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Pilot Lenaigwanai covers her mouth as she speaks. She is trying to hide her broken tooth, a bitter reminder of all she endured before finding refuge at a shelter for abuse survivors in northern Kenya.

The mother of three arrived here in July after being forced from her home by escalating violence. Her husband was abusive even before the drought that’s now ravaging Kenya’s arid north, the worst in decades. When the family’s 68 cattle — their only means of survival — died, the abuse became impossible to bear.

“He was visibly frustrated and turned the heat on me and my children,” she says. “I just think he wanted us out, because he could not provide for us anymore.”

Lenaigwanai is one of the dozens of women who have arrived at the Umoja refuge in recent months fleeing violence that they say got worse as each successive year of low rainfall plunged their families deeper into poverty. Her semi-nomadic Samburu community of pastoralists are particularly vulnerable to drought because they depend on the livestock whose emaciated corpses litter the barren lands that once provided plentiful grazing.

For these and many other women around the world, the threat of violence could become more common as climate change makes extreme weather events more intense and frequent.

A woman stands outside her mud-walled hut at the Umoja Village women's refuge in northern Kenya.
Domestic violence survivor Pilot Lenaigwanai stands outside her mud-walled hut at the Umoja Village women’s refuge in northern Kenya. (By Geoffrey Ondieki)

Scientists have long warned that climate change disproportionately impacts the world’s poorest and most vulnerable, and negotiators from wealthy countries at the U.N. Climate Change Conference in Egypt pledged to do more to help poorer countries already grappling with its devastating effects.

Until recently, relatively little attention has been paid to its disproportionate impact on women and girls. But this year the U.N. Intergovernmental Panel on Climate Change identified a link between climate change and violence, citing the growing evidence that extreme weather events are driving domestic violence, with global implications for public health and gender equality.

A 2021 study of extreme weather events in Kenya by researchers at St. Catherine University in Minnesota found the economic stresses caused by flooding and drought or extreme heat exacerbated violence against women in their homes. The research, which used satellite and national health survey data, showed that domestic violence rose by 60 percent in areas that experienced extreme weather.

That analysis, and 40 others published this year as part of a global review in the journal The Lancet, found a rise in gender-based violence during or after extreme weather events.

Women dance together at the Umoja Village women's refuge in northern Kenya.
Survivors of domestic violence at the Umoja Village women’s refuge in northern Kenya, which is suffering its worst drought in decades. (By Geoffrey Ondieki)

Terry McGovern who heads the department of Population and Family Health at Columbia University’s Mailman School of Public Health, called the scientific evidence for this connection “overwhelming.”

“Heat waves, floods, climate-induced disasters increase sexual harassment, mental and physical abuse, femicide, reduce economic and educational opportunity and increase the risk of trafficking due to forced migration,” said McGovern, who added that the data remains limited on some fronts, including on psychological and emotional violence and attacks against minority groups.

Several academics, activists and humanitarian workers said the links between violence against women and extreme weather events need more research. Unlike the hard science of climate change, they said, the complex drivers of violence cannot easily be captured in numbers.

“The climate discourse is all about the numbers, but the evidence on violence and changes in power dynamics cannot be captured that way, and so it is not given the same weight,” says Nitya Rao, a professor of gender and development at the University of East Anglia in the U.K. “It is very difficult to make a linear connection.”

A carcass of a waterbuck in Samburu National Reserve, Samburu county on Nov. 4. (Fredrik Lerneryd/AFP/Getty Images)

In Umoja, no one is in much doubt that the drought is driving up violence — its swelling numbers are proof enough. Jane Meriwas, whose nonprofit organization the Samburu Women Trust helps women who have fled abusive homes support themselves, says the number of women at Umoja has doubled to 51 in the last year.

“As communities and families lose their livelihoods and suffer hunger, there is increased experience of weak or broken family structures,” Most are now engaging in dangerous activities to get a meal,” she said, such as sex work and bootlegging.

With their semi-nomadic lifestyle, Samburu women are particularly vulnerable. They have little or no stable access to health facilities, police protection or support services, Meriwas said, making it harder for them to report abuse. “They are really suffering in silence.”

‘The violence peaks during the floods’

In eastern India, more frequent downpours and devastating floods are what’s driving violence. Poverty is exacerbated by sudden economic stress, and societal inequality often traps women with abusive partners or other family members because they have nowhere else to go and cannot rely on authorities for help.

Indian residents wade along a flooded street carrying their belongings following heavy monsoon rains in Sitamarhi district in the Indian state of Bihar on July 17, 2019. (Sachin Kumar/AFP/Getty Images)

A mother of five who asked to go by her middle name, Devi, to protect her identity, said she doesn’t know anything about climate change. She just knows that whenever floods come to her village in Bihar state, her husband comes home angry and violent.

With her husband working away from home much of the year as a farm hand, each season can be challenge. But the monsoon season, Devi said, is by far the toughest. That is when the rivers in her low-lying village downstream from the melting Himalayan glaciers swell to bursting, flooding large swaths of land and making farming impossible. With no prospect of work until the floods recede, her husband returns home and takes his frustration out on his family.

“The violence peaks during the floods. Everything gets worse at that time — the hunger, the stress. We have snakes coming into the house,” says Devi, 40.

“The anger gets taken out on me. There’s a lot of stress during those times and I can’t sleep because of all the tension,” she says, wiping away tears as one of her young sons leans in closer.

Devi, who shares her small thatched-roof home with her mother-in-law, has little privacy to describe the nature of the violence. But when the older woman went out of earshot, she said her husband beats her and verbally abuses her “day and night” during the floods.

Muzaffarpur, India was flooded following heavy monsoon rains in July 2019. (AFP/Getty Images)

Shilpi Singh, who works with women in India’s poorest state as director of a grass roots organization called Bhoomika Vihar, said she sees the connection between floods and violence as straightforward.

“It comes down to economic distress. When there is no food to eat in the house, the men vent out their frustration by beating the women, who are raised with the belief that leaving is not an option.”

For Devi, the floodwaters themselves trap her. When they surround her home, they cut her and her family off from the outside world, increasing her vulnerability even further. As she talks about her situation, she repeatedly invokes a well-known Hindi phrase that translates roughly as “I endure,” which almost always refers to women’s suffering.

“If my daughters find themselves in this situation, I will tell them, they must endure,” she said. “If there are bad days, good days must surely follow.”

Lessons from a typhoon

Scientists emphasize that extreme weather events do not cause domestic or gender-based violence, but instead exacerbate existing pressures or make it easier for perpetrators to carry out such violence.

The mass displacement that follows disasters can expose women to greater danger, according to studies in Bangladesh and parts of India.

The Philippines ranks as one of the world’s most disaster-prone countries, suffering frequent earthquakes and storms that are becoming more intense as the world warms. Nine years ago, Typhoon Haiyan — one of the strongest cyclones ever recorded — flattened entire villages in the Philippines, killing more than 6,000 people and displacing around 4 million.

When Typhoon Rai hit the Philippines in December 2021, the country was better prepared. The relatively low death toll — in the hundreds — has been attributed in part to improved early warning systems and other measures put in place by local authorities. But it caused nearly as much property damage as previous storms. Just over a year later, many victims are still living in makeshift shelters after losing their homes, and in many cases, their crops and livelihoods.

An aerial shot showing destroyed houses and fallen coconut trees days after super Typhoon Rai devastated Cebu province. (STRINGER/AFP via Getty Images)

Rommel Lopez, spokesperson for the local social welfare department, said these stresses often acted as triggers for abuse within families in a country where violence against women is common. One in every four Filipina women aged 15 to 49 has experienced physical, emotional or sexual violence from a husband or partner, according to a 2017 demographic survey conducted by the Philippine Statistics Authority.

“When there’s a calamity or disaster or conflict, that can put families in difficulties. The situation at evacuation centers is a contributing factor,” Lopez said. “It makes them agitated. It adds to their frustration. When someone is frustrated, they could reach a certain point and that could trigger [violence].”

Aira Nase, 37, has been running away from violence all her life. Her mother suffered beatings from her partner and as a young girl, Nase vowed never to be like her. She was proud of raising her three children alone, taking on jobs in Manila, the capital, to provide for them.

When covid hit in 2020, she decided to leave the city and take her family back to her home province of Southern Leyte on the eastern side of the archipelago that makes up the Philippines. She got together with a local fisherman, and for a time the couple enjoyed a quiet life. They would occasionally quarrel over his drinking, particularly after Nase became pregnant in 2021, but never got into physical fights.

All that changed after Typhoon Rai made landfall shortly before Christmas 2021, devastating swaths of the country and destroying the couple’s home. They spent the holidays in a school library that doubled as an evacuation site, remaining there until May.

Her partner began drinking more frequently and the couple fought daily. Then Nase’s breast milk dried up, but the couple could not afford formula for their two-month-old baby. Her 16-year-old daughter gave birth to a premature baby who died after they could not afford hospital care.

The tensions between the couple peaked in February, when Nase’s partner returned drunk and rowdy to the library, disturbing other evacuees. Nase said she tried in vain to quiet him down. When she went to leave, he kicked her before rushing out of the room. Nase passed out and when she regained consciousness the next day, he was in jail.

“It was a very stressful time for us. We were broke and jobless. He was hotheaded and often drunk,” Nase said. “I told him: you’re not the only one who suffered from the storm, our neighbors did too. If you have a problem, why don’t you talk to me?”

There’s no official data showing how extreme weather disasters affect levels of violence against women and girls in the Philippines. One study, based on in-depth interviews with 42 people including survivors of Typhoon Haiyan, aid workers and government officials found reports of domestic violence, sexual violence and incest had increased in its aftermath. A separate survey of more than 800 households in the affected area carried out by the International Federation of the Red Cross and Red Crescent Societies (IFRC) found increases in both early marriage and domestic violence.

Women walk past debris left in the aftermath of Typhoon Rai in Leyte, Philippines on Dec. 20, 2021. (Anadolu Agency/Getty Images)

Humanitarian organizations working in the Dinagat Islands, which were badly hit by Typhoon Rai, sought to break this pattern. They launched a poster campaign highlighting where women can go for help if they are facing violence at home, along with a phone number to call.

For the Samburu women at Umoja, escaping the twin pressures of violence and drought has become key to their survival.

Rose Lairolkek sat in the little remaining shade afforded by the cluster of traditional mud-roofed huts that make up the refuge. She recounted how her husband came home angry after discovering all his cattle had died and attacked her, and how she still bears the scar on her right shoulder more than two years later.

“It almost cost me my life.”

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Before the pandemic, Vaishakhi Rustagi, a Delhi-based pediatric endocrinologist, found that cases of early puberty were pretty uncommon, but not unheard of: In a typical year, she would see about 20 such patients.

Then the pandemic hit, and the cases started to pile up. Since June 2020, Rustagi has seen more than 300 girls experiencing early puberty, she said.

Precocious or early puberty is defined as the development of pubertal changes among children earlier than what is considered normal, which stands at 8 for girls and 9 for boys. It’s known to sometimes be caused by genetic syndromes, a family history of the disease, central nervous system problems, and tumors or growths on the ovaries, adrenal glands, pituitary gland or brain.

The phenomenon of increased cases during the pandemic hasn’t been restricted to India — pediatricians across the world, from Italy to Turkey to the United States — have reported increases in precocious puberty cases. Parents have, too.

When Khyati first noticed blood stains on her daughter’s dress last January, she assumed the child got hurt while playing; after all, at 8 ½ , she didn’t believe there was a chance her daughter could have started menstruating.

Khyati, a 38-year-old stay-at-home mom in Mumbai who is being identified by her first name only to protect her daughter’s identity, told her daughter to change her clothes and check for cuts and scrapes. The child came back crying, afraid of the blood that was now soaking her dress, Khyati said. Over the next few days, the girl grew aloof, refrained from interacting with her family and wept incessantly, Khyati added. Increasingly anxious, Khyati approached a pediatric endocrinologist, and learned that her daughter, a second-grade student, was indeed having her first period.

Other things started to make more sense, Khyati said. She had noticed her daughter was developing breasts, but had ignored it, assuming the girl was too young to reach puberty. They hadn’t even had the menstruation chat yet; Khyati was saving the talk for when she got a little older and was able to understand the process better. Khyati said her daughter grew disconsolate, and her family struggled to calm her tearful outbursts.

“She hasn’t even told her friends about it,” Khyati said. “Luckily, there were lockdowns, so no school. Otherwise, it would be very embarrassing for her.”

While Khyati sees the lockdown as saving her daughter from the cruelties of the school playground, some doctors around the world are blaming the pandemic for causing accelerated puberty in the first place.

A study published in January of 2021 surveyed children across five Italian centers of pediatric endocrinology, and found that 328 girls were referred for suspected precocious puberty over seven months between March and September 2020, as opposed to 140 during the same period in 2019. The study concluded that there was an association between “the complex lifestyle changes related to the lockdown” and a higher incidence of precocious puberty in Italian girls, though no difference was observed in the incidence of early puberty among boys.

Pediatricians in the United States and India are also reporting cases of early sexual maturation, with girls as young as 5 developing breasts and those younger than 8 starting menstruation in some reported cases.

“I noticed that quite a few of my [girl patients] got their period after a lockdown,” said Adiaha I.A. Spinks-Franklin, a pediatrician at Texas Children’s Hospital.

In her cases, the girls were already in the early stages of puberty, with breast buds and pubic hair. But their periods were expected to be months, if not years, in the future, she said.

“Breast buds come at about 10 or 11 years, and then your period comes two years later. That’s the normal process,” Spinks-Franklin said. “From 9 to like 15, you’re going through this process, but the stress of the pandemic sped up that physiological process. Meanwhile, socially and emotionally, they’re still children.”

In Delhi, Rustagi also believes the surge in early puberty cases is linked to the pandemic, which saw children holed up in their homes, with prolonged exposure to electronic devices, increased consumption of unhealthy food, increased stress and reduced physical activity — all factors known to increase the risk of early puberty.

“I think it’s directly related to the amount of stress that the children have gone through,” said Rustagi, adding lockdowns are not the only factor, with many children also coping with grief. “These children have lost family members.”

A global phenomenon

Early puberty is relatively uncommon, affecting about one of 5,000 to 10,000 children, with a female to male ratio of approximately 10:1. For doctors to see such a spike — hundreds of patients in Rustagi’s case — is highly unusual, and a leading indicator of other mental and physical health problems.

In 90 percent of early puberty cases among girls, the cause is never ascertained. With the recent surge, said Rustagi, the cause cannot be identified for nearly all of her precocious puberty patients.

“We have to do all the investigations because we cannot call it idiopathic, which is causeless, without ruling out all other causes,” said Rustagi. In one example, a 6-year-old girl who had started developing breasts was given an MRI scan and an abdominal ultrasound to check for tumors before being declared a case of idiopathic early puberty.

“Previously, we used to treat one or two patients a month due to precocious puberty, but during the lockdown period I had to treat two or three patients a week.”

— Dr. Sezer Acar, pediatrician

The average age of the onset of puberty has decreased over the last century, said Alok Sardesai, a pediatric and adolescent endocrinologist practicing in Mumbai. He added that while genetic factors play a major role, there is also consensus that environmental variables — such as weight, fetal nutrition, childhood dietary habits, physical activity and psychological factors — have an impact.

He pointed to two pandemic-related factors that could have led to the increased incidence of precocious puberty among girls: obesity resulting from decreased physical activity during the lockdowns and increased exposure to endocrine-disrupting chemicals (EDCs) at home. Sardesai added that he, too, has seen an increase in such cases since March 2020.

September 2021 study carried out in Italy questioned whether there was enough evidence to link rising cases of early puberty with weight gain, but noted that the trend was clearly a real phenomenon in Italy and one that seemed to be related to “persistent changes in lifestyle” since the start of the pandemic, and not just limited to the lockdown period.

A recent Turkish study, which examined the data of all patients diagnosed with precocious puberty in a pediatric endocrinology clinic in Izmir, Turkey, also found a substantial increase in the number of idiopathic cases. The study compared data from the first year of the pandemic (April 2020 to March 2021) with the three preceding years. It found the number of girls diagnosed with idiopathic precocious puberty during the one-year study period during the pandemic was more than double that of any of the previous three years, with 58 cases of idiopathic CPP reported during the pandemic year compared to a total of 66 cases over the course of all three preceding years.

Sezer Acar, a pediatrician at Dr. Behçet Uz Children’s Hospital in Izmir and one of the authors of the study, said they decided to investigate what was going on after seeing a sharp rise in cases.

“Previously, we used to treat one or two patients a month due to precocious puberty, but during the lockdown period I had to treat two or three patients a week,” Acar said. “I asked my doctor friends in the city I lived in and in surrounding cities about this, and they also had noticed an increase in the frequency of precocious puberty.”

An indicator of other health problems

Among girls, precocious puberty leads to the development of breasts and pubic hair, in addition to acne, growth acceleration, menstruation, voice changes and other secondary sexual characteristics. It is also known to augment depressioneating disorderssubstance abuse and anti-social behavior. A 2018 study that examined the psychological repercussions of early puberty on girls found that affected girls have higher anxiety levels, lower self-esteem and a more negative body image compared to girls who did not go through precocious puberty.

Rustagi, the Delhi-based pediatric endocrinologist, said the immense stigma around menstruation across the world can make life much harder for girls experiencing early puberty. She added that the mainstream treatment for the condition, a form of hormone therapy known as GnRH analogue therapy, is highly effective, but she suspects most patients never seek out treatment in India, where taboos around periods mean that the majority of women and girls suffer from a lack of awareness about menstrual hygiene.

“In many cases, parents refuse treatment for precocious puberty as they believe menstruation is a doing of God, and that meddling with menses would mean insulting the deities,” she said.

Khyati faced a similar struggle when her daughter got her first period at 8½. Khyati lives with her parents-in-law, who insisted that the girl should not undergo the treatment, as menses were “God’s gift” and interfering with them could lead to complications in the future.

“But my husband was adamant,” Khyati said. “It was too early for our daughter. Now that treatment is available, we did not want to torture our child.”

The Fuller Project’s Erica Hensley contributed reporting from Georgia.

Every day after the sun rises in Limestone, Tenn., a 27-year-old Mexican farmworker walks into the barn where she washes and packs yellow squash and zucchini, her three young children carrying their backpacks next to her as she leads them straight to the break room.

Her 8-year-old and 10-year-old settle into chairs and use a hotspot to connect to the Internet. Her 4-year-old huddles over a notebook or iPad, sketching pictures and playing electronic games. Other farmworkers’ children join them, pulling out their laptops. Soon her eldest two are doing history or English exercises, logged into their classroom portal with classmates as farmworkers plunge their hands in water, rinsing off produce for eight hours near the makeshift classroom.

This arrangement has been the family’s reality for the duration of the harvest. Since the season began in May amid shuttered schools and child-care centers, the woman, who spoke on the condition of anonymity because she is undocumented, has brought her children to the farm. The coronavirus forced her kids’ school to close in March, and the farmworkers’ day-care program came to a halt in May. Unable to afford to quit working, she began bringing her children to work soon after the season began. Her boss has allowed it, she says, because he knows there are no other child-care options.

We know that some children that are 8, 9, 10 years old are working in the fields.”

Mily Treviño-Sauceda, Executive Director of Alianza Nacional de Campesinas

“I have to take advantage of it when there is work and bring them with me,” she says over the phone, relaying how she works seven days a week during the harvest season with no days off. Although the grueling workweeks and the stress of bringing her children to the barn makes her bone-tired and anxious, she needs the job. “Right now, there is no day of rest for me.”

The coronavirus has created a distinct crisis for impoverished farmworkers across the country. Many live in rural areas with limited access to day care and rely on schools and specialized programs to watch their children while they work long hours in the fields; without those lifelines, parents have resorted to bringing their children to work, potentially risking their health and safety to maintain an income. Experts say this has led to more kids laboring alongside their parents, a long-standing issue in the agriculture industry that has been exacerbated by the pandemic, and worry the return to online schooling will leave vulnerable families without reliable Internet access further behind.

Child labor in agriculture continues to grow

In Bakersfield, Calif., Silvia Garcia, a former farmworker who now conducts outreach in the community, has been seeing children in the fields during on-site visits since mid-March. The youngest was 4 years old, Garcia estimates.

Sometimes children haul water to parched workers huddled over the crops or help their parents pick fruit like grapes, Garcia says. Just being there can be dangerous, even for kids not working. “There are a lot of snakes sometimes, especially when they work in oranges,” Garcia says. “There is a lot of risk in taking them, but they don’t have a choice.”

Child labor in agriculture is not new — approximately 500,000 children have worked in the industry as of 2014 — but coronavirus-related school and day-care closures have led to more children working in the fields, advocates and experts who work closely with the farmworker community say, including kids who do not meet the exceptions to work under federal labor law.

“We know that some children that are 8, 9, 10 years old are working in the fields,” says Mily Treviño-Sauceda, executive director of Alianza Nacional de Campesinas, a national organization that advocates for farmworker women.

At a farm outside of Tampa, a 36-year-old undocumented migrant farmworker from Guerrero, Mexico, picked blueberries in April while three of her six children — aged 8, 11 and 12 — would sometimes join her under the blistering sun. Her 5-year-old lingered nearby as they worked, and her 4-month-old baby sat in a stroller in the fields, she says over the phone after work, her voice catching as she recounted those moments.

“He was very fussy, very restless, not used to being in the sun,” she says. “I regretted having brought him, but it wasn’t out of pleasure, it was out of necessity.” (Like the other workers interviewed for this story, she spoke on the condition of anonymity because of her immigration status.)

Online learning brings new challenges

In July, she and the children moved to Michigan for the blueberry and apple season; as a migrant farmworker, she travels there annually with her kids for the harvest. Her 12-year-old watches his four siblings in the family’s apartment now as she picks fruit. But with remote school in session, the 12-year-old will be busy with schoolwork during the day and unable to watch them. The mother may have to bring the five other children back to work, she says. The thought brings back a flood of bad memories, particularly of her infant wailing in the stagnant heat. The thought of returning to the fields is a source of anxiety for the children.

“I hope they won’t,” she says. “I don’t know what to do. There is no child care.”

With the return to the school year, many farmworker parents grapple with the same dilemma that confronted them in the spring. Online learning poses a particular challenge to farmworker families without Internet access or computers, putting students at risk of falling behind in their classes and leading some parents to leave their jobs.

After a month of bringing her three children with her to an outdoor plant nursery near Miami, a 36-year-old undocumented farmworker from Guatemala quit. Because of her immigration status, she is ineligible for unemployment benefits. Her family needed her weekly $300 dollar salary, and she felt anxious about leaving her youngest in the care of her eldest. So two to three times a week this spring, she brought her children — aged 7, 12 and 15 — with her.

“In the neighborhood where I live, there are lots of people walking around the streets, and sometimes they break into houses to rob them,” she says. “I didn’t want to leave [the kids] alone because it is a danger to them. [If they’re in the fields] I could keep an eye on them and watch them.”

The kids struggled when they joined her at work. They tried to do their schoolwork remotely in the middle of the fields, taking turns hoisting up the phone amid the rows of plants to log in to their classes, but sometimes there was no cellphone reception or Internet access. All three fell behind in school. Her 12-year-old snapped on plastic gloves and helped pull weeds in hopes the extra help would let them escape the sun sooner, while the 7-year-old told her he could not stand being in the heat and begged her to go home. On days she brought them to work, she would at times burst into tears.

Economic constraints add stress

“I would say, ‘My God, what is happening? Why did the coronavirus come to us? Look at how we are suffering with the kids.’ And it made me depressed,” she says. She quit working in April to stay home with the children, making ends meet by selling tamales while her husband continues to work in the fields. She makes about $100 a week, and he earns between $200-$300. The economic constraints mean they can’t make upgrades to meet the challenges of remote schooling. Instead of buying a desk for one of the kids, they stacked cabinets for a makeshift workspace for the children. The family’s Internet connection is shaky and routinely cuts out during torrential downpours, plaguing her with anxiety about how her children will fare with remote schooling.

“I tell them, ‘Pay attention to class because otherwise you’ll have a life like mine,’ ” she says. “ ‘Do something different. My life is hard.’ ”

In Tennessee, as the 27-year-old mother of three continues to pack and wash vegetable after vegetable, her children have adjusted to their new reality, she says. Her time indoors is a welcome relief from the spring and summer, when she stopped harvesting cabbage to check on her children every 45 minutes, stuck in the barn with no air conditioning as temperatures reached the 90s. Midsummer, her boss installed an air conditioner.

Now she takes some comfort in being able to see her children hunched over their Chromebooks as she submerges her squash and zucchini in water, rinses and packs rhythmically seven days a week until harvest season ends in November, when she will be out of work for the rest of the year.

At least, for now, her family is able to barely hang on, she says.

“Stopping work is not an option. We are living day-to-day.”

CHINO, Calif. — On a morning in mid-May, Anna “C.J.” Rugg, a 38-year-old transgender man who had tested positive for the coronavirus at the California Institution for Women, set his room in the medical isolation unit on fire.

“I made my room an inferno,” he told The Washington Post by JPay, the inmate emailing system, and “laid down on the floor and waited for the smoke to get me.”

Rugg had serious health issues and struggled with acceptance since coming out in prison as transgender, but it was the extra stresses of covid-19 measures that pushed him over the edge. “This lockdown is too much,” he wrote to Arlene Veronesi, a close friend and former cellmate. “I lost it. Don’t hate me.”

Even before the coronavirus pandemic, incarcerated individuals in California’s 35 state prisons faced poor mental health care. The situation is especially dire for the rapidly increasing number of female prisoners, who make up 4 percent of the state’s incarcerated population but 11 percent of suicides, according to 2016 figures. Seven women committed suicide between 2013 and 2016 at the California Institution for Women, a 1398-bed prison currently housing close to 1500 women; in 2018, a woman experiencing a psychotic episode waited hours for care, ripping out and swallowing her own eye before receiving treatment.

Multiple state audits of the prison have found slow response rates to mental health incidents as a major factor in suicides. A class-action lawsuit filed in 1990, on behalf of all of California’s incarcerated individuals receiving mental health services, is ongoing.

The pandemic has exacerbated the lack of mental health care at CIW. Inmates have refused tests, temperature checks and other measures meant to contain the virus’s spread to avoid being put in isolation, and four women have attempted suicide while in quarantine or isolation for the coronavirus. “Rather than treat[ing] their mental health,” the pandemic has shifted the entire correctional health care system’s priority to “basically just trying to keep people alive,” said Michael Bien, lead counsel in the class-action lawsuit.

When CIW’s first positive coronavirus test came back on April 6, correctional officials quarantined women to their own cells if they might have been exposed. Prison officials put whole housing units into lockdown and moved positive patients into separate medical isolation units.

But a number of inmates say that CIW staff never told them what was happening.

On the same day as the first positive test at CIW, the California Department of Corrections and Rehabilitation (CDCR) issued guidance requiring all staff to wear face masks. It was “our first time seeing any staff in a mask,” Rianne Theriaultodom, an incarcerated woman who was in the medical isolation unit with Rugg, told The Post via JPay. This left the women “confused and terrified” about the disease’s progression in their facility.

Thirty-six hours later, during which women screamed and banged on their doors, demanding answers, they were officially informed that they were in quarantine because of the virus. “Everyone in my unit seemed to have lost all control over their emotions,” Theriaultodom said. Even more shocking than the women’s deterioration was “that no one from mental health came by our doors to see how we were holding up.”

It was worse, however, in the medical isolation unit. According to April Harris, an incarcerated woman who spent a month in medical isolation, women were refusing to take coronavirus tests to avoid being sent there. “People aren’t scared of covid-19, they are scared of the treatment of isolation,” she wrote to The Post in a Jpay email.

In early April, shortly after the first women were moved into medical isolation, a woman attempted suicide.

Suicide attempts

Before the pandemic, women at CIW were allowed out of their cells for 23 hours a day. They worked and participated in professional training or personal development programs. That ended in mid-March, along with family visits.

Women say they now often spend 23 hours locked in their cells, with little information on how long the latest lockdown measures will last or when they’ll be able to exercise outside, call their families or even be allowed to shower.

Amend, an organization affiliated with the University of California San Francisco’s School of Medicine that advocates for a more health-oriented approach in prisons, has warned that “keeping people socially isolated in a closed cell . . . causes immense, and often irreparable, psychological harm.”

Additionally, mental illness is associated with higher risks for infectious diseases such as covid-19, given the prevalence of underlying conditions associated with both. As of July 14, according to court documents filed by Bien and other class action lawyers, patients from the correctional mental health delivery system made up over a third of California’s prisoners hospitalized for covid-19, and 44 percent of the 34 deaths. Prisoners with mental illnesses make up a third of the incarcerated population.

Ignoring mental health makes containing the virus more difficult, said Brie Williams, Amend’s director and a professor of medicine at the University of California San Francisco, as it is common for incarcerated individuals to hide their symptoms to avoid isolation.

By the time Rugg set his mattress on fire, he had made four formal requests to be seen by mental health staff, starting from the first day of lockdown on April 6, as well as verbally during the twice-daily temperature checks. He says only one mental health staff came to see him but only to tell him to put in his paperwork. “I can’t sleep and my doctor won’t come,” he wrote to Veronesi in a letter, and “I feel overwhelmed by everything” in another.

In the medical isolation unit in mid-May, Rugg refused food, medicine and the temperature checks required for everyone who tested positive for the coronavirus for three days, without any staff taking action. “I tried to cut my wrists . . . but the blade kept breaking,” he said. That’s when he resorted to fire.

“Those [who] express they are in distress or seek assistance are seen within 24 hours by a mental health professional to determine if the patient requires a higher level of care,” Dana Simas, a CDCR spokesperson, said in an emailed statement, though she did not specify what would constitute “distress.”

Bien, the lawyer, added that “the whole mental health care delivery system depends on the ability to identify people who medically need it and refer them to a higher level of care.” Other women confirmed the difficulty of accessing care.

Corene de la Cruz, an incarcerated woman who has not contracted the coronavirus, said she made multiple requests for counseling but neither mental health staff nor “chaplains were available on the premises to speak to.”

Once, after quarantine had already been lifted, a male mental health worker she had never seen or spoken to offered her a counseling session in the day room, in front of other inmates. According to CDCR policy, counseling is supposed to be private.

Puzzles and coloring pages

More frequently, since mid-May — shortly after Rugg’s suicide attempt — mental health staff walk through the women’s general housing units once or twice a week passing out connect-the-dots puzzles and Hello Kitty images to color, de la Cruz said. Sometimes there are handouts on how to cope with anxiety, she added, but she said she did not find any of this helpful.

Neither did April Harris, who spent a month in isolation with covid-19, just across the hall from Rugg. She was the first to see the fire.

Harris screamed for help. “I thought she was going to die, and I was going to watch her burn,” she wrote in a journal entry she shared with The Post.

Her actions might have saved Rugg’s life. After his suicide attempt, Rugg was moved to an inpatient psychiatric facility, where he says he is receiving care and awaiting transfer to a state psychiatric hospital. However, he’s not sure when he’ll be moved, as transfers to outside facilities have been paused because of the virus.

After witnessing the suicide attempt and being temporarily evacuated from the burning building, several residents requested counseling. A week passed before any mental health staff visited the unit. When they arrived, it was not to offer counseling but to slide sheets of yoga poses, crossword puzzles and coloring pagesunder their doors.

Simas, the spokesperson for the correctional department, did not respond to a specific question about the coloring book pages but recently filed court documents stating the correctional department is working to replace the loss of programming during the covid-19 restrictions with “therapeutic treatment packets” and “workbooks.”

“It was an emergency for a while, but now it’s 100 days out,” Bien says of the pandemic’s effect on mental health care. “The question is: What’s the plan? This is going to last at least a year, maybe two. . . . How are you going to improve mental health care?”

On July 15, Bien and class action lawyers presented a comprehensive solution to the court, requesting “the State reduce the mental health population commensurate with the reduction of the overall prison population.” As a measure to contain the spread of covid-19, the state has already released 3,500 incarcerated individuals, and Gov. Gavin Newsom (D) announced this month that California would release up to 8,000 more, with a partial focus on eight state prisons with outbreaks, including CIW. By July 24, 280 incarcerated women at CIW had tested positive for the coronavirus, and one had died, while 7,481 incarcerated individuals in all of California’s prisons had tested positive, and 42 had died. Mental health patients, however, were not specifically included in either cohort for release.

The only solution in providing better mental health care, Bien told The Post a few days ahead of the filing, is to “reduce the patient population.”

MILWAUKEE — When Ascension’s St. Joseph Hospital in Milwaukee announced it would cut back services in 2018, residents of the surrounding Sherman Park area protested.

The predominantly black, low-income neighborhood already faced its share of challenges. Nearly a third of residents in the ZIP code live in poverty, and black infants born there are more than twice as likely to die as white infants.

Residents feared that reducing services would exacerbate these disparities, and even pave the way for the hospital to close. St. Joseph’s parent company, Ascension Wisconsin, eventually put the cuts on hold.

“It’s an anchor institution there,” says Reggie Newson, chief advocacy officer at Ascension Wisconsin.

But St. Joseph remains the target of a different kind of protest. The hospital is Catholic, which means it follows Ethical and Religious Directives, a set of rules written by the U.S. Conference of Catholic Bishops. The rules prohibit Catholic hospitals, except in extreme situations, from providing procedures the church deems immoral — including abortions, contraception and sterilization. In-vitro fertilization is banned.

Asma Kadri Keeler, a staff attorney at the ACLU of Wisconsin, recently met with members of the St. Joe’s Accountability Coalition, a community group formed after Ascension announced cutbacks. Although most people surveyed by the community group had positive views of St. Joseph, some residents told Keeler they were hesitant to send their pregnant loved ones there.

The nonprofit news outlet Wisconsin Watch provided this article to The Associated Press through a collaboration with Institute for Nonprofit News.

Keeler says the ACLU works to safeguard religious liberty, but it also has sued when patients were denied care based on religious restrictions.

“We take the position that it (religious liberty) can’t be used to harm other people,” she says.

Reproductive rights advocates say the restrictions impose religious doctrine on patients and violate medical standards of care in ways that disproportionately affect communities like Sherman Park.

Catholic health systems argue that they serve as safety nets in impoverished communities and provide the same quality of care as secular hospitals. According to the Catholic Health Association (CHA), which represents more than 600 Catholic hospitals in the United States, patients who received care at Catholic hospitals are more likely to recommend those hospitals than patients who receive care elsewhere.

That St. Joseph is both desperately needed and criticized reflects an increasingly common tension facing Wisconsin communities. An analysis by the Cap Times and the Fuller Project, a nonprofit news organization focusing on women’s issues, shows that the number of Catholic hospitals grew by 13% in the state, while the number of non-Catholic hospitals fell by the same percentage, between 2001 and 2018.

In most ways, these Catholic hospitals, which treat one in every seven patients in the United States, differ from secular ones in name only. Yet, critics say, in reproductive care, Catholic ethics can trump medical best practice, bishops can wield more influence than physicians, and patients can be denied care they desire or need.

In Wisconsin, where Catholic Germans and Irish dominated immigration in the mid- to late- 1800s, one-third of hospitals are governed by Catholic religious principles — more than twice the national average.

It is the only state where black women are more likely to deliver their babies in a Catholic institution than a non-Catholic one, Columbia Law School researchers found. And in 12 of Wisconsin’s 72 counties, the only hospitals within the borders are Catholic.

Hospitals are not always transparent about the services they will not provide, and patients often lack a choice of where they seek care, the Cap Times and the Fuller Project found.

Catholic hospitals are governed by 77 directives, which fuse theology with medicine and technology. Several directives cover reproductive care. For example, Catholic-affiliated hospitals will not provide sterilization if the sole purpose is to prevent a woman from becoming pregnant.

And abortion is not permitted, unless it is an “unavoidable” consequence of an action taken to save the mother’s life, according to Brian Reardon, vice president of communications for CHA.

Some physicians provide referrals for abortions and other restricted services or prescribe contraception for menstrual pain rather than birth control. Others adhere strictly to the directives.

SSM Health St. Mary’s Hospital in Madison refers patients seeking a common form of sterilization to undergo the procedure at a nearby eye clinic that does surgeries, according to one doctor and a nurse familiar with the arrangement.

Out of dozens of former and current medical residents, physicians, nurses and midwives in Wisconsin contacted by the Cap Times and the Fuller Project, only one currently practicing physician agreed to speak on the record for this story. Other currently practicing providers agreed to speak only anonymously because of concerns about negatively affecting their careers or because they had been instructed not to by their employer.

To clarify how Wisconsin’s Catholic hospitals use the directives, the Cap Times and the Fuller Project sent a series of questions to six such hospital systems: Ascension, SSM Health, Hospital Sisters Health System, Divine Savior Healthcare, Essentia Health and Holy Family Memorial. Questions were also sent to Aspirus and Mayo Clinic Health System-Franciscan Healthcare, two non-Catholic health systems that own hospitals that adhere to the ERDs.

None responded individually. However, Nathaniel Blanton Hibner, CHA’s director of ethics, sent a statement on behalf of the organization and Ascension, SSM and Hospital Sisters Health System, clarifying that physicians will prescribe contraceptives for “a variety of underlying medical conditions” and will offer emergency contraception to rape victims.

Dr. Kathy Hartke worked in Catholic hospitals for 27 years. She recalls a young woman pregnant with twins who arrived at the Catholic hospital in Brookfield, now known as Ascension SE Wisconsin Hospital-Elmbrook Campus. At about 21 weeks, the fetuses had virtually zero chance of survival.

The longer they waited to terminate the pregnancy, the greater the risk the woman’s uterus would become infected, Hartke said. But at Elmbrook, medical personnel were told they had to wait until the fetuses had no heartbeats.

Hartke recommended the patient be transferred to the secular Waukesha Memorial Hospital, where they could induce labor. But nurses gave the patient the opposite advice.

“Meanwhile, we’re sitting on a possible time bomb of somebody who is going to get very, very sick … and potentially die,” says Hartke, who has retired from practice.

The patient remained in Hartke’s care, growing sicker in the ensuing days. She developed sepsis, a life-threatening condition. Hartke says the patient went into spontaneous labor and was provided antibiotics, which prevented her from growing sicker. The fetuses did not survive.

Hibner says if a mother is suffering from a life-threatening condition, Catholic hospitals will provide all medically indicated care — even if it results in the death of the child.

The Rev. Charles Bouchard, senior director of theology at CHA, says he urges doctors to be “proactive” and not “wait until this infection starts.”

But in her experience, Hartke says, “They push it to the last possible second.”

“How is any physician supposed to be able to predict when it’s too late and a woman is going to die?” she says.

As a medical resident, Dr. Jessika Ralph tried to facilitate an abortion for a patient who became ill after going into premature labor with twins at St. Joseph in 2017. Ralph, who now works at University of Minnesota Health, says she was forced to wait until the woman hemorrhaged or showed signs of infection to help end the doomed pregnancy. And she was unable to use a particular recommended abortion drug. The ordeal lasted 24 hours, she says, and neither fetus survived.

“While overall I believe these hospitals do provide good obstetric and gynecologic care for women, this unfortunately is a really big gap, and it’s a gap that patients don’t know about,” says Ralph, who also told her story to Rewire.News.

Women delivering by C-section at a secular hospital can ask physicians to tie their fallopian tubes, cut them and cauterize the ends while the abdomen is still open — a procedure that might last just a few minutes.

But at a Catholic hospital, the same woman often must schedule a second surgery at a different hospital to get a tubal ligation. Researchers have found that nearly half of women who requested to be sterilized but were denied became pregnant within a year.

Hospitals also charge nearly three times more for postpartum tubal ligations than they do for the same procedure done during a C-section, according to a list of procedure costs from Aurora hospitals in Wisconsin. The median charge for a C-section tubal is $515; a postpartum tubal is $1,390.

Doctors at Catholic hospitals face a dilemma: Risk violating hospital rules, or make the patient go through two surgeries.

Says Hartke: “When you have a moral conflict like that, it eats away at you.”

Secular hospitals commonly implant long-acting reversible forms of contraception such as intrauterine devices (IUDs) after a woman gives birth. Physicians from Catholic hospitals told the Cap Times and the Fuller Project they were not allowed to implant IUDs, which provide contraception that can last for years.

Data from the Wisconsin Hospital Association suggest this is largely true. Ascension’s St. Joseph Hospital, for example, billed for an IUD just nine times for the fiscal year ending June 2019, whereas the non-Catholic Froedtert Memorial Lutheran Hospital, less than 5 miles away, did the same more than 1,500 times.

Cami Thomas is a leader of Maroon Calabash, which describes itself as a black radical reproductive justice organization. She says reproductive health care should be about “dignity and consent.”

Thomas recounts going to a Catholic hospital about a decade ago when she was on the brink of death, having lost two-thirds of her blood after her menstrual cycle went on for six months. Her doctor recommended Depo-Provera, an injectable contraceptive, but the hospital’s rules on contraception prohibited it. Furious, he found a loophole.

“Not all doctors are like that,” she says. “Thank goodness I had that doctor.”

ANGELES CITY, Philippines — The girls onstage were numbered, not named.

Silently, they shuffled in a circle around the mirrored platform in a basement dance bar; arms folded around bare stomachs, eyes fixed on the scuffed metal floor.

At the back of the stage, a 14-year-old in black heels hunched her shoulders and tried to shrink into the shadows. It has been more than a year since she was trafficked into the dimly lit nightclub about 50 miles north of Manila.

She is among hundreds of girls supplied each year in Angeles City to meet the demands of foreign men paying for sex — many of whom are American.

A bell sounded and a tourist entered the bar. Under the gaze of her manager, the girl stepped forward and forced a smile. Her knees shook in the spotlight.

The Philippine city of Angeles — home to a former U.S. military base — has long been a hub for “sex tourism”: illegal prostitution between foreign men and Filipina girls often still in their teens and trafficked into the industry, or young women pushed into the sex trade by family pressure and economic desperation.

The Philippines sex industry and potential for continued exploitation, however, remains indirectly aided by legislative loopholes and apparent indifference from authorities, according to activists.

Prostitution is illegal in the Philippines and commercial sex with a child under the age of 18 is rape. But bar managers can circumnavigate laws. Girls and women are presented as “entertainers” rather than sex workers, and payments for sex are packaged as “fines” paid to the bars by a patron on behalf of a woman leaving her shift early.

Meanwhile, the government of President Rodrigo Duterte has devoted few resources to battling the Philippines’ illicit sex industry even as it wages brutal crackdowns on the drug trade.

Duterte, in fact, has appeared to invite foreign men to the country with the suggestion that young women are waiting.

“They’re all on the beach sunbathing,” Duterte said during his State of the Nation address in July. Last year, he joked that he would attract visitors to the country with the promise of “42 virgins.”

Local leaders are left to mostly handle the repercussions alone.

“I will not give up on this,” said Angeles’ newly elected mayor, Carmelo “Pogi” Lazatin Jr., in July, adding that ending all forms of prostitution in the city was top-priority. “But it will take time. There is a lot of resistance.”

Activists’ warnings

As the sex industry has become more lucrative, corrupt officials have taken steps to give it a veneer of lawfulness, activists say.

More than 9,000 bar girls are registered as “entertainers,” but the government mandates they take sexually transmitted disease tests on a weekly basis — a move criticized by activists as a marketing trick to present the city’s sex industry as clean and tourist-friendly.

Meanwhile, bar owners often pretend to obey minimum-age requirements of 18.

Unregistered, freelance sex workers and trafficking victims abound. The youngest girl interviewed by The Fuller Project was 10 years old.

Next year, a new airport terminal on the outskirts of Angeles is set to triple the number of visitors to the region and bring a possible expansion of sex trafficking and abuses, human rights advocates warn.

“If tourism doubles, then the vulnerability of children doubles, too,” said Dolores Alforte, Philippines executive director for the international nonprofit End Child Prostitution And Trafficking, known as ECPAT.

In July 2018, the then-mayor of Angeles, Edgardo Pamintuan, and Angeles-based nonprofit founder Robert Wagner met with John McGregor, then the human rights officer of the U.S. Embassy in Manila.

They proposed a six-point plan for American assistance in holding U.S. citizens accountable for possible crimes related to exploiting Filipina women and girls, including the placement of closed-circuit TV cameras outside the bars and a kiosk where sex workers and trafficking victims could report abuse and ask for help.

Neither Pamintuan nor Wagner have seen any action taken since.

The U.S. Embassy in Manila declined to make a public comment. But past statements by U.S. officials have emphasized a strong partnership with Philippine law enforcement on human trafficking and related issues.

In June, the State Departement’s Trafficking in Persons Report listed the Philippines among the top-tier countries with laws in place to battle human trafficking.

“Although the [Philippine] government meets the minimum standards, it did not vigorously investigate and prosecute officials allegedly involved in trafficking crimes,” the report added.

Back in the darkened bar, an American man beckoned the 14-year-old down from the stage. She told him that her name was Rose and that she had just turned 18: two lies, taken from the fake papers used to secure her job in the bar. A manager informed the tourist that it will cost 2,000 Philippine pesos, or $38, to take Rose back to his hotel for a “short time.” Two crumpled blue notes are passed between palms.

“They remind me of my grandpa,” Rose said later.

The Washington Post does not identify minors in sex cases or victims of sex crimes.

Of the 30 girls in the bar that evening, Rose thought she was the youngest, but she wasn’t sure.

‘No jurisdiction’

More than 150 women and girls interviewed by The Fuller Project in Angeles City said they wanted to leave prostitution but didn’t know how.

Those younger than 18 were scared that “rescue” would involve leaving their friends or families. Many were afraid that under current anti-prostitution laws, reporting foreign predators to the local police could land the girls in jail.

“It’s just normal,” said Angel, 14, who said she was trafficked into the city’s sex industry when she was 12 years old by an American man. She now works “freelance” with a group of nine friends. All are underage, she said.

“It happens to all of us,” she added.

Under the 2003 PROTECT Act, U.S. citizens suspected of committing child sexual exploitation abroad can be charged in the United States, regardless of where their offense takes place.

But despite a team of U.S. law enforcement agents in Manila specifically tasked with investigating Americans who sexually abuse children across the Philippines, there have been few convictions.

“We’ve identified American citizens going to places like the Philippines with the purpose of having sex with kids who are poor,” said Stacie Harris, an associate deputy attorney general and national coordinator for Child Exploitation and Human Trafficking at the Justice Department.

But the PROTECT Act has no reach over U.S. citizens seeking out adult sex workers while abroad.

“You have a U.S. tourist who goes over and picks up someone on a street corner,” said Harris, “and we have no jurisdiction over that.”

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