Liberia is one of the poorest countries in the world, having suffered years of civil war and regional conflict. Its human development indicators rank 175 out of 189 countries on the 2019 Human Development Index. The child malnutrition rate is 15% among 5-year-olds and younger and many Liberians lack access to basic needs such as food, water, shelter, education, and health care.

In fact, the authors note, nearly 63% of the people in the West African nation established by freed American slaves live in poverty; 69% of the country’s 5 million people live on less than $3.20 a day.

“A functional economy that ensures that most citizens can earn a living wage does not exist,” the authors wrote. “Extreme poverty in some families, high levels of illiteracy and unemployment, and suboptimal economic activities contribute to child servitude and other forms of child exploitation.”

The children of Liberia are not alone. In societies with inherent instability and ongoing conflict, the practice of child servitude can become accepted as a normal way to make money and centralize power when opportunity and resources are scarce.

Jappah notes that for young children and adolescents, this is the period of forming personality, critical reasoning and developing relationships outside of the home, as well as forming opinions about the world around them. Living in such dehumanizing conditions can result in shame and trauma and often have intergenerational effects. They also have lower levels of education and higher dropout rates, contributing to an ongoing cycle of intergenerational poverty.

“These children, as all children do, internalize and, to some extent, normalize their living conditions, and society becomes more acquiescent to such practices, despite their detrimental effects,” Jappah said.  “These practices are widespread in places where laws are not adequate to address them, or if there are laws, few enforcement mechanisms are in place, or they are not enforced.”

Jappah said Liberians must address their cultural history of exploitation if they want to abolish the practice of child servitude. In addition, addressing the larger issues of inequity and the exclusion of marginalized groups is necessary.

“Throughout human history, we have witnessed clashes among social classes and groups,” Jappah said. “The more inequitable a society is, the more likely it is to be rife with social tensions.”

He concluded that those tensions are evident in developing countries as well as the industrialized nations such as the United States, a Western harbor of child trafficking and slavery. According to the Global Slavery Index, on any given day in 2016 there were 403,000 people living in conditions of modern slavery in the United States — or 1.3 victims of slavery for every thousand people in this country.

 “This phenomenon is universal; Liberia is not an exception,” Jappah said.

The second privacy concern is the potential use of health-care facility records to incriminate an institution or its clinicians for providing abortion services. Relevant records could include electronic health records, employee emails or paging information and mandatory reports to state agencies. Clinicians may not realize that if they are using an institutional email address or server, their institution likely has direct access to information and communications stored there, which can be used to search for violations. State Freedom of Information Act (FOIA) laws also allow citizens to request public records from employees of government hospitals and clinics.

“Additionally, state mandatory reporting laws for child abuse might be interpreted to cover abortions — particularly if life is defined as beginning at fertilization,” the authors note.

The third scenario is that information generated from a woman’s online activity could be used to show she sought an abortion or helped someone to do so. Many women use websites and apps that are not HIPAA-regulated or protected by patient-physician privilege, such as period-tracking apps used by millions of women that collect information on the timing of menstruation and sexual activity.

“There are many instances of internet service providers sharing user data with law enforcement, and prosecutors obtaining and using cellphone data in criminal prosecutions,” write Mello and Spector-Bagdady, adding commercially collected data are also frequently sold to or shared with third parties.

“Thus, pregnant persons may unwittingly create incriminating documentation that has scant legal protection and is useful for enforcing abortion restrictions,” they said.

The immediate problem, Mello notes, is in the states that have already banned abortion or passed restrictive laws.

“There could be a problem with states trying to reach outside their borders to prosecute people, but that could well be unconstitutional,” Mello said.

Some states’ laws sweep abortion pills into the definition of illegal abortions, she said, and there are legal obstacles to supplying the pills across state lines.

“There is a lot of energy going into figuring out a workaround right now, but it’s too soon to call,” Mello said.

Recommended Protections

So how can clinicians and health-care facilities protect their patients and themselves?

When counseling patients of childbearing age about reproductive health issues, clinicians should caution their patients about putting too much medical data online and refer them to expert organizations that will help them minimize their digital footprint.

When documenting reproductive health encounters, the authors said, clinicians should ask themselves: “What information needs to be in the medical record to assure safe, good-quality care, buttress our claim for reimbursement, or comply with clear legal directives?” For example, does information about why a patient may have experienced a miscarriage need to be recorded?

Patients and clinicians should be aware that email and texting may be seen by others, so conversations among staff about reproductive health issues may best be conducted by phone or in person.

Finally, if abortion-related patient information is sought by state law enforcement officials, a facility’s attorney should be consulted about asserting physician-patient privilege and determining whether the disclosure is mandated by law.

Leave-Taking Led to Higher Support

The findings are not only timely, but they also provide the strongest evidence yet of how COVID has changed employers’ minds about paid family leave, Rossin-Slater says. Since 2016, she and her co-authors — Ann Bartel, Meredith Slopen, and Jane Waldfogel of Columbia University, and Christopher Ruhm of the University of Virginia — have been surveying employers with 10-99 employees in New York, New Jersey, and Pennsylvania to learn about the effects of paid family leave. As part of their annual questionnaire, they have asked firms in New York and New Jersey to share their overall attitudes toward the policy. This is how they were able to reliably gauge in this latest study how small business owners and managers were feeling about paid leave on the eve of the pandemic.

Another advantage of the survey is that it focuses on employers’ experiences with paid family leave during COVID and not, as most other polls have done, only on workers.

Rossin-Slater says that assessing employers’ overall attitudes, in addition to measuring effects on operational issues, provides further evidence as to whether businesses are harmed by paid leave.

“Actual views provide a summary of how businesses think the policy is affecting operations,” she says. “If it was a disaster and really hard for them, they’re probably not going to be very supportive. The opposite is likely if their experience was smooth and not complicated.”

In all, 539 New York and New Jersey businesses that participated in the 2019 survey also responded in 2020, rating their opinions on paid family leave according to a 5-point scale. The researchers analyzed changes in opinions within each firm and controlled for other factors that could have changed over the time period, such as the total number of employees and their characteristics. They found that the share of employers reporting that they were very or somewhat supportive of the policy rose by 9.6 percentage points, from 61.6 percent to 71.2 percent. Meanwhile, the portion of firms that were somewhat or very opposed declined by 8.8 percentage points, to 11.2 percent.

The increase in support was somewhat larger among employers with 50-99 workers, although the rise in favorable opinions was also meaningful among even the smallest employers in the study. The researchers also found that employee use of state paid leave during COVID was associated with more favorable employer views.

“What’s striking,” Rossin-Slater says, “is that during COVID — when it’s become incredibly clear how important it is for workers to be able to take time off work with pay and job protection to care for ill family members or for kids who are out of school — employers became even more supportive of paid family leave.”

Rossin-Slater says that one drawback to the study is its relatively small sample size. Over the years, she and her collaborators have surveyed 4,711 employers. Of the 1,151 that responded to the 2020 survey, 887 were operating. About two-thirds of those still in business answered questions about their attitudes toward leave and whether workers used it during the pandemic.

Even so, shedding any light on what employers think about paid family leave is important, she says.

“As economists, we focus a lot on measurable impacts like productivity or turnover rates, and those are important to quantify,” Rossin-Slater says. “But at the end of the day, whether these policies get passed is ultimately a political question, and people’s attitudes shape the public discourse in this country. Understanding how attitudes change, especially during a pandemic, is insightful for thinking about where this policy is ultimately headed.”