Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca7-19-01732/USCOURTS-ca7-19-01732-0/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 

---

In the

United States Court of Appeals

For the Seventh Circuit ____________________

Nos. 19-1380, 19-1387 & 19-1732

JEFFREY ORR, et al.

Plaintiffs-Appellees,

v.

LOUIS SHICKER, et al.,

Defendants-Appellants.

____________________

Appeals from the United States District Court for the

Central District of Illinois.

No. 08-cv-2232 — Harold A. Baker, Judge.

____________________

ARGUED NOVEMBER 4, 2019 — DECIDED MARCH 23, 2020

____________________

Before WOOD, Chief Judge, and BAUER and BRENNAN, Circuit Judges.

WOOD, Chief Judge. Plaintiffs are current and former inmates of the Illinois Department of Corrections (IDOC) who 

have been diagnosed with hepatitis C. They filed this lawsuit 

over ten years ago after fruitless efforts to receive treatment 

for their disease while incarcerated. Invoking 42 U.S.C. § 1983, 

their complaint alleges that the diagnostic and treatment 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
2 Nos. 19-1380, 19-1387 & 19-1732

protocols for IDOC inmates with hepatitis C violate the 

Eighth and Fourteenth Amendments. After many years, many 

motions, and the consolidation of many cases, the district 

court granted class certification and preliminary injunctive relief. The defendants—IDOC, Wexford Health Sources, Inc., 

and several doctors—asked us to accept an appeal from that 

decision under Federal Rule of Civil Procedure 23(f). We 

agreed to do so and now reverse the grant of class certification 

and vacate the injunction.

I

A. Hepatitis C

Hepatitis C is a disease caused by the hepatitis C virus 

(HCV). Those who contract HCV may suffer inflammation of 

the liver, which can impair the functioning of that vital organ. 

HCV has six genotypes, the first of which predominates in the 

United States. 

A hepatitis C infection is categorized as either acute or 

chronic. In the acute phase, the infection does not necessarily 

result in any noticeable symptoms, and some people naturally 

clear the virus from their bodies. Others develop a chronic infection. Persons suffering from a chronic hepatitis C infection 

may develop fibrosis—that is, the build-up of scar tissue in 

the liver—which can lead to cirrhosis, a severe condition causing the affected areas of the liver to stop functioning. Cirrhosis 

is irreversible. The rate of fibrosis progression is not the same 

in all HCV patients. 

Several tests are available to determine the degree of fibrosis in a liver. One test, a FibroScan, uses ultrasound technology. This test results in several possible scores: F0 (no fibrosis), F1 (mild fibrosis), F2 (moderate fibrosis), F3 (advanced

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 3

fibrosis), and F4 (cirrhosis). Another test is the AST (which 

stands for the enzyme aspartate aminotransferase) to Platelet 

Ratio Index, or APRI. The APRI is calculated by dividing the 

patient’s AST level by her platelet count. 

B. The Lawsuit’s Early Years

Plaintiffs have all been diagnosed with hepatitis C. They 

filed this lawsuit in 2008, alleging that IDOC’s medical directors and Wexford, a private company that administers 

healthcare to inmates in IDOC’s custody, were deliberately 

indifferent to their medical conditions when they chose not to 

provide necessary treatment. Plaintiffs sought injunctive relief and class certification. In response to a motion from the 

defendants, the district court struck these requests.

In April 2009, Plaintiffs filed amended motions for class 

certification and injunctive relief; the district court denied 

those motions in November 2009. Two years later, the court 

dismissed Wexford from the suit with prejudice. In 2013, the 

court consolidated several related cases. The case dragged 

along until, in January 2016, Plaintiffs moved for reconsideration of the denial of class certification. The district court denied their motion, but it indicated a willingness to certify a 

class and so granted them leave to renew their request. The 

court noted that since the case was filed in 2008, there had

been significant developments in the treatment of hepatitis C. 

In the beginning, the disease had virtually no cure free from

serious risks and extensive costs. New treatments that were 

both significantly more effective and lower in cost had since 

become available.

In November 2016, Plaintiffs filed an amended complaint, 

naming IDOC, Wexford (again), IDOC’s medical director 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
4 Nos. 19-1380, 19-1387 & 19-1732

(initially Dr. Michael Puisis, who was later succeeded by Dr. 

Louis Shicker and then Dr. Steven Meeks), and several other

doctors as defendants. As before, they alleged that the defendants were deliberately indifferent to their medical needs in violation of the Eighth and Fourteenth Amendments. They also 

filed an amended motion for class certification and a motion 

for injunctive relief. 

In April 2017, the district court entered an order summarizing the current status of the case. The order reviewed the 

testimony given by witnesses and experts in 2016 and noted 

that there was “no dispute that Hep C is a serious medical 

condition or that it is present in significant numbers in the 

IDOC prison population.” The court nonetheless recognized

a “sharp dispute as to when treatment should begin.” At the 

time of the April 2017 order, IDOC’s policy was to begin treatment for inmates once their FibroScan score reached F3. Plaintiffs argued that treatment should begin as soon as possible. 

The district court also found that “all inmates should be 

tested for Hepatitis C upon admission” to IDOC. It determined that inmates “who test positively and have at least one 

year to serve on their sentence from admission to release date 

should be offered treatment with direct acting antiviral drugs 

as soon as possible after diagnosis, and, in any event, no later 

[than] testing at a fibrosis level of 2.” Nevertheless, the district 

court concluded that its findings were “too general to meet 

the specific requirements of a preliminary injunction order” 

and that it needed additional information about Plaintiffs’ “fibrosis levels, contributing conditions, sentence length, etc.”

In January 2018, Plaintiffs filed still another motion for injunctive relief; the district court scheduled an evidentiary 

hearing for January 2019. (The court also consolidated this 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 5

case with three others in which Wexford remained a defendant.) In early January 2019, IDOC implemented an updated

protocol for treating inmates with hepatitis C (“the 2019 Protocol”).

C. The 2019 Protocol

Under the 2019 Protocol, IDOC contracts with the University of Illinois – Chicago (“UIC”) for treatment of hepatitis C 

patients using a telemedicine system. The primary care physicians at each IDOC facility perform initial testing to ascertain which inmates are eligible for treatment at UIC. The UIC 

specialists then “determine the specific regimen for patients 

found ready for HCV treatment.”

When an inmate enters IDOC’s custody, he receives an 

HCV antibody test at the receiving and classification prison, 

unless he declines testing. If the test shows that the inmate is 

HCV positive and the inmate wants to be evaluated for possible treatment, further testing is performed at the prison to 

which the inmate is transferred, in order to “determine if the 

patient has chronic HCV disease or [if] the HCV infection has 

resolved (which can happen in about 15-25% [of cases]).” If 

chronic HCV is present, IDOC physicians evaluate “absolute 

exclusion criteria”—in other words, they determine whether 

the inmate has less than 12 months remaining on his sentence, 

has refused treatment, has unstable medical or psychiatric 

conditions, or other contraindications to HCV therapy. 

If no exclusionary factors are present, the inmate undergoes further tests, including a FibroScan and APRI calculation, to determine the severity of the liver disease, although 

the protocol states that a FibroScan should not be done for inmates with certain health conditions. Inmates with a 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
6 Nos. 19-1380, 19-1387 & 19-1732

FibroScan of F2 or less are vaccinated against hepatitis A and 

B, where appropriate. Inmates with a FibroScan of F2 and 

whose APRI score is greater than or equal to .7 are referred to 

UIC. Inmates with FibroScan results of F3 or F4 undergo further testing before referral to UIC. 

The 2019 Protocol also establishes priorities for the treatment of HCV-positive inmates. IDOC recognized that 

“[a]lthough nearly all patients with chronic hepatitis C infection are candidates for HCV therapy, there may be more urgency to treat certain patients first.” Under the 2019 Protocol, 

priority level 1 for HCV treatment includes inmates with any 

of the following: cirrhosis; a comorbid medical condition associated with HCV; a Child Turcotte Pugh score of greater 

than or equal to 7; or newly incarcerated inmates who are already receiving HCV treatment. Priority level 2a includes inmates with FibroScan results of F3 or F4, an APRI score of 

greater than or equal to 2, Metavir Stage 3 or 4, a hepatitis B 

co-infection, or HIV. Priority level 2b includes inmates with a 

FibroScan result of F2 and an APRI score of greater than or 

equal to .7. Priority level 3 includes inmates with a FibroScan 

result of F0 or F1, and an APRI score of less than .7. The level 3 

inmates are enrolled in the Hepatitis C Chronic Clinic, where 

they are seen every 12 months for (1) a targeted physical and 

other lab tests, (2) a FibroScan, (3) the calculation of their 

APRI, and (4) HCV education. 

If an inmate is referred to UIC, all lab work and necessary 

forms are completed at the prison and forwarded to UIC. After the UIC practitioner sees the inmate, prescriptions or orders from UIC are faxed or forwarded to the prison “for medication changes, lab tests to be ordered, studies to be obtained, 

or special requests for the IDOC medical team to address.”

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 7

The 2019 Protocol also requires that IDOC’s medical director receive a monthly report of inmates determined to be ineligible for treatment and the reason why. It requires notification of the medical director when there are inmates who are 

eligible for treatment but who “are having significant delays 

... that could impact their ability to get treated while they are 

incarcerated.”

D. Lippert Consent Decree

Also in January 2019, the state defendants (whittled down 

to Dr. Shicker, Dr. Meeks, and IDOC) filed a motion to stay 

the evidentiary hearing in light of another case, Lippert v. 

Ghosh, No. 10-4603 (N.D. Ill.). In Lippert, several IDOC inmates 

alleged that they were receiving inadequate medical care for 

various medical conditions in violation of the Eighth Amendment. They sought class certification and injunctive and declaratory relief. The district court in Lippert certified a class of 

“all prisoners in the custody of [IDOC] with serious medical 

or dental needs.” In December 2018, the Lippert parties

reached an agreement on a consent decree. 

The consent decree, which was approved in May 2019, applies to “all prisoners in the custody of [IDOC] with serious 

medical or dental needs.” It requires IDOC to implement 

changes in several areas, including chronic disease care, 

which covers HCV. Under the decree, IDOC will “provide 

sufficient nursing staff and clinicians” to complete medical 

evaluations within seven business days of an inmate’s arriving at IDOC’s receiving and classification prisons. If an evaluation shows that an inmate needs medical care, IDOC must 

ensure follow-up for appropriate care. In addition, the decree 

provides for the appointment of a court monitor to “conduct

a staffing analysis and create and implement an 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
8 Nos. 19-1380, 19-1387 & 19-1732

Implementation Plan to accomplish the obligations and objectives in this Decree.” Twice each year, the monitor will report 

to the parties and the court regarding compliance with the decree. 

The Lippert consent decree includes a dispute resolution 

provision. If those plaintiffs believe that the defendants are 

not in substantial compliance with any provision of the decree, they are to provide written notice “referencing the specific provision or provisions” not being complied with to the 

defendants, who must then provide a written response within 

30 days. If the plaintiffs reject the response, the parties must 

meet to try to resolve the dispute. If unsuccessful, the parties 

may jointly or individually seek relief from the court. 

E. February 4, 2019 Order

We may now return to our case. The district court denied 

the state defendants’ motion to stay the January 2019 hearing 

in light of the proposed consent decree in Lippert, finding that 

there were “no concrete proposals for treatment and handling 

of the combined cases.” The court also denied Wexford’s motion for reconsideration. On January 22 and 23, 2019, the district court conducted an evidentiary hearing on Plaintiffs’ motions for class certification and injunctive relief. Many witnesses testified. Plaintiffs also provided a spreadsheet containing some medical information about the horde of named 

plaintiffs (approximately 1,800), including their APRI scores, 

which were calculated by a law clerk.

On February 4, 2019, the district court granted in part and 

denied in part Plaintiffs’ motions for class certification and injunctive relief. First, the court certified two classes of inmates. 

Class 1 includes:

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 9

All current and future prisoners in IDOC custody who 

have been, or will be, diagnosed with chronic hepatitis 

C virus, have at least six months or more remaining [on 

their] sentence, and who have not previously received 

treatment which resulted in a sustained viral response.

Class 2 includes:

All current and future prisoners in the IDOC custody 

who have been, or will be, diagnosed with chronic hepatitis C virus, have at least one year remaining on their 

sentence, have a fibrosis level of greater than or equal 

to two and an APRI score greater than or equal to .7, 

and have not received direct-acting antiviral drugs.

The court denied injunctive relief for Class 1, but it granted 

an injunction for Class 2, finding that Plaintiffs had demonstrated “a more than negligible chance that refusing treatment 

for inmates with a fibrosis level of at least two could amount 

to deliberate indifference.” It acknowledged that the 2019 Protocol set treatment policies for inmates with a fibrosis level of 

two or more, but it concluded that injunctive relief was necessary because otherwise IDOC could abandon the protocol. 

Moreover, it said, the 2019 Protocol “does not actually mandate treatment” because it simply required the referral of inmates with a fibrosis level of two or more to UIC for “possible 

HCV therapy.” In addition, the protocol set no deadline for 

“determining when HCV therapy starts.” 

On the record before it, the court concluded that the balance of harms “weighs in favor of granting a preliminary injunction that adopts, with some reasonable modifications, the 

January 2019 protocol.” It ordered Defendants to “commence 

immediately the treatment of the class 2 plaintiffs’ Hepatitis 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
10 Nos. 19-1380, 19-1387 & 19-1732

C in accordance with” a modified version of the 2019 Protocol. 

The new version added three requirements:

(1) inmates with a fibroscan greater than two and an 

APRI greater than .7 will be referred to UIC and will 

receive HCV therapy unless UIC determines that treatment is contraindicated; (2) fibroscan and APRI levels 

will be determined within three months of admission 

to the IDOC; (3) HCV therapy will be started within 

three months of a determination that the fibrosis level 

is at least two and the APRI is at least .7. 

Defendants appeal the class certification and injunctive relief. We stayed the district court’s order pending appeal. 

II

We review a district court’s decision to grant or deny class 

certification for an abuse of discretion. Red Barn Motors, Inc. v. 

NextGear Capital, Inc., 915 F.3d 1098, 1101 (7th Cir. 2019). Although this is a deferential standard, it “must also be exacting” 

because a decision regarding certification “can have a considerable impact on the playing field of litigation.” Id. The class 

action is “an exception to the usual rule that litigation is conducted by and on behalf of the individual named parties 

only.” Califano v. Yamasaki, 442 U.S. 682, 700–01 (1979).

Federal Rule of Civil Procedure 23 requires a plaintiff 

seeking class certification to satisfy all four requirements of 

Rule 23(a)—numerosity, commonality, typicality, and adequacy of representation—and any one of the general categories of Rule 23(b). Oshana v. Coca-Cola Co., 472 F.3d 506, 513 

(7th Cir. 2006). “Failure to meet any of the Rule’s requirements precludes class certification.” Arreola v. Godinez, 546 

F.3d 788, 794 (7th Cir. 2008). The party seeking class

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 11

certification bears the burden of showing by a preponderance 

of the evidence that certification is proper. Bell v. PNC Bank, 

Nat. Ass’n, 800 F.3d 360, 373 (7th Cir. 2015). The district court 

found that Plaintiffs satisfied all the requirements for class 

certification. Defendants retort that the proposed class is deficient in all respects.

We begin our analysis with Rule 23(a)’s numerosity criterion, which requires that the proposed class be “so numerous 

that joinder of all members is impracticable.” FED. R. CIV. P.

23(a)(1). A “class can be certified without determination of its 

size, so long as it’s reasonable to believe it large enough to 

make joinder impracticable and thus justify a class action 

suit.” Arnold Chapman & Paldo Sign & Display Co. v. Wagener 

Equities Inc., 747 F.3d 489, 492 (7th Cir. 2014). “While there is 

no magic number that applies to every case, a forty–member 

class is often regarded as sufficient to meet the numerosity requirement.” Mulvania v. Sheriff of Rock Island Cnty., 850 F.3d 

849, 859 (7th Cir. 2017).

In its February 4 order, the district court found that numerosity was satisfied because “[j]oinder of all IDOC inmates 

with Hepatitis C, believed to exceed 2,000, is impractical.”

Plaintiffs add that numerosity is also easily satisfied because

more than 1,800 individual plaintiffs have been added to the 

lawsuit. Defendants complain only that the district court did 

not cite any evidence showing the number of inmates included in each class.

While the district court ideally would have been more precise in its order, it did not abuse its discretion in finding that 

numerosity was satisfied. Plaintiffs showed that HCV is prevalent in prison populations. There are thousands of current 

and future IDOC inmates with hepatitis C. The real question 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
12 Nos. 19-1380, 19-1387 & 19-1732

is whether each of the two classes is sufficiently numerous for 

class treatment. (The identified classes do not sweep in all 

IDOC inmates with hepatitis C.)

For Class 1, we look at the number of current and future 

prisoners in IDOC custody with hepatitis C who “have at least 

six months or more remaining [on their] sentence, and who 

have not previously received treatment which resulted in a 

sustained viral response.” While the record does not reflect 

how many inmates, if any, have received treatment that resulted in a sustained viral response, part of the problem is the 

very lack of data and testing. Given what we do know about 

the great number of prisoners with hepatitis C, it was permissible for the district court to infer that there are enough untreated inmates to make joinder impracticable.

Finding numerosity is more difficult with Class 2 because 

it is narrower. Nonetheless, there was (barely) enough evidence to support the district court’s finding of numerosity by 

a preponderance of the evidence. Recall that Class 2 includes 

all current and future prisoners with hepatitis C who “have at 

least one year remaining on their sentence, have a fibrosis 

level of greater than or equal to two and an APRI score greater 

than or equal to .7, and have not received direct-acting antiviral drugs.” At the January 2019 hearing, Plaintiffs provided a 

spreadsheet containing medical information for many of the 

proposed class members. According to the spreadsheet, hundreds of these inmates have an APRI greater than .7. Despite 

significant gaps in the spreadsheet, we are willing to defer to 

the district court’s finding that Class 2 is “large enough to 

make joinder impracticable.”

Although others may have seen things differently, the district court was also within bounds when it found that the 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 13

commonality requirement was satisfied for both classes. 

Commonality requires a plaintiff to show that “there are questions of law or fact common to the class.” FED. R. CIV. P.

23(a)(2). A court need find only a single common question of 

law or fact, but it needs to identify more than the fact that everyone suffered as a result of a violation of the same provision 

of law. Wal-Mart Stores, Inc. v. Dukes, 564 U.S. 338, 350, 359

(2011). Plaintiffs’ claims “must depend upon a common contention ... of such a nature that it is capable of classwide resolution—which means that determination of its truth or falsity will resolve an issue that is central to the validity of each 

one of the claims in one stroke.” Id. at 350. The key to commonality is “not the raising of common ‘questions’ ... but, rather, the capacity of a class-wide proceeding to generate common answers apt to drive the resolution of the litigation.” Id. 

“Dissimilarities within the proposed class are what have the 

potential to impede the generation of common answers.” Id.

In its February 4 order, the district court identified a common question of law or fact: “whether every inmate with Hepatitis C in the IDOC should be treated.” Relying on advances 

in medical treatment for hepatitis C, Plaintiffs argue that 

every inmate with the disease should be treated as soon as 

possible. They urge that IDOC’s current policies, which do 

not mandate treatment for all inmates who test positively for 

hepatitis C, constitute deliberate indifference to a serious 

medical need.

Defendants counter that there are no questions of law 

common to each class because medical care, by its nature, is 

individualized. Hepatitis C, they point out, progresses at different rates, and so treatment for each person requires discretion and will differ based on that person’s medical history.

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
14 Nos. 19-1380, 19-1387 & 19-1732

This discretion is built into IDOC’s policy. Moreover, inmates 

present with different risk factors and different responses to 

treatment, Defendants argue, and so certification of any class 

involving medical care is tricky and potentially dangerous. 

Although the physical symptoms and progression suffered by each inmate undoubtedly vary, there is still a general 

question that can yield a common answer. Plaintiffs assert 

Eighth and Fourteenth Amendment challenges to Defendants’ system-wide policies and practices, which allegedly reflect deliberate indifference to Plaintiffs’ serious medical 

needs. Thus, “[w]hat all members of the [class] have in common is their alleged exposure, as a result of specified 

statewide [IDOC] policies and practices that govern the overall conditions of health care services[,] to a substantial risk of 

serious future harm to which the defendants are allegedly deliberately indifferent.” Parsons v. Ryan, 754 F.3d 657, 678 (9th 

Cir. 2014). “[A]lthough a presently existing risk may ultimately result in different future harm for different inmates—

ranging from no harm at all to death—every inmate suffers 

exactly the same constitutional injury when he is exposed to 

a single statewide ... policy or practice that creates a substantial risk of serious harm.” Id. 

The common question for each class is thus the following: 

whether the specified policies and practices to which all IDOC 

inmates are subjected expose them to a substantial risk of 

harm. “These policies and practices are the ‘glue’ that holds 

together the putative class[;] either each of the policies and 

practices is unlawful as to every inmate or it is not. That inquiry does not require us to determine the effect of those policies and practices upon any individual class member (or class 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 15

members) or to undertake any other kind of individualized 

determination.” Id.

Plaintiffs do not fare as well with Rule 23(a)’s typicality 

and representation requirements. Looking first at adequacy of 

representation, Rule 23(a)(4), we must decide whether the 

Plaintiffs have shown that the “representative parties will 

fairly and adequately protect the interests of the class.” FED.

R. CIV. P. 23(a)(4). A class representative must be part of the 

class and must “possess the same interest and suffer the same 

injury” as the other class members. Wal-Mart, 564 U.S. at 348.

We are stymied at the outset because, despite its certification of the two classes, the district court failed to name a representative for either class or to explain this omission. We thus 

have no way to assess adequacy of representation. On the assumption that the court would have accepted Plaintiffs’ proposed representatives, we have different problems: this record does not reveal whether they would be adequate. In their 

most recent certification motion, Plaintiffs simply listed nine

potential representatives’ names and their (sometimes former) places of incarceration. This is not enough, nor does anything else fill the gap. 

With respect to Class 1, we need a representative or representatives who are “current and future prisoners in IDOC custody,” who have been diagnosed with hepatitis C, who “have 

at least six months or more remaining [on their] sentence, and 

who have not previously received treatment which resulted 

in a sustained viral response.” Based on IDOC’s website, at 

the time of the district court’s February 4 order, six of the nine 

proposed class representatives were no longer in custody, and 

so they cannot serve. As for the other three, Plaintiffs 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
16 Nos. 19-1380, 19-1387 & 19-1732

provided no evidence about whether any had received treatment that resulted in a sustained viral response. 

For Class 2, the representatives must be “current and future prisoners in the IDOC custody” and must “have at least 

one year remaining on their sentence, have a fibrosis level of 

greater than or equal to two and an APRI score greater than 

or equal to .7, and have not received direct-acting antiviral 

drugs.” Once again, Plaintiffs’ evidence falls short. The six no 

longer in custody are equally inappropriate for Class 2. In addition, five of those six do not have a fibrosis level of two or 

more and an APRI score of .7 or higher, and thus they do not 

fit the criteria for Class 2. (There is no information about the 

fibrosis level or APRI score of the sixth person.) Of the three 

proposed representatives who remain in custody, Plaintiffs’ 

most recent data shows that two have an APRI score lower 

than .7, and there is no evidence about the third’s APRI score. 

“Rule 23 does not set forth a mere pleading standard. A party 

seeking class certification must affirmatively demonstrate his 

compliance with the Rule ... .” Wal-Mart, 564 U.S. at 350.

Plaintiffs have thus failed to demonstrate that their proposed 

class representatives are adequate. The district court erred by 

skipping this important step and finding, in the face of these 

facts, that Rule 23(a)(4) was satisfied.

The lack of a named representative also makes it impossible to find typicality. To satisfy the typicality requirement, 

Plaintiffs must show that the “claims or defenses of the representative parties are typical of the claims or defenses of the 

class.” FED. R. CIV. P. 23(a)(3). Typicality requires “enough 

congruence between the named representative’s claim and 

that of the unnamed members of the class to justify allowing 

the named party to litigate on behalf of the group.” Spano v. 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 17

Boeing Co., 633 F.3d 574, 586 (7th Cir. 2011). As there is no 

named representative, there is no way to compare anyone’s 

claims with those of the absentees. If we look at the nine proffered representatives, typicality is missing because it appears 

that they do not, or no longer, belong to either class.

As we said at the outset, a class can be certified only if it 

meets all four criteria in Rule 23(a). Although we have no 

quarrel with the district court’s findings of numerosity and 

commonality, Plaintiffs’ showing of typicality and adequacy 

of representation fall short. We thus conclude that the district 

court abused its discretion in certifying these two classes. 

III

We now turn to the preliminary injunction. Before we address the merits, we take a moment to explain which plaintiffs 

are entitled to seek this remedy. Having rejected both of the 

classes the district court certified, the classes are not the 

proper parties at this point. But, as we noted, unlike in most 

class actions, where only a small number of individual plaintiffs are suing on their own behalf and as possible class representatives, in this case an extraordinary number of individual 

plaintiffs joined the case personally—not as a class representative, not as part of a class, but independently. We do not 

know as much about these people as would be ideal, but 

Plaintiffs proffered a spreadsheet at the hearing held on January 22 and 23, 2019, and that spreadsheet contains just enough 

information to assure us that many of the more than 1,800 individual plaintiffs meet the following criteria:

• currently in IDOC custody,

• diagnosed with chronic hepatitis C virus,

• at least one year remaining on their sentence,

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
18 Nos. 19-1380, 19-1387 & 19-1732

• fibrosis level of greater than or equal to two

• an APRI score greater than or equal to .7,

• have not received direct-acting antiviral drugs.

Plaintiffs’ spreadsheet shows, for example, that Brandon 

Blasa, Ben McCreadie, Charles Sultan, and Nazim Useni all 

have hepatitis C, a fibrosis level of at least two, and an APRI 

score greater than .7. IDOC’s website indicates that these inmates currently remain in IDOC custody, and they all have at 

least one year remaining on their sentences. While we do not 

know whether they have received direct-acting antiviral 

drugs, given that the 2019 Protocol was implemented only recently, we can assume that at least some have not. In other 

words, had Class 2 survived, they likely would have fallen 

within its scope. We therefore proceed to consider the merits 

of the preliminary injunction.

In its February 4 order, the district court granted relief to 

inmates in Class 2, and thus to individual plaintiffs meeting 

those criteria. It ordered Defendants to “commence immediately the treatment of the class 2 plaintiffs’ Hepatitis C in accordance with” the 2019 Protocol. As we noted earlier, the 

court also slightly revised the 2019 Protocol by adding stricter 

referral and treatment requirements. 

We review a district court’s decision to grant a preliminary 

injunction for an abuse of discretion. Girl Scouts of Manitou 

Council, Inc. v. Girl Scouts of U.S. of Am., Inc., 549 F.3d 1079, 

1086 (7th Cir. 2008). “A preliminary injunction is an extraordinary remedy never awarded as of right.” Winter v. Nat. Res. 

Def. Council, Inc., 555 U.S. 7, 24 (2008). In fact, a “preliminary 

injunction is an exercise of a very far-reaching power, never 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 19

to be indulged in except in a case clearly demanding it.” Girl 

Scouts, 549 F.3d at 1085.

In Winter, the Supreme Court instructed that “[a] plaintiff 

seeking a preliminary injunction must establish that he is 

likely to succeed on the merits, that he is likely to suffer irreparable harm in the absence of preliminary relief, that the balance of equities tips in his favor, and that an injunction is in 

the public interest.” 555 U.S. at 20. If the plaintiff fails to meet 

these requirements, the court must deny the injunction. The 

mere possibility of irreparable injury is not enough. Id. at 22.

In each case, “courts must balance the competing claims of 

injury and must consider the effect on each party of the granting or withholding of the requested relief.” Id. at 24 (cleaned 

up). 

We start with likelihood of success on the merits. This case 

turns on the medical care that the individual plaintiffs still before us received and whether it was the result of deliberate 

indifference—i.e. the knowing disregard of a substantial risk 

of serious harm. Petties v. Carter, 836 F.3d 722, 728 (7th Cir. 

2016). “To determine if the Eighth Amendment has been violated in the prison medical context, we perform a two-step 

analysis, first examining whether a plaintiff suffered from an 

objectively serious medical condition, and then determining 

whether the individual defendant was deliberately indifferent to that condition.” Id. at 727−28.

Defendants contend that the district court erred in finding 

that the individual plaintiffs showed the necessary likelihood 

of success on the merits. They emphasize that the 2019 Protocol provides for treatment of F2, F3, and F4 inmates and, because the protocol was created by experts at UIC, it is impossible to say that the Defendants were deliberately indifferent. 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
20 Nos. 19-1380, 19-1387 & 19-1732

We can assume for the sake of argument that these individual plaintiffs have shown an adequate chance of success. 

Hepatitis C is a serious medical condition. Under the 2019 

Protocol, inmates in this class are “refer[red] to UIC for possible HCV therapy,” but treatment is not guaranteed, and it 

comes only after the disease has progressed. Inmates with the

described characteristics, we accept for present purposes,

have a chance of succeeding because their disease has progressed far enough that treatment should no longer be discretionary (as long as there are no counterindications). 

This takes us to irreparable harm, which we have defined 

as harm that “cannot be repaired” and for which money compensation is inadequate. Graham v. Med. Mut. of Ohio, 130 F.3d 

293, 296 (7th Cir. 1997). “The moving party must demonstrate 

that he will likely suffer irreparable harm absent obtaining 

preliminary injunctive relief.” Whitaker By Whitaker v. Kenosha 

Unified Sch. Dist. No. 1 Bd. of Educ., 858 F.3d 1034, 1044 (7th 

Cir. 2017) (emphasis added). This requires “more than a mere 

possibility of harm.” Id. at 1045; see Winter, 555 U.S. at 22. “Issuing a preliminary injunction based only on a possibility of 

irreparable harm is inconsistent with our characterization of 

injunctive relief as an extraordinary remedy that may only be 

awarded upon a clear showing that the plaintiff is entitled to 

such relief.” Winter, 555 U.S. at 22.

The individual plaintiffs have not cleared that hurdle. The 

district court justified its contrary finding in its February 4 order, which stated that “the fibrosis test can be a rough indicator—a level two may actually be a level three. Combine this 

uncertainty with the inevitable prison delays means that waiting until level three could well create a substantial risk to 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
Nos. 19-1380, 19-1387 & 19-1732 21

inmates of liver damage, liver cancer, and painful extrahepatic conditions.”

We conclude, however, that the court’s analysis was 

flawed insofar as it found only that a substantial risk “could” 

arise, not that irreparable harm was likely. The evidence presented during the preliminary injunction hearings was likewise equivocal. Many of the doctors testified that hepatitis C 

is a slow-moving disease and that rates of progression vary 

between individuals. Dr. Patel, a physician at UIC, testified 

that there was “probably not significant harm without treatment from stage 2 to stage 3.” In 2016, Dr. Batey, a court-recruited expert, testified that sometimes hepatitis C does not 

progress for years in patients who do not undergo treatment. 

This evidence does not show likely harm.

To be sure, the fact that a disease may progress slowly

does not mean that IDOC may refuse to treat it. But IDOC is 

not refusing to treat inmates with hepatitis C. The 2019 Protocol lists very specific guidelines for diagnosing and treating 

inmates with hepatitis C. The individual plaintiffs have not 

shown that the treatment under the 2019 Protocol will likely 

cause them irreparable harm.

The district court also feared that “[w]ithout an injunctive 

order, the IDOC may abandon the current protocol.” It was 

concerned that the 2019 Protocol “does not actually mandate 

treatment. Instead, inmates with level two or greater are referred to UIC for ‘possible HCV therapy.’” The existence of 

the Lippert consent decree, however, provides the assurance 

that the court wanted. The Lippert class includes “all prisoners 

in the custody of [IDOC] with serious medical or dental 

needs.” The consent decree covers inmates with chronic diseases, specifically including HCV. It includes a dispute 

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22
22 Nos. 19-1380, 19-1387 & 19-1732

resolution provision, which permits inmates to provide notice 

to IDOC if they believe that IDOC is not in substantial compliance with the decree. If the inmates and IDOC cannot reach 

a resolution, either side may seek relief from the district court 

overseeing Lippert. Thus, if IDOC were to “abandon the current protocol,” the individual plaintiffs in this case could seek 

relief. And if inmates are not receiving treatment, but are 

simply being “referred to UIC,” they could seek relief under 

the Lippert consent decree. The individual plaintiffs therefore 

have not shown that they are likely to suffer irreparable harm 

absent the preliminary injunction, and thus it was error to 

grant injunctive relief. 

IV

The district court abused its discretion in certifying both 

classes and in granting preliminary injunctive relief for Class 

2 (or, more precisely, for the individual plaintiffs who meet 

that class’s criteria). We therefore VACATE its order and remand for further proceedings consistent with this opinion.

Case: 19-1732 Document: 47 Filed: 03/23/2020 Pages: 22