When Gabe Christenson started feeling run down a few years ago, he didn't go to the doctor.
Like roughly 30 million other Americans, the 45-year-old railroad worker doesn't have any paid sick leave and he didn't want to get punished for taking time off.
According to Gabe, his company's attendance policy meant marks against a worker for any time away, "so I was putting off going", he said.
When he finally scheduled an appointment, the doctor told him he had a gut infection. If caught early, it could have been treated with medication, but as it was, Gabe learned he would have to have some of his tissues removed.
In recent weeks, demands for paid sick leave from rail workers like Gabe pushed the US to the brink of its first national rail strike in 30 years.
The walkout was averted only after President Joe Biden and Congress intervened, forcing rail workers to accept the terms of a new contract.
It offered a pay rise, an additional personal day and a few other benefits - but no paid sick leave.
The outcome has outraged thousands of workers who had hoped for more support from a political party and a president who had campaigned on the promise of passing national sick leave and supporting unions.
"It's a slap in the face," said Gabe, a registered Democrat who voted for Mr Biden in 2020 and is part of Railroad Workers United, an informal group that raised concerns over the issue. "People are scared for their jobs ....We need protection."
"Here Biden is supposed to be this super pro-labour president and Amtrak Joe and everything like that," he said, referring to a nickname given to the president for his fondness of riding the national passenger rail.
"People are just deflated because this has happened so many times."
US lawmakers vote to block potential rail strike
What would be affected if a rail strike happens?
Sick leave is a major sticking point not just for rail union members.
The US is one of only two countries in the 38-member Organization of Economic Cooperation and Development without a national law guaranteeing paid sick leave for its workers. (The other, South Korea, is now trialling a paid sick leave programme.)
Though 16 states have passed laws requiring paid sick leave over the last decade, one in five workers across the country still does not have access to the benefit, with low-wage workers most at risk.
Erica, a single mum of three, said she left a job she loved in 2020 - working as a paediatric nurse in an emergency room in Tennessee - to work for a rival hospital that offered paid sick leave, in addition to other time off.
"It just shocked me that they wanted us to use our paid time off and we would be off 10 or 14 days," said the 38-year-old, who is a community advocate for A Better Balance, an advocacy group, referring to the extended quarantines that were common at the start of the pandemic.
When she didn't have paid sick leave, she ended up with no vacation and had to take unpaid days to care for her daughter, straining her finances.
"It's clearly an area where we need federal protections," said Jennifer Pomeranz, a professor of public health at New York University, who has tracked the issue. "It shouldn't be because you live in a state that's more pro-business than another state that you lose paid sick leave."
For a moment, during the pandemic, it seemed like a national policy might emerge.
In 2020, Congress passed a temporary law requiring most companies to offer two weeks of paid sick leave to staff forced to quarantine due to Covid-19.
But that expired at the end of the year and firms quickly trimmed the benefits.
Despite efforts to revive the issue, many Republicans were opposed to the principle of government-given "business mandates", and talks petered out.
"We need to remember that we're really not good at running businesses from Congress," Senator Richard Burr, a Republican from North Carolina, said in May 2021, the last major public hearing on the issue.
While he said he believed people should be able to take time off if sick, "the one-size-fits-all approach does not work on issues, especially on paid leave".
Sherry Leiwant, co-founder of A Better Balance, who has been working on paid sick leave campaigns since the early 2000s, called the decision not to extend the benefit in 2020 "the most disheartening thing that has happened in my work on this issue".
"I found that devastating," she said, adding that a national law now looks "impossible".
"At a moment when we were celebrating all these front-line workers, who were keeping the economy going at the risk of their own health, that we couldn't include paid sick days as a requirement in our Covid relief package - it was just shocking."
Erik Loomis, a professor of labour history at the University of Rhode Island, said the Biden administration made a mistake not to take the issue more seriously as it worked to broker a deal between unions and railroads earlier this year.
But he said no president, no matter how labour friendly, would be willing to risk an economically damaging strike over sick pay.
"Paid sick leave at the national level is not even part of the conversation at this point," he said, adding that the rail contract otherwise is "very good for workers".
"Theoretically maybe a situation like this could spark some conversation ... but I think it's unlikely."
The National Railway Labor Conference, the organisation representing the freight rail firms in the labour negotiations, argued that rail workers have ample personal and holiday leave, which can be used in the event of illness, as well as the ability to take unpaid time off.
They disputed claims by workers that managers are increasingly rejecting such requests, as staffing levels have fallen.
Gabe, who has worked for the railroad since 2004, said the companies could afford the benefit, noting that they have earned record profits in recent years.
"Nobody out here will tell you that they don't want to work - we're all out here to make money. We know that it's all hours and we're on call, but you used to have the ability take time off," he said. "Now they're just squeezing us so hard, like blood out of a turnip."
"They could give me 300 personal leave days but what are they worth if I can't use them?"