Ann Hermes/Staff

A physician consults with a pregnant woman (visible names digitally altered) on her options at Hope Medical Group For Women on April 1 in Shreveport, Louisiana. Hope Medical Group For Women is one of the few remaining abortion clinics in the state.

He’s provided abortions for nearly 40 years. Now, the man known in court documents as “Dr. John Doe 1” – or “Doe” for short – is ready to retire and wondering whether anyone will be around to take his place. There are one or two local physicians who might be willing to hack it – to risk judgment from their peers and neighbors, face hostility from antiabortion extremists, and conceal their identities from the public, as Doe has done for most of his career.

But at some point, likely late this year, he plans to hang up his scrubs for good.

“We’re going to kind of face the point where [I have to] say, ‘Look, if none of the other OB-GYNs in this state are willing to come up and step up to the plate, then too bad,’” he says one April afternoon after his shift at Hope Medical Group for Women in Shreveport, Louisiana, where he’s performed abortions since 1981. “I’ve done as much as I can do, you know?”

Providers have for decades been a key target of anti-abortion activists; an entire category of abortion regulations is aimed at chipping away at their ability, and by extension their desire, to offer abortion care.

Now, as activists on both sides prepare for the possible overturning of Roe v. Wade, that long-term strategy is paying off. When not facing the threat of public animosity, doctors in anti-abortion strongholds like Louisiana are often shamed for their decision to provide abortions. A barrage of laws restrict how, where, and when they can perform the procedure. Clinics that manage to stay open are tied up in compliance and litigation, a drain on time and resources. The pressure has seeped into medical schools, especially in conservative areas where providers are most scarce: Students aren’t getting exposed to even basic abortion care unless they seek it outside their regular coursework.

Abortion rights opponents say you can’t force doctors to do, or teach, something to which they’re morally opposed. Abortion is often a medically unnecessary procedure, and it would be unethical to compel anyone to perform it, they say. Medical schools and residencies need only train students to attend to emergency abortions or miscarriages – which schools and hospitals do – and not actively prevent students who want to from learning about abortion.

Abortion rights activists, however, say that the current environment is one in which doctors who choose to provide abortions feel scorned and even threatened. It discourages physicians who would otherwise perform abortions from doing so and chokes the provider pipeline, particularly in restrictive states. Women then have to deal with longer wait times at clinics and doctors who are tired or overextended. Some women aren’t able to access abortions at all.

What good is a woman’s right to choose whether or not to have an abortion, they ask, if no one is able or willing to perform them?

‘How terribly naive I was’

Doe is still in scrubs when he walks into the clinic administrator’s office at Hope Medical. It’s only about 4 p.m. but he’s had a long day; he was late for his shift at the clinic, he says, because he had to deliver a baby that morning for a patient at his private practice.

Providing abortions had never been Doe’s first choice. The clinic had first approached him in the early 1980s, less than a decade after the Supreme Court legalized abortion in the United States via Roe v. Wade. He’d only lived in Louisiana a few years, having moved here from Texas for his residency. He says he believed abortions should be legal and safe, and that women should have access to them. But it seemed every doctor he knew who volunteered to perform abortions soon found themselves overwhelmed by the demand.

Ann Hermes/Staff

A.J. Haynes (r.) speaks with visitors at Hope Medical Group For Women on April 1 in Shreveport, Louisiana. Hope Medical Group For Women is one of the few remaining abortion clinics in the state.

What changed his mind was a young man’s sense of bright-eyed duty, helping women in need. “I kind of viewed myself as this knight in shining armor,” he says with an ironic smile. “How terribly naive I was.”

He soon discovered that a wall stood between him and his colleagues. He had been in partnership with two other physicians, both of whom wound up leaving the practice because he was doing abortions and “they couldn’t stand the pressure.” These days, only two local OBs in his hospital network will take calls for him, forcing him to work six, seven, eight days without reprieve.

Meanwhile, the landscape for providers was changing. Abortion clinics like Hope Medical began cropping up, moving abortion care away from hospitals and the schools with which they were affiliated. The shift broadened access to the procedure, but it also created a gap between abortion and academic medical care.

Clinics were also becoming easy targets for harassment and violence. The National Abortion Federation, the professional association of providers, counted 40 clinic bombings and seven murders of doctors and staff between 1977 and 1999. The first murder was that of Florida physician David Gunn, who was shot and killed outside a clinic in Pensacola in 1993. A rash of others followed: In 1994, receptionists Shannon Lowry and Leanne Nichols were gunned down at the clinic where they worked in Brookline, Massachusetts. Later that year, provider John Bayard Britton and volunteer James Barrett were shot and killed outside another abortion clinic in Pensacola. In 1998, security guard Robert Sanderson died in a bombing at an Alabama clinic, while provider Barnett Slepian was murdered in his home in Amherst, New York.

All this began to weigh on Doe, who struggled with depression. He started hiding his identity, although that didn’t stop protesters from accosting him when he went to and from Hope Medical, or sending nasty mailers about him to his neighbors. “I was receiving so much grief over providing abortion services, I wanted to quit working here,” he says.

He kept going because he felt – still feels – an obligation to the women and girls who came to the clinic for help: Like the intellectually disabled young woman who’d been raped by her brother, and who’d hummed church hymns in the operating room. Or the woman whose pregnancy was at risk because she’d needed a heart transplant. Or hundreds of others, he says, their stories both tragic and everyday.

“I’m not pro-abortion. I’m just pro-choice,” Doe says firmly. “If you believe that abortion should be available, you at some point decide: Where does the buck stop?”

Demand outweighing supply

A similar question drew Rachael Phelps into the reproductive health field more than a quarter-century ago. In the spring of 1992, just before she started medical school, Ms. Phelps heard a speaker at a women’s rights march in Washington, D.C., talk about the lack of physicians willing and able to perform abortions. She decided that day to become a provider herself. After getting her degree at Johns Hopkins University in Baltimore, she worked at Planned Parenthood, spending 13 years as the organization’s medical director. Dr. Phelps still provides abortions about one day a week, driving hundreds of miles from her home in upstate New York to support clinics throughout the state.

Ann Hermes/Staff

‘Street preacher’ Mark Lee Dickson protests with images and teddy bears outside Hope Medical Group For Women on April 1 in Shreveport, Louisiana.

But she and Doe are in the minority. A recent survey in the journal Obstetrics & Gynecology found that in 2016-17, 72% of OBs reported having had a patient in the past year who needed or wanted an abortion, but only 23% said they had performed one. Most of those who said they did not provide abortion care came from the South and the Midwest. The most common reasons given were personal beliefs, restrictions placed on their practice, and attitudes among office staff. A previous study by the Guttmacher Institute also found that more than a third of OBs in private practice who declined to provide abortions also said they wouldn’t provide a referral to patients seeking one.

“There’s a lot of people who go into private practice who want to provide the service for their own patients and are kept from doing it because of ... partners who won’t do it, staff who object, hospitals who won’t let you do the case in the hospital,” says Dr. Phelps, who now works at Medical Students For Choice (MSFC), a Philadelphia-based nonprofit that funds and advocates for abortion care training in medical schools.

Since starting at MSFC earlier this year, Dr. Phelps has focused on connecting medical students in campuses nationwide with professionals willing to train them in abortion care. She also leads training sessions herself.  

“Most medical schools in the U.S. never mention the word ‘abortion’ in their curriculum,” Dr. Phelps says in a phone interview. “There is a huge shortage of providers, and there’s nobody getting trained to replace [them].” 

“It’s really dependent on your experience,” adds Alana, a former president of the Tulane Medical School chapter of MSFC, in New Orleans, who asks that her last name not be used. “If a resident or attending [physician] is not comfortable discussing any of these topics, and you don’t have a lecture about it, how are you going to learn about it?”

A spokesman for Tulane – which is a private university and not subject to state restrictions on abortion in public institutions – told the Monitor in an email that abortion education at the school “is restricted to lecture instruction as part of our third year clinical rotation.” He did not respond to a request for details on what the instruction looks like.

Anthony Levatino, a retired OB-GYN who performed more than 1,200 abortions early in his career but has since become a vocal opponent of abortion rights, says he doesn’t remember much specific training on abortion provision from his years in med school. Most of what he learned came from his residency, and he says students today who want that kind of training should choose hospitals and clinics where they can get that exposure.

“I would tell them, ‘If this is important to you, look critically at the training in residency,’” says Dr. Levatino, who stopped doing abortions after his daughter was killed in a car accident in 1984. “‘Don’t put yourself in a position where you’re going to face some kind of barrier – for instance, a Catholic hospital.’ [Students] are not helpless.”

In Dr. Levatino’s view, one reason fewer physicians are performing abortions is that the procedure takes a toll on them. They start to see, he says, that abortion is taking a life. Doctors who feel that way have the right to choose not to provide abortions, he adds.

“What Roe v. Wade says is that patients can legally obtain this procedure. It is not granted as a positive right,” Daniel Sulmasy, who teaches biomedical ethics at Georgetown University. “[The law] respects the conscientious choices of physicians who, even if they don’t want to interfere in that opportunity for women, do not feel comfortable providing it themselves.”

Physicians who do choose to perform abortions shouldn’t have to face violence or harassment, he adds.

It’s also unrealistic to expect uniformly broad access to any medical procedure in a country like the U.S. says Jeffery Bishop, a professor of philosophy and health care ethics at St. Louis University. “You’re going to get a different kind of medicine in New York City than you will in some rural town in Wyoming,” he says. “That’s just the nature of it.”

For providers like Doe who live that reality, however, it’s a lot to shoulder. Hope Medical is one of only three remaining clinics in Louisiana – and that number could go down under a state law, currently being litigated (Doe is a plaintiff), that would require abortion providers to have admitting privileges at a nearby hospital. “I don’t know where to go from here,” Doe says.

Learning on a papaya

On a Monday night this spring, Alana sits in a conference room with 20 or so other medical students. On the table before her is a papaya – a proxy for a uterus – and a pump. The students are here for an MSFC-hosted training session on manual vacuum aspiration, the most common form of abortion. For about half an hour, Alana and her peers practice the technique on the fruit as two physicians, both volunteers, roam the room, commenting on and correcting their work.

It’s the kind of event that Alana had hosted when she was MSFC president her freshman year. Under her leadership, the chapter had forged relationships with local women’s rights groups and MSFC affiliates at other universities. Alana herself had testified against antiabortion bills in Baton Rouge and, in the summer of 2017, spent two weeks shadowing doctors at an abortion clinic in Mexico City. All done in addition to her required coursework.

Now a year away from graduation, Alana remains an active MSFC member. At a café in New Orleans the morning after the training session, she talks about seeing her work as a kind of advocacy. “If you’re really trying to provide a full spectrum of care,” particularly to underserved or underprivileged communities, she says, then that must include “trying to change the system in some way.” 

She knows that she’s unusual in her cohort, that she’s choosing a difficult path. She’s not even sure she’ll want to live in a state like Louisiana if she becomes an abortion provider. But she sees medicine through a humanitarian lens – she worked in international development before switching gears and going to med school – and hopes to use her skills to improve women’s lives.

“Unfortunately, or fortunately, there’s a lot of prestige that comes with wearing a white coat,” Alana says. “I’m going to wear it and use it as a tool to advocate.”

In Shreveport, Doe mulls the idea of a new generation of activist abortion providers, and the thought brings a smile to his face. “I’d love to talk to them,” he says. He’d have advice; stuff he learned the hard way over four decades. 

“Most of the time it’s really not horrible,” he says. “But I am reminded almost every day of ... how difficult my life has been because I work with this clinic.”

“You’ve got to do it just because you believe women deserve the opportunity.”

Editor's note: This story has been updated to correct the nature of Dr. Doe's private practice. It is an OB-GYN practice.

The crew demolishing an old house in the Lok Kalyan Marg neighborhood of India’s capital, one blow of a sledgehammer after the other, is taking a water break.

With Delhi temperatures rising to a literally scorching 118 degrees Monday – a record for the month of June, and less than a degree off the city’s all-time record high – water breaks are an absolute necessity.

“We have to keep working even if our skin is heating and burns, but we also know we need to keep drinking, drinking,” says Asharam, a day laborer sporting a red scarf around his head and a crystal around his neck. “We have to keep drinking water so we can keep working. We all need to make money to send back to our children.”

As Delhi swelters under a road-melting sun, the city’s upper crust finds ways easily enough to deal with what the Indian Meteorological Department has deemed an “exceptional heat wave.”

Houses and cars are air-conditioned; activity and time spent outdoors are reduced. Done.

But for the millions in this city – and the tens of millions more across northern India’s high-population zones – who must keep working without such luxuries, the heat is not just a nuisance but a threat to be reckoned with.

“We are used to heat, but these past days have been something else,” says Radesh, another of the house demolishers. Adjusting the green-checked scarf protecting his head, he adds, “You just tell yourself, ‘OK, it’s even hotter, so remember to drink that much more.’”

The men of the Lok Kalyan Marg demolition crew are not laboring in the front-page-worthy heat for the fun of it of course, but out of necessity. All farm laborers from the adjacent state of Uttar Pradesh, the men migrate to New Delhi and snag whatever day labor they can while the farms back home sit out India’s hottest months.

The men’s water source is not on the job site, but across the street and down the road: a community water spigot of sorts at a whitewashed malaria clinic. Together the men share a green plastic one-liter soda bottle, which they take turns walking the short distance to fill.

That may sound like an inconvenience, but there are probably thousands of Delhi women who would roll their eyes and scoff at the notion that going to fetch a liter of water, even if it is 118 degrees, is much of a hardship.

‘Water mafias’ and exceptional heat

About one-fifth of the city’s 24 million residents still do not have running water. In those households, the task of fetching water for the family cooking, bathing, and washing generally falls to women.

In the city’s slums and shantytowns, a community water pipe is often as good as it gets. And not uncommonly, powerful local families constituting “water mafias” will take over those pipes and charge exorbitant fees for access to them. And so many women are left to walk long distances with large plastic water jugs to a place where they hope city trucks distributing free water will pass.

Over recent days, some women have reported waiting for two hours or more in the officially “exceptional” heat. And if a water truck does come by, there is often jostling for access to it. Sometimes the mafias control the truck tankers as well.

And then the real work begins: how to get the heavy jugs of clean water safely back home? In recent days, reports have surfaced of women being robbed of their precious cargo. In a few cases, deaths have resulted from an altercation over a water jug.

Not surprisingly, water consumption – already at the limits of what city authorities can provide – spikes during heat waves. Government studies show that as global warming intensifies, an already hot India is heating up.

A recent study by the Indian Institute of Tropical Meteorology found that heat waves in India are growing in frequency and intensity. The current spate of ovenlike temperatures confirms the pattern. Temperatures in New Delhi dipped slightly Wednesday, as a sandstorm moved in. But with temperatures predicted to rise again for the rest of the week, back up to 112 Saturday, this month is almost certain to clock in as the hottest June on record.

Adjusting to a new normal

The men at the Lok Kalyan Marg demolition site don’t care much about records.

Taking their lunch break, the men get out small plastic bags of kulcha, bread that they eat with a bit of salt. Today Shamlalpal, another member of the crew, has walked down to a vendor selling aluminum tins of a turmeric-spiced chickpea and tomato dish (30 cents a tin) to add something to the makeshift picnic.

In the center of the circle of bread-dipping men is the green plastic liter of water.

The conversation turns to their biggest worry: getting paid. Too often, unscrupulous employers promise the going rate for such black-market work – 500 rupees for an eight-hour day, or about $7 – but then fail to pay when the job is done. Next comes the makeshift camp for sleeping they staked out under a highway overpass, and whether or not it will still be there when they return each night.

Always on their mind, they say, are the families they left back in Uttar Pradesh, and whether they’ll make enough over these three months in New Delhi to keep their kids in school. At the mention of children, they readily hold up the three or four fingers it takes to indicate how many each has. They rib a proud Radesh who needs two hands to indicate his seven offspring.

But in these days of high heat, the men must also remember to drink.

“On a normal day I might drink four or five cups of water, but this is not normal,” says Asharam, “so maybe now I drink four or five liters a day. In this heat you have to have water.”

What Asharam and his crew may be finding is that, as heat records topple and heat waves grow longer, remembering to drink more water will become their new normal.

When Cayla O’Connell Davis launched Knickey, a subscription service for organic cotton underwear last year, she also started a recycling program for customers’ old underwear, allowing them to trade in worn-out undies for a new pair.

After just six months, Knickey has collected thousands of pairs and gained a steady customer base, and Ms. Davis calls it “a successful driver of business.”

But Ms. Davis, who has a master’s in sustainability from Parsons School of Design, also started the program to educate consumers about the impact their clothing choices have on the environment.  

“Brands have a responsibility to not only provide wonderful offerings but to also think about garments beyond the customer’s use and where that ends up in the world,” she says.

That focus on sustainability is on the rise among apparel businesses and customers alike. The idea of recycling fabrics may be at best a partial answer to improving this industry’s often-damaging environmental profile. Yet the success of companies like Knickey is a sign of how consumer attitudes are shifting. And recycling itself can be a foot in the door of consumer consciousness.

“Consumers need to look at the total effect” of their choices, says Jeff Galak, associate professor of marketing for Carnegie Mellon University’s Tepper School of Business. If the goal is sustainability, he says, then rather than returning a product and buying a new one, it would be better to hold on to that shirt for another season.

Knickey, for its part, emphasizes the goal of sustainable materials and supply chains in its business, along with accepting boxes of no-longer-used undies.

Some shoppers show signs of critical rigor in their purchasing habits.

“I would want to see proof that the clothing is actually recycled and that companies aren’t just dumping them,” says Sarah Jean Harrison, a consumer who works as co-founder of the creative agency Peace Flag House in York, Ontario.

Five years ago, Ms. Harrison watched “The True Costs,” a documentary about the fashion industry, and stopped buying clothing. “I was always looking for cheap clothes that looked good and I realized I couldn’t be part of that anymore,” she says. For a long time she didn’t buy anything, then she started to buy vintage and secondhand clothes.

Now Ms. Harrison only buys clothes from sustainable brands. “I research the brand before I buy anything,” she says. She looks at the “about page” for information about where it’s made, who is making it, and where the company sources materials.

Ann Hermes/Staff

Serge Lazarev, founder of Green Tree Textiles Recycling, displays recycled fabrics made into insulation at the Stuyvesant Town Greenmarket in New York City on June 9. Green Tree processes about 20,000 pounds of fabric per week for reuse or recycling.

Other resources for assessing sustainability include the Good On You App, which rates different fashion brands, and Remake’s Beginner’s Guide to Sustainable Fashion.

Knickey sends the used underwear to a local New York City nonprofit, Green Tree Textiles, where they’re sorted. Since underwear won’t be reused, it is recycled into insulation. When Green Tree receives clothing that can be worn again, it goes to for-profit and nonprofit partner organizations.

“Our mission is to keep it out of the landfill,” says Serge Lazarev, Green Tree’s director. Some of the clothes will end up overseas, but they’re sent by container ship so the impact on the environment is minimal, he says.

If anything, it’s now becoming the norm for U.S. clothing makers to offer textile recycling programs as an incentive to buy new clothing. 

Fair Harbor is both a gatherer and a user of recyclable materials. It uses old plastic bottles to make new swimwear. It also encourages customers to recycle used swimwear by offering a 10% discount for each swimsuit sent back, for up to 30% off their purchase.

Ann Hermes/Staff

Customers pass by the pop-up shop for Fair Harbor, an apparel company that produces swimwear made out of plastic bottles, in the Brookfield Place shopping center in New York City on June 9.

“We think it’s important to discard clothing correctly, and we’re happy to offer that service to our customers,” says CEO and co-founder Jake Danehy. Fair Harbor partners with 2ReWear, which is able to use about 45% of collected fiber “as is,” while the rest becomes things like home insulation, carpet padding, or wiping rags. However, most apparel that is reused “as is” is exported and sold in markets around the world.

Apparel firms ranging from J.Jill to H&M offer customer discounts for drop-offs of worn clothing. But experts say it can be difficult to know if collected items are actually recycled or just sent overseas to countries that may or may not want them.

“Giving a discount or coupon to shop is a marketing ploy,” says Ayesha Barenblat, founder of Remake, a nonprofit focused on educating shoppers. “We feel good about it but it doesn’t mean we’re actually recycling.”

The Sustainable Apparel Coalition developed the Higg Index to measure and score a company or product’s sustainability performance. But unlike the term “organic,” there is no government agency defining sustainability or how to measure textile recycling, says Professor Galak. To a large degree each company can decide on its own how it will measure its sustainability efforts.

“That doesn’t mean it’s incorrect or bad,” he says. “It just means there isn’t an easy way to compare.”

Even just the process of collecting and sorting clothing has an impact on the environment. A consumer must ship or bring it to a retailer, and then it’s transported again by truck or ship for processing and reuse.

“The current pace of fast fashion is still outpacing our growth in sustainability,” says Rachel Faller, creative director and founder of Tonlé, which makes clothing from scrap waste sourced from mass clothing manufacturers.

Fashion companies should encourage people to keep their clothes longer and teach them how to properly wash them, she says. Clothes should be washed with cold water and, instead of putting them in the dryer, hang them to dry to increase their lifespan and decrease their carbon footprint, Ms. Faller adds.

The culture of disposability stems partly from low-quality apparel, but it’s also because people get tired of what’s hanging in their closet.

Ultimately, sustainability means a shift in buying habits. For instance, when Ms. Harrison started buying clothing again, she began budgeting and thinking strategically, because sustainable clothing is typically more expensive.

“It isn’t a feasible choice for everyone,” she says. “But you can use your buying power to make small changes, even if you just reduce how much you buy from a fast-fashion outlet.”

Feroza Mushtari was barely a teenager – just 12 or 13 years old – when a desperate knock on the front door changed her life.

Darkness was falling over Kabul on that pre-winter day two decades ago when her mother answered the door. Outside was an older woman who had brought a younger relative, heavily pregnant and in need of urgent help.

The archconservative Islamist Taliban then ruled Afghanistan: Was a man available, as required, who could escort them to the hospital?

The pregnant woman “was twisting in pain and screaming,” and within minutes went into labor and began to bleed, a shocking scene for the young Afghan girl, Ms. Mushtari recalls today.

There were no men around, so the girl came up with a bold plan. She would disguise herself as a boy and be the “male” escort herself. She put on one of her uncle’s turbans, which partly covered her face, and draped a broad-shouldered man’s jacket over her petite frame.

With some Quranic verses slipped into her pocket, Feroza then stopped a taxi and jumped in the front seat, a place reserved only for males. The two women climbed into the back.

“On the way to the hospital, I was practicing how to talk like a boy, if our car was stopped by the Taliban,” Ms. Mushtari recalls. “I remember hearing my heartbeat, just drumming and drumming!”

They arrived safely, and the woman gave birth to a son. The new mother was so grateful, she named the boy Feroz, after their barely teen savior.

Transforming maternal health

And Feroza was so happy at seeing them both survive that she decided to devote her life to becoming a midwife in Afghanistan, a country with some of the worst birth statistics in the world.

“Then I decided to help women, and not let them die because there is no professional to help them when they need it,” says the soft-spoken Ms. Mushtari, speaking with a passion that is radiant with confidence. Today she is an adviser on health affairs for Afghanistan’s first lady, Rula Ghani.

Her climb from housebound bookworm during the Taliban era – albeit one willing to risk danger for the right cause – to being a leading maternal health advocate has been a driving force in transforming childbirth safety for Afghan women.

In 2002, a year after the Taliban were forced from power, the United Nations Children’s Fund (UNICEF) reported there were just 467 trained midwives in the entire country – a number that has surged to 15,000 today, says Ms. Mushtari.

Just a decade ago, Afghan women faced a lifetime risk of death from causes related to pregnancy or childbirth of 1 in 8, the second highest rate in the world, UNICEF reported.

Even in 2014, an Afghan woman still died every two hours from causes related to pregnancy, the U.N. noted in a report that year. But Afghanistan by then had also become “a regional leader in the midwifery profession, and a model for reducing maternal mortality in low-resource post-conflict settings.”

The country has lowered maternal mortality from 1,600 deaths per 100,000 live births to between 1,200 to 800 deaths, though some reports have suggested an even more dramatic improvement, to below 400.

Highlighting Ms. Mushtari’s role, a 2014 U.N. report on midwifery in Afghanistan described her “passion” for her work. And in 2015, she was featured in a “Celebrating Afghans” profile and video to mark the 70th anniversary of the U.N.

“Other midwives, they are trying, because when we see Feroza Mushtari, we are encouraged about how we can work hard, about how we can serve our people in the community,” says Mursal Musawi, president of the 3,000-member Afghan Midwives Association (AMA) and a former student of Ms. Mushtari’s.

Most recently, Ms. Mushtari used her position to raise midwife issues to the cabinet level, where last year her advocacy, with her lobbying, helped establish the country’s first official regulatory body, the Afghanistan Midwives and Nurses Council, says Ms. Musawi.

Bundles of books

Ms. Mushtari’s education began at home when her father, a Soviet-trained engineer, would visit every three months from his job in the Taliban stronghold of Kandahar.

Each visit he brought 40 or 50 books for the bespectacled girl and her siblings to read. She estimates she read more than 1,000 books in the five years of Taliban rule, everything from school textbooks to novels – including stories of characters who changed their appearance to get something done, which helped inspire her to dress up as a boy for the emergency hospital visit.

Feroza Mushtari finished ninth grade two years early, and enrolled in the country’s first formal midwifery school, where she says she studied midwifery “with all my heart.” The day after she graduated in 2004 she began to work. She then learned English and traveled to India to study health psychology.

But Ms. Mushtari soon felt the difficulty of making a difference in a rudimentary health system dominated by male doctors who often dismissed issues of pregnancy, motherhood, and newborns as “caring” issues only.

A crucial turning point came in 2005 with the creation of the AMA. Ms. Mushtari was the first vice president, and later served as president, but found that she had to fight to change attitudes.

“It took me years to find my place and my position within the health system, to convince decision-makers to let me sit at decision-making tables, and talk,” she says.

‘We didn’t invite you’

“I remember when [Health Ministry officials] didn’t inform the association of any decision-making meetings,” she recalls. “I was, on my own, knocking on the door and entering the room. I said, ‘I am a midwife, and this is a midwife-related agenda, and I want to talk.’

“At first, they wouldn’t allow me to sit in the first row [or] allow me to speak, even when raising my hand,” she says. “They said, ‘Oh, we didn’t invite you.’ And I said, ‘Yes, that is why I am here.’

“I had to jump in. Just after two or three meetings, when I started talking, they were listening to me,” she says. “Then I realized, ‘Yes, Feroza, now you know your position, which door to knock on, where to enter. You shouldn’t wait until they invite you.”

But it wasn’t just Afghanistan’s decrepit health system that needed opening up.

In the decade after the fall of the Taliban, with an infusion of tens of millions of dollars from foreign donors, a system of midwifery schools was created, even in remote, deeply conservative regions.

Ms. Mushtari trained midwives for several U.N., local, and international organizations. And as a member of the midwife association’s accreditation body, she traveled to the provinces and heard firsthand about the challenges faced by mothers and newborns.

“At the beginning we had to travel [countless] kilometers to talk to hundreds of people, elders of the community, influencers – always men,” recalls Ms. Mushtari. “It took us weeks to convince them to let their daughters come to midwifery schools. Then after a year we were receiving thousands of applications.”

Pillar of empowerment

The result was twofold and profound, with women becoming breadwinners in their family, and gaining respect through an increasingly accepted profession that is available 24 hours a day, for every family.

“It was not only saving the lives of mothers and babies, it was also educating women,” says Ms. Mushtari. “Now when we talk about women’s empowerment, midwifery is one of the pillars of that [by] educating thousands of women who are now proud midwives, proud teachers, and proud mothers, and proud community mobilizers.”

Yet maternal death rates are still too high in Afghanistan, Ms. Mushtari says. And the country remains an active war zone, where survival is often top priority, and health issues fourth or fifth on the list.

Different strategies are now required to reduce mortality rates, to shift from midwife schools to changing minds, she says.

“It is not only to knock on the door and enter, now you need to knock on their mind and enter inside their minds,” she says. In the past “it was a hardware process, but now it’s a software process.”

On the eve of his U.S. concert tour, Ludovico Einaudi enters the Watergate hotel with a mild-mannered stroll. An evening networking event has transformed the lobby into a chicken coop. Young professionals strut in close proximity, squawking with laughter and pecking at their drinks. They pay little attention to the bespectacled composer trying to pick a path through them to meet his interviewer. 

Your correspondent shakes Mr. Einaudi’s hand, gestures to the baby grand piano in the lobby, and half-jokingly asks if he’d like to play it. Mr. Einaudi smiles and shakes his head. A cocktail party is hardly a conducive atmosphere for hushed compositions such as his latest project, “Seven Days Walking.”

“With my music, I like that it is more like an inner experience,” the Italian musician explains later.

The lively networkers have unwittingly missed out on a free performance by a man who’s just about to play venues such as the nearby Kennedy Center and New York City’s Carnegie Hall. But the lobby revelers may already have heard Mr. Einaudi’s music anyway: He’s the most streamed classical artist in the world. His work, which has cumulatively racked up 2 billion streams, spans piano-based chamber music, orchestral pieces laced with electronic textures, and ambitious compositions that connect indigenous musical traditions from across the globe. What’s driving the demand? Perhaps it’s the mindful quality of his music, an organic escape from the hubbub of overscheduled, digital lives.

“Working with Ludovico on ‘The Taranta Project,’ I saw his qualities as leader of a large and diverse group of musicians – from West African griots to Japanese Taiko drummers, electronica artists, and Southern Italian traditional players,” says Justin Adams, a solo artist and longtime guitarist in Robert Plant’s band, in an email. “He led with calm grace and good humour, with humility and a beautiful limpid touch on the piano. He manages to make music that is direct and clear and straight to the heart, uncluttered by pretension or technical over-complication.”

Ray Tarantino/Courtesy of Shore Fire Media

Mr. Einaudi’s latest project, ‘Seven Days Walking,’ was inspired by a daily hike along the same trail in the Swiss Alps.

As someone who appreciates quiet, Mr. Einaudi seeks refuge from the lobby in a nearby room with tulip-shaped, midcentury modern chairs. Comfortably seated, the maestro explains how “Seven Days Walking” was inspired by a daily hike along the same trail in the Swiss Alps. The project consists of seven albums – he’s releasing a new one each month through September – that explore variations of a theme. If the concept sounds as heady as the altitude at which it was conceived, the music is grounded in accessible, piano-based melodies in the minimalist tradition of the influential 19th-to-20th-century French composer Erik Satie. Each of the seven albums has a different mood that reflects different approaches to the recurring motifs.

“My vision of this piece of music was similar to my walk, because most of the time I was doing the same route with some variations,” he reflects, sometimes pausing to search for words in English. “I wanted to create something that was like a continuum of music, not just in terms of instrumentation, but also in terms of how the music is built and connected. Similar to how, for example, if you take a suite of Bach, you play the minuet and then you go to the gigue and then to the saraband. It’s like you end one and you enter into the other one with different movements, but they are all connected as part of one idea.”

Questing for inspiration

The most difficult part of the writing process, he admits, is staving off boredom by searching for inspirational fuel that sets his inner pilot light ablaze. He’s constantly searching for fresh musical approaches. To hear Mr. Einaudi tell it, his surprise success is the unintended result of that questing nature. At first, his musical career followed a seemingly ordained path. Born to a pair of pianists, Mr. Einaudi graduated from the prestigious Milan Conservatory in 1982. But he quickly tired of adhering to the conventions of his training.

“I felt that the academic world was in a way controlling my freedom. And the reasons why I started to make music were connected to the freedom that I wanted to express,” he explains. “So at a certain point I felt that I had to be completely sincere with myself and follow my vision and my credo.”

If anything, he shuns an intellectual approach to music, opting for instinctively embracing uncomplicated beauty – an approach that has resonated with his many listeners. From the time he was a young composer, he has yearned to experiment with different textures and also occasionally draw from his love of rock and pop. (He cites Radiohead, Portishead, Massive Attack, and alt-J as current examples.) Mr. Einaudi initially found liberation by writing for dance companies. Later, he was commissioned to pen scores for Italian arthouse movies and soundtracks for British TV shows, such as “Doctor Zhivago.” His popularity has grown alongside his substantial body of work, which has garnered radio play and been excerpted for TV spots. The academic world now views him as a black sheep, he says.

Grounded by natural spaces

More recently, Mr. Einaudi received attention for partnering with a very different high-profile collaborator: Greenpeace. In 2016, the environmental group filmed the pianist performing a solo piece, “Elegy for the Arctic,” while floating on a barge in the Arctic Ocean. The acoustics are enhanced by nearby glaciers.

“There was a moment where I was playing that there was a coincidence between what I was doing with the piano and the wall of ice falling down,” he recalls. “My body was completely covered with different layers and, of course, my hands couldn’t have gloves. I was stopping every five minutes to warm them up.”

Indeed, Mr. Einaudi’s work often takes its cues from nature, whether it’s the musical connections to geometry behind his 2015 album “Elements,” or the nocturnal play of shadows and light that informs his 2009 record “Nightbook.” On “Seven Days Walking,” compositions have self-explanatory titles such as “Fox Tracks,” “Low Mist,” and “Golden Butterflies.” Mr. Einaudi recalls feverishly scribbling those musical ideas with a pencil.

“I love to look at those manuscripts because I can see that there’s a lot of energy in the paper,” says the musician.

Asked where he thinks the music comes from, Mr. Einaudi pauses to think.

“There’s something that is, of course, part of your background, part of your interest in what you have done in your life. Part of this is also something unknown,” he muses. “I don’t know if there is a spiritual force. ... I mean, I don’t say yes or no – I don’t think too much about it – but I can accept the idea.”

The following night at the Kennedy Center, Mr. Einaudi is accompanied by the other two musicians on “Seven Days Walking”: Redi Hasa on cello and Federico Mecozzi on violin and viola. Half-shadowed by lighting that changes like phases of the moon, the trio are keenly attuned to each other’s delicate touch. Perched over the keyboard, often as still as a praying mantis, Mr. Einaudi leaves notes suspended in the air. The music’s spaciousness and tranquility are transportive.

“People say, ‘I was so relaxed at your concert,’” Mr. Einaudi noted during the previous day’s interview. “People get lost in their thoughts. Inside themselves, they start to have like a sort of internal voyage into their life. And this is more interesting because I think it’s a form of meditation that happens. I quite like that the concert generates a sort of inner experience in the deep.”

Nati Harnik/AP/File

Farmer Don Bloss examines a tall sorghum plant in his field in Pawnee City, Neb.

Trying to remove heat-trapping gases from Earth’s atmosphere to halt global warming is a huge undertaking. But big challenges can provoke big solutions. A recent proposal even suggested one of the most radical ideas so far: Forget about reducing carbon dioxide. Instead, just push Earth’s orbit 50% farther out from the sun, about where Mars is and where solar heating would be less intense. Problem solved.

A big idea no doubt, but hardly practical.  Meanwhile two much more down-to-earth big ideas to cut global warming are gaining momentum. Pulling carbon dioxide from the atmosphere into the soil through reforestation and improved farming techniques could be a powerful duo. Neither idea is new, but the thinking about how best to carry out these concepts keeps being refined as more research is done.

Farming techniques such as rotating crops, not turning soil over when planting, and using cover crops to restore soil quality help whatever is planted do what it does naturally: take carbon dioxide from the air and fix it in the soil. The Rodale Institute, a nonprofit research group, has forecast that, in theory, 100% of today’s worldwide carbon emissions could be captured this way.

Among the challenges standing in the way is the need to give farmers a financial incentive to change their methods. That likely means funding the effort through carbon offsets – creating a market where carbon-emitting industries must pay to have farmers fix carbon in soils. It also means finding ways to measure how much carbon is actually being captured so its value can be established.

Preserving large swaths of forested land around the world has long been seen as an important climate-saving technique. Trees also suck carbon dioxide out of the air and store it in the ground. Efforts to combat further deforestation as well as reforest degraded land are crucial, say environmental groups such as The Nature Conservancy. 

Letting degraded land naturally return to forest, rather than replanting trees, may often be the best way to go. That lets nature choose the species that will flourish in that particular region. Some 7.7 million square miles of degraded forest, about twice the size of Canada, could be restored in this fashion, the World Resources Institute estimates.

Changing farming techniques and regrowing forests to take carbon dioxide out of the air can’t replace efforts to cut emissions. Reducing the use of fossil fuels through techniques such as generating more energy from sun and wind remains crucial. 

But these two approaches do show that the campaign against global warming needs to take place on many fronts, from lowering the amount of carbon dioxide going into the atmosphere to pulling more back out of it.