COLUMN: Cutting Access at the Source

From Bertie Bregman's "On Call," Fall '93 Postmarked in Texas, it was a pamphlet of "abortionist jokes" - mostly recycled lawyer jokes with a sprinkling of racist and anti-Semitic favorites - illustrated with cartoons portraying doctors in a style reminiscent of Nazi propaganda posters from the 1930's. It turns out that a Texas pro-life group had printed 100,000 copies of these pamphlets and sent them to medical students all over the country. They tricked the AMA into providing them with a mailing list and stole material from a lawyer-joke book. Add plagiarism to the list of their moral shortcomings. Is there a connection between these two events - a doctor murdered in Florida and a medical student direct-mail campaign? The answer lies in the political shift toward abortion rights, and the reaction of some anti-abortion groups. Ever since President Clinton was elected, the anti-abortion movement has been on the political defensive. Strongly pro-choice, Clinton has the chance to steer the flavor of legal interpretation away from the social conservatism of the past 12 years by appointing a possible two or three Supreme Court Justices, and a slew of Federal judges to boot. In his first week in office, Clinton repealed Title X, which made it a crime for doctors and counselors in federally-funded clinics to even mention the word "abortion" to their patients. And it looks as though Congress may finally pass the Freedom of Choice Act, making the right to an abortion a publicly-mandated law. The anti-abortion movement feels itself backed into a corner, and is casting about for some way to counter their political losses. They have settled on two targets - doctors and clinics - and without intervention, their strategy is likely to succeed. In the chain of events leading up to an abortion in this country, the weakest and the most important link is access to the procedure itself. Many of us know that over 80% of U.S. counties have no abortion provider. What we may not realize, is that what few clinics there are have a hell of a time finding doctors. One Georgia women's clinic, for example, invited 3,000 doctors to apply for a position on their staff. They received only one response. Fewer and fewer doctors - including obstetrics/gynecology residents, for whom it is a common, basic procedure - are interested in even being trained to perform abortions. Their reasons are not hard to understand. Just last month, another doctor was shot by a fundamentalist woman at an abortion clinic in Boulder, Colorado. Between the harassing phone calls, the "wanted" posters plastered all over town, and the ever-present physical threat of clinic bombings, who needs the headache? Doctors willing to perform abortions these days are a dedicated, besieged, and dwindling breed. It is cold comfort for a woman to know that even though she can't get an abortion, at least it's her legal right. An obvious solution is to expand the pool of abortion providers to include nurses, physician's assistants, and midwives. There is no reason why these medically-trained professionals, especially those who are already qualified to deliver babies, cannot safely perform abortions. An abortion is not a very complicated procedure. I know a woman who used the menstrual extraction technique to abort her own pregnancy with the help of a circle of friends. Certainly, this was a risky, dangerous move - especially considering that she had access to a clinic - but she did it successfully and with no complications. Imagine the results if she had tried the same thing with triple bypass surgery. The point is, not all surgery is alike, and not all procedures require four years of medical school and a three-year residency. If we could increase the number of abortion providers, it would make them more difficult for extremists to target; it would make it easier to establish and staff clinics in underserved areas, and it should make abortions more affordable to low-income women through the law of supply and demand. This plan is already being tried in Vermont where physician's assistants are legally allowed to perform abortions in a clinic setting that ensures a sterile environment and prompt evacuation to a hospital if any complications arise. Women should not have to choose between an expensive, doctor-performed abortion, and an unsafe, self-performed abortion, when such a reasonable alternative exists. Opposition to allowing mid-level medical practitioners to perform abortions is inevitable. And it will come from places that may surprise those of you who don't hang out in HUP. The AMA, with its "slippery-slope" mentality, doesn't like to see change of any type, particularly if it means broadening the therapeutic scope of non-M.D.'s. Midwives, who have enough trouble gaining acceptance for birthing, may not want to risk their public credibility by getting tangled up in the thorny political thicket of abortion. But the alternative is to allow a de facto victory to anti-abortion forces just when it seems like the tide is turning in favor of abortion rights. Many pro-lifers are rational, thoughtful people, committed to fighting for their cause within the democratic process. But it only takes a few nutcase extremists, of which lately there seems to be no shortage, to block access to abortion in a system with so few providers left. Last time I checked, abortion was a legal right in this country. We are all responsible if that becomes no more than an empty phrase. Bertie Bregman is a second-year Medical School student from New York, New York. On Call will appear alternate Thursdays.