David T. Zhu is a Master of Public Health (MPH) candidate at Yale School of Public Health, Department of Social and Behavioral Sciences
In this article, I interviewed Dr. Katherine Kohari, Dr. Audrey Merriam, and Dr. Mark Mercurio (three physicians at Yale School of Medicine), Dr. Louise King (a bioethicist and OB-GYN professor at Harvard Medical School), and Ally Tran (a first-year PA/MPH joint degree student at Yale School of Public Health) about the ways in which public health and medical institutions can rethink their curriculum, infrastructure, and community partnerships to advocate for patients seeking abortions after the downfall of Roe v. Wade.
Where were you when Roe v. Wade was overturned?
June 24th, 2022 started as an uneventful day. I sat with a group of friends at my favorite café, jovially chatting about our upcoming summer plans. At 11:30 a.m., my phone lit up with a notification from CNN: “Supreme Court overturns Roe v. Wade”. We collectively gasped. The silence in the room became deafening as we struggled to process the news. Another public health crisis was upon us—only this one was made by human hands.
The United States has never been a safe haven for reproductive rights. For several decades, a torrent of bills and legislations have eroded away Americans’ equitable access to abortion care—Helms, Hyde, and gag rules, just to name a few. Dobbs v. Jackson, which overturned the constitutional right to abortion set forth by Roe v. Wade half a century ago, is merely the latest symptom of a crumbling healthcare system.
Therein lies a monumental call-to-action for institutions to rethink public health and medical education. This, in turn, can empower institutional leaders and students to mobilize resources, infrastructure, and community-based partnerships to bridge disparities in the access and quality of reproductive healthcare in the aftermath of Dobbs.
Historically, a comprehensive abortion education has been elusive in graduate-level public health training, and often remains secluded to niche electives and conferences. As a current MPH student, I believe that we can do better at incorporating productive discourse about abortion and reproductive health into our core curriculum. For example, the foundational courses in public health, such as epidemiology and health policy, can adapt by incorporating modules and longitudinal coursework that expose students to the latest evidence-based findings about social disparities, as well as maternal and child health outcomes.
In addition to traditional didactic lectures, public health institutions may consider exploring interactive and community-engaged forms of programming with local organizations. These include Planned Parenthood, The REACH Fund, The Brigid Alliance, among others. Integrating their perspectives into the core and foundational courses offers unique insights about the practical roles that students can undertake in the fight for reproductive justice after Dobbs. “If you only approach [reproductive health education] from a scientific or academic standpoint, then your perception might be different from somebody who is able to see all the nuances from their on-the-ground experiences,” says Ally Tran, a PA/MPH graduate student at Yale.
Strong and sustainable relationships between students and the local community serve as a bulwark against the emerging legal threats on abortion rights. Students acquire valuable, firsthand insights about the real-world challenges arising from Dobbs by volunteering, pursuing internships, and becoming involved with various organizations that support people in need of complex family planning and abortion services. For example, at Yale School of Public Health, all students in the MPH program are required to complete an applied practice experience (APE), typically over the summer between their first and second years. This can be an excellent opportunity for Yale to further strengthen and expand their partnerships with organizations such as Planned Parenthood to make these field experiences more streamlined and accessible to students. “At Planned Parenthood, they often have patient chaperones, doulas, and things of that nature that students can absolutely get involved in, and also, to get the word out about medication abortion services after the Dobbs ruling,” says Dr. Katherine Kohari, the interim family planning chief at Yale School of Medicine.
Public health institutions can even take this one step further—expanding their reproductive health curricula to the public through open access platforms. This, in turn, can improve broader health literacy, empowering people seeking abortions with the information needed to find abortion clinics, medications such as misoprostol and mifepristone, and other essential resources. Dr. Louise King, a bioethicist and professor of OB-GYN and reproductive biology at Harvard Medical School, echoes this sentiment. “I was inspired by British universities that recently made their content online, free to anybody, for instance, to women excluded from schooling in Taliban-controlled areas… it would be amazing to have sex ed or public health lectures made widely available to clarify what abortion is, who seeks abortion, and what it means to not have access,” she says. Yale School of Medicine, for example, offers the Program for Biomedical Ethics, spearheaded by Dr. Mark Mercurio. It is completely free, and open to all students and the public. He adds, “I think that questions in bioethics are hugely important for all of society, not just for medical students or public health students… so we would love to have everybody at the table to discuss and learn about these types of issues.”
The cataclysmic reverberations of Dobbs v. Jackson are not limited to public health institutions. Healthcare providers and medical trainees also face significant disruptions to reproductive health education and care provision. A recent comment in The Lancet Regional Health—Americas found that, after Dobbs, only 30% of U.S. medical students train in abortion-protected states, while 50% and 20% train in states with restrictive or mixed abortion laws, respectively.
Abortion education is not only critical for guiding medical trainees through how to perform an abortion procedure. More importantly, it helps our future clinicians improve lifelong human-centered skills in areas such as empathy, emotional intelligence, cultural sensitivity, ethics, and professionalism that constitute the bedrock of patient-centered care. By restricting some of these humanistic opportunities from medical trainees, this can lead to significant emotional distress and will be damaging towards the fundamental ethos and pathos of the patient-physician relationship.
These restrictions also directly threaten the well-being of the medical workforce. According to an article in Academic Medicine, approximately 15% of medical students have had an abortion. In the wake of Dobbs, many medical students will be denied equitable access to the full spectrum of reproductive health and family planning services, which may compound disparities related to their academic, financial, and psychological well-being. A recent viewpoint published in JAMA found that Dobbs has led to widespread moral distress among U.S. medical residents. Providers in abortion-restricted states are torn between their obligations to patients and their adherence to state policies. Looming over these providers is the possibility of having their medical licenses revoked or even facing imprisonment. In a healthcare system that is already brimming with disproportionately higher rates of burnout among physicians and nurses, the mental health and emotional challenges brought forth by Dobbs will cause devastating harm to our front line workers.
There is no silver bullet to addressing these humanistic challenges in the medical profession after Dobbs. But medical institutions can rise to the occasion by expanding access to student health and wellness resources, such as increasing the accessibility of academic accommodations and student health and leave policies, or connecting students with institutional and local health centers. After all, how can we expect a medical student to study for an upcoming anatomy exam when they are under pressure to find essential reproductive health services?
Further, medical clerkship and residency program directors should extend these same benefits and privileges to students coming from out-of-state. After the Dobbs ruling, we can expect that many medical trainees in abortion-restricted states will travel to neighboring states to receive comprehensive training. Medical institutions in abortion-protected states can streamline this process by providing transportation networks and funds for out-of-state students, rethinking infrastructure to increase their capacity for training visiting students, and partnering with other institutions to create a network for comprehensive abortion training. For example, the University of Washington School of Medicine provides abortion and reproductive health training for medical trainees from Idaho and Wyoming, both of which restrict abortion. These initiatives are inspiring to see, but there must be a greater emphasis on equity, particularly for medical trainees who come from disadvantaged backgrounds. “Residents who come from underserved backgrounds with less financial means will be disproportionately unable to take advantage of these opportunities unless we get those funds in place,” explains Dr. Audrey Merriam, the OB-GYN residency program director at the Yale School of Medicine.
Although national inequities have already unfolded after Dobbs for both patients and providers, the worst may be yet to come. Dobbs is just the tip of the iceberg. And if history has taught us anything, the underlying philosophy of Dobbs—that the right to health and healthcare are not constitutionally protected in the U.S.—will repeat itself. Thus, by advocating for abortion rights, public health and medical institutions also forestall collateral damage and future encroachments on other health services, such as chronic diseases and neonatal care. After Dobbs, many arthritis patients have reported difficulties obtaining methotrexate, an FDA-approved medication for treating joint inflammation but is considered by some states to be abortion-inducing because it increases the risk of a miscarriage. Dr. Mercurio adds, “When people are given less latitude with regard to their own pregnancies, this may carry over into the care of newborns… for instance, I’ve had neonatologists from other states ask me, ‘What does this mean for our management of extremely preterm newborns or certain congenital abnormalities?’”.
In the aftermath of Dobbs v. Jackson, public health and medical institutions stand at a pivotal crossroads for the future of reproductive health education. One path consists of the status quo, risking exacerbations of the social and health disparities in abortion care and other related health issues. The other path consists of rethinking current practices in graduate-level education, which requires institutions and community leaders to rise together. By expanding reproductive health curricula, resources, infrastructure, and community-based partnerships, we can turn the tides against Dobbs. Will higher education respond to this call-to-action?