S1E35: What’s Essential Health Care in a Pandemic? / Cecile Richards & Kersha Diebel

“…the pandemic has simply highlighted for some people that hypocrisy, where politicians use so-called medical reasons, protecting women’s health, as an excuse for what are really political goals, which is to end access to safe and legal abortion writ large.” -Cecile Richards

The COVID-19 pandemic has had profound effects on women’s’ access to abortion services and reproductive health. In some states, abortion was categorized as elective surgery, and procedures were suspended. In today’s episode, we hear from Cecile Richards, the former president of the Planned Parenthood Federation of America, Kersha Deibel, President and CEO of Planned Parenthood Southwest Ohio, and an abortion provider. They discuss the barriers to reproductive health access raised by COVID-19, the disparities this causes, and the impacts on women and healthcare providers.

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Celine Gounder: I’m Dr. Celine Gounder. And this is “Epidemic.” Today is Tuesday, July 14th.

Mike DeWine: I want to thank you everyone for all the great work everyone is doing across the state of Ohio. This has really been a time when people have truly come together.  

Celine Gounder: Ohio Governor Mike DeWine has won a lot of praise for taking swift action to limit the spread of coronavirus.

DeWine: Distance is probably the most important. Wearing some facial covering if you’re out in public is certainly good practice. The virus, as I said, is still very much out there. 

Celine Gounder: He announced that the state would be under a stay-at-home order until early April. The order included something else that was common in the early days of the pandemic—a ban on all nonessential health procedures.

Doctor: And they had a very clear list of things that could continue.

Celine Gounder: This is Dr. Doctor, a family doctor based in Ohio. the doctor was listening closely that day, and every day after, trying to understand how the ban would impact her line of work.

Doctor: I practice mostly abortion care in Ohio.

Celine Gounder: She listened as a Department of Health official detailed four categories of care permitted under the ban. She relaxed slightly because…

Doctor: There was a category of time-sensitive. And in my opinion, and the opinion of most medical professionals, an abortion is a time-sensitive procedure, and that’s because every time you delay an abortion by a couple of weeks or a couple of months, the procedure becomes a little more risky.

Celine Gounder: But…

Doctor: That was not the opinion of the governor of Ohio.

DeWine: The order was issued in regard to elective surgery. This applies to abortion clinics, as it applies to urologists, as it applies to anyone else. 

Celine Gounder: In a state that already carries some of the nation’s strictest abortion laws, offering this essential service was about to become even more challenging.

Doctor: There were a lot of layers of kind of how horrible things became very, very quickly.

Celine Gounder: This week on “Epidemic,” we’re discussing access to abortion care in the time of COVID. Some states have increased access, while others—including Ohio—have used the pandemic as cover to restrict access, passing new mandates that make it even more difficult to obtain essential care.

And this week we’re going to do something a little different. This is the first in a series of episodes we’re going to do with our interns. So I’d like to introduce my co-host for this episode… oh, and I was going to ask you. Sonya, what do you prefer: doctor-to-be or future-doctor?

Sonya Bharadwa: Future-doctor.

Celine Gounder: Future-doctor Sonya Bharadwa. Sonya, welcome to the show.

Sonya Bharadwa: Thank you, Celine.

Celine Gounder: Sonya, if you could tell our audience a little bit about yourself.

Sonya Bharadwa: Yeah, I’m a third-year medical student studying at Harvard Medical School and I’m hoping to go into OB-GYN and family planning.

Celine Gounder: Sonya, how did you get involved with working with us?

Sonya Bharadwa: Well, due to the pandemic, the medical students had to be recalled from the hospitals and we were studying virtually at home for a while. I then saw an email about the Epidemic podcast looking for interns and I was really interested after listening to a few episodes and knowing that the podcast brings essential news and coverage about the pandemic.

Celine Gounder: Sonya, you came to us with an idea about doing an episode about access to abortion services during the pandemic. Why that topic?

Sonya Bharadwa: There are a few folks and I who are really passionate about reproductive justice and reproductive health at Harvard and I think I remember getting an article sent to our group chat and all of us just being completely shocked that this is something that politicians would choose to focus on at a time when there’s so many issues and so much help people need. Take Ohio for example.

Doctor: What they were saying was that this care that we think is absolutely essential and absolutely time-sensitive was not important and was not care that needed to be provided during this really, really scary time for people.

Sonya Bharadwa: Access to abortion services was already a challenge in Ohio…  even before the coronavirus.

Doctor: There were already so many restrictions that we were dealing with…

Sonya Bharadwa: There’s a state-mandated waiting period before offering care…

Doctor: When I provide abortion care and someone comes in, I can’t give them that care the day that they come in. I have to make them come back a second day, at least 24 hours later.

Sonya Bharadwa: And at that first appointment…

Doctor: We have a mandatory ultrasound law.

Sonya Bharadwa: There’s also a law requiring all clinics to have an agreement with a hospital within 30 miles, and four back-up physicians on their roster, all with admitting privileges at those hospitals.

Celine Gounder: And now, by way of the pandemic, politicians were attempting to add even more restrictions. The state justified the ban by saying that it was important to preserve all personal protective equipment—PPE—for hospital staff treating patients with COVID.

Sonya Bharadwa: But clinics were already adjusting their care to limit PPE use…

Doctor: We had already decided to do the best we could to limit surgeries. We had already decided to make some changes in our clinic that would have limited the face to face contact that we had with patients.

Sonya Bharadwa: That meant encouraging patients to choose a medication abortion when possible.

Doctor: And what it is, it’s a series of pills meant to induce uterine contractions that result in kind of what looks like a miscarriage.

Celine Gounder: In this time of COVID, a medication abortion reduces the amount of contact needed between healthcare providers and their patients… so less PPE would be needed. But there are laws in Ohio that make this kind of social distancing difficult.

Doctor: If I have a patient who wants a medication abortion, I have to bring her into the clinic and hand her the pill myself. I’m not allowed to prescribe that to her over the phone.

Sonya Bharadwa: Social distancing measures also mean women seeking care won’t have support from the friends or family who might otherwise accompany them to the clinic.

Doctor: I think it’s really sad for people, but in some, you know, I think it’s necessary, especially as we’re still trying to understand transmission and how to keep people safe and provide safe care during this really confusing and scary time.

Sonya Bharadwa: Other clinics in the state made similar adjustments.

Kersha Deibel: We quickly moved into action to provide telehealth for our preventative healthcare services.

Sonya Bharadwa: This is Kersha Deibel, President and CEO of Planned Parenthood Southwest Ohio. Planned Parenthood’s practitioners were also recommending medication abortions whenever possible. And the clinics were limiting in-person services, too.

Kersha Deibel: We were complying and are continuing to comply with ODH’s health order regarding PPE.

Sonya Bharadwa: But their adjustments weren’t enough to satisfy state leaders.

Kersha Deibel: On Friday, March 20th, we actually received, Planned Parenthood Southwest Ohio, received a letter from the Ohio attorney general General’s office stating that we weren’t following the state’s orders to preserve PPE.

Celine Gounder: Every practitioner received the same letter. The state wanted all PPE set aside for healthcare workers treating COVID patients. the doctor says they were doing their best to comply with everything, but the new rules felt like a moving target.

Doctor: It was really hard to keep track of things because the non-essential surgery ban went into effect, and then, I would say I had a week or so where every day on my way to work, I was on a call with the lawyers who were trying to interpret the non-essential surgery ban, prepare to take the case to court.

Celine Gounder: But procedures didn’t stop…

Kersha Deibel: If a patient was under ten weeks we were still able to see those patients for a medication abortion.

Celine Gounder: But surgical abortions for patients beyond ten weeks were delayed.

Kersha Deibel: We weren’t talking a day or two days, we were talking potentially, you know, a week that some of these patients had to wait in order to actually come back and get the care that they needed.

Celine Gounder: And this posed serious risks to patients.

Kersha Deibel: There are more risks that can come along, more complications, and we want to make sure that our patients can get in when they need to get in, and unfortunately during the pandemic patients were forced to delay care, which just makes it incredibly frustrating. If you know that you have made a decision, and you’ve made the right decision for you and yourself and your family together, then a patient shouldn’t have to wait and they should be able to get the care that they need immediately, no matter what.

Sonya Bharadwa: Physicians weren’t the only ones having trouble navigating the new regulations. The doctor worried about the news being misinterpreted.

Doctor: I think as soon as this conversation was introduced into the press, many patients assumed that they wouldn’t be able to get an abortion during the pandemic, and it concerned me that they wouldn’t even call and ask, and they wouldn’t get care.

Sonya Bharadwa: In a state where accessing these healthcare services is already difficult, vague rules and misinformation made it even more challenging.

Doctor: I think patients already jump through hoop after hoop after hoop to get an abortion in Ohio. Every time they have to jump through a hoop, it’s extra shame. Every hoop is a little more shame on their shoulders about the decision that they’ve made, so I think this new restriction just added more shame and stigma.

Sonya Bharadwa: Eventually they were able to come to an understanding with the state over the PPE question.

Kersha Deibel: Now, despite coming to an agreement with our attorneys, the state, you know, obviously continue to question whether our services should be deemed essential and anti-abortion groups worked overtime to essentially exploit the pandemic to campaign against abortion access.

Sonya Bharadwa: Part of this campaign was protesting. Protesters aren’t uncommon at Planned Parenthood facilities. The doctor says there are as many as ten protestors outside her clinic on a typical day. But with a pandemic having shut down the economy, suddenly a lot more people had time on their hands… and they were showing up.

Doctor: And they just became more angry. I found them to be meaner, calling me out by name, calling patients out. They seemed to find the fact that we were continuing to provide care during this time really, really troubling. And in return, I… I think that the fact that they were out there harassing patients was really, really troubling.

Sonya Bharadwa: Abortion opponents also inundated state health officials with complaints. And it worked.

Kersha Deibel: Representatives, they came here and they visited all of the providers in the state, including our surgery center, on a, you know, quote-unquote “complaint investigation.”

Celine Gounder: The presence of the investigators, the increasing number of protestors outside the clinics, the confusing public health messaging…  it was all adding to the existing challenge of obtaining an abortion.

Doctor: We were just seeing patients who were terrified. They were really, really scared to be even coming out of their houses and exposing themselves to the virus. They were really scared about coming into the building, they were really scared about the decision, and then over and over I kept hearing people say, you know I have to ask them to come back for a second visit 24 hours later and people kept asking me, are you going to be here tomorrow? Are you still going to be able to do this tomorrow? I know you can do this today but what about tomorrow? If I can’t come back tomorrow if I have to come back next week are you guys going to still be open? Are you still going to be here for me? And I would try to reassure them, you know, the way I’m reading the law right now I think we’re going to be here next week but I understand that you’re concerned.

Sonya Bharadwa: Needing clarity, and to protect their patients’ right to abortion care, the state’s clinics joined forces.

Kersha Deibel: We took emergency legal action to ensure that we actually could remain open to provide time-sensitive, essential abortion care to our patients. And luckily, we were able to get a temporary restraining order, a TRO. And the state appealed that TRO to the sixth circuit court of appeals, and a three-judge panel on the sixth circuit dismissed the case because they didn’t have jurisdiction. And while a court battle is the last thing that we wanted, we knew that it was necessary to ensure patients can continue accessing that care without a delay.

Celine Gounder: Ohio’s stay-at-home order ended on April 6th, and with it, the new restrictions. In other states, the confusion and court battles continue.

Cecile Richards: Well, of course, we’ve had several states that have seized this moment where we have this global pandemic and used it for their own political purposes which is to restrict women’s access to not only abortion services but actually to reproductive healthcare more broadly.

Sonya Bharadwa: This is Cecile Richards. After serving for twelve years as the President of Planned Parenthood nationwide, she co-founded Supermajority, an organization that provides resources and training to female activists and leaders.

Cecile Richards: I come from the state of Texas, where trying to restrict access to abortion has been, is an ongoing matter. And of course, it’s one of the first states that tried to use the pandemic as a reason to further restrict and even end access.

Celine Gounder: On March 23rd, Texas Attorney General Ken Paxton announced that abortion providers must stop all medically unnecessary surgeries and procedures. Like Ohio, Texas officials argued that this was to preserve PPE for hospital use. But here, the mandate clearly outlined that abortion was banned and that physicians violating the order faced up to $1,000 fine or 180 days in prison.

Cecile Richards: I saw this certainly in the state of Texas where it was changing day by day by day. Women are then having to call healthcare providers, to find out whether they can still come in for services. And that’s completely unnecessary for healthcare reasons.

Celine Gounder: Louisiana, Arkansas, Missouri, and other red states were taking similar actions. And not all women experience these restrictions in the same way.

Cecile Richards: Every time we restrict access to reproductive healthcare, it falls hardest on women with low incomes, women who live in States where already healthcare access is limited and certainly women, women of color.

Sonya Bharadwa: The pandemic has also created an especially volatile environment for intimate partner violence or domestic violence.

Cecile Richards: You know, there’ve been so many articles too about women having to, you know, are, who are stuck at home, sometimes stuck in relationships, who may become pregnant and not want to be. And then you add to this, their inability to have access to pregnancy termination is incredibly troubling.

Sonya Bharadwa: And it’s not just at the state level.

Cecile Richards: Even in the very first stimulus package, this issue was raised over funding for groups like Planned Parenthood that provide a wide array of women’s healthcare services, and even for those of us who work in this area for a long long time, it was even surprising to us how they seized the moment to make it more difficult for women to access healthcare.

Celine Gounder: As in Ohio, women’s healthcare providers in Texas and other Red States are fighting back.

Cecile Richards: Planned Parenthood and others had to continue to go back into federal court, just to reestablish services that were completely legal, that should have been available, but politicians were using to try to confuse women and, and try to make it much more difficult for them. And so it’s really one of the most cynical things I’ve ever experienced to see essentially bureaucrats and politicians try to make what is a decision that women have had for more than forty years in this country now becomes something that they can no longer exercise. And that’s, that’s incredibly disturbing.

Sonya Bharadwa: In some states, the pandemic has actually ushered in better access to abortion services. In New York and New Jersey, for example, lawmakers loosened controls on telehealth that would allow physicians to prescribe medication abortions over the phone.

Celine Gounder: But in Red States, Cecile, the doctor, and Kersha have to fight just to maintain the status quo.

Cecile Richards: We’re going to continue to see this. And again, I think the pandemic has simply highlighted for some people that hypocrisy where politicians use so-called medical reasons, protecting women’s health, as an excuse for what are really political goals, which is to end access to safe and legal abortion writ large.

Sonya Bharadwa: But that doesn’t mean they’ll give up the fight.

Kersha Deibel: Medical experts like the, the American Board of Obstetricians and Gynecology, they confirm that abortion is an essential and time-sensitive medical procedure and it has to remain so, you know, especially right now during a public health crisis that we’re in around COVID. And if anything, this current pandemic, it actually shows us, you know why healthcare is a basic human right and we’ve got to do everything that we can to ensure that, you know, access to essential care is here to stay. So, while yes, it’s frustrating to know that our state is playing political games with our patients and with access to healthcare, we’re going to do whatever we can to, to keep our doors open.

Celine Gounder: “Epidemic” is brought to you by Just Human Productions. We’re funded in part by listeners like you. We’re powered and distributed by Simplecast.

Today’s episode was produced by Zach Dyer, Danielle Elliot, and me. Our music is by the Blue Dot Sessions. Our interns are Sonya Bharadwa, Annabel Chen, and Julie Levey.

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I’m Dr. Celine Gounder. Thanks for listening to “Epidemic.”