This story is part of the Life After Roe package, which looks at the surprising resilience of the abortion access movement in the Dobbs era—and at how hardliners are doubling down on their efforts to ban abortion nationwide.

When Lena walks into the cafe near an airport somewhere outside the US, she looks like any other traveler grabbing a cup of coffee before a flight. She orders a drink and picks a table out of earshot of other patrons, keeping her suitcase close by her side.

In the clandestine world of underground abortion activists, Lena—not her real name—is a courier. The trips she takes abroad—we can’t say where—are supply runs to pick up generic versions of mifepristone and misoprostol, the two drugs that make up the standard medication abortion regimen. Soon, another traveler—her supplier—approaches her table, also dragging a suitcase.

After a few minutes, the supplier heads to the bathroom, toting both their bags, and transfers abortion medication into Lena’s. Back at the table, neither has another pressing appointment, so they linger and chat. “It’s almost like we could be medical people discussing innovations and research,” Lena says. “It is nice to nerd out in safe places with safe people, because no one in my real life knows what I do.”

Lena will sneak the pills back into the US, where they will be distributed to community support networks, a modern version of the underground feminist activists who helped women get abortions before Roe v. Wade. Since Roe’s overturning, these grassroots groups have sent abortion meds—for free—to tens of thousands of women who struggle to access care through mainstream channels, including minors, undocumented immigrants, and pregnant women past the first trimester.

Unlike telemedicine providers who practice under blue-state shield laws, community networks operate outside the legal and medical systems. “It really doesn’t matter what [state and federal authorities] do legally—we will continue,” Lena says, adding, “there may come a time where we are one of the only, if not the only, option for the nation.”

As the signs of an impending crackdown on aboveground abortion-pill providers become increasingly ominous, Lena and her fellow activists are stockpiling the medication—building relationships with new suppliers, devising new ways to get pills into the country, and sending more couriers on more supply runs around the world.

“It’s kind of a let’s-take-matters-into-your-own-hands situation. No one’s coming to save us; we have to save ourselves.”

“We’ve tried for so long to do it the right and legal way, and that’s never worked, so it’s kind of a let’s-take-matters-into-your-own-hands situation,” Lena says. “No one’s coming to save us; we have to save ourselves.”

As the Dobbs v. Jackson Women’s Health Organization decision loomed in 2022, my question wasn’t if an underground abortion movement would reemerge in the US, but who and how. The answer came through a surprise message on Signal from an activist I’ll call Stephanie, a retiree in a red state whose soft-spoken demeanor belied an iron will. Like many liberal white women who revered Roe as a landmark victory, she had assumed that because abortion was legal, it was also widely accessible. But after the 2016 presidential election, she started volunteering for reproductive rights organizations and witnessed the massive financial and logistical hurdles many patients face, particularly the young and the poor. A seminar on self-managed abortion further radicalized her. Clinics or doctors or multiple screenings weren’t necessary for safe abortions, she discovered; a handful of pills in the privacy of home was just as effective.

Stephanie says her catalyst for becoming an underground supplier was the pandemic, when an activist acquaintance asked her to help her college-student daughter obtain an appointment at a clinic. The student drove six hours across state lines only to find the clinic was closed, and at the time, FDA rules forbade abortion pills from being prescribed via telemedicine and mailed.

So Stephanie reached out to a doula friend for misoprostol, a routine medication in obstetrical care that can be taken alone to end a pregnancy. She put the pills in the mail, the student self-managed her abortion without complication, and the seeds of a community support network were sown. Soon, Stephanie was mailing pills to a handful of people every month who found her through word of mouth.

When Roe’s demise seemed imminent, Stephanie scaled up: refining security and mailing protocols, recruiting new volunteers, and exploring ways to source both mifepristone and misoprostol, because the combined regimen is more effective and has fewer side effects than misoprostol alone. At first, she purchased the drugs from online pharmaceutical sites and international telehealth services such as Aid Access and Women on Web, but they were expensive. Then she connected with a prominent Mexican activist named Verónica Cruz Sánchez, whose organization Las Libres had created an underground system to distribute abortion pills in Mexico.

After Texas implemented its 2021 law banning abortion after six weeks, Cruz offered to train American activists on how to start networks of their own, using mifepristone from Las Libres’ own donated stockpiles and misoprostol purchased in Mexican pharmacies. Stephanie sent a trusted colleague on a test run—meeting Cruz at a Starbucks in San Miguel de Allende, stocking up on over-the-counter misoprostol, and smuggling it home in her toiletry bag. When the Dobbs ruling hit, Stephanie and dozens of other activists already had the framework for expanding community networks across the US.

Lena found her way to Stephanie’s network through a friend. Younger than Stephanie, she’d gotten involved in activism during the Trump 1.0 era. Then Dobbs made abortion her top priority, and a breakup changed her personal life. “I had always felt like I should be doing more, but you know how boyfriends can be draining,” she says, half-joking that she does this work “so no one gets stuck with a shitty boyfriend they don’t want.”

When she first started at the end of 2022, community networks—which never require real names or payment information, since the pills are free—were one of the only options for women in red states who couldn’t afford to travel for care. Requiring only a mailing address, they work with people who need to keep their abortions secret from ultra-religious parents, abusive partners, or anyone else who might try to stop them. I once heard about an activist who hid pills inside a small plush toy for a teenager in an abortion-ban state who didn’t want her family to find out she was pregnant—an impossible option in the conventional system with its parental consent laws and strict regulations for pharmaceutical packaging.

The networks follow a decentralized model, Stephanie tells me, operating as regional affiliates that serve their own communities. This structure also spreads the risk and workload, which is critical because volunteers like Lena are unpaid. Each network has an encrypted email address where it receives inquiries, which abortion seekers can find on informational websites such as Plan C, Red State Access, and INeedAnA.

Once an order is received, the meds will go into a prepaid envelope with a fake return address gleaned from unsold properties on Redfin and Zillow. Mailers don’t have direct contact with recipients, so when she was in that role, Lena adopted a ritual to help her feel more connected. Every time she dropped a package in the mail, she’d whisper, “You’re going to be okay.”

In the early days, community networks primarily relied on mifepristone from Las Libres, but that strategy wasn’t sustainable. When it came time for American activists to set up their own supply chains, the obvious option was India, the center of the global generic pharmaceuticals market.

“I’ve knocked on a lot of doors, I’ve made a lot of phone calls, and you can’t feel any of those results. And this has real results.”

I traveled to India in 2024 to learn about this supply chain for my book Access: Inside the Abortion Underground and the Sixty-Year Battle for Reproductive Freedom. My main takeaway: Far from being shoddy knockoffs, abortion medications originate from the same manufacturers working with global NGOs and government programs. “The drugs are high-quality, generic pills,” Lena confirms. “They’re carefully packaged and at an excellent price.”

The real challenge was getting them into the US undetected. The networks experimented with international shipping, but found that packages with more than 90 doses tended to get flagged or confiscated by customs, and relying on smaller shipments was too slow and expensive. It might seem counterintuitive, but sending people abroad to pick up the pills in person turned out to be cheaper, even with the expense of international travel.

The courier model has a long history of bridging gaps in politicized forms of healthcare. During the AIDS crisis in the late 1980s, advocates like Ron Woodroof—Matthew McConaughey’s character in Dallas Buyers Club—traveled the world to buy experimental treatments and smuggle them back into the US. India, where scientists successfully reverse-engineered generic versions of AIDS treatments in the 1990s, was a primary source.

Today, thanks to sky-high prices at home, large numbers of Americans travel abroad for all kinds of lower-cost drugs, often to Mexico or Canada. The global medical tourism industry is also booming, and transporting medication for longevity or weight loss is common, making it easier for abortion-pill couriers to hide in plain sight. As Lena says, “I am a drop in an ocean of travelers.”

So far, no couriers or community activists have been caught, but Texas and Louisiana have passed laws targeting abortion-pill providers with especially harsh penalties. Lena spent a month learning safety and security protocols honed by other couriers—turning off the Face ID feature on her phone, using a VPN, and deleting sensitive chats before traveling. Then she booked her first plane ticket, flew to her destination, met with the supplier, and returned home without incident. If anything, she says, it was all a little anticlimactic, and she volunteered to go again. She discovered she was suited for the job: She’s good at staying calm under pressure and well positioned to take on the risk. Some people in the network have partners, kids, important jobs, and elderly parents they care for. “I don’t have as much to lose as many other folks,” she says. “That’s a big factor.”

Lena invested in durable luggage and learned to nap on chairs at unoccupied gates. She and her fellow activists use aliases when talking to each other (and me) and communicate only via encrypted channels. During meetings with the suppliers—usually in a cafe, once in a parking garage—she is acutely aware of her surroundings, on the watch for seemingly innocuous people who might be trying to eavesdrop.

After the handoff, Lena spends the next few days in her hotel room, working. Her anxiety level ratchets up as her departure nears, because going through customs is when the risk of getting caught is the highest. She reviews her emergency contacts, wipes her phone, and rehearses her backstory for why she’s traveling, in case anyone asks. Then she does a ritual a therapist friend suggested: visualizing a safe arrival home. Only when she’s in her car, driving back from the airport, does she finally let herself relax.

I’ve long heard people from across the abortion movement discuss the importance of “redundancies”—creating multiple pathways for abortion access that can endure despite politics or the courts. If mainstream channels—such as telemedicine providers operating under shield laws—or other modes of access are forced to shut down, the underground channels are prepared to pick up some of the slack, doubling or even tripling their volume. “As far as our operations go,” Lena says, “we will continue to provide the two-medication protocol, mifepristone and misoprostol, no matter what.”

She’s determined to keep doing these runs, even when she returns home exhausted to a mountain of deferred chores and pets grumpy because of her absence. Most of her family and friends don’t have a clue what she’s up to, so she can’t reach out for support. But she believes that the risks are worth it. Now, as the abortion access movement faces a new series of dire threats, the stakes have never felt higher. She’s in it for the long haul.

“This is one of the most tangible acts of resistance you can get,” she says. “I’ve knocked on a lot of doors, I’ve made a lot of phone calls, and you can’t feel any of those results. And this has real results.”

Additional reporting by Sophie Bridges.

This project was supported by the USC Annenberg Center for Health Journalism.