COLUMN ONE : More Like War Than Medicine : Abortion doctors live in a medical nether world, and one that has grown more dangerous. The hostile atmosphere and emotional trauma are thinning their ranks.
There is an image that haunts Dr. Warren Hern, a recollection three decades old that nags at his consciousness. The scene is the gynecology ward of Colorado General Hospital, where Hern trained as a 24-year-old medical student in 1963.
Night after night, it seemed, the patient roster included at least one frighteningly sick woman, the victim of an illegal abortion gone awry. “The picture,” Hern said, “was always the same.” Bleeding. Fever out of control. Shaking and chills. A deathly gray pallor. An infection of the uterus, spreading so rapidly that if left untreated the patient would be dead within hours.
Although he did not know it at the time, the sight of these women--helpless and desperate, some suffering from wounds they inflicted on themselves--would have much to do with shaping the young physician’s career.
Today, Hern is an abortion doctor.
His practice, conducted out of medical offices in a low-slung unassuming brick building in a neighborhood of Boulder, Colo., consists of nothing but terminating pregnancies. In addition to handling a steady fare of relatively simple first-trimester abortions, Hern is among the few physicians in the nation who perform controversial “late-term” abortions--on rare occasion as late as seven months into a pregnancy if a fetus is severely deformed.
“I do it because it matters,” he said simply. “It matters to the women we help, it matters to their families, it matters to the health of our society. . . . To me, it’s an intellectual and emotional commitment.”
It is hardly an easy cause to be committed to, as became apparent last week with the death of Dr. David Gunn, a Pensacola, Fla., physician who was fatally shot during an anti-abortion protest. Gunn’s death put a name and a face to the difficulties faced by abortion doctors, who work in an atmosphere that at times seems more akin to a Third World guerrilla war than the realm of modern American medicine.
Are there other physicians who worry that the lug nuts on their tires have been loosened during the day, or that bullets will hurtle through the office window? Who else in medicine receives death threats mixed in with the mail, or must cross a picket line to get into his own house, or feels compelled to wear body armor to work? In what other line of health care must doctors travel hundreds of miles, as Gunn did, to treat patients who other physicians refuse to see?
Twenty years after the landmark Supreme Court decision of Roe vs. Wade made it legal, abortion remains as emotionally divisive as ever. Abortion doctors linger in a medical nether world, unable to shake the dark shadow cast during the days when the procedure was against the law.
Although some gynecologists quietly perform abortions in their offices for their own patients, doctors who specialize in abortion generally fall into two camps: those, like Hern, who have deep philosophical reasons for providing the service, and others who are in it solely as a moneymaking proposition with little emotional connection to the work.
These doctors acknowledge that there is a stigma attached to performing abortions, perhaps because horror stories persist about shoddy procedures in some abortion facilities. Last month in New York, a doctor was found guilty of assault in connection with an abortion in which he severed the arm of a fetus. The baby survived and was delivered despite the loss of the arm. In Los Angeles, authorities are currently trying to strip an abortion doctor of his license, alleging that he was responsible for the death of three of his patients.
“What we end up getting are some of the best doctors and some of the worst doctors,” said Dr. Curtis Boyd, whose clinic in Texas was firebombed by abortion opponents four years ago. “What we need is to get the great mainstream of doctors (to) do this as part of an ordinary medical practice.”
That may prove a difficult goal to attain. Ironically, just as the political climate in Washington is becoming favorable toward abortion for the first time in 12 years, the number of residency programs offering abortion training is dropping and the number of doctors who perform abortions is dwindling.
Those who have studied this phenomenon have dubbed it “the graying of abortion providers.” Veterans of the legalization war--people like Hern, who is 54, and Boyd, 55--are growing older and retiring. And younger physicians are not motivated to replace them, particularly given the obvious risks of the job.
This pleases abortion opponents, who say the decline is not so much a function of their protests as it is reflective of the uneasiness doctors feel about performing abortions.
“The reason doctors don’t do abortions is because they don’t like to,” said Nancy Myers, spokeswoman for the National Right to Life Committee. “It’s distasteful. They know what it’s all about, and even if they may support abortion in certain circumstances they are not willing to perform them because they are not comfortable with it.”
But Dr. David A. Grimes, a professor of obstetrics at UC San Francisco, cites a different reason. He says that after two decades of legal abortions, the medical profession has become complacent.
“We as a profession have lost our collective memory,” Grimes said. “Physicians younger than their mid-40s do not remember what it was like in the bad old days of America, when women were dying of illegal abortions. If you have cared for these women, watched them die, you become committed for life to see that this never happens again.”
A recent Columbia University survey of 216 of the nation’s 271 obstetrics and gynecology residency programs, for example, found that 47% of graduating residents had never performed a first-trimester abortion. The study, published in last month’s issue of the Journal of Obstetrics and Gynecology, also found that while a third of the programs had an abortion clinic or service, only 20% of the students spent any time there.
And a 1990 study by the Alan Guttmacher Institute, a nonprofit research group based in New York, reported that the number of doctors, clinics and hospitals providing abortions dropped 11% between 1982 and 1988, when it stood at 2,582. The study found that one half of all urban counties--and 93% of all rural counties--had no place for a woman to go if she wanted an abortion.
The shortage is so severe that the National Abortion Federation, which represents abortion providers, has embarked on a campaign to turn the numbers around. The so-called Access Initiative is designed to persuade medical schools to reintroduce abortion training and to link residency programs with clinics to provide a training ground for young doctors in areas where local hospitals do not perform abortions.
But Boyd, the Texas physician, says change will come only when abortion is viewed by society--and by doctors--as a routine part of medicine.
“Doctors are not social activists,” he said. “They come out of medical school, they want to join the county medical society, become president of the hospital staff. They’re not going to want a stigma; they may not want to take undue risks. So they’ll let someone else do it, because this is controversial. . . .
“I have doctors who call me and say, ‘I’m sorry, I’m not doing this. I feel bad about it, but I’m going to refer my patients to you.’ ”
This reluctance is evident even among those who perform abortions.
One Los Angeles-area gynecologist who did not want to be identified said he spends half a day each week seeing abortion patients, usually low-income women who are referred by clinics or other gynecologists. But he will terminate pregnancies only during the first trimester, or 12 weeks. First-trimester abortions account for the vast majority--91%--of all those performed in the United States.
“I don’t like to do advanced terminations,” the doctor said. “I believe in the right to have them done, but as long as we have people (who) agree to do advanced terminations, I will let them do them.”
Another gynecologist, Dr. George Flesh, said he stopped doing abortions three years ago, after 15 years of performing the procedure for patients in his Century City medical practice.
“At a gut level I just became emotionally upset every time I had to do one of these procedures, and at an intellectual level I began to feel that it was wrong,” Flesh said. Flesh still believes in a woman’s right to an abortion, although only during the first trimester of pregnancy. But, he adds: “I just don’t want to do them personally.”
It is difficult to obtain a true picture of who the nation’s abortion doctors are, partly because many do not want to talk about their work. According to the Guttmacher Institute, of the 1.6 million abortions performed each year, 64% are performed in specialized abortion clinics, with the remainder being performed in other clinics, hospitals and doctor’s offices. Many of the doctors who work in these specialty clinics do so on a part-time basis, said Stanley K. Henshaw, the researcher who conducted the study.
“My impression is that some of the doctors have practices and do one day a week in a clinic for extra money, or whatever reason,” Henshaw said. “Some doctors are retired and semi-retired, and want to work just part time. And some doctors are young and maybe getting started, and want to do abortions while they are trying to get their practices established.”
These physicians are not particularly well paid; the market is competitive, and clinics are interested in keeping costs down. According to Grimes, the UC San Francisco professor, doctors who perform abortions in high-volume clinics generally receive between $30 and $50 for a routine first-trimester procedure--no more than they were paid when it became legal in 1973.
The largest abortion provider in California--and probably the nation--is Family Planning Associates, a Long Beach-based medical group headed by Dr. Edward Allred. Allred owns a chain of more than two dozen clinics, with most in Southern California and a handful in Chicago.
Among abortion providers, Allred’s clinics have a reputation for providing quality, low-cost care in a setting that is clean and safe--if reminiscent of an assembly line. The doctor, however, is extremely close-mouthed about his work. He declined to respond to the Guttmacher survey and refused a request for an interview.
“We never do interviews, ever,” said a Family Planning Associates spokesman. “It’s not something we’ve ever done, in 18 years. Never have and never will. There’s no comment on it.”
Allred did make an exception, in 1980, when he talked to a reporter from the San Diego Union. At that time, he owned 12 clinics and a 22-bed abortion hospital, and estimated that his staff would perform more than 60,000 abortions that year. The story quoted him as saying that he was motivated by an interest in population control and was proud of the efficiency of his operation.
Saying that he thought he was more suited to business than medicine, Allred described how he encouraged his doctors to spend no more than five minutes on each abortion to keep prices down and reduce the risk of complications from anesthesia.
“We streamlined, we made efficiencies, we employed the suction technique better than anyone and we eliminated needless patient-physician contact,” the paper quoted him as saying. “We usually see the patient for the first time on the operating table and then not again.”
To doctors who view providing abortions as an ideological calling, such comments are anathema. For them, the most rewarding part of the job is the care and comfort that they can give women who come to them at a crossroads, faced with perhaps the most difficult decision any woman must make.
Boyd, the Texas doctor, calls these physicians “doctors of conscience.” The 55-year-old doctor, who is active in the Unitarian Church and says his strong religious beliefs propelled him into the abortion field, considers his work a matter of fighting for human rights.
In the late 1960s, before abortions were legal, he risked his career to perform them. Before long, he was caring for women from all corners of the country, as well as residents of Mexico and Canada. Often, he says, his patients were referred by clergymen.
“I was moved by the knowledge that women’s lives could be ruined when they could not afford a pregnancy,” Boyd said. “If you saw the women that I see, heard their stories, it would be easy to understand. In all my years of medical practice, I have never had patients express such gratitude to me.”
But not all patients are so grateful, said Hern, the doctor from Colorado. For some, the last thing they want to do is have an abortion, and the last person they want to see is the abortion doctor.
“The difficult thing for me is when the patients are angry at us because they don’t want to be in this position,” he said. “Even without the anti-abortion controversy, it is emotionally very difficult and exhausting work.”
The business can also be lonely and isolating. Medicine is a profession that is wrapped up in status, with a caste system all its own. Neurosurgeons, for instance, command more prestige than pediatricians. Abortion doctors say they often feel they are on the ladder’s bottom rung--particularly in rural areas or small cities, where their work may be less socially acceptable than in large urban areas.
“The feeling that I get from the medical community is that they are barely able to tolerate me,” Hern said. “I certainly have friends, and there’s a fair amount of passive support there, but there were a number of doctors who were openly and vociferously opposed to what I was doing and have gone out of their way to make me feel like a rotten person.”
And then, of course, there is the fear of physical harm, a fear that has heightened considerably since Gunn’s death in Florida. In the wake of the slaying, abortion advocates say they expect some doctors to quit performing the procedure. Others, like Hern and Boyd, say it only strengthens their resolve--although it will make them even more careful than usual.
Both have been threatened at work and at home.
Anti-abortion activists once fired shots into Hern’s clinic, narrowly missing one of his employees. He says his picture appears in the current issue of an anti-abortion newsletter, and he has growing fears that, because he has been so outspoken in the wake of Gunn’s death, that he could become a target of a copycat crime.
At Boyd’s Dallas clinic, protesters once broke in and chained themselves to the furniture. On Christmas Eve, 1988, the Texas doctor received a middle-of-the-night telephone call from his answering service telling him his facility was on fire. It had been doused with gasoline and set ablaze, causing $100,000 in damage.
The fire taught Boyd a valuable lesson: “I wouldn’t (work in) a wood-frame building now,” he says matter-of-factly. “It’s too easy to burn. I would recommend a more secure building. An upper floor is better; don’t get on the ground floor.”
It was a lesson that only an abortion doctor would have to learn.
