 It's my pleasure to join you all today. We have launching a three-part series on contemporary issues in health, law, and bioethics. Today we have a program that's centered on ethical and workforce considerations in abortion care provisions. The guest joining me today is Dr. Monica Miklamore. She is an associate professor of family health care nursing department at the University of California San Francisco. I'll give a more in-depth introduction in just a moment. I want to alert all of you that if you have questions for us today then please put those in the Q&A. We have a program that's going to be an armchair fireside type of discussion and I couldn't be more pleased than to be doing this with one of my favorite people of all times ever, ever with Dr. Monica Miklamore, not only for the professional experience that she brings, but also the great depth of integrity that she brings to all that she does. Couldn't be more honored than to have her with us today. So I'm going to get us started. My name is Michelle Bratcher Goodwin. I am a senior lecturer at Harvard Medical School and a chancellor's professor at the University of California Irvine where I'm also the founding director of the Center for Biotechnology and Global Health Policy. Some of you might be familiar with my work outside of that as the executive producer and host of On The Issues with Michelle Goodwin at Ms. Magazine. I'm so happy to have also had Dr. Miklamore on that show as well. And as I mentioned, today we launch off a three-part series focusing on contemporary issues in health, law and bioethics. This session will be focused on ethical and workforce considerations in abortion care provisions. And Dr. Miklamore joins me and at the University of California, San Francisco. She is a tenured professor in the family health care nursing department and affiliated scientist with advancing new standards in reproductive health and a member of the Bixby Center for Global Reproductive Health. She retired from clinical practice as a public health and staff nurse after almost 30 years of a career in that regard. Her program of research is grounded in reproductive justice, a lens she uses to understand reproductive health and rights for people with the capacity for pregnancy. Her work is grounded in the hypothesis that if we center the most marginalized and vulnerable of people, then great health care can improve, then we can perhaps reach great health care, but certainly care can improve for everybody. She conducts research across the reproductive spectrum, including abortion, birth, cancer risk, contraception, family planning, and healthy sexuality, pleasure and consent. And pleasure is very important, especially once we begin to sort of break down these intersections and histories of subordination. It couldn't be a better time for us to launch and have this conversation considering that we are in February. This is Black History Month and this builds on programming that has been done at Harvard Medical School and the Center for Medical Ethics regarding Black History. And it is also a time of tumultuousness around the world and also in our country, a time in which we're seeing the banning of books, attacks on critical race theory, attacks on President Biden saying that he will nominate a Black woman to the United States Supreme Court, attacks on reproductive health rights and justice that have taken form in state legislation in Texas, in Mississippi, those cases seen by the United States Supreme Court, but even beyond that in Florida, Indiana, Ohio, Alabama, and many other states. I want to get right to that. And I want to get us started with asking Dr. McLemore what exactly she means by ethical and workforce considerations in abortion care provisions. What does that mean and how have you, Dr. McLemore, approached that in your professional life? Well, first of all, thank you. It is always good to be in community with you. And I'm very deeply grateful for both our professional and our personal relationship. I use she and her pronouns for the folks in the audience and we want to welcome you to use the Q&A as things come up. So let me just start by saying that I think it's really important for all audiences to understand a couple of things. We know that, you know, real versus weight is hanging in balance and we are all sort of sitting on pins and needles trying to figure out what the abortion care provision landscape is going to look like. But I want to give folks a little bit of a history lesson because I think if you're going to understand the abortion conflict in the United States, if you're going to try and understand the ethics sort of behind it, then you have to have a historical perspective to understand how we got here. So I'm going to talk about two things and then I'll answer your question. The first one is you cannot talk about abortion care provision in the United States without acknowledging the discrediting of the grand midwives because when you think about the black, granny midwives and the people who are taking care of folks across the country before organized medicine decided to get itself together, it was those grandmamas and midwives and lay folks and public health people who were providing care across the reproductive spectrum for everyone. And so, you know, when we think about the provision of care to pregnant capable people, if we don't acknowledge the important role of the grand midwives, then I think we would be remiss so that they were discredited from doing their work and the tools of public health were used to discredit them. When they were providing relatively good and safe care at that time, and this was before the criminalization of abortion started to happen in the United States, and it was physicians, mostly white men and white nurses who teamed up to discredit them. So, we used to have a diverse workforce of individuals who were providing reproductive justice and form care across the spectrum. I get really, I go really nuts when people, you know, act like that's not true. I know you have additional points to add to that, but I want to ask a question that builds from that because we don't spend time really nursing the information that we get and sitting with it. So, you could just explain something really, really important, and if we sat with that for a moment, the fact that the majority of people providing reproductive health care in the United States had been these midwives, and the majority of those midwives, I mean, overwhelmingly it was, nearly 100% of that care was done by midwives, right? And people thought about it, right? There were no guys with stethoscopes roaming across the plains of Africa, right? Like, you know, if people really think about it, right? Like, there are no guys in lab coats roaming around Europe, right? In the, you know, 500, 600, right? You know, that that's just not happening. And then if we realized that, in what became the United States, that half, a little bit more than half of those midwives were black women. And I'm wondering, like, how do we understand that economically in terms of what that would have meant for them if they had been allowed to continue their profession? What would that have meant in terms of how we understand and revere and look up to these medicine women, these medicine people? Right. And I mean, and so the ethics behind who should be able, who's qualified, who's capable, who's competent to be able to provide abortion care. One of my big take home points is we have, you know, siloed abortion care and abortion care training with physicians, and then we want to be mad that we don't have greater access because we actually cut out an entire workforce that was actually safely provided. So that, that's one of the ethical issues around workforce. The second point I want to make, though, is we have to, I would be remiss. I'm trained as a nurse. I always like to clarify that for people because folks on Twitter think I misrepresent my credentials and I do not. I'm a proud nurse. It's the only thing I've ever done for pay as an adult. But we have to own the public health nurses, the white public health nurses who were super harmful at the time of turn of the century who actually also contributed to this problem. I always like to remind people that Margaret Sanger, the founder of Planned Parenthood, was trained as a nurse. She was in the Lillian Wall, the Henry Street House group of people who are watching maternal morbidity and mortality run rampant across New York City and decided that she wanted to be able to do something about that. And that's how we got to account the family planning and contraception. But to deny that history, that I exist and exclusively have worked in a profession that was part of and problematic, but also really important and helpful, right? We can hold two seemingly conflicting things together at once. We can chew gum and walk, right? Black women certainly have had to, right? I mean, so, I mean, again, if you sort of take seriously, if you take seriously what you have said, and if we took seriously the history of Black women in medicine in this country and healthcare in labor and capital development of this country, right? Yes, as you say, walk and chew gum at the same time and juggle all while at it. Exactly. So this idea that we've had this very limited notion of what's possible, that's why we're good at the justice is so powerful. When you think about the ethics of abortion care provision, there's also this other piece that there has to be truth telling, right? There was a discrediting on the grand myth was that happened. So we could have always had a diversification of the healthcare workforce. That could have always been a thing because it was a thing, right? But then the second piece is this idea that we have had problematic people in our field who have made determinations about who is legitimate workforce and who isn't. And one of the ways that I think we've been really, really remiss, I mean, we opened up with a lot of the sort of harm and doom and gloom of row and are the cursive affairs and all of that. But we've had some serious landscape wins throughout the pandemic, right? When I think about advanced practice clinicians, right? When I think about midwives, physicians, assistants and nurse midwives, right? We've had expansion of practice and codification of their capacity to provide abortion care in New Jersey, in Virginia, in Hawaii. Why do I know this? Minnesota, right? Is because my research and my data and my findings have been used along with advancing new standards as a reproductive healthy answer program to show that advanced practice clinicians can be safe providers of abortion care, right? I've been the expert witness providing testimony, educating judges and other individuals who are trying to adjudicate these cases to sure up grow that we can be safe providers of care. That's why it's unethical that if you limit who can be classified as an abortion provider, including the people having abortions themselves, right? And yes, that's a hat tip and a nod to self-managed abortion because people who need abortions, people who seek abortions, can be their own abortion providers, right? That's why this whole ethical thing of who gets to decide who is an abortion provider is important. So I wanted to spend one more moment on the history, right? And you should because at this point, Dr. McLemore, people are trying to cut the history, right? I mean, it's a stunning time where we're in where there are medical books that are being proposed for destruction. There are books, children's books written by Rosa Parks that are being removed from school shelves. There are books about the Holocaust that are removed from schools. A lot of denialism that is taking place. So spending this moment on our history, I think, is critically important. And it's critical to the conversation that you're leading in here. So a couple of points that I want to add to it and then happy for your response. So as you've mentioned, the Granny Midwives doing this important work, and really in Roe v. Wade, that 1973 opinion, seven to two opinions was not even close. Written by Justice Blackman, who's put on the court by Richard Nixon. He canvases history and he says abortion was not always criminalized in the United States and it wasn't. And it becomes around the time of the Civil War, right? And it becomes this important kind of galvanizing piece that implicates race and also sex. And it implicates race as folks like Horatio Storer, Joseph D. Lee, are saying that white women need to use their loins and go north, south, east and west. And they're using the American Medical Association as a platform for their work. And so this very clever smear campaigns that they launched were meant to be politically persuasive and to achieve legal reforms that would push Midwives out. This smear campaign, as you were talking about, claimed that Midwives were unhygienic, were barbarous, were non-efficacious, non-scientific. And I want to actually quote from a speech written by Dr. Joseph D. Lee, who was a prominent figure at the time, seeking to rid Midwifery altogether. And he said, the Midwife is a relic of barbarism. This is how he was describing the work that Black women had been doing and that they had been relied on for doing for centuries. He said, in civilized countries, the Midwife is wrong and has always been wrong. He says that the Midwife is a drag on progress and a drag on science and the art of obstetrics. He says that quote, her existence stunts the one and degrades the other. And then he goes on in really, really horrific ways to describe Midwifery. And that's part of the history that's missing. And that's part of what it is that you're looking to have audiences understand. Absolutely. And I'll take it a step further. Take it. Pregnancy is not a disease state. It is a clinical condition to be witnessed and managed. So this whole idea that medicalization also contributes to, like people always say, well, we always have to deal with abortion exceptionalism. And we can't have nice things because everybody's worried that abortion is going to come into something. Actually, in some discussions, it's the notion that a normal physiological process like pregnancy, regardless of how it is, is not a disease state. I always say to people, we're always studying the outcomes of pregnancy. We study birth, we study abortion, we study miscarriage. But pregnancy is the actual condition. And I would argue that it's not a medical or a disease state. It's not a disease. It's a normal physiological process. And so if we're ever going to change a narrative, if we're ever going to have a nuanced discussion about the role of abortion in society, then we need to really shift that to get people to understand two important concepts. The first concept is that bodily autonomy, we have that in life and death, or at least right now we do, right? Nobody can go to your grave and dig up your remains without your consent. You have to sign an organ donation form when you go to renew your driver's license, right? Nobody can take your body parts without your consent right now, at least. But the second point that I think really, really matters is this whole idea that if you have bodily autonomy in life and death, then that means you are the sole arbiter, in my opinion. You are the only decision maker. That matters. All right. So now we're going to unpack further because that's a notion that's being challenged right now. Right. Right now, right? So, you know, and the reason why I go back to the decision of Rowan that it was seven to two is that there are people who would think that there has always been this tussle over abortion and that it's always been Republicans on one side and Democrats on the other, which is why I always mention that of seven justices that vote to strike down laws that banned abortion, five of them were Republican appointed on the United States Supreme Court. President George H.W. Bush, the first president, George Bush, his father was Prescott Bush. Prescott Bush was the treasurer of Planned Parenthood. Planned Parenthood, that when Title 10 was shepherded through Congress and supported by Richard Nixon, that was done by George H.W. Bush. And Title 10 provides reproductive health care for the most vulnerable of Americans. And I share that because we have gone so askew now and there's such a dramatic threat to reproductive health care as a whole. Right. I mean, abortion is just one lens of it. But just this week, we heard about the growing rates of maternal morbidity and mortality in the United States. So I'm going to take us there. But first, for definition, because some people have said, well, I've heard reproductive justice, I've heard reproductive rights. What's the difference? And so Dr. McLemore, when you center your work on reproductive justice, what does that mean? I sure will. And I would also add, you know, outside of just the new numbers on maternal morbidity and mortality, we also saw Governor Abbott, you know, introduce legislation around trans youth and gender affirming treatment that they need in order to be able to support their own behavioral mental health. Well, if we filled out the whole wheel, right, because what we know and what we've talked about before is that when we're thinking about these areas, it includes being able to carry a pregnancy to term with dignity and integrity and without the risk of dying in the process. It means being able to have access to sex education for young people and older people too who still need it. It means access to being able to terminate a pregnancy. It means access to being able to have contraceptive health care. It means the government's staying out of your business if you need the kind of gender affirming care and so much more, right? So when we're talking about these issues to just level set. Exactly. I mean, but that's where definitions are helpful, right? So reproductive rights are the legal protections that we used to have. I don't even know what language I'm going to start using anymore, but rights are like reproductive rights. When we talk about that, those are the legal protections in which, you know, we are able to operationalize or actualize, you know, our reproductive life goals. When we talk about reproductive health or reproductive health services provision, we are talking about you go into an office or you go into a health care providing facility and someone will take your blood pressure and someone will do a physical exam and someone will, you know, put their hands on you in a way to help you optimize whatever the reproductive issue that you have is, whether it's infertility or gynecologic cancer or whatever it is, right? That's reproductive health services provision, right? So the legal protections in the ways that we think about them. Reproductive justice is a completely separate, you know, construct that I think is very important for folks to understand because it is a direct response to what we call reproductive oppression and reproductive oppression is grounded in heterosexism, gender oppression, patriarchy, and racism. Okay. Reproductive justice was coined by 12 Black women in 1994 in response to the limited conversations that people are having around choice, right? We, as Black women, understood that it is completely impossible to separate out social justice from reproductive health and from reproductive rights. So reproductive justice posits, I mean, and some people have put it forward as a theory, as a practice, as a practice, this as a strategy, as an advocacy tool. I think about it as all of them. I am not trying to be limiting because I think ownership is a tenet of white supremacy. So it can be as big as it needs to be, right? It has four basic fund, well, three basic fundamental tenets. If you sit with reproductive justice organizers and people who coined term in the South, they really believe that you have a human right to decide when you want to become a parent and birth and to have all the supports that you need and the ways to be able to do that with dignity. Conversely, you have the human right to prevent and or end the pregnancy with all the supports that you need in terms and able to be able to do that with dignity and free from coercion. And then the third tenet is that you have the right to parent the children you already have in safe environments, free from violence or coercion from any individual or from the state or the government. So that covers people like folks who are incarcerated. You don't have to, you know, terminate your parental rights or if you're, you know, disabled, you don't have the, like you get the parent, the children that you have with all the supports and the dignity that you need, right? I like the fourth piece, which is we need to disassociate sex from reproduction because that allows us to have really different conversation about health and sexuality and pleasure and consent. This default heterosexism we have in our country, it's really weird. And when you ask people how did they know what their sexual orientation was, if they're not a queer person, it's a default. And so this idea that we, we don't allow for more nuanced and more complicated conversations about why we need reproductive justice or why reproductive justice is, you know, deeply connected to voting, right? So, right. So then this brings me, you know, as I think about our conversation and just that importance of tracking through our history, clawing through our history, so that we come to understand this because when people think about, or certainly what we've seen in news recently, people struggle with this idea of understanding systemic inequality, systemic discrimination, systemic racism, systemic heterosexism and sexism within these spaces. And so what you're helping to do is to bring the terms in light with what has actually happened. So what I think of, based on what you've said, it makes me think about eugenics as part of a legalized sanctioned systemic for, so for people who are in denial, you're like, well, there's never been these histories, right? And there's never been systemic inequality in this space. Then 1927, the United States Supreme Court in Buck v. Bell, upholding a Virginia law providing for the compulsory sterilization of people who are poor and considered unfit. And in this law, which has no definition about what unfit means, which basically leads to disparate kinds of policing of people in their bodies and overwhelmingly, it's all poor people, right? And the case involves a 16 year old poor white girl who had been raped by her employer's nephew and became pregnant. And Virginia used her as a test case because Virginia wanted to make sure that there would be a law upheld by the United States Supreme Court that would allow Virginia and every other state that wanted to do it to basically round up people and prevent them from ever continuing their kind. And they got it in that case. In that case, the Chief Justice Oliver Wendell Holmes said that three generations of imbeciles are enough. He said that the power that the state had to impose inoculation was broad enough to cover cutting the fallopian tubes. His words was that better than to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. That's US law. And that's US jurisprudence. And US jurisprudence that's never been overturned. It's still on the books. It's still on the books. For the people who are on this call, a lot of people don't know that my dad is a constitutional lawyer. I've spent my entire life engaging with lawyers. And yeah, I was pretty stunned to realize that what we're about is still on the books. Yeah, it's never been overturned. Yeah, and that the pregnant capable people, the people at the center of that case, never got to say, never got to say. And kids as young as 10 and 11 years old, sterilized, right? And the process that Virginia would do before the Supreme Court took on the case. And after they would ask the kids, do you like jump rope? Do you like bubble gum? Do you like being sterilized? Two or 10 year old, two and 11 year old, right? That history, this is what you're talking about. So that when we look at, well, where we are today is not a matter of imagination. And it's not a matter of, oh, this just happened yesterday. But we're actually talking about the sort of dismantling of systems that have grown over time. And I'm going to come back to that because it relates to the Mississippi abortion case and the injunction put in that case by Judge Carlton Reeves and his reference to the Mississippi appendectomy. So we're going to come back to that. But I want to take us to ethics. Ethics and what this means in a time today when we see the dismantling of abortion rights in states like Texas with SB 8 in Mississippi with the 15 week abortion ban law. So how does ethics fit in to these spaces and in your profession? Well, I'm going to tell the story to answer this question. When I was training as a nurse, you know, in 1988, I'm younger than I look, we had just come forward with universal precautions because a novel infectious agent was killing gay people in cities across the United States. And it was the first time in my adult life. And I can't believe I'm saying the first time in my adult life because I've seen this happen again. We're 600,000 of our citizens just died. Right. I started training during HIV and AIDS. And one of the things that happened was, you know, there was a I was a nursing student. And our faculty worked side by side with us during our training just like our faculty have been doing now with other nursing students. And a lot of people said that that was unethical. And I never forget the day that I came into work with my preceptor. There was a old gentleman, older gentleman who he had swastikas on his arms and he had been abusing the nursing staff. He had been there for weeks because they couldn't figure out what what was causing his GI bleed. And he pulled his NG2 out and he had been harassing the nurses. And so when it came time for a report to come up, my preceptor said, man, Ms. Macklemore will take him. And this was, you know, pre electronic medication dispensing. We had a card X room room where you went into and you had to get the cards and write the medication down in the care plan for the day. And I followed my preceptor into the medication room and I said, why did you volunteer us to take care of him? And she looked me straight in the face and said, Ms. Macklemore, you are my strongest student. She said, take a look around. She said, these nurses are worn down. They are tired. They are sad. They have been disrespected. If we take take him today, you and me and we give him really good care, then we've cared for our colleagues today too. I have never forgotten that. So when I think about conscientious objectors of abortion care, I can talk to them in the same way I can talk to conscientious providers of abortion care. Because for me, if we want to talk about ethics, part of the ethics when you're thinking about the health professions is, whose needs matter first? Is it your personal discomfort and your need? I mean, when this first hit me, I realized when emergency department nurses wouldn't take care of our abortion patients who were going downhill quickly or they were having complications. I'm like, wait a minute. You just patched up the person who was in the gang-gung fight outside. That's to go upstairs to OR for surgery so they can remove the bullet. But you want to fight the 13-year-old that's pregnant here in the ED because you don't want to take care of it because you object. Make that make sense to me. And one of the things our research found is when people say no in abortion, most of the time it's not that they actually philosophically have a problem with abortion. Our data have shown, especially our qualitative data have shown, either people have a personal experience with abortion and they have not dealt with whatever feelings they have around it. They have never thought about abortion. And so this is the one time in real time when they have to make a rapid decision where they have to unpack how they actually feel about it, which is really unfair. Right? Or they are fundamentally diametrically opposed to abortion and that is the smallest proportion of people that I've talked to in my research. And we've looked at this quantitatively and qualitative. The no is to make it somebody else's problem. Not that they don't support abortion, not that they don't believe that people should have abortion. For some nurses that no is I've never taken care of an abortion patient. I don't even know what I would need to do. Right? So basically you're getting us to the point about training, which raises some very significant questions. Right? And so let me just start that off with history again. You all thought you were just going to get us like this. You didn't know that we would be taking you to history. Well, it makes me think about Dr. Marion Sims. Yeah. Dr. Sims' statute has been yanked now from Central Park. Dr. Sims notorious experimentation, cruelty, terrorism, torture of Black women's bodies was documented by himself in his memoir. Right? So these are not histories where we can say, well, someone made that up and somebody else wrote it. Right? We can look right at the Supreme Court record. We can look right at what Dr. Sims wrote as he denied Black women that he kept in a shack at the back of his house and would rouse in the middle of the night when he had an epiphany. He denied them pain relief, anesthesia. He either believed that Black women didn't need it, didn't deserve it, didn't feel pain, all of those things you see in various kinds of iterations. But it makes me think, given how much medical schools have clung to him, labeling him the father of gynecology and whatnot, which says a whole lot about framing, then why the framing hasn't been that we mandate that you know these procedures in medical school, nursing school, et cetera. We mandate that you know how to perform a pregnancy termination. We mandate that you know how to engage in appropriate miscarriage, you know, relief, all of these things. Why aren't we there? Because that will require us to center the people that we serve and not ourselves. Right? I mean, I'm sorry for the mic drop, but- Now drop that mic. Let me give you a few more mics so that you could drop those too. Every time I talk to students about this, I always say, why go back to your personal statements, go back to your professional statements when you wrote to get into graduate school? What's the number one reason that people say they wanted to become a nurse, a dentist, a pharmacy, you know, a physician? They say they want to help people, right? It's a number one reason. I can answer that question. And so, but I always push them, I say, okay, so what people? And what do you mean by help? And can you really walk me through what it means to serve the public? I have often said that we have to be more discerning with who we admit into the health professions because the work that we do is in service to the public. It is a gift. When I think about the ways in which my life has been structured around the fact that I was able to become a nurse during the last deadly global pandemic that we had, right? Then at any moment a needle stick could have killed me. But I was still willing to step up and willing to serve because I felt that strongly about making sure that people had dignified experiences regardless of how they got to us, that returning to homeostasis and to wellness or whatever level of acceptability that we could get them to would allow them to have a dignified life, right? I always say this to students and they are horrified when I say this, but I have never been pregnant. I am lucky. I have never had to make a pregnancy decision in my life. I have no idea what kind of decision I would make. But people assume because of the kind of work that I do, centering the people that we serve that somehow they can make all these assumptions about. These short cuts are going to get us in trouble. They will continue to get us in trouble. So it also seems that what you're saying is you're making an argument that the ethic of care is an ethic of care and not an ethic of denial of care. Yes, it is. And that care provision, if we take oaths to say, whether it's, you know, Hippocratic in your physician or whether we're talking about Intala and not turning people away from emergency departments, if we take all these different oaths to say that these are the different things that as a profession, we are committing to serve the public and in exchange, the public will afford us prestige. They will afford us expertise. They will afford us reverence and reverence, right? If that's the exchange, then, you know, we have to be willing to provide care. It is an ethic of care, regardless of how folks got to care, right? This idea that we can pick and choose which patients we want to take care of is a problem. Well, you know, and this actually, since we are still in February, as short as this month is, and that this is Black History Month, it reminds me of the documentary and the book, The Power to Hill, because there is also this history of race that coincides and overlaps with this history of discrimination with regard to sex and LGBTQ folks, right? Which is that, you know, it used to be racialized, right? Black people dying on the front steps of hospitals. Black people not being able to be admitted in for the people who are on this call that may remember Sammy Davis Jr. When he was in a car accident where he lost actually one of his eyes, he wasn't able to go to the nearest hospital because even he, a world-renowned talent and musician, an actor, knew that he would not be served at certain hospitals, even in the state of California, because of segregationist kinds of policies and these segregationist kinds of policies that were actually supported by premier medical organizations. I mean, it actually was a real fight by President Johnson to get Medicaid through, because there were Medicaid, essentially, desegregated hospitals and desegregated American Medical Association, that, right? They did, absolutely, historically. People argue that's one of the reasons why we don't have single payer and I can't believe we have not used the word capitalism yet. I can't believe that either in this conversation, right? Or profit or whatever you want to use, right? I mean, the other thing is as long as our health training program, so again, getting back to ethics, right? Because we also have to look at, well, how are our health training programs financed? Right? How do we pay for that? Generally, it was a public dollars out of CMS and Medicaid and Medicaid, right? I mean, so when we think through, again, using that history but bringing it to the present, whose bodies are being used as primary training sites for our clinical workforce in order to be able to learn the skills that they need to, is poor people at public institutions or to patients at Planned Parenthood, because that's the other thing. We allowed, and I've been saying this everywhere, right? When we segregated abortion care from all other aspects of physical care and we left them to be neutralized, isolated, harassed, now all of a sudden we want to be confused because misinformation, the same tactics that were really honed on abortion care providers and abortion clinics are now being used and politicized as part of COVID-19. Like, why? We shouldn't be surprised. We were the nary's that call one. Right, right. The ethics of that. Well, and I also think about the sort of ethics, the ethics and morals, right, of what is the role of government then when we see these things in operation and practice. And here I'm thinking about the threats that, and this is actually taking the conversation in a way that I didn't anticipate but I perhaps should have, right? Because your work, it's not as if the work that you do has not come with its own threats and challenges. Correct. I've talked about this before, and you open the door to this just now. You know, being in a practice area where there have been the bombings of clinics, right? Since Roe v. Wade, there have been nearly 50 bombings in the United States of places that are providing patient care. Every day in the United States, there are medical professionals, providers of care that are harassed and tormented as they are about to give care to their clients and patients. Every day in the United States, there are people who are either supporting people who want to terminate a pregnancy or are going into terminate a pregnancy themselves, who are spot upon, who are pushed, who are shoved. I've talked with clinic directors who say that there are people who show up every day with guns right outside of their clinic. There have been clinics that have been fire-barmed where arson has set a flame. And more staff and more nurses have been killed in that clinic-based violence than physicians. I say this all the time. The other thing I say all the time too is, you know, when Mass General had to deal with the neo-nazis outside of their hospital because their health equity, you know, black and Latinx physician, folks were trying to provide care there, they shouldn't have been surprised because y'all let that happen to abortion care clinics, right? I was talking to our good colleague, Dr. Elita Maybank, who is the chief equity officer at the American Medical Association. She was stunned and horrified when she rolled out their equity blueprint that somebody came and put graffiti on her house. And I'm sitting here thinking about, wow, I hope you've read, you know, Attorney David Cohen and Carol Jaffee's books on, you know, obstacle course and being in the crosshairs. These are tactics that people have tolerated in mainstream health care. It's been okay to let the abortion people have that happen to them. But now all of a sudden, when you get neo-nazis showing up at Brigham in Boston, folks are upset around health equity. Same tactics, same people. It's just something on January 6th. You talk about what's the role of government in the ethical provision of health care. Well, one place might actually be this idea that if you have citizens, a historical citizen, running around who think that they can, you know, storm the capital and create an insurrection, people will really stun that many abortion groups who maintain databases of people who harass clinics. They showed up on January 6th. They were able to be tied. These like photos that were identified by the site of clinics. Exactly. Because the venn diagram between anti-abortion people and white supremacists is a cycle. And it is because there is this deep, you know, lack of folks understanding how the dots connect. And that if black people brought to this country against their will, terrorized, captured as chattel slavery, built an entire country, drove an economy. This is why mentioning the word capital is matters, right? And then we create different health care providers and different silos of service, either based on insurance status, ability to pay, or, you know, one's geographic location, that that's been acceptable and remains acceptable. Yeah. It's a problem, which again goes back to the ethics of the distribution of abortion care providers, because we haven't talked about that either. No, we haven't. And when we think about that distribution and what it means nationwide, we think about a state like Mississippi having only one abortion clinic remaining, and that there are other states where now that is the same. When you think about people having to drive hours, and it's not just driving the hours in order to get to the nearest clinic, but because there are targeted regulations of abortion providers and all these kind of trap laws, you may drive, but you're gonna have to actually drive back right a few days later and have to get babysitting care, take time off from work, all of this because of lies and misinformation you have to listen to in the waiting room, right? The unnecessary ultrasounds that you may may or may not need, like all of that, right? But again, we've allowed that to happen because unlike our good public health colleague, Dr. Kamara Jones, who happens to be the presidential chair at UCSF this year, she always talks about we have to distribute resources based on need. That's a real public health approach. That's a real care ethics of care approach. We would distribute our resources based on need. So you mentioned capitalism, and so let's talk about it because it also gets us back to some foundations where people really sort of struggle to understand, and so let's open that door up more because we're also talking about histories where the capital in the United States, and here I'm talking about the financial capital generated in the United States was born quite literally in the wombs of black women, right? Where Wall Street, that the second largest auction block in the United States, Wall Street, where people, if you think about the mortgage on your house, did you know that kind of mortgaging started with black bodies, right, where people want to be able to, and then the insurance that you'd get sort of like life insurance based on because what use is a bed enslaved person? So life insurance meant like work hard, work hard, and then here's some life insurance that kicks back. All of these kinds of systems and then laws created around that, laws such as a child in the United States, the earliest laws in the United States that a child will inherit the status of her mother, her father, complete change of the laws that otherwise would have been adopted from England, but purposefully for the status of reinstantiating next generations into enslavement, even if their fathers happen to be white. And this is part of that capitalist history that you're talking about in terms of the quantification. And I just want to add one point and then let you respond to it, which is that when we think about that famous speech of sojourner truth, anti a woman and most people thinking of it as a matter of chivalry, she starts off that speech with saying, and I bore 13 children and saw nearly each one snatched from my arms and nobody heard my cry but God, anti a woman. And that's a story of, that's a story of capitalism and it's also a story of ethics and morality and law. Yeah. Yeah. I mean, and it gets to, I mean, you know, the worst person who just went through my mind in a couple of different ways. But it really does get to this whole idea that, you know, when we enter the health professions and we want to be able to take a life course perspective in assisting the people we serve, reach their reproductive life goals. Abortion is an essential component of that. Right. I mean, Why is that because some people might say, well, you know, I don't know that abortion has to be a part of that. Why should abortion be a part of that? Well, because, you know, the truth of the matter is the people who have births and the people who have abortions are not different people. They are the same people that just set different time points in their lives. Right. Our collaborator, you know, at answer Dr. Diana Green Foster shown beautifully in the turn away study that, you know, upwards of 88% of people who have abortions already parents, we knew that. Right. And so this idea that someone else can, you know, make a determination for you that will impact the future of your life without consulting you is really ethically problematic. And when we codify that in the workforce training to be able to say that the only people whose opinions matter in clinical environments are conscientious subjectors and not conscientious providers of abortion care, we are having an incomplete conversation. Right. Right. Well, I'm glad that you mentioned that I want to take a moment for our audience. In case you have questions, please begin to populate them in the Q&A. And I will try to get to those questions, but this is a time for you to begin doing that placing your questions in the Q&A. So I'm wondering then where do we go to from here because we're at a time in which the United States Supreme Court may very well dismantle row, not that row was ever the North Star, which you've talked about. And I've heard you talked about which I've talked about too, but this is about you, right? Like, you know, so right exactly. And given that that's where we are with, you know, the Dobbs case before the United States Supreme Court will probably hear its ruling in the case in May or June. Right. So what happens next? How do we correct this this tide given where we're going? What's the role of medical providers in doing this, of nurses, of doctors in this space? Well, I mean, so, you know, Schumer and the Senate have reintroduced a women's health protective protection act. And I'm glad they're going to vote. I don't think it'll pass. But, you know, it's nice to have people on the record saying what they will and won't support. Row was never the best that we could get. And one of the reasons why I started off with some of the current landscapes and some of the wins when you think about the codification of abortion, you know, within, you know, law in New Jersey and, you know, advanced practice clinicians becoming of abortion providers in Hawaii and in Virginia. When you think about the fact that the South Carolina fetal heartbeat protection from abortion act was defeated. When you think about the race and sex selection bands that were defeated in Arizona with a partnership between knockoff and in double ACP. In coalition, we stand with the public and we educate them about these issues. They're with us. Right. So maybe this is a prime opportunity. And I'd like to remind listeners in, you know, Dobbs, we got our first ever human rights grounded black maternal health brief led by Dr. Julia career period and national birth equity collaborative making argument that human rights trumps any states rights in the context of a pregnancy. Right. So for me, I sort of see this as an opportunity for us to try and do better than what Roe actually gave us while also trying to ensure that the people who need abortion care now can receive it with dignity, you know, with all the supports that they need. That said, there are some asks that we need to make people that historically we have not made asks of. And one, you know, notion that I have always rejected that I know is really rampant in our field is this idea that people have just shrugged their shoulders and said, well, well, they'll never be the hospital hospital based abortion. They just accepted that as a, you know, pregnancy and that will never happen. And I don't I don't agree with that. I don't. And I keep asking organizations that are very, very overtly focused. You brought this up earlier on maternal morbidity and mortality are rising statistics, right? I've asked the centering health care and centering pregnancy folks. I've asked the March of Dimes and the NIH folks, in fact, I have a call with the Gender Policy Council next week for all the people who want to mitigate maternal morbidity and mortality, and particularly the black maternal health crisis, you know, specifically, how do you think you're going to do that in the context of having Roe being dismantled and having further reduced? Well, that's right, because it seems to me that one of the things that's been missed, right, with the reporting that's been done about the increase rather than the decrease of maternal mortality and its effects in black women's lives and other women too, because we saw those rates increase also for Latinx women as well, is that it's being framed as well, this was about COVID rather than no, this was about attacks on abortion to have clinics closing. Where are people getting their contraception? Right, who are people being able to get prenatal care? We've just seen across the country the closing of places that were providing the most essential care for people who are becoming pregnant, all gone, and we've not seen in the place of that in places like Louisiana and Texas and other places where this is happening. You've not seen county hospitals opening, you've not seen the governor saying, well, okay, let's make sure that we put a clinic there that's going to provide care for low-income people just like that clinic that was closed because of our trap laws, which is now time, that didn't happen. And the other ethical piece to that is they're using the fake clinics, the crisis pregnancy centers or the pregnancy health centers, some of which have clinical services, some are brought with misinformation, some are religiously affiliated, some people in some states like Ohio and Texas, they are trying to use those as a potential replacement to address the social determinants of health without acknowledging the harm that those people caused. So another question that came up, just as you were mentioning that, because part of this dismantling, so let's put some more facts out there so people can be armed, right? So we know that a person in the United States is 14 times more likely to die by carrying a pregnancy to term than not. So that's important for level setting because so much of the rhetoric is, isn't it the most dangerous thing in the world to terminate a pregnancy, right? Rather than it being the opposite. Rather than pregnancy being a dangerous condition. Exactly, as it is, right? So the World Health Organization compares the safety of an abortion to a penicillin shot, right? So just to kind of level set, we know that in Texas where we've seen the most prolific of anti-abortion legislating taking place, it's much more dangerous to get a colonoscopy than it is to terminate a pregnancy. And we also know that when we're looking at maternal mortality, Black women as a national matter are three and a half times more likely to die. But once we actually, even the white counterparts, but once we start digging into these counties or places in which Black women are 10 times more likely to die than the counterparts, 15 times more likely to die. 12, like it was in New York City. Exactly, right? So given that, it's startling to me that that kind of framing hasn't been more front and center. Yeah. And so I'm wondering why that is because, I mean, we're talking about matters of life and death. If we really think about it in that way, and it gets to your question of personhood, whose personhood matters? Right. And it's something that I think that clinical health services provision and public health are going to have to wrestle with. So we would be remiss not to make a distinction between those two things because I also think that's really important. Clearly, we're having a problem with that in COVID. I mean, public health and other kinds of mitigation strategies to be synergistic with health services provision. But again, with the over medicalization of everything, we've tried to put everything into the clinical care provision bucket without forgetting that we also need its sidekick. All services provision has a sidekick. It's called public health mitigation strategies. Right. We were able to reduce large numbers of auto fatalities by introducing the public health measure called soup delts. Yes. Yes. I'm getting folks to break it down just like that. Exactly. Exactly. A public health mitigation strategy. Sometimes you need an umbrella when it's raining outside. Sometimes you need a mask when COVID is surging in your neighborhood. Sometimes you can take them off, right? But it's this notion that we want everything to be these weird binaries when it's much more complicated than that. So as we're thinking about what comes next, do you think that there are certain opportunities that have actually come through these dark times and what do the opportunities look like if you think so? And I want to maybe start with, you know, abortion pills. Individuals being able to be at home, avoid being spat at, avoid the threats and people taking their photos by having people to be at home. We have new tools and technology now than we had prior to the decriminalization of abortion at the row. And, you know, having access to Miphyprishtone and Misoprostol is game changing, right? So knowing that those technologies exist is one, you know, bright spot. Maybe we can have a more nuanced discussion of making them even more accessible if having an inclinant or an aspiration of abortion is going to continue to be, you know, further distinguished or eliminated in different geographies. Here's another thing that's controversial, right? I don't understand why midwives are allowed to catch live babies, but they're not allowed to attend at induction terminations for people who need them. That's a whole other discussion too. We're going to do a workshop on that at the American College of Nurse Midwives, because I'm like, wait a minute, you normally are responsible for shepherding two people through a process safely, but now you only got to get one through and somehow you want to tell me on how to do that? So there's that. But there will always be people who need aspiration abortions, right? Medication abortion is not a tendency. So how do we create those services for those individuals who either need those or who will choose those and to make that everybody's responsibility? Like now we can have a conversation about MUA and MVA, right? Having, you know, manual vacuum aspirators for everybody. Well, you know, I think that that's really important. What you've, you know, suggested, which is that as we go forward, there is a way to think about actually what the north stars should be within this particular constellation, rather than just thinking about it within a very narrow framework and thinking beyond the framework that it's only MDs who should be centered in these conversations, but rather as you started with that the centering itself should be the patients, the people who are in need of the medical services and then building from there. And that that really is the ethical challenge for us, that that's the lane in which we need to be. So I'm going to offer for a Q and A for one last time before we wrap up any additional questions that you all might have, then please place them in our Q and A before I wrap up with Dr. McLemore. But I also want to ask you, you know, we're at a time in which we can't separate what's happening in medicine and the attacks on reproductive health rights and what this means for reproductive justice from other things that are taking place at the same time, because this is not a silo, right? It's not as if everything else is great. And it only happens to be this is where questions are arising. So I'm wondering how you see this within the context of our democracy. People are just beginning to sort of ask questions about, is this related to the rule of law? Is this related to democracy? And what's your response to that? Well, voting rights, I mean, historically have allowed us to be able to ensure that as citizens, you know, we are protected under the law. I don't know how else to explain this to people, right? And so voting rights are reproductive justice rights because the different legislatures that have been introducing these bills clearly are not representing the interests of the people that they're supposed to be representing. I mean, we've had a Texas legislation evaluation project for what almost a decade. And those data show that the pregnant capable people in Texas want different things than what legislatures are affording them, right? Or same in Mississippi, right? When I think about the pink house defenders and when I think about the yellow hammer fund, they are the first people to say that they are being held hostage by the people who govern their legislature. So therefore voting rights becomes a reproductive justice, right? When we think about surveillance and, you know, policing and unarmed shooting of black men, who did George Floyd call for? He called for his mother. Yep. Right? These are reproductive justice rights. Yeah. Yeah. When I think about how do we string together a new coalition that will be grounded in human rights that will free us from our fear of gender oppression and patriarchy and heterosexism and racism and actually allow us to build, we had an opportunity. I still think we do at the height of the pandemic. Remember all that mutual aid? Yeah. Remember how everybody was trying to really balance fear with disorientation because, oh my goodness, we're in a global pandemic? Yeah. Right? There was an opportunity. We can make, here's the secret that nobody wants you to know. We can make opportunities like that again. Mm-hmm. And we don't need crisis to create opportunity. No. Right? Exactly. We need to move beyond that, right? And it's sad, right? Because when we think about this. But we can take a harm reduction approach, right? How do we reduce harm? Exactly. And the easiest way when I think about this ethically is we need to diversify the workforce of abortion providers of people who can get trained to be able to make sure that people can get MIFI and MISO, who can get trained to understand how to manage, you know, abnormal and unintended pregnancy, who can get trained to know how to do manual vacuum aspiration. That's a harm reduction approach. And it's an urgently needed approach. Dr. Monica Mechlemore, I am again so honored that you joined me today and that you helped to launch our three-part series on contemporary issues and health, law and bioethics with our session today on ethical and workforce considerations and abortion care provisions. For our audience, I want to thank you as you have placed it so much respect and love for this conversation in our Q&A over and over again, saying that this is the smartest conversation that you've heard about reproductive justice, social justice, and history. Thanking us and thanking you, Dr. Mechlemore, for lifting up such important considerations in your talk today, including what's been happening in Boston, appreciating the connections and truth telling. And thank you all so much for placing that in our Q&A and for your support of this program today. We really appreciate it. Before we close out, any last comments, Dr. Mechlemore? Well, first of all, thank you and thank you to the audience. I'm very grateful to have an opportunity to share some of these thoughts. And we really need to continue to expand the voices that we are listening to. All right. Well, with that, thank you all so very much for joining us. This has been Dr. Monica Mechlemore, who is a professor at the University of California San Francisco and whose work is everywhere. I hope that you follow her on Twitter where you'll be able to see some of her work when she posts it there. Look for her on her website where you'll be able to follow her work. Thank you so much for joining me today. It's been an honor and pleasure. It's always good to be with you. And thank you to our audience. That's it for now. Join us for our next program.