Mr. Thabani Zuma is a professional nurse who works in the Ethembeni HIV Treatment Clinic in a small hospital, tucked away deep in the heart of Zululand, the epicenter of the HIV epidemic in South Africa. The remote location, harsh living conditions, and bad roads make it difficult to recruit doctors here, so nurses-the backbone of the health services-must carry the load. But traditional nursing education has not prepared them to prescribe and dispense the powerful, lifesaving antiretroviral treatment drugs. So the South African Government in collaboration with international aid agencies now offers courses to prepare nurses for this expanded role. Mr. Zuma attended this program and achieved 96% on the certifying examination, the highest score in the class. He seems like a good candidate for the nurse mentor course we will sponsor, and I invite him to tea to see if he is interested.

Mr. Zuma is a tall, slim thirty-four year old Zulu man. He is dressed in his nurse uniform-blue slacks and sweater, white shirt, and the maroon, military-style epaulets that nurses in this part of the world wear to signify their status. When he speaks, his sentences are punctuated with laughter and his whole face lights up and dances. We chat a bit and I ask him what led him into nursing. He tells me his story.

Mr. Zuma was born during apartheid in a black township in Durban, South Africa. His father worked as a security guard in an industrial part of town. When he was two, the family “had to move” thirty eight kilometers away to Fredville. He is not sure why.

He attended primary school in Fredville and then won a scholarship for a boarding school back in Durban. After he graduated, the company that had sponsored him encouraged him to study mechanical engineering. He had really wanted to study medicine, but there was no money for that, so he agreed to enroll in the engineering course. He graduated in 1999 and was awarded the National Diploma.

“But then it went all black-I couldn’t get a job. When I went for interviews they said, ‘No, we’ll call you back’, and then they never called back. When I went for other interviews at other companies, they’d say, ‘No, you are overqualified for the post that was advertised.’”

Mr. Zuma knew he had to do something. He had eight people to support. No one at home was working and by then he had fathered a daughter.

“I couldn’t get a job-yes-but the job that was available to me was driving a taxi.”

My mouth must have dropped. When I hear the word “taxi driver,” I picture a reckless guy slouched behind the wheel of a beat up van, his arm hanging out the window-not the intelligent young nurse sitting across the table from me. Taxi drivers on the continent are a law unto their own. They disregard the rules of the road, cut in front of you at will, and stop in the middle of the road to drop off or pick up passengers. Many taxis are unsafe and become death traps for the people crammed inside. Mention the word “taxi driver” to the ordinary motorist and you will get a mouthful of vitriol. Yet these 16-seater minibuses are the source of transport for over half the population. I asked him what it was like to drive a taxi.

“A nightmare. You know how taxi drivers are. When I tell people the story now, they ask, ‘How did you get out of being a taxi driver and start doing something constructive?’ Because you get stuck there. You get quick cash-good money depending on how fast you drive and how many people you squash in.” We laugh.

“Honestly-good cash-I wouldn’t lie.”

Mr. Zuma worked as a taxi driver for four years. But he wanted more than good cash, and he continued to look for other opportunities. During those years he took vocational courses and earned certificates in baking, in entrepreneurship, in catering. Still no job.

Then one day he received a recruitment letter in the mail.

“The Department of Health was looking for people who wanted to do nursing. I thought with nursing I may be able to do one or two things I wanted to do. I had wanted to be a doctor. Nursing was a part of it. I wanted to help people. I put in my application and-Walla!-this was it-they said I must start.”

Mr. Zuma had an excellent high school record and was accepted into the College of Nursing at Grey’s Hospital and awarded a stipend. With this income he could help his family as well as cover his own expenses. During the apartheid years hospitals were segregated by race, and Grey’s had catered only for whites. But by 2003 apartheid was nearly dead, and the hospital served everyone.

“Nursing school-it was difficult! Anatomy and Physiology was my nightmare.”

But he made it through.

“My area of interest was the operating theatre. I could see doctors opening people and doing things-I would have loved being a surgeon.”

When Mr. Zuma graduated in 2007, he applied for a position at Ethembeni Clinic because one of his relatives was employed here.

“It used to be nurses just take care of sick people, follow doctor’s orders. But here most of the things we do ourselves. This clinic is different from working in the wards. What we do we are accountable for.”

In the years that followed, Mr. Zuma became quite the expert in HIV care and treatment. When the nurses have a problem, he is the one they call. When he himself has a problem or a question, he gets in touch with one of the doctors in his network or phones the 24 hour hotline for HIV clinicians.

“If I am not sure of what I am doing, I am putting that life in danger. I should ask.”

Mr. Zuma has been carrying a heavy load of responsibility in this remote area for over four years. During the week, he stays in the Nurses’ Residence in one of the few en suite rooms. But he spends weekends at home.

“I like being at home. Every Friday afternoon I drive two and a half hours to Fredville. And every Monday morning I leave my house at four in the morning and arrive at the clinic by seven.

“I love what I’m doing right now. I must tell you. I really like ART’s [antiretroviral therapy]. I can see progress. That’s the main thing. You see the client today. When you see the client three months down the line, you see progress. That’s lovely. You say, at least I’ve done something that helped this client. That keeps me here. I’m happy.”

“Do you think you’re going to stay?”

“Well, I’ve never seen myself in the office, sitting there in front of the computer, because I love people. Right now I’m doing the one year course on Primary Health Care. They teach us the steps to take to properly diagnose the patients, not just to treat. Let me tell you one story.

“The other day after I had been at my course, a client came in. I looked at him and said I wonder what is wrong with him. I examined him and he had hepatomegaly, an enlarged liver. I never used to do that, diagnose patients myself.”

“The passion that you’ve got-it goes a long way. With me it’s the passion.”

I tell him that we would like to prepare him as a mentor for other nurses. He agrees.
“Whenever I am exposed to new information, I would love to share. Afternoons, when it is quiet, I bring people together-lay counselors, caregivers, and others-and say, let me teach you about one big word that I know.”

Mr. Zuma also sees patients in the outreach clinics. People in the area are poor and transport, including taxi service to the hospital, is limited and costly. So the nurses go out to the community and treat patients in thatched huts, under trees, or in churches.

“I feel for this area. Here they see the difference you are making in their lives. When you go out, people come to thank you with a bucket of potatoes or cabbages, spinaches. Just the appreciation makes you want to do more. It’s one lovely area. I won’t lie to you.”

We finish our tea and get ready to go back to the clinic. The weekend is almost here and Mr. Zuma will start on his long drive home to Fredville.

“My aunt has got taxis,” he tells me. “When a driver needs to go somewhere on Saturdays and asks me nicely, I drive. There’s no harm in that. Like I told you, for me, people are all the same.

“Sometimes the people tease me, ‘Oh, today we’re got a doctor driver.’

“And I say to them. No, I’m trying to push you people to see that when you are here, it doesn’t mean the end of the world, and when you are up there, it doesn’t mean you can’t mix with people down here. With me everyone is the same. I am driving with you.”

I will never again look at a taxi driver slouched behind the wheel, arm hanging out the window, without thinking of Mr. Zuma. I will always wonder…

When I told our hospital vice president I was making home visits with the residents, he gave me a polite smile that said “how quaint.” He then told us how the hospital was developing important new things like a joint replacement program, with concierge service and wood paneled patient rooms. They’re recruiting orthopedists. Like most hospital administrators, consultants keep him well informed on health care reform and other emerging trends. Home visits by family physicians are not part of the conversation. This is curious because of all the talk in health policy circles about the “Patient-Centered Medical Home” as a means to improve quality and decrease cost. In the latest set of standards for the Patient-Centered Medical Home developed by the National Center for Quality Assurance, there is no mention of the patient’s home as a locus of care. There is, however, a great deal about information technology. Information technology is a major concern of our national health policy experts.

The idea of physicians going to patients’ homes calls up nostalgic Norman Rockwell images of a simpler time. For the past two generations home health services have been the province of visiting nurses and other health care workers, not physicians. It’s simply economics. Medicare pays home health agencies enough to make it worth their while, but the overhead of a physician office is so great that making home visits is a money loser. And inconvenient. It’s possible to have a practice that entails only home visits, and a few physicians have done it. But most doctors who still go to patients’ homes squeeze in visits before or after office hours. It’s easy to see why it’s not popular.

I made my first home visits as a family medicine resident in Brooklyn. It didn’t take long to realize I could learn more about my patients in five minutes of a house call than a year’s worth of visits to the office. You see the family photos, the clutter, the pill bottles, the pets, the family dynamics all laid out in front of you. Like one visit to an elderly couple in Flatbush to check on the husband’s diabetic foot ulcer. He was a retired cab driver with Alzheimer’s disease who had finally stopped driving after he ran over the curb and smacked into a street sign. We went over instructions for wound care and then witnessed a shouting match between his wife and their adult son. When I went to say good-bye to the husband I found him washing his feet in the toilet bowl.

Our home visits are not house calls. We only get paid for seeing patients who meet criteria for being “home bound.” Insurance won’t pay for us to visit a child with fever. Still, there are plenty of frail elderly or patients with long-term disabling illnesses who qualify. When we added a required home care rotation to our residency training program we had a few simple goals-to learn more about our community, to see the different types of settings where our patients live (not just houses and apartments, but assisted living facilities, group homes, etc.), to assess their social support and the safety of the home environment, and to learn more about the role of other health care professionals in providing care in the home. In addition to making visits to their own patients, residents go out with home care and hospice nurses, physical therapists and advanced practice nurses. These other health care professionals seem happy to have a physician join in.

Our family medicine program is in a fairly typical small American city. It has a university, some large employers-a middle class and blue-collar community with its share of new immigrants, poverty, mental illness, drugs, and homelessness. If there’s anything that has emerged from our visits, it’s the awareness of how so many of our patients and families-even those we would call middle class-struggle to get by, each in their own way. When they come to the office we hear it in their voices but we don’t see it. The home care nurses know. We visit an 89-year-old woman in a moderate-sized Cape on a quiet suburban-like street. This is not the ghetto. The paint is peeling and old cars are parked in the driveway and the front lawn. Our patient walks from room to room holding on to furniture to keep from falling. The rooms are too cluttered for her to pass through with her walker. She’s taking medicine that makes her a bleeding risk if she falls and injures herself. Her bed is downstairs in the living room. Her daughter sleeps on a mattress on the floor next to her. Her three adult sons have the three bedrooms upstairs. There are family photos everywhere-filling the walls and cabinets, propped up on the backs of sofas, left on chairs. Her calcium tablets expired a year ago. Her out-of-pocket medication cost is $150.00 a month.

A mental health patient is morbidly obese from her anti-psychotic medication. She chain-smokes and uses home oxygen. Dust is everywhere and the room smells of cat urine. She is taking courses at the community college, transported to class by the Red Cross. She says she doesn’t want to live but hasn’t given up yet. When she needs a knee replacement she’ll get a wood paneled hospital room for a few days, maybe a few more if she has complications. At another home a daughter is taking care of her elderly demented mother and her deaf 90-year-old father-in-law between shifts at the family owned restaurant. She serves us Chinese food she brought from work. We see an elderly Italian-speaking man whose son, a local police officer trained for the SWAT team, comes over to translate. It takes fifteen minutes just to go over his medication. His wife serves us Italian Christmas pastries. It’s easy to gain a few pounds doing home visits. An overweight 84-year-old woman with bad arthritis lives alone. She has a walker but has fallen twice in the past several months. The firemen come and pick her up. Her house had structural damage from the heavy snow this past winter, but the insurance company is refusing to cover repairs. The resident sees why it takes her an hour in the winter to get from her house to a car to the office a mile away.

I’m impressed by how well the residents know their patients and their families, and how well liked they are in return. The patients are amazed and appreciative that their doctor is actually coming to their home, just like in the old days. In fact they have trouble believing it. If the system supported them, these young physicians would be happy to make home visits a regular part of their practice. Maybe then our patients wouldn’t have to go to the emergency department or be hospitalized quite so often. Maybe their lives would be a little more manageable. Maybe then we’d really be doing patient-centered care.

Interview with Dr. Marsha Fretwell

By Eva Sage Gordon

Sisyphus: Thanks for joining us Dr. Fretwell. I’ll begin with the most basic question: What is PACE?

Dr. Fretwell: It stands for Program for All-inclusive Care of the Elderly. The PACE programs began 30 years ago. They offer an alternative model to nursing home placement for frail older adults. But the exciting thing, in these times of conflict over health care funding, is a new way to pay for elder care.

Older individuals are often placed in institutions. Sometimes they are unhappy there, and often the costs are a real burden. PACE uses day care center that integrates social services, rehabilitative services, and medical care into a single organization. Its focus is to keep people in the community for as long as possible.

S: How is the funding different from traditional care?

MF: Each PACE program receives a fixed monthly payment and must provide all heath and social services from this. Physicians and others who work with the clients focus on health maintenance and improvement, rather than waiting to respond to illness.

The majority of funding comes from Medicaid and Medicare dollars, so this program aims to serve those who are elderly and poor. This structuring of financial incentives is innovative for the U.S. health care system.

S: You work with the North Carolina PACE program. What can you tell us about the beginnings of PACE in N.C.?

MF: The first PACE program in North Carolina opened in Wilmington in 2008. It has grown to four more sites across the state. Eight additional communities have PACE programs in development.

S: What kind of treatment options do PACE participants have? Who decides what is best for each person?

MF: The PACE program cares for individuals with both psychosocial and medical frailties. The participants and their caregivers become part of an interdisciplinary health care team which, on enrollment to the program and every six months afterwards, reviews a standard set of functional areas (nutrition, emotion, mobility are some of the domains) and the individual’s diagnoses and medications.

This process leads to a Plan of Care. Its goal is to maximize wellness for the participant and minimize stress for family caretakers.

S: What role do diet and exercise play in the care and maintenance of PACE patient health? What options are available on that front?

MF: Every participant exercises daily at the center, either individually with the Physical Therapist, or in balance and strengthening groups, or by riding an exercise bike for 30 minutes a day. Nutrition is part of the plan. In addition, participants have the opportunity for individual and group sessions to help them address emotional issues and patterns.

S: Where do doctor visits and other treatments take place? Is travel involved? Is there a shuttle system offered?

MF: The participant’s primary nursing and physician care are provided in the day center. Primary care nurses work there, communicating with the primary care physician, specialists, families, and with nursing aides who deliver care in the home.

PACE provides daily transportation to the day center and to appointments with specialists. With complex consultations, the primary care RN will accompany them.

S: How might this program interact with government health care spending changes brought by the health care legislation passed last year?

MF: Several themes have emerged from the legislation. The Centers for Medicare and Medicaid have focused on improving quality, reducing costs, and thinking in terms of serving populations rather than fee for services to an individual.

They have also proposed new ways of organizing and reimbursing providers that create accountability and reduce fragmentation as the means of improving care and reducing cost.

Creating Medical or Health Homes that have primary care at the center is currently being facilitated by grants to states from the federal government. PACE programs represent one end of the spectrum of providers who are already embodying these concepts; The Mayo Clinic model of multispecialist/hospital care represents the other end. In the Mayo Clinic Model, large numbers of primary care and specialists are on salary at the Clinic, providing care to a large population. The Clinic receives a fixed reimbursement for an episode of illness and is accountable to Medicare for the outcome.

S: How might the program expand? How much expansion would be good?

MF: PACE programs currently serve 21,000 Medicaid/Medicare funded individuals in 71 sites across the United States. Each site serves between 100-400 people. The Medicaid and Medicare offices would like for us to serve millions more of these “dual eligible” people because they represent a rapidly growing segment and expensive group of patients under the current “fee for service” system.

Much of the success of the PACE program depends on moving participants and their caretakers to a prevention, wellness, home and community based care system from a highly specialized, illness and hospitalization and nursing home placement system.

Our current system of care-fee for service-rewards physicians and hospitals by volume of care delivered, not by quality of outcomes. Patients and families are insulated from the cost of care.

To engage families and patients in moving from illness treatment to prevention and wellness, there must be trust between them and their physicians and other providers. I place trust and empathic relationships at the center of a successful PACE program. Patients and families must focus on wellness, including exercise, nutrition, and addressing emotional and behavioral patterns. This may require a change in their thinking and behavior, just as it does in health care professionals.

Currently, the goal for our PACE programs is to serve 150 participants, using one physician and one nurse practitioner and four primary care nurses. This is the number of individuals cared for in the average nursing home. Expanding centers beyond this size may impair communication and the intimacy required for trust and social support.

Increasing the number of PACE programs (rather than increasing the number of nursing home beds in a community), and linking smaller centers throughout a state by their funding and standard approaches to measuring patient outcomes, may be a better model for expanding the numbers of frail older individuals the program can serve.

S: And finally, why do you advocate for PACE, rather than other frail patient care models? Do you see any way that PACE could be improved?

MF: I advocate for PACE because it is the first health care program model that aligns the incentives for innovation, shared responsibility, high quality and individually appropriate care for everyone involved. Most exciting is the innovation that comes from working from a fixed reimbursement per month, allowing us to create a budgeting process for setting goals and reaching them.

After 30 years in practice, I have found a new source of intellectual challenge: how to help caregivers become more responsible yet less stressed. I, as a physician of frail older adults, have often struggled with difficult, dysfunctional families, but never have I been so motivated to actually get at the root cause of the problems and help families solve them. Part of the problem is that, as a physician, I didn’t have the psychological and social resources available to me. The PACE interdisciplinary team program supports both the physician and families in providing better care.

How to improve PACE? I would like to see less regulation by the state and federal governments. Time spent fulfilling regulatory documentation is time not spent seeing participants. We are at a level of sophistication with assessment measures that we should be able to provide financial statements and outcome reports to fulfill regulatory requirements. Electronic health records should facilitate this process. The direct and quantitative link between an individual’s level of function and the cost of care sustains the motivation toward optimizing each participant’s physical, emotional and cognitive function.

All of this leads me to close with a final statement: the organizing principles of a care system of high quality and sustainable cost are: aligned financial incentives, trusting relationships, and the goal of optimizing the psychosocial and physical function of older individuals and their caregivers. Thank you for this opportunity to share my thoughts on this topic.

S: Thank you, Dr. Fretwell.

Eva Sage Gordon is co-author of The Everything Guide to Writing Children’s Books, 2^nd edition, published by Adams Media in 2011. During 2010-11 she has taught high school in Spain and worked on her MFA in Creative Writing degree at Spalding University.

There is hunger in Florence, Alabama.

You wouldn’t think so to drive through this pretty little town with its thriving downtown and well-kept historic neighborhoods. At night when the restaurants are buzzing, it’s hard to find a homeless person on the street.

Florence does not have the kind of grocery store where union labor stocks the shelves with freshly made sushi and baby watermelons straight from a Chilean summer. For the last two decades I have shopped at a neighborhood grocery store where snuff and chewing tobacco are prominently displayed and where the hourly-wage workers know nothing about ‘bargaining power.’ Organic milk-or organic anything, for that matter-is not available at this store.

The reason I have shopped here for the past twenty-three years is because it is close to where I live and WalMart has closed down anything else that resembled competition. I have never lived in a subdivision nor do I ever intend to. People from the “section 8 houses” (government subsidized) walk to this store daily for food and cigarettes. Because it is a small store-easy to get to and easy to walk around in compared to the behemoth Walmart located on the outskirts of town-the elderly like to shop here. College students pop in for cases of the beverage du jour. But mainly it is the grocery store of the working poor. The featured items prominently displayed include a lot of saltines, white bread, canned vegetables, and store-brand boxes of macaroni and cheese and breakfast cereal.

Through the years I have seen a lot of young mothers, usually with their babies in their grocery carts, sorting through envelopes of clipped coupons as they shop, working hard to save a dollar here or there. I have seen fast food workers still in their uniforms in the check-out line with a cart full of the makings for chili or spaghetti. Later in the afternoon, the construction guys come in for a six pack and something to throw on the grill. Very rarely have I been in line behind someone using food stamps or WIC (supplemental nutrition for mothers and infants) cards.

This Tuesday I saw something at this store I had never before seen. It was around 4 P.M. and parents had just picked up children from school. This is a popular time for people to grab a few items before heading home to make dinner. I was there myself for toilet paper, some grapes and a bag of rice, not an entire cart of groceries. As I picked up a basket and headed down the first aisle, a kid, maybe eight years old, in badly fitting glasses, pleaded with his mom to buy a jar of mayonnaise. “But we’re out!” He had picked up the mayonnaise from the sale floor display and held it up to show her the product as he pleaded. “You said!” he accused. He tried another tactic. “It’s on sale.” He held the jar of mayonnaise like a sports trophy above his head before he shifted it down to cradle it in a ‘baby-doll’ position. Whatever the mother said was whispered, but the kid in the glasses put the mayo back on the display and they headed for the checkout, a loaf of sliced bread the only item in her hands.

I don’t think the reason they did not buy that jar of mayonnaise was because it was not organic.

Then on my way to find the toilet paper, I strolled by the meat counter. A man and woman in their thirties with two kids under the age of five held court at the hamburger section. They looked serious. They had obviously been in the store for a while because their cart was already relatively full of bags of potatoes, cans of green beans and corn, some dried beans, and several packs of the brand of hot dogs on sale this week. The dad had bought a can of store-brand grape soda from the cold drink machine, taken a big swig, and then handed it to the little girl, telling her to share it with her brother. When the wife showed him a package of hamburger meat, it was time for a conference. You could tell that they were adding up the cost of what was already in their cart and trying to decide if they could afford the hamburger meat. But what killed me, really killed me, was the pleading look in her eyes as she asked her husband if they could buy it, as she tried to rationalize the expenditure, there at 4 P.M. on a Tuesday afternoon in Florence, Alabama. She would really like to have the hamburger meat for her family, but they must first consult the rest of their grocery list and see if there would be enough money to buy it and the rest of the necessities they would need that week.

My grandfather was an accomplished gardener. By the time I was old enough to ride the school bus to his farm in the afternoons, he had two gardens. One was to supply food for his family. The other was to give vegetables to anyone else who needed food. One of my aunts was outraged by the people who came by to fill up bags with tomatoes, green beans, corn, and onions, people she had labeled as ‘sorry people.’ “They’re just using him,” she would say. “Just too lazy to make a garden for themselves.” My grandfather smiled at her and never said a word as he kept on cutting lettuce and pulling onions and radishes out of the ground and putting them into the trunks or back seats of the cars of anyone who stopped by and asked. My grandfather’s farm was-and this is God’s truth-halfway between Equality and Richville. My brother found the road sign the state of Alabama had bulldozed when they widened the intersection there at my grandfather’s farm. To the left: Equality. To the right: Richville. We were located exactly halfway between the two.

Coosa County is a great poor man’s county. Halfway between the struggle for equality and whatever lay on the other end of the spectrum. When my ancestors gave up owning slaves and moved there, I am not sure they knew what the future held other than hoping it was something more fair than the county from which they had escaped. Happier times, if no longer Richville.
It worries me that we seem to be drifting more and more toward what Jimmy Santiago Baca described in 1977 as “only a few people got all the money in this world, the rest count their pennies to buy bread and butter.” My father came back from WW2 and never told us anything at all except that he had seen a man shoot another man dead over a wheel of cheese. Later we found out that Daddy had been in several major battles, including the Battle of the Bulge, and that he had sat on a snow-covered ‘bench’ in Germany all winter as he ate his provisions only to find in the spring thaw that the ‘bench’ had been a frozen dead mule. We found out that he was wounded twice and one of only two people from his platoon to live through the entire war. But of all the horror he must have seen, of all the unspeakable horror there was in WW2, what he wanted me and my brother to know was this: given the right circumstances of hunger, people will do what they feel they have to do.

Butter or bullets is not a new dilemma, but in the meantime as our country figures out this latest round, maybe it is not the time to rub our gourmet acquisitions in the faces of others. As best-selling novelist Julianna Baggott, who attended Catholic school as a child, wrote in a recent FaceBook post: “Dear food gloaters who upload pics of their (gorgeous) meals: As Sister Mary Bertha would say, ‘Did you bring enough for everyone?’”

Published on the author’s blog, Talking in Accents, at amgarner.blogspot.com/2011/03/halfway.html

The contentious maelstrom around abortions routinely neglects an important aspect, the well-being of those who are pregnant.

I was trained at Los Angeles County Hospital in the mid-1960s. In those days, if you decided to terminate your pregnancy and were well-off, your family flew you to Japan or Sweden. If you were poor, you sought a local abortionist.

Abortion being thoroughly illegal then, there were no professional standards. Abortionists didn’t need a degree, experience, or, for that matter, scruples. They did their work with whatever came to hand–kitchen implements, harsh chemicals, even turkey quills. More often than not, their patients/victims developed bleeding, perforation, and infection. When I was on my Ob-Gyn rotation, we daily saw an average of eight to ten women with these complications. Many were as young as twelve, often hurriedly dropped off at the ER by frightened boyfriends or parties unknown. On the average, one died every day.

Imagine that: your daughter, who still keeps dolls in her bedroom, getting secretly pregnant, mutilated by a backstreet criminal, and shamefully dying alone. If abortion once again is declared illegal we’ll return to those days. As always, the wealthy will find little difficulty terminating pregnancies and the less affluent will risk death while their impregnaters suffer no risk at all.

To say to these young women, “You should have thought of that before…” strikes me not only as inhumanly callous, but actually supportive of the taking of a human life.

Article originally published on Dr Kane’s blog at http://healthcareasthoughpeoplematter.blogspot.com/