicos recientes, probablemente se deba no solo al formaldehído, dijeron.

El formaldehído se ha asociado con un mayor riesgo de cáncer nasofaríngeo y pulmonar, y de leucemia mieloide, dijo Bumpus en un , publicado en X (ex Twitter).

Pero Kimberly Bertrand, profesora asociada de la Facultad de Medicina Chobanian & Avedisian de la Universidad de Boston, y otros científicos, dijeron que no sabían de ningún estudio que vinculara al formaldehído con los cánceres ginecológicos o aquellos relacionados con hormonas, que son los que impulsaron el reciente llamado a la acción de la FDA.

Por lo tanto, dijo Bertrand, “me cuesta imaginar que eliminar el formaldehído tendrá un impacto en la incidencia de estos cánceres ginecológicos”. Bertrand es epidemióloga y fue la autora principal del segundo con un mayor riesgo de cáncer de útero, publicado en diciembre.

Los productos para el cabello que se venden y promocionan a personas afroamericanas contienen una gran cantidad de sustancias químicas peligrosas, dijo , profesora asociada de epidemiología en la Harvard T.H. Chan School of Public Health, que ha estudiado el tema durante 20 años.

Estudios han demostrado que los alisadores contienen ingredientes incluyendo ftalatos, parabenos y otros que imitan a las hormonas del cuerpo. Estos compuestos se han relacionado con el cáncer y con la pubertad temprana, los fibromas, la diabetes y la presión arterial alta durante el embarazo, un factor en las altas tasas de mortalidad materna en las mujeres negras, afirmó James-Todd.

“Tenemos que hacer más para regular los ingredientes a los que están expuestas las personas, en particular las más vulnerables de este país”, dijo. “Los niños están expuestos a estas sustancias”.

El primer estudio que vinculó los alisadores de cabello con el cáncer de útero, publicado en 2022, encontró que el uso frecuente de estos químicos duplica con creces el peligro. Este estudio siguió a otros que mostraron que las mujeres que usan alisadores para el cabello frecuentemente tienen el doble de riesgo de cáncer de ovario y un 31% más de riesgo de cáncer de mama.

Bumpus elogió los estudios, que calificó de “científicamente sólidos”. Dijo que la agencia iniciaría el proceso para considerar la propuesta en abril.

Algunos procedimientos, como el estilo brasileño, utilizan formaldehído para mantener el cabello lacio durante meses. Los estilistas suelen sellar el producto en el pelo con una plancha. El calor convierte el formaldehído líquido en un gas que libera vapores que pueden afectar la salud de los trabajadores y clientes de los salones de belleza.

El formaldehído no solo está en los cosméticos: también se encuentra en medicamentos, suavizantes de ropa, detergente para lavavajillas, y pinturas. El químico irrita la garganta, la nariz, los ojos y la piel.

No hay voces en contra de la prohibición. Incluso el Personal Care Products Council, la asociación que representa a las empresas fabricantes de estos productos, apoya la prohibición, dijo la vocera Stefanie Harrington en un correo electrónico. Dijo que hace más de 10 años, un pagados por la industria determinó que los productos para el cabello con formaldehído eran peligrosos cuando se calentaban.

California y Maryland prohibirán el formaldehído en todos los productos de cuidado personal a partir del próximo año, y los fabricantes ya han reducido el uso del químico en productos para el cabello. Los informes presentados al del Departamento de Salud Pública de California muestran que la presencia de formaldehído en los productos se redujo 10 veces entre 2009 y 2022.

John Bailey, ex director de la Oficina de Cosméticos y Colorantes de la FDA, dijo que la agencia federal suele esperar a que la misma industria elimine ingredientes peligrosos de forma voluntaria.

Cheryl Morrow cofundó a fines del año pasado, un grupo de abogacía que nuclea salones de belleza, como California Curls, que heredó de su padre barbero, especializados en el cuidado del cabello de personas negras. “Prohíbanlo”, dijo Morrow, refiriéndose al formaldehído, “pero por favor no lo confundan culturalmente con lo que hacen las personas negras”.

Insistió en que los alisadores que usan los afroamericanos no contienen formaldehído ni otros carcinógenos y que son seguros.

Un encontró que los productos para el cabello utilizados principalmente por mujeres y niños negros contenían varios ingredientes peligrosos. Los investigadores examinaron 18 productos, desde tratamientos a base a aceite caliente hasta lociones anti-frizz, acondicionadores y relajantes. En cada uno de estos productos encontraron al menos cuatro y hasta 30 sustancias químicas que alteran el sistema endócrino.

Por mucho tiempo, el racismo en los ideales de belleza ha hecho que las niñas y mujeres con cabello rizado se lo alisen. Entre el 84% y el 95% de las mujeres negras en Estados Unidos dicen que usan relajantes, según estudios.

La aplicación frecuente y continua de relajantes químicos en el cabello y el cuero cabelludo podría explicar por qué los cánceres relacionados con las hormonas matan a más mujeres negras que blancas per cápita, dicen Bertrand y otros epidemiólogos. Estos relajantes crean tanta dependencia que algunos los llaman “crack cremoso”.

Astrid Williams, educadora de salud pública y directora de programas e iniciativas de Black Health Network, en California, ha estado al tanto desde hace años de los riesgos para la salud asociados con los alisadores para el cabello. Sin embargo, usó estos productos desde los 13 años hasta hace dos años, cuando tenía 45.

“Sentía que tenía que verme de cierta manera”, dijo.

Prohibir el formaldehído no hará que el “crack cremoso” sea seguro, afirmó. “Ni siquiera es una solución transitoria. Deberíamos ocuparnos de todas las sustancias químicas peligrosas”.

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