Archana Ashok Chaure has given her life to sugar.

She was married off to a sugar cane laborer in western India at about 14 — “too young,” she says, “to have any idea what marriage was.” Debt to her employer keeps her in the fields.

Last winter, she did what thousands of women here are pressured to do when faced with painful periods or routine ailments: She got a hysterectomy, and got back to work.

This keeps sugar flowing to companies like Coke and Pepsi.

The two soft-drink makers have helped turn the state of Maharashtra into a sugar-producing powerhouse. But a New York Times and Fuller Project investigation has found that these brands have also profited from a brutal system of labor that exploits children and leads to the unnecessary sterilization of working-age women.

Young girls are pushed into illegal child marriages so they can work alongside their husbands cutting and gathering sugar cane. Instead of receiving wages, they work to pay off advances from their employers — an arrangement that requires them to pay a fee for the privilege of missing work, even to see a doctor.

An extreme yet common consequence of this financial entrapment is hysterectomies. Labor brokers loan money for the surgeries, even to resolve ailments as routine as heavy, painful periods. And the women — most of them uneducated — say they have little choice.

Hysterectomies keep them working, undistracted by doctor visits or the hardship of menstruating in a field with no access to running water, toilets or shelter.

Removing a woman’s uterus has lasting consequences, particularly if she is under 40. In addition to the short-term risks of abdominal pain and blood clots, a hysterectomy is often accompanied by the removal of the ovaries, which brings about early menopause, raising the chance of heart disease, osteoporosis and other ailments.

But for many sugar laborers, the operation has a particularly grim outcome: Borrowing against future wages plunges them further into debt, ensuring that they return to the fields next season and beyond. Workers’ rights groups and the United Nations labor agency have defined such arrangements as forced labor.

“I had to rush to work immediately after the operation, as we had taken an advance,” Ms. Chaure said. “We neglect our health in front of money.”

Sugar producers and buyers have known about this abusive system for years. Coca-Cola’s consultants, for example, visited the fields and sugar mills of western India and, in 2019, reported that children were cutting sugar cane and laborers were working to repay their employers. They documented this in a report for the company, complete with an interview with a 10-year-old girl.

In an unrelated corporate report that year, the company said that it was supporting a program to “gradually reduce child labor” in India.

Labor abuse is endemic in Maharashtra, not limited to any particular mill or farm, according to a local government report and interviews with dozens of workers. Maharashtra sugar has been sweetening cans of Coke and Pepsi for more than a decade, according to an executive at NSL Sugars, which operates mills in the state.

PepsiCo, in response to a list of findings from The Times, confirmed that one of its largest international franchisees buys sugar from Maharashtra. The franchisee just opened its third manufacturing and bottling plant there. A new Coke factory is under construction in Maharashtra, and Coca-Cola confirmed that it, too, buys sugar in the state. These companies use the sugar primarily for products sold in India, industry officials say.

Both companies have published codes of conduct prohibiting suppliers and business partners from using child and forced labor.

“The description of the working conditions of sugar-cane cutters in Maharashtra is deeply concerning,” PepsiCo said in a statement. “We will engage with our franchisee partners to conduct an assessment to understand the sugar-cane cutter working conditions and any actions that may need to be taken.”

Coca-Cola declined to comment on a detailed list of questions.

The heartland of this exploitation is the district of Beed, an impoverished, rural region of Maharashtra that is home to much of the migrant sugar-cutting population. One local government report surveyed approximately 82,000 female sugar-cane workers from Beed, and found that about one in five had had hysterectomies. A separate, smaller government survey estimated the figure at one in three.

“The thinking of women is, if we get the surgery, then we’ll be able to work more,” said Deepa Mudhol-Munde, the district’s magistrate, or top civil servant.

The abuses continue — despite local government investigations, news reports and warnings from company consultants — because everyone says somebody else is responsible.

Big Western companies have policies pledging to root out human rights abuses in their supply chains. In practice, they seldom if ever visit the fields and largely rely on their suppliers, the sugar-mill owners, to oversee labor issues.

The mill owners, though, say that they do not actually employ the workers. They hire contractors to recruit migrants from far-off villages, transport them to the fields and pay their wages. How those workers are treated, the owners say, is between them and the contractors.

Those contractors are often young men whose only qualification is that they own a vehicle. They are merely doling out the mill owners’ money, they say. They could not possibly dictate working conditions or terms of employment.

Nobody pushes women to get hysterectomies as a form of population control. In fact, having children is commonplace. Because girls typically marry young, many have children in their teens.

Instead, they seek hysterectomies in hopes of stopping their periods, as a drastic form of uterine cancer prevention or to end the need for routine gynecological care.

“I couldn’t afford to miss work to see the doctor,” said Savita Dayanand Landge, a sugar-cane worker in her 30s who got a hysterectomy last year because she hoped it would end her need to visit doctors.

India is the world’s second largest sugar producer, and Maharashtra accounts for about a third of that production. In addition to supplying major Western companies, the state has exported sugar to more than a dozen countries, where it disappeared into the global supply chain.

The abuses are born from the Maharashtra sugar industry’s peculiar setup. In other sugar regions, farm owners recruit local workers and pay them wages.

Maharashtra operates differently. About a million workers, typically from Beed, migrate for days to fields in the south and west. Throughout the harvest, from about October to March, they move from field to field, carting their belongings with them.

Instead of wages from farm owners, they receive an advance — often around $1,800 per couple, or roughly $5 a day per person for a six-month season — from a mill contractor. This century-old system reduces labor costs for sugar mills.

Our reporters interviewed people at every stage of the supply chain, including dozens of laborers, contractors, mill owners and former executives at multinational companies. The Times also examined medical records and interviewed doctors, lawmakers, government officials, researchers and aid workers who have spent careers examining the livelihoods of Maharashtra’s sugar workers.

Ms. Chaure is petite, barely five feet tall, with a tiny gold nose-ring in the shape of a flower and a grin that takes over her whole face. She speaks a million miles an hour and, when she feels particularly passionate, she grabs your wrist to make sure you are listening.

“It’s easy for people to take advantage of us,” she said, “because we have no education.” She has spent her life cutting sugar for a mill owned by NSL Sugars.

She began working in the sugar fields as a preteen and, now in her early 30s, she expects to continue for the rest of her life. The work has kept her family in the most grueling poverty, the kind that makes her skip meals so her three children have enough to eat.

Ms. Chaure knows there is nothing for her beyond sugar. But she hopes things will be different for her children.

‘There Wasn’t Any Option Left’

Ms. Chaure laid back on an operating-room cot last winter preparing for her hysterectomy. The hospital was bigger than any near her village, with clean floors and a busy, professional-looking staff.

As she looked at the white ceiling, the thought crossed her mind that, once she slipped out of consciousness, she might not come back.

Her hands trembled.

Who, she wondered, would look after her children?

“But since there wasn’t any option left for me,” she said, “I did it.”

Ms. Chaure had traveled to a city hospital hours from her village.

On a given day, the waiting room is crowded with patients from the countryside sitting nervously on metal chairs or cross-legged on the floor as a loudspeaker blares out names.

The women often have familiar ailments: pain that radiates down from their lower backs and prolonged or irregular periods that make work more difficult.

For Ms. Chaure, it was a heavy kind of ache, like a pull. She had pain in her hip, too. It pulsed down her leg and never seemed to go away. Her periods were irregular, which she suspected was from working all through her pregnancies, often forgoing food.

In the fields, Ms. Chaure, like the others, sleeps on the ground, spends hours a day hunched over and carries heavy loads on her head.

Tampons and pads are expensive and hard to find, and there is nowhere to dispose of them. Without access to running water, women address their periods in the fields, with reused cloth that they try to wash discreetly by hand.

“All the problems are intermingled with their personal hygiene and their economic condition. They have to work so hard,” said Dr. Ashok Belkhode, whose Maharashtra practice includes gynecology.

Hysterectomy is a routine surgery performed around the world, though infrequently for women in their 20s and 30s. In India, it is more common, including as a form of birth control, and other parts of the country also have high hysterectomy rates. But in Maharashtra’s sugar industry, everyone — contractors, other workers, even doctors — pushes women toward the surgery.

That is what happened to Ms. Landge, a mother of four with a red bindi and arms full of green bangles. She lives in a tiny concrete home atop a hill, overlooking her village and acres of farmland that turns the color of mustard seeds during the dry months.

Doctors prescribed painkillers and vitamins for her back and abdominal pain, but every appointment cost her a day’s wages and a fee for missing work.

“Everywhere I went,” Ms. Landge said, “hysterectomy was suggested.”

Ms. Chaure ended up on the operating table because a sonogram showed that she had ovarian cysts, her medical records show.

Instead of simply removing the cysts, her surgeon told her she should have a hysterectomy. She did not question the advice. She knew so many women who had done the same. She was terrified of getting cancer. And maybe this would end her pain, and the doctor visits.

“I might not be able to work well if the problems persist,” she said.

Years earlier, to pay one of her children’s medical bills, Ms. Chaure had sold a pair of gold earrings, a gift from her father worth about $30. Now there was nothing left to sell.

So she and her husband borrowed more money from their sugar contractor, promising to return next season to repay it. They already owed so much, Ms. Chaure figured, that they would have to go anyway.

The surgeon removed Ms. Chaure’s uterus, a cyst, an ovary and a fallopian tube. In an interview, her surgeon said it was necessary because the cyst was unusually large.

The Times shared details from Ms. Chaure’s file with Dr. Farinaz Seifi, the director of gynecology at Bridgeport Hospital and a professor at the Yale School of Medicine. “There was absolutely no indication for hysterectomy,” she said.

‘I Was Very Young’

In her wedding photographs, Ms. Chaure stares straight-faced into the camera. She had never met the groom. But that was normal. The same had happened to many of her friends.

Like many rural women in Maharashtra, Ms. Chaure does not know her exact age. She figures she was about 14 on her wedding day. It was two years after she dropped out of her village school so her parents could take her to the sugar fields.

“I was scared to get married,” she recalled, “really scared.”

She knew that marriage meant the end of something. She had dreamed of becoming a nurse. She could picture it — she would wear a crisp, clean uniform and work beneath a whirring ceiling fan, protected from the sun.

But marriage is the moment when many girls give up their futures, and their bodies, to sugar.

Every fall before the harvest, usually in October, the mill owners dispatch contractors to villages in Beed like Ms. Chaure’s to recruit laborers.

Child marriage is illegal in India and is regarded internationally as a human rights violation. Its roots in India run deep, and it has complex cultural and economic causes.

But in this part of Maharashtra, two economic incentives push girls into marriage.

First, sugar cutting is a two-person job. Husband-and-wife teams make twice as much as a man working alone. The two-person system is known as koyta, after the sickle that cuts the sugar cane.

Second, the longer that children accompany their parents in the field, the longer parents must support them. So families often seek to marry off daughters young, even in early adolescence.

“If we are married, their stress reduces and the responsibility is shifted to our husband’s shoulders,” Ms. Chaure said. “So they marry us off.”

Several women recalled being married only months after their first periods.

The links between marriage and sugar go so deep that girls were once married at the mill gates. Even now, weddings are often held before the harvest and the term “gate cane wedding” still comes up.

“Without koyta, there would be no reason to get married,” said Zhamabai Subhashratod, a 30-something sugar laborer who was married in her early teens and later had a hysterectomy.

Contractors, too, have an incentive to find brides, even if it means pressuring parents to marry off young daughters, said Tatwashil Baburao Kamble, the former head of Beed’s child-welfare committee.

“I’ve seen cases where the contractors tried to get it done before taking laborers to the farm — all their belongings were packed,” Mr. Kamble said. “All that was left was to get married.”

Some contractors even lend money for weddings.

“I’ve paid for weddings, for hospital bills,” said Bapurao Balbhim Shelke, a contractor who formerly worked for Dalmia Bharat Sugar.

“I just add the amount to the next year’s bill, and they can work it off,” said Dattu Ashruba Yadav, a contractor who lives in Beed. He said he had lent one couple 50,000 rupees, or about $600, for their wedding. That represents several months of a typical couple’s earnings.

Mira Govardhan Bhole has been working in the sugar fields since her marriage, about a year after her first period. Ms. Bhole is in her 30s but has a round baby face that always looks cheerful.

As a newlywed, she would disappear into cooking to avoid her husband.

When he told her she would have to cut sugar, she sobbed uncontrollably. “They brought me by throwing me in the vehicle,” she said. “I hadn’t even taken a bath or anything.”

In the field, she felt overwhelmed. There, sugar cane surrounds you, the stalks growing so high and close together that you can make out the sky only in patches.

The men bend forward, whipping machetes. The women usually do the rest.

First, they tear the sharp leaves off the cane. It takes practice. Pull downward and you will be fine, but stroke upward, even by accident, and the leaves make gashes as thin as paper cuts.

What Ms. Bhole remembers most about her first weeks is that her palms hurt so badly that she cried and cried.

After stripping the leaves, the women stack the cane in bundles.

They carry the bundles on their heads, then load them onto trucks.

Season after season, the weight can break down the disks in your neck, leaving a constant stiffness. If you ask doctors in the region what happens to the bodies of women in the sugar fields, this is the first injury they mention. Ms. Chaure has this problem, too, and she winces when she thinks about it.

More relentless, though, is the punishment of field life. The workday often ends after midnight, when trucks have hauled away the last of the day’s crop. Women sleep under tarpaulin tents with their families on thin mats cast onto the ground.

They wake as early as 4 a.m. to fetch water, build a fire, boil tea and cook lentils and vegetables. They wash clothes in a basin and then it is back to work, stripping and hauling sugar cane.

Workers said there were almost never official contracts or records tallying how much they cut. At the end of the season, contractors almost always declare that a balance remains.

“There is no possible way they could pay it back within one season,” said Ranjit Bhausaheb Waghmare, a contractor for Dalmia Bharat Sugar.

Dalmia supplies Coca-Cola in Maharashtra, according to S. Rangaprasad, who runs one of the mills there. Dalmia records also list Mondelez, the owner of Cadbury, as a customer. The company said it was “deeply concerned to hear allegations of labor issues at one of our suppliers. We will investigate.”

Pepsi’s franchisee also buys from Dalmia, but from mills outside the state, PepsiCo said.

Ms. Bhole sometimes fantasizes about a different life. A relative in a city a few hours away works as a housekeeper. The idea of getting paid to do chores sounds incredible.

But she says that no matter how hard she and her husband work, at the end of each season, her contractor says they still owe money. They have to return.

Worker-rights advocates say this is tantamount to bonded labor, a practice banned by law.

When Ms. Chaure’s husband took her to the fields after their wedding, she hoped they would be done in a season. That was more than 15 years ago. They are still in debt.

“We take an advance, repay some, and again take another advance,” she said.

The sugar mills keep all of this — child marriage, underage labor, wage debt and working conditions — at an arm’s length. Child marriage, they say, is a social problem that has nothing to do with the industry.

They say the contractors are responsible for the workers.“The mill does not take on the burden of employing them,” said Mr. Rangaprasad, the head of a Dalmia mill.

Things Could Have Changed

Shubha Sekhar, a Coca-Cola executive who has focused on human rights in India, talked during the Covid pandemic to a group of university students. Speaking by videoconference, she described the challenges of operating in a country that Coke’s own documents identify as risky because of child and forced labor.

Typically, corporations buy from suppliers, she explained. With sugar, she said, at times “one doesn’t have visibility of what is happening beyond, in deep agriculture.”

But those deep fields are typically just outside the doors of Coke’s own suppliers. Sugar cane loses weight — and value — each minute after it is cut, so mills are usually built close to the farms.

All of the problems, including child marriage and hysterectomies, have been known in the region for years.

There was even a moment, not too long ago, when things might have changed.

In 2019, the newspaper The Hindu BusinessLine reported on an unusually high number of hysterectomies among female sugar-cane cutters in Maharashtra. In response, a state lawmaker, along with a team of researchers, launched an investigation. They surveyed thousands of women.

Their report that year described horrible working conditions and directly linked the high hysterectomy rate to the sugar industry. Unable to take time off during pregnancy or for doctor visits, women have no choice but to seek the surgery, the report concluded.

By happenstance, Coca-Cola issued its own report that year. After unrelated accusations out of Brazil and Cambodia about land-grabbing, Coca-Cola had hired a firm to audit its supply chain in several countries.

The auditors, from a group called Arche Advisors, visited 123 farms in Maharashtra and a neighboring state with a small sugar industry.

They found children at about half of them. Many had simply migrated with their families, but Arche’s report found children cutting, carrying and bundling sugar cane at 12 farms.

Nearly every laborer interviewed by reporters said children commonly worked in the sugar fields. The youngest ones do chores. Older ones perform all the work of cane cutters. A Times photographer saw children working in the fields.

The 2019 report includes an interview with a 10-year-old girl who “loves to go to school,” but instead works alongside her parents.

“She picks the cut cane and stacks it into a bundle, which her parents then load onto the truck,” the report says.

Arche noted that Coca-Cola suppliers did not provide toilets or shelter. And it cited “flags in the area of forced labor.” Only a few of the mills it surveyed had policies on bonded or child labor, and those applied only to the mills, not the farms.

The government report called on factories to provide water, toilets, basic sanitation and the minimum wage.

Few if any changes have been carried out.

Major buyers like PepsiCo and Coca-Cola say they hold their suppliers to exacting standards for labor rights. But that promise is only as good as their willingness to monitor thousands of farms at the base of their supply chains.

That rarely happens. An executive at NSL Sugars, a Coca-Cola and PepsiCo franchisee supplier that has mills around the country, said that soda-company representatives could be scrupulous in asking about sugar quality, production efficiency and environmental issues. Labor issues in the fields, he said, would almost never come up.

Soda-company inspectors seldom if ever visit the farms from which NSL sources its sugar cane, the executive said. The PepsiCo franchisee, Varun Beverages, did not respond to calls for comment.

Mill owners, too, rarely visit the fields. Executives at Dalmia and NSL Sugars say they keep virtually no records on their laborers.

“No one from the Dalmia factory has ever visited us in the tents or the fields,” said Anita Bhaisahab Waghmare, a laborer in her 40s who has worked at farms supplying Dalmia all her life and said she had a hysterectomy that she now regretted.

Ed Potter, the former head of global workplace rights at Coca-Cola, said the company had conducted many human rights audits during his tenure. But with so many suppliers, oversight can seem random.

“Imagine your hands going through some sand,” he said. “What you deal with is what sticks to your fingers. Most sand doesn’t stick to your fingers. But sometimes you get lucky.”

Sanjay Khatal, the managing director of a major lobbying group for sugar mills, said that mill owners could not provide any worker benefits without being seen as direct employers. That would raise costs and jeopardize the whole system.

“It is the very existence of the industry which can come into question,” he said.

One thing that changed after the government report was a rule intended to prevent unscrupulous doctors from profiting off unneeded surgeries.

“Some doctors have made it a way to earn more money,” said Dr. Chaitanya Kagde, a gynecologist at a government-run facility in Beed. (Though public hospitals offer hysterectomies free or at reduced cost, they are often far from rural women.)

The new rule required the civil surgeon, the district’s top health official, to approve hysterectomies.

But hysterectomies on younger women continue. Though many doctors agree that some surgeons perform them too often, they also note that patients request the surgery.

In an interview last May, Beed’s civil surgeon at the time, Suresh Sable, said the government should not second-guess doctors. “It’s not necessary to question their authority,” he said.

He said his office still approved 90 percent of hysterectomy requests.

Trapped

One day last May, a few months after the harvest, Ms. Chaure and her husband made their way to the plot of land they farm near their home. It was 104 degrees. There was almost no shade or breeze and the air was so hot it took the shape of waves in the distance.

Her son, Aditya, was at the age where he was putting everything in his mouth — the back of a sticker, a Good Day biscuit, a pink toy watch. He was so preoccupied that he seemed to have forgotten to fuss.

Ms. Chaure, wearing a light floral sari, scooped him in one arm and hiked down the field.

It had been about six months since her hysterectomy and Ms. Chaure’s body hurt worse than usual.

Everything ached, especially her midsection. She was fed up with doctors and the work that had done this to her.

For the first time since being a teenager, she did not know whether she could migrate to cut sugar cane that season.

But the idea of borrowing more money without working to repay it terrified her.

She already stretched the family budget paper thin — growing tomatoes and peppers in a patch behind their home of concrete and corrugated metal.

“We have wasted our whole lives in this work,” she said.

By September, with the harvest looming, she still did not know if she could work. The contractor, she said, had been hassling her and her husband to take a bigger advance.

“It makes me so mad when those people say, ‘Nobody forced you to be a laborer,’” she said. She was washing her family’s clothes in a plastic bowl, slapping each garment against a rock. “Nobody chooses this life.”

It had been an exhausting few days. All three of her children had been coughing. The day before, she and her husband had fought, and he had hurled a basket of fresh cotton that she had just picked to the ground, covering it with mud. It could not be sold.

Finally, her husband left for the fields, to work alone. She stayed behind, resigned to the fact that it would push her family even deeper into poverty.

She worries about her children. She still harbors hopes for Aditya and his two big sisters, who are about 8 and 5 years old.

But Priyanka, the oldest, drove her crazy, skipping school to horse around with her younger siblings. Ms. Chaure remembers missing school herself, then dropping out. She remembers her dreams of being a nurse.

She wants things to be different for her daughter.

“I want her to be someone,” she said. “Do something in life.”

But for all her optimism, Ms. Chaure knows how tough it will be for her children, and how things are likely to go.

“They don’t like it,” she said. “But they need to get used to this life.”

Ankur Tangade contributed reporting. 

The young Kenyan housekeeper, dressed in a crisp uniform and a head scarf, nods her head from side to side to the beat of a tune in a video, an expression of mock exasperation on her face as she stares into the camera and mimes the refrain: “Don’t got it.”

Words like “freedom” and “respect” pop up on the screen, and the worker, Brenda Dama, 26, swats them away one by one. A single day off? “Don’t got it.” A peaceful life without quarrels or insults? “Don’t got it.”

Ms. Dama’s post on the video-sharing app TikTok, a parody of the song “Renee” by the American indie rock duo Sales, vents about the stresses of her job as a house cleaner for a family in Saudi Arabia, where she has worked since she left her native Kenya in 2019. It is one of several videos by her that have spread widely on the platform and has amassed more than 900,000 views and nearly 6,000 comments since it was posted in August.

Far from home and in unfamiliar settings, domestic workers in the Gulf, like Ms. Dama — the vast majority of them women — have long used social media to keep in touch with friends and family. As the popularity of TikTok exploded last year, they increasingly turned to the platform to to open up about their lives and working conditions — many of them overworked, sexually harassed and targets of discrimination.

“Here, it is really tough,” Ms. Dama said in a telephone interview from Saudi Arabia. “You end up crying every day. But when you see the positive comments on your videos, you’re like, oh, this person understands.”

The oil-rich monarchies of the Persian Gulf depend on migrant laborers from Africa, Asia and poorer Arab countries to keep the machinery of daily life running — millions of maids, construction workers, delivery workers, garbage collectors, guards, hairdressers and more. Those workers often outnumber the native population.

As of 2016, there were nearly four million foreign domestic workers in the Gulf, according to a study by Abu Dhabi Dialogue, a forum on migrant labor, and the number has most likely risen since. Before the pandemic, an estimated 36,000 new domestic workers headed to the region each year, according to the same forum.

Most foreign domestic workers in the Gulf are employed through a sponsorship system that gives their employers almost total control over them. They are unable to change jobs or leave the country without permission from their employer and their bosses often confiscate their mobile phones and passports.

Female domestic workers, who are often isolated, are particularly vulnerable to abuse, according to rights groups.

With their already minimal freedoms further diminished by the pandemic and their isolation growing, the domestic workers are unflinchingly using TikTok to tell the world how they are being treated even though it could be dangerous to do so.

Some women use the posts simply to blow off steam. Others are seeking to spread the word of their often dire working conditions, particularly those in the Gulf where abuse is rife. Their audience, many of them also foreign workers, say that scrolling through funny videos is a way to ease loneliness and can provide a brief respite from stress, anxiety or depression.

“Many here are suffering,” said Merygene Cajoto, 35, a Filipino working in Saudi Arabia who posts as @kapossahawten to more than 18,000 followers. “The way they express their depression, their stress from their work, is through TikTok. Friends send me videos and advice. It’s a kind of help line.”

Ms. Dama started posting on TikTok about a year ago, documenting the travails of workers like herself in the Middle East. under the username @iamdee_2540 Before the “Don’t Got It” video went viral, she had fewer than 20,000 followers. After it came out, that number jumped by about 5,000 within days and she now has more than 32,000.

Her videos, often tinged with sarcasm, dissect some of the weighty problems facing domestic laborers in the Gulf.

In another video, Ms. Dama dons a head scarf to mimic her employer. Her boss accused her of stealing money because she “comes from poverty back home,” according to Ms. Dama.

While it’s difficult to determine exact numbers of domestic workers using TikTok, Marie Kretz Di Meglio of Uplifters, a Hong Kong-based nonprofit that offers online education to migrant workers, said she had noticed an increase after the pandemic started.

“All of a sudden, they were all using it,” she said.

Many of the workers use humor or dramatization to present the difficulties of their day-to-day life.

Last year, Nieza Tuñacao (@niezatun, 27, created a scripted series in which she acts out problems faced by housekeepers. She titled it “OFW Diaries” — a common abbreviation for overseas Filipino workers.

Often set to melancholic piano music, she films fast-paced vignettes in her room. In one, she depicts an employer confiscating a worker’s phone, while in another her family is relieved when she is finally able to call home. She posts them to her 1.2 million followers.

After moving to Kuwait in 2018, Ms. Tuñacao said that she had forged virtual friendships with many domestic workers on TikTok. Each episode in the series is based on their real experiences as well as on her own.

“When overseas workers see my videos, they smile. They can relate. They say I am their happy pill,” she said in a telephone interview, laughing.

Many on the app have created educational videos explaining to followers how recruitment agencies and contracts work and encouraging those working in the region to share their experiences.

In some instances, women are not only risking their jobs by posting on TikTok but also their safety.

Sandigan, a Kuwait-based organization that campaigns for domestic workers’ rights, was contacted by around 70 women seeking help for problems related to posts on TikTok and Facebook Live since late 2019, according to the co-founder Ann Abunda. Most had been reprimanded by employers and were asking for guidance, and a few had been deported, she said.

In some parts of the Middle East, taking pictures or videos inside an employer’s home, particularly of children, and posting them online without permission could lead to criminal charges or deportation.

“They’re showing private moments to the public,” Ms. Abunda said. “They need to be careful.”

Both Ms. Cajoto and Ms. Tuñacao said that their employers were aware of their videos but tolerated them, knowledge that provided a degree of job security and safety from physical harm. But for many other low-paid housekeepers working in foreign countries, life is not as secure.

In recent years, a number of countries have passed domestic-worker labor laws. Both Kuwait and Saudi Arabia stipulate that employees are obliged to protect the secrets of their households. Women will often be asked to sign employment contracts with similar wording on arrival in the country of employment.

As the language is broad, the contracts and labor laws can be used against domestic workers who already have minimal power, said Rothna Begum, senior women’s rights researcher for the Middle East and North Africa at Human Rights Watch.

For Ms. Dama, things took a turn for the worse last year. Early one July afternoon, she said, she headed to her employer’s empty veranda during her break to record a TikTok video. While she was in the middle of filming it, her employer walked past.

“My madame acted shocked,” and asked me “‘What are you doing? You’re here to work,’” Ms. Dama said. “She could act rudely sometimes, but after she was shown my TikTok videos, it became worse. She could insult me like an animal. Like I was not even a human.”

Two months later, Ms. Dama said she grew tired of what she described as verbal abuse and left to work elsewhere as a housekeeper in Saudi Arabia.

As her “Don’t got it” video grew in popularity, she started to receive a torrent of online abuse. Commenters from the region accused her of lying and told her to go back to her country.

The bullying is tough, she said. But she refuses to delete her videos because domestic workers frequently flood her profile with messages of support. When she feels loneliness creeping back in, she said, their words keep her strong.

“You feel like you have company,” she said. “Our phones are our best friends.”

At 26, Jennifer Laude was full of joy, her friends said. She was fearless and beautiful, her sister added. She was a generous daughter, according to her mother. And she died shortly after 11 p.m. on Oct. 11, 2014, in a motel room in Olongapo, a port city about 100 miles north and west of Manila in the Philippines, at the hands of an American she had met earlier that evening at a nightclub, a Marine who was in the country for joint military exercises.

After discovering that Laude was transgender, Lance Cpl. Joseph Scott Pemberton, who was 19 at the time, choked her and pushed her head into a toilet bowl until she drowned. Then he took a taxi across town to Subic Bay, where his ship was docked, and, according to a shipmate who later testified in court, admitted what he had just done.

Fourteen months later, Pemberton was found guilty of homicide, a charge downgraded by the judge from murder, and was sentenced by the Olongapo Regional Trial Court to six to 12 years in prison, which was later reduced to a 10-year maximum on appeal. Pemberton was the second U.S. service member in living memory to be convicted of a felony by a Philippine court — and the first whose conviction stood without being overturned. It marked a major victory in the eyes of human rights advocates in the country who have been fighting to hold American service members accountable for violence against Filipina women — which they see as a byproduct of the U.S. military’s 120-year presence that fueled an exploitative and still-thriving sex industry. With the Pemberton conviction, it seemed that justice was finally moving in the right direction.

Presidential pardon

But on Sept. 13, Pemberton was put aboard a U.S. military cargo plane and flown out of the Philippines, a free man. A week earlier, President Rodrigo Duterte made the bombshell announcement that he had granted Pemberton an absolute pardon, nullifying the Marine’s sentence after less than six years served.

The pardon is the final chapter of a polarizing, high-profile case that has cost the U.S. Marine Corps more than half a million dollars and provoked debate over decades-old defense treaties between the two countries. In recent weeks, the legal maneuvering intensified in complexity and speed, to the point where the presidential pardon came just hours after Duterte’s own administration filed a motion to block a court order that would have freed the Marine on other grounds. Underscored by Duterte’s seemingly inconsistent approach to his country’s relationship with the United States and a historic power imbalance between the Philippines and its former colonial ruler, the recent developments have seen the case deteriorate into an apparent tool for political leverage rather than justice.

“This should give us a lesson that the U.S. has no respect for our sovereignty,” Virginia Lacsa Suarez, the attorney for the Laude family, told The New York Times in response to the court order to release Pemberton that was issued even before the pardon. “It shows that the U.S. looks down on us, that the U.S. does not even respect our laws.”

From the beginning, the United States maintained an influence over the Pemberton case, despite the Philippines’ jurisdiction over crimes committed by U.S. service members. In 2014, Pemberton was first questioned by the United States Naval Criminal Investigative Service instead of Philippine police, and he was initially held onboard his ship, the U.S.S. Peleliu, anchored in Subic Bay, and then under U.S. guard at a Philippine military base, instead of in a Philippine jail. After he was arrested, the Marine Corps hired an attorney to represent him and paid all his legal fees, which had exceeded $550,000 by this fall, according to Lt. Col. Chris Perrine, a spokesman for U.S. Marine Corps Forces, Pacific. “The U.S. government is authorized to enter into a contract and pay for the legal representation of service members in foreign criminal matters,” Perrine said by email.

It tells us how, even in our own country, if you are of a particular gender, if you are a transgender woman, your life matters less

Rey Valmores-Salinas, Bahaghari National spokeswoman

After the guilty verdict was announced, the judge ordered Pemberton to start serving his sentence at New Bilibid Prison, the largest detention facility in the Philippines, where more than 26,000 convicted men sleep in crowded cell blocks, disease festers and temperatures can reach over 100 degrees in the summer. But that detention order was revised just hours later, in deference to the Visiting Forces Agreement, the 1999 legal framework that governs many aspects of the United States military presence in the Philippines. The agreement grants the United States considerable privileges toward determining where convicted American personnel will be detained, and Pemberton remained in a private air-conditioned cell fashioned from a shipping container at Camp Aguinaldo, a Philippine military base where he was monitored by two guards from the Philippine Bureau of Corrections and a steady rotation of U.S. service members. Pemberton’s rank remained unchanged and he continued receiving his monthly salary of about $2,300, totaling more than $160,000 since the killing. “Pemberton is entitled to receive pay until judicial proceedings, including appeals, are complete and the court affirms the conviction,” Perrine said.

The pardon last week brought back bitter memories for Filipinos of another case in which a U.S. Marine was accused of rape. In 2006, Lance Cpl. Daniel Smith received a 40-year prison sentence for raping Suzette Nicolas, whom he met at a nightclub in Olongapo — the first felony conviction of an American service member in a Philippine court since the United States closed its military installations in the early 1990s. Smith was held briefly in a Philippine jail, but after the United States canceled a joint military exercise in the Philippines, he was handed over to the U.S. Embassy. Smith remained at the embassy for more than two years, until Nicolas unexpectedly recanted her accusation and Smith was acquitted and returned home.

“In both cases, there are many forces trying to undermine the testimonies of the victims, or the witnesses or their families,” says Cristina Palabay, who was involved in protests that included picketing the U.S. Embassy in 2005 after Smith was accused of rape. Today Palabay is the secretary general of the Philippine human rights organization Karapatan. “I still really believe, in the context of the Philippines, no woman would claim that she was raped when she was not.”

Suspicions grew

Suarez, who has been working pro bono on behalf of the Laude family since 2014, said she had guessed that something was going on with Pemberton’s case almost two weeks before Duterte’s announcement. On Aug. 25, Pemberton’s attorney, Rowena Garcia-Flores, met with Laude’s older sister Marilou to hand over a check for roughly $95,000 in civil liability damages, a penalty that was issued in 2015 when the Marine was convicted. The next day, Suarez learned that Pemberton’s defense team had quietly withdrawn his appeal from the Philippines’ Supreme Court in June.

“From the get-go, it was fishy,” says Rey Valmores-Salinas, a spokeswoman for the L.G.B.T.Q. organization Bahaghari National, a Manila-based nonprofit that has coordinated events and protests using the hashtag #JusticeForJenniferLaude since 2015. “If you were in Pemberton’s shoes and you wanted to be free, why would you withdraw your petition at the Supreme Court? Our suspicions were that he was confident that he was going to be released soon.” Less than a week later, Suarez says, she received an email confirming their fears. Garcia-Flores had submitted a motion under the Philippines’ Good Conduct Time Allowance law, and Judge Roline Ginez-Jabalde, the same official who convicted Pemberton in 2015, ruled that the Marine was free to go, on the grounds that he had already served almost six years and had earned four years off his sentence for good behavior while in custody.

“A crime happened, and Pemberton paid for it under the Philippine law without any special privileges,” Garcia-Flores says. “If people think that he’s being given some special treatment, they are wrong.”

Suarez immediately moved to oppose Pemberton’s release, and so did the Department of Justice, arguing that only the Bureau of Corrections, not the Philippine courts, had the authority to determine whether Pemberton deserved time off his sentence for good conduct. But on Sept. 7, shortly after the Department of Justice filed its motion, Duterte met with Secretary of Justice Menardo Guevarra to discuss his constitutional right to grant an absolute pardon. At 4:51 p.m. the same day, Duterte’s secretary of foreign affairs, Teodoro Locsin Jr., announced the pardon in a tweet. “If there is a time when you are called upon to be fair, be fair,” Dutuerte said later in a televised address.

#JusticeForJenniferLaude

The news drew protests as the president’s critics took to social media and the streets, organizing demonstrations in Manila to voice their anger at Duterte’s decision. Many members of the L.G.B.T.Q. community thought the president was sending a signal that the Philippine government doesn’t believe that the lives of transgender women are important. “It tells us how, even in our own country, if you are of a particular gender, if you are a transgender woman, your life matters less,” Valmores-Salinas says. “This is about how we are the people that are silenced, that are raped, that are killed first because we are the ones that society listens to last.”

Beyond the question of whether the pardon was an anti-trans reaction by Duterte, it may have also been a strategic move to gain an advantage in relations with the United States. For nearly a century, the United States maintained a large military presence at a series of bases across the Philippines — a period that saw much abuse and violence against Filipina women and girls by American service members. At that time, military personnel were protected from prosecution in Philippine courts under a Status of Forces Agreement; criminal actions, when they were acknowledged, were instead addressed by the U.S. military justice system. In 1991, after years of protests from anti-base campaigners, a volcanic eruption and the end of the Cold War, the Philippine Senate rejected a renewal of the treaty, ending America’s ongoing military presence. But U.S. troops returned eight years later under a new Visiting Forces Agreement and continue to participate in hundreds of joint military exercises every year.

In February, Duterte gave notice that he was terminating the Visiting Forces Agreement, a move that many interpreted as a response to the U.S. State Department revoking the visa of Senator Ronald dela Rosa, the former National Police chief widely regarded as the architect of the administration’s notoriously violent war on drugs. Then in June, Duterte confirmed that he wouldn’t be canceling the agreement for at least another six months, and in July, dela Rosa announced that the United States would be reinstating his visa.

An agreement between two countries

Despite Duterte’s outwardly critical stance toward the United States, relations between the two countries remain strong. In August, the U.S. Agency for International Development donated 100 ventilators to the Philippines, as part of more than $22 million in U.S. funding to help the country tackle the novel coronavirus. Days earlier, the State Department approved a $126 million sale of scout, assault and light support boats to the Philippine government. It’s the latest in more than $1.5 billion in arms that Duterte’s administration has moved to purchase from the United States this year, despite calls from Human Rights Watch for Congress to block the sales, citing the Philippine armed forces’ lengthy history of military and human rights abuses.

John Schaus, a senior fellow in the International Security Program at the Center for Strategic and International Studies in Washington, says Duterte was always likely to take a pragmatic approach to Pemberton’s release. “He’s willing to engage with us, but it’s not his first preference in most situations,” Schaus says. “But when an opportunity presents itself to advance his priorities in a way that is palatable to him, he’s willing to entertain it. He doesn’t strike me as someone who is going to terminate things or cut things off if they’re beneficial to him.” Just months before a general election in the United States, he added, it would make more sense for Duterte to wait to see the outcome before deciding whether to scrap the Visiting Forces Agreement.

From a U.S. military perspective, visiting forces agreements (and status of forces agreements in countries where the military is permanently based) are necessary precautions in countries where the United States wants to maintain a strategic presence — including the Philippines, a key player in responding to China’s rising power in the western Pacific. The Visiting Forces Agreement ensures that the two countries have a predetermined process to be followed if a service member is arrested and charged with a crime, when tensions are likely to be high. In Pemberton’s case, Schaus thinks the process proved a success: Pemberton was consistently subject to Philippine law. “Whether or not he should be incarcerated longer or has served an adequate amount of time — the Philippine court system came up with a judgment about that, based on its own internal standards, and I think that’s exactly what the Visiting Forces Agreement would call for,” Schaus says.

Upon leaving the Philippines on Sunday, Pemberton was brought to Camp Smith in Hawaii. “The Marine Corps is taking appropriate administrative action,” Perrine said. He was unable to indicate whether Pemberton will be demoted, or if he will be given a less-than-honorable discharge.

As the Laude family grieves for their daughter, many Filipina women and members of the L.G.B.T.Q. community say the message from their president is clear: The decision to pardon Pemberton was not about justice, or Jennifer. “If you call for justice for Jennifer, that’s never going to happen for so long as the Visiting Forces Agreement stands,” Valmores-Salinas says. “That’s never going to happen for so long as any U.S. soldier stands in Philippine soil.”

“I said: ‘We are from Baghdad. We know how to handle difficult situations.’”

Lubab al-Quraishi, a pathology assistant in New Jersey

A few days a week, Lubab al-Quraishi, 47, wakes up before sunrise and drives to the diagnostics lab where she works as a pathology assistant, in northern New Jersey. There, she picks up the gloves, gowns, face masks and face shields she needs to do her job in relative safety. Then she’s back on the road, crossing the Hudson River into New York City, sometimes alone, staving off exhaustion, and sometimes dozing in the passenger seat while a colleague drives.

Months ago, when the coronavirus was just starting to spread through the U.S., the director of the lab asked employees to help test for the virus in nursing homes. Many of al-Quraishi’s colleagues were nervous about the work. One of the first major outbreaks in the U.S. had taken place in a Seattle-area nursing home, and now it seemed elderly Americans across the country were vectors of a little understood but frightening disease. The director explained that testing for the disease could expose his staff members’ families. “He didn’t think anyone would do it,” she said. “I said, ‘I am ready.’”

Now al-Quraishi spends half her week visiting nursing homes across Staten Island, Queens and Brooklyn. Some of the homes are fine, like a cross between a hospital and a decent hotel. Others leave her in despair for the residents and workers.

One home she visits is dark and filthy. It smells of urine. Residents, gathered together in the basement for testing, seem to al-Quraishi stuck in a lonely and uniquely American tragedy, one exposed and exacerbated by the pandemic. In her native Iraq, al-Quraishi didn’t know anyone who sent their mother or father to a nursing home. It was never a question that her mother, who is 78, would live with al-Quraishi. “I prepare her food, I take her to the restroom, clean her, put her back to bed, give her the medication,” she said. “She’s a little disoriented. But I would never put her in a nursing home. That’s another thing I learned in Baghdad.”

The nasal swabs are painful, and if residents test positive they have to be retested again that week.

“I feel guilty when I swab them,” she said. “They’re at the end of their lives. They are in a different world.” The tests take less than a minute to administer, but the mornings are long as al-Quraishi talks the residents through their discomfort and confusion, trying to connect with them.

Al-Quraishi, who graduated ninth in a class of 300 from the College of Medicine at Baghdad University and went on to specialize in surgical pathology, is one of a large number of immigrants and refugees being asked to lend their expertise to America’s coronavirus response. Their sacrifices come during an administration that has passed legislation severely limiting refugee resettlement, that has used the health crisis to further deny asylum to migrants at the U.S. border with Mexico, and that has made it more difficult for foreign doctors to work in the U.S.

In Iraq, al-Quraishi was expected, like most of her colleagues, to take a turn in the E.R. The conditions were appalling, brought on by years of war and years of sanctions preceding it, she said. “Kids were dying of the simple flu, a simple GI infection, because we had no medicine,” she said. “I worked in a hospital where we had no IV fluid, and when we did, no line to run the fluid through.”

For reasons she still doesn’t know, al-Quraishi and her husband, who also trained as a doctor, were targeted by the insurgency in Iraq. “We kept moving from one area to another,” she said. “Trying to keep my children safe. We were one family of thousands who experienced the same thing.”

Eleven years after the U.S. invasion, after a lengthy and often bewildering application process, al-Quraishi and her young family were resettled as refugees in Texas, where she tried without success to resume her life as a doctor.

“I made an appointment with the head of the pathology department at a huge local hospital,” she told me. “I said, ‘I am a pathologist from Iraq and I am interested in volunteering.’ I just wanted them to know me.”

Recertifying in the U.S., though, is notoriously costly and time-consuming; in 2020 there were, by one estimate, about 263,000 immigrants and refugees living in America who, despite being trained internationally in health and medicine, are unable to work. Instead, al-Quraishi took jobs at CVS and Popeyes and tried to stay current in her field, eventually moving her family to New Jersey for the job as a pathology assistant, for which she was initially paid so little she struggled to make rent. Working, once again, in the medical field, was both a relief and a heartbreak. “Doctors don’t take you seriously,” she said. “That’s the most painful part.”

Uniquely prepared

When Covid-19 hit the U.S., exposing systemic flaws in medical care, al-Quraishi felt uniquely prepared by her experience in Iraq. Not only did she understand how to work in extreme situations, she found the Iraqi medical education to be more well-rounded than the American one. “Not necessarily better,” she said. “But the system is different.” The fact that doctors were required to work in E.R.s strained by crisis felt particularly relevant now. “Iraq went through a lot,” she said. “There was always a need.”

After Gov. Phil Murphy of New Jersey wrote an executive order granting temporary licenses to internationally trained medical professionals to help respond to Covid, al-Quraishi and her husband put on their own scrubs and masks and showed up at a hospital. “I said, ‘We are from Baghdad,” she said. “We know how to handle difficult situations. Just give us the chance.”

She reached out to the governor on Twitter. “I wanted to say ‘Thank you, Mr. Governor, we will help you as much as we can. But we have been here for years. What happens when this is all over?’”

“Maybe it wasn’t the right time to tell him this, but I felt a little bit upset,” she said.

The staff members at the nursing homes where al-Quraishi works are primarily women of color and also vulnerable.

Al-Quraishi thinks frequently about their compassion for the residents, and their devotion to the work. Staff members sit with residents, holding their hands through the eye-watering swab. They painstakingly explain to the residents why they have to undergo testing. They explain it again a few days later when al-Quraishi returns. And they explain it again a few days after that, when residents have forgotten al-Quraishi was there in the first place.

At first, nursing homes seemed foreign to al-Quraishi. But, soon she began to imagine an older version of herself in place of one of the residents.

More than 70 percent of Americans using long-term care like nursing homes are women, according to a recent CDC study. “My daughter said, ‘This is how Americans do it,’” al-Quraishi said. “But I was raised in Iraq. To end up in a nursing home is really sad.”

Months into the pandemic, more than 40% of deaths in the U.S. can be linked to nursing homes.

Al-Quraishi will work in nursing homes as long as she is needed. She tries to tune out, or even to understand, the continuing pressures on immigrants and refugees coming out of the White House, but it can be difficult. “If you ask me to go back home, I would collapse,” she said. In November she filed an application for citizenship, but while the country is overwhelmed by Covid, she has been left waiting for the next step.

“I think we need to start a campaign,” she said. “We need to talk about our rights as refugees and international doctors. We need to talk about a system that needs to be thoroughly changed.”

When the nine African women lost their jobs as domestic workers in Saudi Arabia because of the coronavirus lockdown, the agency that had recruited them stuffed them in a bare room with a few thin mattresses and locked the door.

Some have been there since March. One is now six months pregnant but receiving no maternity care. Another tore her clothes off in a fit of distress, so the agency chained her to a wall.

The women receive food once a day, they said, but don’t know when they will get out, much less be able to return to their countries.

“Everybody is fearing,” one of the women, Apisaki, from Kenya, said via WhatsApp. “The environment here is not good. No one will listen to our voice.”

Families in many Arab countries rely on millions of low-paid workers from Asia and Africa to drive their cars, clean their homes and care for their children and elderly relatives under conditions that rights groups have long said allow exploitation and abuse.

Now, the pandemic and associated economic downturns have exacerbated these dangers. Many families will not let their housekeepers leave the house, fearing they will bring back the virus, while requiring them to work more since entire families are staying home, workers’ advocates say.

Other workers have been laid off, deprived of wages and left stranded far from home with nowhere to turn for help.

In Lebanon, employers have deposited scores of Ethiopian women in front of their country’s consulate in Beirut because they could no longer pay them as the economy imploded.

More than four million domestic workers

Persian Gulf countries alone had nearly four million domestic laborers in 2016, more than half of them women, according to a study for the Abu Dhabi Dialogue, which focuses on migrant labor in the region. Experts say the real number has risen since and is probably much higher.

Hundreds of thousands of foreign housekeepers and nannies work in other Arab countries, including Lebanon and Jordan, giving the Arab world the most female domestic migrant workers of any region, according to the International Labor Organization.

Most come to the Middle East through recruitment agencies and are employed under a sponsorship system that links their residency status to their jobs, giving their employers tremendous power. In many cases, they cannot quit without losing their residency, or move to new jobs or leave the country without an employer’s permission.

And in practice, many employers confiscate workers’ passports and deprive them of time off, rights groups say. Some prevent them from using cellphones or the internet. Physical and sexual abuse are common.

The combination of their gender, the sponsorship system and their isolation makes female domestic workers especially vulnerable, said Vani Saraswathi, associate editor of Migrant-Rights.org, an advocacy group.

“You have this person who controls your every movement, and you are in their house 24-7,” she said, “so imagine the kind of power that gives them.”

Alarm among such workers rose as Covid-19, the disease caused by the coronavirus, spread across the Middle East and shook the economies many migrants depend on.

“Even in cases of extreme abuse, workers are hesitant to leave their employers, as they fear being made completely homeless,” Ms. Saraswathi said.

Dozens of Kenyan women in Saudi Arabia have complained of “not enough food, no rest, violence, even being threatened, trapped and monitored,” said Ruth Khakame, chairwoman of the National Domestic Workers Council of Kudheiha, a Kenyan union. “You’re being denied from using your phone. So you’re struggling, you’re alone and you’ve nowhere to turn.”

Fear of contagion has upset relations between many domestic workers and their employers. Some who used to get breaks when their employers left for the office now have to serve and clean up after entire families stuck at home all day. Other families distrust their workers as potential vectors for the virus.

“From the beginning, my employers were not friendly,” said Justine Mukisa, 33, a Ugandan working in Oman. But during the pandemic, her salary of about $180 per month has been cut in half, her workload has increased and her employers have grown hostile.

“Before coronavirus, we sometimes played with the children,” she said. “Now this is not allowed. My employers do not want me to touch their food or sit near them.”

In recent years, a number of countries have passed regulations regarding domestic workers, granting them one day off each week, annual or biannual leave and an end-of-service benefit based on length of employment.

Qatar has capped the workday at 10 hours, the United Arab Emirates and Kuwait at 12 hours and Saudi Arabia at 15 hours. Kuwait has a monthly minimum wage of about $195 for domestic workers. Kenyans in Saudi Arabia are supposed to earn at least $375 per month plus benefits, and the Philippines has set a $400 minimum wage for its citizens across countries.

As the coronavirus has spread, Bahrain, Kuwait and the Emirates have facilitated visa renewals to stranded migrants to help them avoid fines and detention if their residency status lapses. Qatar and Saudi Arabia have announced free treatment for migrant workers who get Covid-19.

“High level of exploitation”

But workers’ advocates say that enforcement of regulations is often spotty and that those who face abuse have little recourse.

“The way these countries have perfected this system of disposable labor lends itself to a high level of exploitation,” said Mustafa Qadri, the executive director of Equidem, a labor rights organization based in Britain.

Those who get the virus can be easily discarded by their employers.

Two months ago, Hanico Quinlat, a Filipino domestic worker in Saudi Arabia, came down with a severe headache and moved into her agency’s hostel to recover. When she tested positive for Covid-19, the agency supervisor locked her in a room alone, giving her only painkillers and vitamin C to treat her illness.

“When they give us food, they throw it into the room,” Ms. Quinlat said by telephone from the room where she was being held. “We are people, not animals.”

Among the most vulnerable workers are women who have fled their employers or entered countries on tourist visas, hoping to freelance.

“We are people, not animals.”

Hanico Quinlat, Filipino domestic worker

Kelleh Njoki, 25, arrived in Dubai from Kenya as a tourist in February seeking work, but soon discovered she was pregnant. She is now sleeping in a crowded private dorm and cannot afford maternity care or a $400 repatriation flight.

“I’m seven months pregnant; how am I going to have my baby here?” she said in a phone interview. “I’m stuck. I’m confused. I really need help.”

For Apisaki, the Kenyan locked up with eight other women in the Saudi capital, Riyadh, the trouble started when she left her job last month after not being paid for months and returned to her recruiting agency, she said.

She was soon held with others from Kenya and Uganda who also had no work and no way to get home because of the lockdown — and because the agency had taken their passports.

The New York Times verified the details of the women’s confinement through interviews with two women in the room, including Apisaki, who is being identified only by her middle name for her safety, and videos she shared showing their conditions.

The women are in a single room whose only sunlight comes from a small window that was recently taped shut. They share a toilet, wash clothes in the sink and cook one meal per day when the agency drops off food. The pregnant woman hasn’t seen a doctor in months, Apisaki said, and the woman who tore off her clothes spent weeks lying naked on the tile, her arm chained to the wall.

New arrivals are not tested for the coronavirus, potentially endangering the others in a country recording thousands of new cases daily.

For the Kenyan women, the agency that recruited them in Kenya is responsible for helping them return home. But the agency that recruited Apisaki is no longer answering its phone or responding to messages, she said.

Last week, the Kenyan Embassy in Riyadh announced a possible repatriation flight to Nairobi but said travelers had to prove they did not have Covid-19, buy a $525 ticket and quarantine once home.

But Apisaki can’t get tested or fly if she can’t leave the room, and her efforts to reach the embassy have failed, she said.

The women said they had been locked up by their Saudi agency, Almuhait Recruitment. It did not respond to requests for comment on Sunday.

In an emailed response to questions, Peter Ogego, the Kenyan ambassador to Saudi Arabia, said that he was alarmed by the “serious allegations” of the women’s detention and that he would work with the Saudi government “to bring justice to the victims and address the loopholes in the law and any underlying causes.”

But he said it was Saudi Arabia’s job to ensure the safety of foreigners working there and questioned Apisaki’s inability to reach embassy officials.

“Much of our work is daily spent largely addressing such allegations,” he wrote.

After The New York Times contacted Almuhait Recruitment about the women’s situation on Sunday, Apisaki told an associate outside of Saudi Arabia that several of the women, including the pregnant woman, had been taken to a hospital for medical checkups and Covid-19 tests.

“They can’t hold women without any right,” Apisaki said. “I don’t get sun to my body, no space to stretch my legs, to walk or exercise. These are the things that make my brain crazy.”

This article was originally published in The New York Times.

“The critical mass we’ve seen suggests something is shifting in the ether.”

Brittney Cooper, author of “Eloquent Rage.”

The “angry black woman” stereotype has been picked apart and widely condemned in recent years. Michelle Obama has spoken about distancing herself from the trope. Shonda Rhimes, the Hollywood showrunner, has fought back against the label too. When Serena Williams was penalized for “verbal abuse” of an umpire in 2018, there was repudiation of the stereotype again.

But Brittney Cooper, a scholar and activist, has urged black women to reclaim the label rather than reject it entirely. “The clarity that comes from rage should also tell us what kind of world we want to see, not just what kind of things we want to get rid of,” Dr. Cooper writes in “Eloquent Rage: A Black Feminist Discovers Her Superpower.”

The focus of Dr. Cooper’s writing — how anger can be a rational, revolutionary principle — has proved resonant in recent weeks amid nationwide protests against police brutality, discussions of systemic inequality and black Americans dying from Covid-19 at alarming rates.

A few days before Juneteenth, I spoke with Dr. Cooper, an associate professor of women’s and gender studies and Africana studies at Rutgers University, about the shared anger of black women and why that power needs to be harnessed right now.

The interview has been shortened and edited for clarity.

In light of the past month, how are you thinking about the future of black women and girls?

The public narrative is about black women and girls continuing to express their collective outrage about the killing of black men. But you don’t just see black women in the street protesting. You also see them behaving politically in ways that are designed to build and restore public institutions, so that it can support more citizens. That’s not a thing that has just emerged in the middle of a pandemic. There’s very little investment in recognizing that black women are the sort of deep thinkers and theorists about how you actually build a society for the common good.

You recently wrote an op-ed for Time questioning why the death of Breonna Taylor, who was killed on March 13, didn’t ignite national protests immediately. You used the term “secondary outrage” to describe the reaction to her death. What did you mean by that?

Black women are not the folks who are the first thought ever when it comes to black protest movements.

Some folks said to me, Look, we were in the middle of a pandemic and that’s why there wasn’t a protest, not that there wasn’t outrage. I said, Look, we’re still in the middle of a pandemic and George Floyd got killed, and people said, We will not stand for this, so we will risk it all in the streets, multiple days — and at this point, multiple weeks — of massive protest, doing the one thing that we’re told will get you sick. So it is that moment where the culture cannot abide the killing of a black man in that way but the culture can abide it when it’s a black woman being killed by police. And she’s attacked in her house, sleeping. She’s not even under arrest. And we see that as the lesser evil.

It seems like black women’s stories are erased in the public sphere but also in the private sphere …

You know, we have this thing in feminist theory where we say, The public sphere is traditionally the sphere of men and the private sphere is traditionally the sphere of women and, of course, we mean white men and white women. So what black folks are outraged about is that the public sphere is not a sphere that is particularly hospitable to black men. But we do not react as vehemently when we learn that the private sphere is not a sphere that’s hospitable to black women.

Do you think in our lifetimes we’ll see national protests over the death of a black woman, on par with the reaction to Trayvon Martin or George Floyd?

The critical mass we’ve seen suggests something is shifting in the ether, so I’m hopeful. But we’ve got to decide if that’s our marker of success. Is the marker of success for black protest that something so horrific happens to a black woman that now we are outraged? The political thinking that leads to that is already a problem. There are all of these other cascading conditions that make black life hard as hell to live — whether we’re talking food deserts or health care or the education system or even intra-communal violence. It has to be about all of those other things that kill us quite slowly but deliberately in our communities every day.

What’s your assessment of the protests so far?

Nobody has thought, apparently, in weeks of protest that if you have that many people in the streets, then part of what you should be demanding is more PPE, more testing, more funding for vaccines and laptops for kids if schools don’t reopen. The police kill about 230 black people a year. The pandemic has killed over 22,000 black people in three months.

Who is Darnella Frazier, and why did you write about her?

Darnella Frazier was the 17-year-old black girl who was heading to the store with friends, saw the officer putting his knee on George Floyd’s neck and took out her camera and filmed it. So most of the iconic images that we’ve seen from that moment were shots of her video. I’m just reminded that there are always these black girls bearing witness to the racial atrocities. There’s a way that we ride for the black man who died and we ignore the black women who witness it and live.

We’re talking a few days before Juneteenth. Do you believe embracing anger and rage is part of breaking the intergenerational cycle of slavery?

Our ancestors have been fighting back since enslavement. They were jumping off the boats. They were staging mutiny on the ships. I like to see us as being in this long tradition of struggle and I think black people have always been clear about their rage.

“As a nurse, there are just times when it’s very intuitive. You just sense that something catastrophic is going to happen.”

Bonnie Castillo, the executive director of National Nurses United

In early January, before most people in the U.S. had even heard of Covid-19, Bonnie Castillo called a meeting with two trusted health care deputies at the country’s largest union of registered nurses. Castillo was alarmed by news reports about how a virus — so mysterious it didn’t yet have a name — was ravaging Wuhan, China, and asked the union’s director of health and safety and its industrial hygienist to go through some scientific reports.

As she listened, Castillo, the executive director of National Nurses United and a former intensive care nurse, grew worried. The disease, they told her, was spreading rapidly. Many carriers were asymptomatic. Particles could stay in the air for a long time. “As a nurse, there are just times when it’s very intuitive,” Castillo said. “You just sense that something catastrophic is going to happen.”

After the meeting, she immediately directed her staff to investigate how prepared U.S. hospitals were for an outbreak. The union contacted hundreds of hospitals requesting information in granular detail about stocks of personal protective equipment such as respirator masks and gowns. It also surveyed thousands of nurses nationwide, asking for their sense of their health facilities’ readiness.

Even before the pandemic, Castillo, 60, had expanded the union’s health and safety team, which focuses on issues such as on-the-job injuries and workplace violence. That emphasis on bread-and-butter concerns earned her criticism from some people who said the organization was shifting away from the more politically charged brand of labor activism for which it is known.

But it was precisely this focus that positioned Castillo to raise the alarm long before others recognized the scale of the oncoming crisis. “She was one of the earliest voices for a response,” said Liz Shuler, the secretary-treasurer of the A.F.L.-C.I.O, an umbrella organization for more than 50 labor unions.

Castillo’s attention to nurses’ day-to-day lives comes as they work longer hours and treat more patients, often without adequate access to testing and protective gear. (Instead of medical gowns and respiratory masks, some nurses have reportedly resorted to wearing rain ponchos and racquetball goggles.) More than 100 have died.

On March 2, Castillo’s team sent a letter to Vice President Mike Pence and the coronavirus task force coordinator Dr. Deborah Birx, warning that “the majority of U.S. health care facilities are completely unprepared to safely contain Covid-19.”

Two days later, Castillo became one of the first to call for the Occupational Safety and Health Administration to issue an “emergency temporary standard” for infectious diseases that would compel employers to put in place certain minimum safety standards — for example, providing more effective N95 masks to nurses working with coronavirus patients, instead of basic surgical masks. OSHA did not follow her advice, saying the standard was unnecessary.

Lack of personal protective equipment

By then, the Centers for Disease Control and Prevention had acknowledged that hospitals lacked sufficient personal protective equipment, among other materials — as Castillo had warned. The C.D.C. responded by loosening standards, requiring hospitals to provide their staff with only surgical masks, not N95 masks in many situations. Furious, Castillo and her team began agitating more publicly for P.P.E.

The union staged more than 350 socially distanced protests, including two vigils in front of the White House for the nurses who died from the virus.

When some hospitals later raised safety standards, the nurses’ union claimed credit. After intensive care nurses at Kaiser Permanente campuses across California picketed over a policy of using N95 masks only for certain high-risk procedures, officials began allowing the masks for all nurses working with confirmed or suspected Covid-19 patients. Sutter Health hospitals in Northern California made similar changes, though a spokeswoman for the hospitals attributed the decision to the efforts of supply chain staff to locate and acquire additional P.P.E., not the nurses’ protests.

When it comes to effecting change at the government level, the union has had more limited success. It has urged President Trump to fully invoke the Defense Production Act to scale up domestic production of protective equipment. The president has so far invoked certain provisions, but not others. In May, House Democrats passed a stimulus bill that included some of the nurses’ demands, including mass production of P.P.E. through the Defense Production Act and an emergency temporary standard for infectious diseases. Castillo will appear before Congress on Wednesday to testify about the bill, which she supports, but the current iteration is not expected to pass in a Senate vote expected as early as this month.

Castillo, the first woman of color to head the union, has a low-key demeanor and brings a decidedly different sensibility to this work than her predecessor, RoseAnn DeMoro. DeMoro, who helmed the union for three decades, is best remembered for her political activism, especially on the topic of single-payer health care but also on issues unrelated to health. (DeMoro, who has been described as “Mother Teresa with brass knuckles,” once chartered a plane to fly over the house of the then-California governor Arnold Schwarzenegger during a Super Bowl party to protest a policy decision.)

But Castillo bristles at the suggestion that her approach signals a retreat from broader social concerns and said the union continues to focus on issues like single-payer health care, climate change and racial justice. She has been tweeting in condemnation of police brutality, and in support of protesters, after the killing of George Floyd. But she feels that nurses’ issues like health and safety are important in themselves and that any suggestion that they matter less is misguided, even sexist.

First woman of color to head the union

Castillo is outspoken about the role gender plays in exacerbating power imbalances between nurses, mostly female, and hospital administrators, mostly male. “People like to pigeonhole nurses,” she said.

“A lot of people expect you to have that posture of being tough and being adversarial and in your face,” Shuler, of the A.F.L.-C.I.O., said. “Bonnie is not like that, but she is equally fierce and effective because people don’t see it coming.”

Castillo is warm, with an easygoing disposition, but the occasional eye roll (usually when talking about hospital administrators) reveals the hint of an edge. In interviews conducted from her home over Zoom, paintings of rural farm workers, or campesinos, could be seen on the walls behind her. Once, Castillo’s husband, a construction worker, slipped quietly through a door wearing shorts and a sweatshirt.

Raised in a working-class Sacramento family with immigrant roots — all four of her grandparents immigrated to the U.S. from Mexico — Castillo was exposed to labor activism early in life. Her mother, a clerical employee for the state department of corrections, and father, a railroad worker, were both active union members; the famed labor leader Dolores Huerta was an acquaintance of her mother’s. Castillo’s parents introduced her to Mexican-American art and Che Guevara’s book “Guerrilla Warfare” when she was young. When her father’s union went on strike, she accompanied her mother to drop him off at the picket line. “You don’t cross a strike line,” she remembered her father telling her.

Castillo married at age 17 and gave birth to her daughter, Manae, a year later. She stayed at home taking care of Manae, but when she and her husband divorced, she needed a stable livelihood to provide for her daughter, then in elementary school. (She later remarried.) She went to nursing school at night and became the first in her family to graduate from college. “I remember when she got her first job,” Manae, now 42, recalls. “She opened the letter and I feel like she screamed. She was like, We’re going to Toys ‘R’ Us, and you can buy anything you want.”

Castillo started out as an intensive care nurse at the now-shuttered American River Hospital; soon, she was promoted to a supervisory role as a charge nurse.

Less than half an hour into her first shift in that position, before the physician on duty had arrived, a patient “came in crashing and burning” from another hospital, she said. “We needed to put him on every imaginable form of life support, including the intra-aortic balloon pump” — a mechanical heart-pumping device — “which I had only operated maybe half a dozen times.” The hospital was understaffed that night, as it often was, and Castillo had to call on a mentor to come help.

Staffing shortages

Some nurses tried to raise the issue of staffing shortages with their superiors and, when that wasn’t successful, tried to unionize, but couldn’t gain enough support from nurses. It wasn’t until administrators tried to change nurses’ jobs — including, Castillo said, making them re-interview for positions with the prospect of being downgraded to roles and salaries that didn’t align with their professional training — that enough nurses changed their minds. With the help of the California Nurses Association (which would later join with two other unions to form National Nurses United), Castillo and her colleagues won the right to bargain collectively.

Eventually, Castillo quit practicing to join the California Nurses Association as a field organizer. Her colleagues joke that she has held virtually every role at the union, rising through the ranks to direct government relations, health and safety, and the union’s disaster-relief network (which she founded), before finally being named executive director of the national union as well as the California organization in 2018.

Castillo now works from the dining table in her two-bedroom Sacramento bungalow, waking up as early as 4 a.m. to talk with colleagues on the East Coast. Some days, she shows up to protests, does media interviews, or sorts through solicitations from P.P.E. suppliers. “There are a lot of scams out there,” she said.

With the pandemic still raging and concerns growing about a second wave of infections in the fall, Castillo’s emphasis on health and safety is arguably more important than ever. She has continued to call for adequate protective gear for health care workers and is among the chorus of people cautioning states against reopening too quickly. “While it’s been months since #COVID19 struck the U.S.,” she recently tweeted, “our employers and the government are STILL not protecting us nurses and our patients.”

OAKLAND, Calif. — Like many parents, Zainab Alomari has spent the last month trying to help her children learn at home. But unlike most, she has been talking to teachers and working through lessons in a language she barely understands.

Ingrid Brown loves the peace of the night, especially these days. When the sun sets, it’s just her and the road, her truck lights illuminating the highway stretching out ahead. The quiet is “like a breath of fresh air,” she says.

As America stocks up and hunkers down during the coronavirus crisis, Brown isn’t sheltering in place at home in North Carolina.

Instead, the 58-year-old outspoken truck driver and grandmother of six is on the road, crisscrossing the U.S. in an 80,000-pound truck filled with produce. Over the past two months, as highways have quieted, schools have closed, and non-essential shops have shuttered, Brown has delivered fruit, vegetables, eggs, and dairy products from coast to coast, making stops in Missouri, Florida, North Carolina, New York, New Jersey, Ohio, Texas, Arizona, California, Oregon, Arkansas, and Washington.

Brown is one of some 3.5 million truck drivers in the U.S., more than 200,000 of whom are women, keeping America well fed and well stocked during the pandemic.

These days, Brown drives largely without protective equipment. She can’t easily find masks or disinfectant supplies to wipe down her truck. While some large trucking companies have provided supplies to their personnel, many truckers are left to protect themselves.

“We’re going into this naked,” Brown said by phone, as she drove through Missouri earlier this month. “We are running through a fire with a pair of gasoline pants on. That’s what’s happening. Drivers have no protection.”

As someone who is in regular contact with people across the country, she says, she could become a carrier and infect someone else.

Brown also worries that she could fall ill, thousands of miles from home. Her yearslong battle with melanoma skin cancer might mean she’s more at risk if she gets the virus. Two years ago, doctors removed a third of her throat. Just a few weeks ago, she was hauling produce with fresh stitches in her leg and lip from surgery to remove cancerous and precancerous cells.

Even so, Brown has no plans to go home anytime soon. She loves trucking, and “America moves by truck,” she says. The “’rona-19,” as she calls it, can’t keep truckers home. They’re essential workers who make up the backbone of a hugely important, yet troubled, industry. Nearly all of America’s produce, goods, and equipment are transported by truck.

“The babies will tell you, ‘Grammie’s out taking food to other people,’” said Brown, speaking fondly of her young grandchildren back in Georgia. “‘And as soon as this is over, when everybody gets well, Grammie is coming straight home in the big truck.’”

Brown has been driving trucks for four decades. When she’s not on the road, she FaceTimes with her grandchildren and advocates safe working conditions and better opportunities for truckers.

Despite the millions of truck drivers on the road, there is an overall shortage of big-rig truck drivers like Brown, even though the percentage of women in trucking increased by 68 percent from 2010 to 2018, according to data from the American Trucking Associations. It’s a grueling job that can keep truckers far from their families for long stretches of time, in difficult working conditions.

She’s one of the founding members of the nonprofit Women in Trucking, a national organization that supports women truck drivers in an overwhelmingly male-dominated industry, advocating sexual harassment education, better safety measures, like better lighting and surveillance cameras at truck stops, and safer seatbelts for women. (It takes the length of two football fields to stop an 80,000 pound truck going 65 miles an hour, Brown says, and truck seatbelts aren’t designed for most female bodies.)

This isn’t the first time Brown has worked through a crisis. In 2017, when billowing prairie fires wiped out farmland and killed livestock in Oklahoma, she donated her truck, time, and fuel to haul hay from Minnesota to help the “families who lost everything.”

But this crisis is different. It poses an invisible threat, one that can linger for days before you even know you’re sick. She’s in touch with a network of colleagues across the country to navigate the health risks and find safe places to eat, shop, use the bathroom and shower.

Coronavirus certainly makes the job harder: Shipments are no longer predictable. Orders for essential items like medical goods and food have skyrocketed in recent weeks to keep up with demand, while other shipments have been canceled as stores, hotels and restaurants shut down operations.

Meanwhile, millions of Americans are isolated at home, cooking up a storm. Brown recently unloaded a shipment of cabbage at Hunts Point Produce Market in the Bronx, in New York City. They were running dangerously low on cabbage before she showed up. “I didn’t realize New York City ate so much cabbage,” Brown said, laughing. “I guess they like slaw.”

On the road, meals and supplies are more difficult to come by. Many restaurants are closed. Truck stops are running out of certain goods, and truckers can’t easily pull into parking lots — like a Target, or a Walmart — to buy essentials if there isn’t a designated truck parking space. Even if they can, Brown says, coveted items — like Clorox wipes — are mostly out of stock.

The other day, Brown pulled into the Ingrid R. Brown Petro truck stop and travel center in Oklahoma City, Okla. (yes, it’s named after her in recognition of her decades of dedication to the trucking community).

Brown asked a few truck drivers at the Petro if they’d seen hand sanitizer sold inside. There wasn’t any.

The next morning, after finishing an interview with Fox & Friends (she frequently makes appearances as a trucking advocate), one of the men — a “gentleman” from Iowa, as Brown described him — walked up to her truck and offered her a one-ounce bottle of hand sanitizer. It was half full.

“I don’t have much, but I’d love to share this with you,” he said.

It “just touched my heart,” Brown said. And it’s far from the only act of kindness in recent weeks. Across the country, hotels, companies, and individuals have been stepping up to help feed and house truckers.

One luxury hotel in Lava Hot Springs, Idaho, offered to house truckers for free, so they could have a comfortable place to sleep outside of the cramped quarters of their truck cabs. “How blessed this is,” Brown said. She was thrilled.

And then, a change of heart. She called back to cancel the reservation. The manager was shocked.

“I can’t come,” she told him. “I can’t do that to you.”

Brown didn’t want to sicken the manager and his family, or the hotel and cleaning staff, if she was unknowingly an asymptomatic carrier of the coronavirus.

“If I don’t protect y’all by protecting myself,” she said, “this is not going to stop.”

On Wednesday, March 18, 28-year-old Latoyha Young and her mother, Thomasina Hayten, rushed to Sutter Health Hospital in Sacramento, believing that Young was in labor. Hospital staff sent her home — she wasn’t far enough along.

Two days later, Young spent her expected due date searching stores in Sacramento for key items: baby wipes, diapers and hand sanitizer.

The mother-and-daughter pair, who are homeless, dependent on city transportation and have been staying temporarily with a relative, needed supplies before a shelter-in-place order that went into effect on Monday. They found wipes, but no diapers.

That evening, they returned to the hospital, but were sent home. Young was only two centimeters dilated, rather than the three inches that would indicate active labor.

Nothing seemed to be going right.

The plan had been for Young to be accompanied during childbirth by a community doula, funded by a grant through Sacramentos’s Black Child Legacy Campaign. But when Young’s doula, Joy Dean, drove them to another hospital — one of the few that accepts her Medi-Cal plan, California’s Medicaid program — the new limits on visitors permitted in labor and delivery departments in an attempt to contain the spread of Covid-19 meant that she was unable to accompany them inside.

“I’m not worried about the virus. I’m worried about going back and they’re not listening to me,” said Young, adding that if Dean had been with her, they might have treated her differently.

Giving birth in unprecedented circumstances

As the United States struggles to respond to the Covid-19 crisis, tens of thousands of women across the country are giving birth in unprecedented circumstances. Hospitals are shifting their prenatal and postpartum care to telemedicine, limiting or outright banning visitors, offering elective inductions to full-term mothers and converting labor and delivery wards to coronavirus units.

These changes are leaving health care providers, industry associations and patients reeling as they try to make informed decisions. “It’s changing day by day,” said Thorild Urdal, a nurse in the San Francisco Bay Area with almost 35 years of experience in labor and delivery.

Coronavirus is straining a U.S. health care system that, for years, has had the worst maternal mortality rate in the developed world. In 2007, 12.7 of every 100,000 women died during pregnancy, labor or within 42 days of giving birth, the measurement set by the World Health Organization. In 2018, that number had risen to 17.4 deaths per 100,000, according to data from the Centers for Disease Control and Prevention.

Health outcomes are even worse for women of color, especially black mothers, with C.D.C. data showing that in 2018, black mothers died at twice the rate of white mothers. Other studies suggest that the C.D.C.’s numbers are conservative, and that black mothers are dying at 3.3 times the rate of white mothers.

With this kind of maternal health baseline, many birth workers are concerned that efforts to contain the coronavirus pandemic will have unintended consequences on mothers and infants that will only become visible after the pandemic ends.

Meanwhile, hospitals are struggling to keep up.

Last week, the Permanente Medical Group, Kaiser Permanente’s Northern California network, which collectively delivers 45,000 babies a year, became the first major hospital group to offer induced labor to women at 39 weeks, which is considered a full-term pregnancy, or offer earlier dates for women with already-scheduled inductions. Typically, it is only offered for medical reasons at 39 weeks.

The network is intentionally “trying to get patients delivered before this pandemic gets worse, as long as they are past 39 weeks,” said Dr. Amanda Williams, the head of ob-gyn at Kaiser Permanente Oakland in California. That way, they can “get delivered and get back home before they get sick, their partner gets sick and staff gets constricted.”

“We cannot force anyone to have an induction,” Williams added, “but we can very strongly recommend it if this continues to get worse.”

For Jhoanna Galvez, a licensed midwife based in Los Angeles, induced labor is the last thing that she would recommend during a pandemic, “because it may actually increase time in the hospital,” she said, and “if you induce and you’re there for 72 hours, you’ve defeated the purpose.” (Studies consistently show that induced labor lengthens the birth process compared with non-induced labor.)

The American College of Obstetricians and Gynecologists has not yet issued guidelines on the matter, but a spokesperson said induction is “under discussion.”

Separately, the college noted that while pregnant women are not more susceptible to Covid-19 than the general population, symptoms of the disease like upper respiratory infection and high fever can affect infant health.

And while early studies from Wuhan, China, suggest the virus does not transmit vertically (for example, during delivery), for mothers who test positive, or are presumed positive, U.S. hospitals may separate them from their infants for a 14-day quarantine period — whether in a separate room or by a barrier in the same room.

Hospital systems shuttering labor and delivery wards

Complicating matters, some hospital systems are shuttering labor and delivery wards entirely to keep beds clear for coronavirus patients.

In San Francisco, the California Pacific Medical Center network of hospitals converted one of its two labor and delivery units into a Covid-19 unit. Women in labor (with no symptoms of coronavirus) are now sent to another hospital in the network. This change, however, has not been publicly announced.

Urdal, the Bay Area nurse, said that while consolidating birth centers in the face of a pandemic “sounds good in theory,” in practice it doesn’t work well because when women are in labor, “the vast majority simply show up. And it’s not in any way prudent to move a woman in active labor.”

And then there’s the visitors dilemma.

NewYork-Presbyterian Hospital and other city hospitals have banned all visitors from labor and delivery wards in an attempt to stop the spread of coronavirus from asymptomatic carriers. And at hospitals which allow just one visitor, mothers are facing the almost impossible choice of who to have by their side: a partner or a doula. Studies have shown that the presence of doulas improve both mother and infant health outcomes, regardless of race.

“Oftentimes people are seeking support because they’re already emotionally, financially vulnerable,” said Galvez, the Los Angeles-based midwife. “So already they’re saying, ‘I need support for this incredibly vulnerable thing, and that’s not going to be available.’”

Smita Nadia Hussein, a mother of two, gave birth on March 17 in Morristown, N.J., accompanied by just her husband, rather than her support network of mother, sister and doula. “I didn’t feel like it was unfair of the hospital. I thought it was unfair of the universe,” she said, adding, “It sucks, it really sucks.”

The issue of support doesn’t end in the delivery room: Casey Hogle, a first-time mother who delivered at Massachusetts General Hospital in Boston on March 14, said that while delivery went smoothly, being at home highlighted other challenges. “The biggest impact is a social impact,” she shared, her voice wavering. “Both of our moms are probably not going to see the baby for quite some time now.”

That social support is especially important for people who have already been marginalized by the U.S. health care system.

Williams, of Kaiser Permanente Oakland, acknowledged that her hospital’s policies and the disproportionate effect that they have on women of color and at-risk people are adding countless layers of stress in an already uncertain time.

“The marginalized just become more marginalized when there is stress on the system,” she said. But, she added, “These are extraordinary times, and we’ve had to take extraordinary measures.”

Kathryn Hall-Trujillo, founder of Birthing Project USA, which focuses on improving black maternal health outcomes, added that many people already distrust the health care system, which they see as racially biased. “We have spent a lot of time convincing black women their link to survival in the health care system is their doula,” Hall-Trujillo said. Now they don’t even have that.

Instead, women like Latoyha Young are doing their best to navigate the health care system — and a city under virtual lockdown — by themselves.

As of Thursday, Young was still waiting to go into active labor, and still has not found diapers. When the time comes to push, Thomasina Hayten refuses to leave her daughter’s side, regardless of hospital policies. She doesn’t want her daughter to give birth alone.

“If they [want to] cite me for it, they can cite me,” Hayten said. “Because she’s not going to do this herself.”

The crisis has led some mothers to consider giving birth at home instead of at the hospital, where over 98 percent of all American births still take place.

Galvez has received five to eight new inquiries per day from mothers with due dates in the next two weeks who are interested in home births, a huge increase from her usual three clients per month.

But Dr. Taraneh Shirazian, president and founder of Saving Mothers, a nonprofit focused on maternal health globally, and an ob-gyn at NYU-Langone Medical Center, stresses that hospital births are still the safest option, given both the high risks of complications in labor, as well as the additional logistical challenges that a pandemic presents.

“When any system is under stress, it’s going to slow the process,” she explained, so it’s best to be in the hospital already, where you can get access to care quickly.

Lisbeth takes out her cellphone and flashes a picture of her foster daughter. Two years ago, the teenager was living on the streets near Miami. Her mother, who was addicted to drugs, would disappear for long stretches at a time, and her father was in jail. The 14-year-old girl would steal noodles and cold cuts from local bodegas to feed herself and her two half-siblings, aged 4 and 5. She wasn’t in school.

Eventually, she was found by staff at the Florida Department of Children and Families, who determined that she was being sold for sex. Her legs were pocked with cigarette burns. “She doesn’t talk about the past,” Lisbeth said.

After child welfare found her, she lived briefly in a group shelter before going to live with Lisbeth and her husband, Rolando (the couple’s last names are being omitted to protect the family’s privacy). Lisbeth and Rolando are courageous people. It’s hard to be a foster parent, harder still to parent a teenager and harder still to parent someone who has suffered the extreme trauma of being trafficked. But the family is part of a small group in Miami involved in Chance, for Citrus Helping Adolescents Negatively Impacted by Commercial Exploitation, one of the first child welfare programs in the country designed specifically for trafficked foster youth.

Miami is one of 13 cities considered by the F.B.I. to be a hub for child sex trafficking. While there are no reliable estimates of how many children have been trafficked in the United States — the most conservative estimates hover around 3,000 — it’s the most vulnerable children who are most often targeted. African-American, Latino, L.G.B.T.Q. and migrant youth are disproportionately victimized, as are children who are homeless or have spent time in foster care. These children are more likely to have histories of trauma, which makes them more susceptible to manipulation by traffickers.

“Over 80 percent of them have early childhood histories of sexual abuse,” said Dr. Kimberly McGrath, who oversees the Chance program as clinical coordinator for foster care services at Citrus Health Network, a nonprofit community mental health center in South Florida.

In 2013, Dr. McGrath was asked by the Florida Department of Children and Families to design a way to help sexually exploited foster youth. Between 50 percent to 90 percent of trafficked children have spent time in foster care.

Despite that staggering statistic, when Dr. McGrath went to look for what worked for these children, she found little. “In 2013, there was an incredible sparsity of research,” she said. “We knew programs were in existence, but there was no research on those programs, no independent evaluations, no outcome measures.”

Two dozen Afghan women in their early 20s, dressed in camouflage uniforms, trudge through prickly thistle plants under a nearly full moon. No one dares speak, the silence broken only by too-big army-issued boots crunching to a chorus of stray-dog howls and midsummer cricket chirps. It’s one of the first times these women, all seniors at the Afghan National Army Officer Academy in Kabul, have taken part in a nighttime exercise. Normally they would be tucked away in their dorm — its hallways plastered with posters of Marie Curie, Rosa Parks, Amelia Earhart and Col. Latifa Nabizada, Afghanistan’s first female helicopter pilot — surrounded by barbed wire.

Female cadets must adhere to a strict 9 p.m. curfew. But on this warm night, the women smile in the darkness, leaping over ravines and clambering up hills of dirt, spreading out into formation with their rifles in tow. Off in the distance is a flurry of commotion — the pop pop pop of blank rounds fired by their male counterparts; their flares pierce the night sky and set the dry grass ablaze. (The female cadets’ Afghan superiors have not yet allowed them to fire blank rounds or flares as part of a nighttime attack drill; so far, they’ve only had limited daytime firearms training.) Led by a female sergeant known to the women as Sergeant Hanifa, the group is flanked by American and British advisers who advocate drills like this while trying to navigate cultural norms that dictate how Afghan women must act and how they are viewed. In this case, in a bid to recruit more women, academy leadership has assured parents that female cadets won’t be out unsupervised at night, for their own protection.

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KIGALI, Rwanda –  Marie shuffled seven chairs to fit around the table in her courtyard, placed down a tray of tea, and poured water into glasses. When her friends arrived, she hugged each of them.

“If they won’t let us in,” Marie paused, “We’ll have to find another way.”

“They” were the Burundi government, and the women were members of a 300-strong, women-only advocacy group, ‘Women and Girls Movement for Peace and Security in Burundi.’

Led by Marie Louise Baricako, a 64-year-old Burundian activist, the group hopes to help stop the bloodshed in Burundi, a country teetering on the edge of genocide. President Pierre Nkurunziza has led a campaign of intimidation and violence on citizens who oppose his contested presidency, driving masses of citizens into exile. Marie’s group aims to find a way for women to be both seen and heard by the Burundi government, the African Union, and the United Nations Security Council, and to call for women’s inclusion in the political negotiations and peace talks.  

“You cannot have peace if you don’t listen to women,” Marie said. That afternoon, the group discussed ways to be involved in the country’s ‘peace talk’ held in Tanzania in mid-February, a talk in which 31 men were invited, but only two women. “Women must be involved in these conversations the leaders are having. We cannot influence something from the outside.”

Nearly 400,000 Burundians have fled the country since 2015. The U.N. says torture and sexual violence against women is on the rise; one report described women as “running from rape,” committed by “Imbonerakure,” the government youth league. Women have also been brutally beaten and gang-raped by men armed with guns, sticks, or knives, according to Human Rights Watch.

The peace talks are essential to creating stability and calm in the country.

But women’s involvement in the talks appear to be a threat to the Burundi government and their international allies. Earlier this month, a member of the movement was barred from giving a briefing to the U.N. Security Council about the atrocities committed in Burundi after Russia objected to her participation.

“No one dares tell him the truth,” Marie said, referring to the Burundian president. “He tells the rest of the world everything is fine and under control – and it’s a lie.”

Marie’s position as a leader for the group fell into her lap. After several years in political advocacy across multiple countries in Africa and following a stint with the United Nations, she returned home to Burundi at the beginning of the crisis in 2015. Marie says that when President Nkurunziza announced his third term, it not only sparked the country’s turmoil, but also marked a women’s uprising.

“I came back home and found the movement had already begun,” she said, gesturing to the women sitting around the table. “Women were saying about me, ‘our coach is back! Take your position.’ There was no discussion: they were waiting for me, and I got to work.”

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