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This interview with Michael Brumage, the Medical Director of Cabin Creek Health System and Program Director of Public Health/General Preventive Medicine Residency at WVU School of Public Health, was conducted and condensed by frank news.

frank: Thank you for speaking with us Michael. Will you tell us about your background?

Michael Brumage: My name is Michael Brumage, I'm an MD and I have a master's in public health. Currently I'm the medical director for Cabin Creek Health Systems. I'm also the program director for the general preventive medicine residency at West Virginia University in the school of public health.

I am a native West Virginian. I went to undergraduate and medical school at West Virginia University.

How did you get your start working on pandemics?

I started by working in internal medicine for the United States Army and later became a preventive medicine physician. From 2005 to 2007, I was the chief of preventive medicine at Tripler Army Medical Center in Honolulu. While I was in that job, I wore two other hats, one as the public health emergency officer, PHEO, for the Pacific Regional Medical Command, and PHEO for Joint Task Force-Homeland Defense, which covered all the U.S.-affiliated islands in the Pacific. I was up to my neck in pandemic planning.

At the time we were planning for Influenza A H5N1, the “bird flu”, the highly pathogenic avian influenza we worried would become the next pandemic virus. Fortunately, it never acquired the characteristics to spread easily from person to person. While it had a very high mortality rate, it didn’t spread easily. I understood what was at stake from the very beginning of this current pandemic.

This has transpired, largely as I hoped it would not.

How so?

I had hoped that our government would have been more proactive in seeing the danger and expressing that to the American people, and that did not happen. Now we have to make really hard decisions about what price we're going to pay. In places like New York City, Seattle, Boston, we are reaching the capacity of our healthcare system and may soon overrun it.

How will this affect rural communities, like yours in West Virginia?

We have to consider how we can prevent the spread to rural areas of the United States. Where we are in West Virginia, we serve people from all walks of life, but are primarily in underserved areas. We have clinics in formerly very heavy coal producing areas, and we deal with a lot of chronic illnesses like heart disease, lung diseases, and diabetes.

The Kaiser Family Foundation recently did a study evaluating at-risk populations for a pandemic.

West Virginia had 51% of its population over the age of 20 at risk for complications. The national average is 41%.

We are not only dealing with individual human beings that have chronic medical illnesses, but also Hepatitis B and C, and HIV cases related to intravenous drug use. In addition to these problems we now have to address a pandemic that strains our own internal capacity. What's most concerning to me is that we are working with very high-risk populations for complications from coronavirus.

How do you prepare for a pandemic in the face of that reality?

As the medical director, my effort in the last couple of weeks has been almost solely focused on preparing Cabin Creek Health Systems for a pandemic, which includes 11 sites in Kanawha County. We've been preparing to try to segregate people with respiratory symptoms away from other patients, moving toward deferring visits that do not require an in person visit, and trying to shift more to telephone and telemedicine to care for patients. We will still need to see patients in person for a variety of issues.

Yesterday I was in clinic for the first time in a while and actually swabbed someone for COVID-19. He had been on a cruise with two other family members with upper respiratory symptoms. I tested him for COVID-19 after donning personal protective equipment and administered the nasopharyngeal swab. We will find out the results in a few days.

This has been the pressing issue for me: worrying about a pandemic with the background of people in a state that ranks first in almost every bad category of health indicators, and usually bottom three for every good category of health outcomes.

It's a real challenge because our population is sicker than most.

If it hits here the way it does in other places, we're soon going to be out of ICU capacity and hospital bed capacity. There may be difficult triage decisions made for people to access care.

One advantage I think we have is that we are rural. People either live on ridge tops or they live in the hollows and that tends to create its own capability for social distancing. Whether you're in rural America or urban America, you're going to do pretty well if you practice social distancing. The question is whether or not we have the discipline to maintain social distancing, and biting the bullet on economic damage that it is going to do.

The case number is currently low in West Virginia. How are people responding in a place that is not visibly taken by the virus?

_{https://dhhr.wv.gov/COVID-19/Pages/default. | 39 Total Positive Cases as of 11:47PM PST 3.24.20}

First of all, we don't really know how many cases there are. This is a huge blind spot everywhere in the United States, and here in West Virginia as well. While we know we have eight cases [on 3.21.20], I think everybody in public health understands that the real number of cases out there is much, much higher.

We are really like soldiers on a battlefield in a fog. We know the enemy is out there, but we don't know their strength in numbers.

I think many people here, from what I can gather from social media, are still in disbelief that this is as bad as it was because of messaging that came from some conservative media sources and the message that was coming from the White House for some time. I think the lingering effect of that is that there are many people who don't take it seriously. Two days ago, I went to a supermarket and I still saw people walking out with rolls of toilet paper under each arm, which I can't comprehend because there is no toilet paper shortage. And instead of just getting in and out with their toilet paper, I saw people congregating in the parking lot having discussions, which is an anathema to what we should be doing right at the moment.

Right. There is something strange about going to a store right now, without knowing what the future looks like – even with all the information I have, I pause and think, do I need more stuff?

Definitely. That attitude can be very contagious.

When we look to countries ahead of us chronologically, how can we use their experiences as a model?

If we stop and take a look around the world and how different people handled it, we're going to find success stories that could help lead us to a better place. One is China.

China of course, made the fatal flaw of suppressing the information on the virus, and we're all suffering because of it.

Because they have much more authority to enforce disciplined public health measures than we do in Western democracies, they were able to clamp down very rigidly on their population. This sort of radical social distancing and enforcement of quarantine seems to have worked in China. I think they may be out of the woods, depending on how they manage the subsequent waves of disease that are inevitably coming. While there may be no more new domestic cases, China is very connected to the rest of the world and can import cases.

Then you have South Korea. South Korea was an early leader in terms of number of cases and number of deaths. The Korean CDC is a capable and intelligent organization. They rapidly deployed testing kits and identified the people at risk and tested them. Whoever was positive, was isolated immediately. This is very widespread, population-based testing, an aggressive management of the disease seems to be flattening the curve in South Korea. They seem to be a model we can follow. In general, South Korea looks a lot more like Western countries politically, than they do a rigid, authoritarian country like the People’s Republic of China.

If we want to really get a hold of this, we have to expand testing radically.

Part of this is buying time everyday so we can slow the spread and allow industry to catch up, to allow research to catch up, and to implement widespread testing. This will really make a major difference in our response.

What can we expect given our current reality?

My concern is what frequently happens when you start to get success is that you become complacent. I anticipate we will eventually succeed in controlling this in some manner or another. The reality of the situation is going to hit home, even for the people who are still out there in denial. I anticipate that over the summer months, the disease will wane and give us the sense of security that we've kind of got this thing under control.

I really worry about what's going to happen in the fall if we let universities reconvene and schools reconvene.

People from all over the country are going to descend on campuses and share their viruses, which happens every year. This could reignite the whole situation. That’s why we really need to have a much tighter testing regimen in place by fall. We can buy time through the summer months and become very aggressive about developing testing, including point of care testing. There's a difference between what we're doing now with testing, which is the nasopharyngeal swabs and sending it off to a lab for evaluation, and things like the rapid flu test, which we can do in an office setting in about 30-45 minutes. We have a similar test already for influenza. In those cases we test, keep the patient in the office and tell them whether or not they have influenza. A similar test for coronavirus would be ideal. I believe it could be a prerequisite that the student body and the faculty would have to be tested and be certain they were negative before returning to campus.

Coronaviruses are not new to the United States. There are at least three other coronaviruses that show up in our communities and present like a common cold. What we are concerned about here is the more pathogenic and dangerous COVID-19 virus. We need a test that could be easily administered, and then we need to be able to isolate the positive cases that do come back away from the population.

In some ways, it's like when you think you've put out the forest fire, but those smoldering embers lying in wait can help reignite the fire all over again. My greater concern over the long term is that we become complacent and that this disease makes a resurgence in the fall months.

Data is finally emerging, but I feel like data is only as useful as the person interpreting it. How are you reading what comes out of China, Italy, or South Korea?

Data is also only as good as the people collecting it, and what they are collecting.

The Chinese data and the South Korean data especially, are the best gauges for what the real case fatality rate is.

There's a lot that comes into play here. So again, South Korea has done much broader testing, they're identifying the less symptomatic cases, as well as the extremely ill cases. The last time I looked, the fatality rate was 0.8%.

Italy on the other hand, is not doing the broad-based testing. It could be that their case fatality rate is in fact higher because they can't deliver the level of care required to every person coming in because they're making triage decisions – literally who's going to live and die. Because they are in this dire situation where they have outstripped their capacity, people who might have survived previously are no longer given that opportunity because there's not enough intensive care unit beds, ventilators, and intensive care unit staff. We have to look at all the data from a wide variety of angles.

What is the real number? I'm looking at the South Korean model as the most accurate, even though it's probably not perfect. If we can drive the case fatality rate down to 0.8% that means: a), we're doing enough testing and b), we're maintaining our capacity to care for those who are extremely ill.

What else do we need to pay attention to right now?

One is that we have to plan ahead for vaccine distribution. We know when this vaccine is finally produced, we are not going to have enough for everybody, and it's going to be available gradually as production increases. People like health care workers and first responders are going to be among the first in line. People at highest risk of disease are going to be next in line. We have to begin to communicate those priorities well in advance, in order to prevent public panic.

Think about people trying to get vaccine when you see people hoarding toilet paper.

The communication has to be clear.

One of the most touching things I saw in relation to pandemic preparedness was a mass vaccination on Saipan in the Commonwealth of the Northern Mariana Islands. In 2007 and 2008, the Department of Defense received an excess of flu vaccine they were planning on paying a company to destroy. At the same time there were people in places like the Pacific US territories that weren't getting enough. I thought, we have this need in the Western Pacific, so why not use it? I was able to get it shipped out and used as part of the community's pandemic planning.

How do we plan for a mass vaccination?

Ultimately, that's going to come down to planning at the local level. That means local health departments and hospitals and other health organizations will have to collaborate with law enforcement to set up mass vaccination sites that may include drive-through vaccination clinics where you are.

Got it.

I wanted to mention that at the end of this, we have to ask ourselves, “How could we let our public health system fail the way it did?”

When it comes to a pandemic, you see how the system has failed because it was underfunded and under-resourced at the federal, state, and local levels for many years. We often boast that we have the best healthcare system in the world. That myth is busted if we are failing even the doctors, nurses, and other staff on the front lines of this pandemic without adequate personal protective equipment. How could this be allowed to happen when we knew that a pandemic would eventually hit?

I was just listening to NPR on the way to talk to you and I heard somebody talking about how a pandemic bears a similarity to earthquakes, another periodic natural event. If you live in Los Angeles, you know that the big one is coming sooner or later. We knew pandemics were coming. It was inevitable. And yet we were so ill prepared for this.

This is a societal failing to undervalue public health.

We have to reimagine how we view health. We have typically viewed health through the lens of health care, when we know about factors called the social determinants of health that account for 80% of a population’s health. I'm talking about things like employment, economy, education, housing, transportation. All of these things play together in the health of people. The growing homeless problem you have in Los Angeles, in San Francisco, and even here in Charleston, West Virginia is a nationwide phenomenon, and these are people who are at high risk for all kinds of bad health outcomes. We are together only as healthy as the least healthy among us. They are the weak links in the chain of health. We have to have the view that we are interconnected.

We need to be prepared for the next pandemic that will inevitably come, and look at health from a holistic perspective. At the social services, at education. All of these things are crucial determinants of health for our nation and for our planet. If we fail to do that, then we have fundamentally failed to learn the lessons of this pandemic.

You’re so right about LA – it's cognitive dissonance. It's too big to wrap your head around. Right now there’s no looking away. Hopefully we use the opportunity as you suggest.

You nailed it. This cognitive dissonance is so true. We can't ignore it, and we're all paying the price for all of the weaknesses in our chain of health, in our chain of healthcare, and in our failure to plan for the inevitable. I think it's just such a profound quote from Tom Friedman who said, “We have to manage the unavoidable to avoid the unmanageable.”

And I thought, wow, that's really the whole pandemic in a nutshell. We have to face what's clearly in front of us. We can no longer look away, otherwise, we are setting up future generations for a failure on the scale that we see today.

Hi Karissa, so happy to speak to you today. Would you mind starting by introducing yourself and telling us a bit about your background?

Sure. I'm Karissa Haugeberg. I am an assistant professor of history at Tulane University. I teach courses on US women and the law and also the history of medicine in the United States. My first book was about women's participation in the US anti-abortion movement from 1960s until the early 2000s. My next book project will be about the history of nursing since 1964 in the United States.

Incredible, I was hoping we could begin by framing abortion in a historical context. As far as I understand, it's gone through different legal phases: from unregulated to regulated and then to a reform of that regulation. Is that correct?

Yeah. I'll just begin with this: women have always had abortions. That in and of itself is not a new phenomenon. Women have always sought them no matter what the legal status of abortion has been.

Until the 1820s, women were permitted to have an abortion before quickening. Quickening was the moment a woman recorded that she felt the fetus move. Basically, people had to trust a woman's judgment and what the woman was saying. As long the woman claimed that she hadn't felt the fetus move, no crime had been committed.

And that is until when?

Until about 1821.

Okay, wow. So when did contemportary abortion law come about and why?

The first more contemporary anti-abortion law was passed by Conneticut in 1821. What's interesting about that first wave of abortion laws is that they were largely poison control measures and they did not target women. The laws resulted from concern about unregulated salesmen who were selling abortifacients. These were herbal remedies or pills that were actually unsafe and were sometimes harming and killing women. It could be argued that really the intent of the laws was to protect women's health, protect them from these unlicensed, unregulated entrepreneurs.

There was a really thriving trade of abortion practice in this time. Typically, women just went to their networks of other women, similar to the advice networks set up for figuring out who to deliver your baby. It wasn't uncommon for the midwife to also be an abortion provider. There was just very little attention paid to this.

It was all considered a private issue, personal, medical. The state just wasn't that interested in regulating it.

During the conversation during this time, whether it's between a woman and their physician or amongst the family, is there any moral argument being made or is this something that's detached and medical?

There was not a whole lot of moral discourse about abortion, the exception being the Catholic Church. The Catholic Church has been pretty consistently anti-abortion, but they didn't have a lot of political sway in the 19th century. They weren't politicians for the most part, they weren't influential lobbyists, so this moral argument was pretty small and limited to the Catholic Church. One thing to keep in mind is that Catholicism is associated with immigrants in the early 19th century, and for middle-class white Protestant Americans, this just was not one of the moral issues they were talking about.

Things started to change in the middle of the 19th century. It was physicians who really led the charge to criminalize abortion in the way we now think of there being anti-abortion laws, ones that target both women and providers.

What was the response of physicians?

This coincided with the professionalization of medicine in the United States. We were really late to the game. Physicians in Europe already had to be members of a guild, go to college, pass exams in order to be admitted to practice medicine. In the United States until the middle of the 19th century, a person could go to college for a year, graduate from high school, hang out a shingle and call themselves a doctor. That was perfectly legal. Physicians, beginning in the 19th century, tried to professionalize and have national standards: make everyone graduate from college, make people pass an exam in order to be admitted to the American Medical Association.

In that process of trying to take away business from midwives, but also delegitimize them. They understood abortion and labor to be lucrative. It was a way to establish that relationship with a future client. If a physician delivers a baby, that's perhaps who those women will turn to when those children get sick or when their spouse gets sick. It was a targeted business decision and it was about establishing their authority. To establish their authority, they argued that abortion was profoundly dangerous, which it really wasn't. It was safer than actual childbirth. Physicians also began to use the moral rhetoric that we now associate with ministers. They started talking about how it was just so immoral that these women were making this decision. Several of these prominent physicians would say things like, "Abortion is murder, but it's sometimes necessary. That's why you need a physician to intervene, to figure out if this is an acceptable time to commit this act." They almost provided this moral authority to arbitrate whether it was permissible or not.

What's the response then from women at the time?

A lot of their critique of the way that men were treating women got wrapped up into the way they were talking about abortion. It wasn't until well into the 20th century that marital rape was considered a crime, so a lot of these feminists pointed out so long as men are just entitled to their wives' bodies, these women are always going to vulnerable. It's going to put them at risk of needing abortions if they want to control their fertility because this is before there's reliable birth control. That's part of the context that they're thinking about when they think about abortion. They see abortion as potentially dangerous and that it seems really unfair that women have to subject themselves to this potential danger because of all these factors, these ways in which women lack equality.

Right. Is family planning a part of the conversation at this point, also? Obviously, you're saying there's lack of access to reliable birth control. Is that a consideration from women in this discussion?

That’s a really good question and, in a sense, one could argue that the history of abortion demonstrates that women have always sought to plan their families. We can look from the perspective of 2020 and say, "Yeah, it looks like those women were committed to family planning." They wouldn't have used those words to describe what they were doing, but that's it. That is what they were doing.

In the 19th century, a lot of women who got abortions were married women who were trying to control the spacing in between children, arguing that in order to be good moms, they needed to not have five children under the age of five. Alternately, women who were single often turned to abortion in order to remain marriageable because it was so hard to find a partner who was willing to marry you if you had a child out of wedlock. The rhetoric of family planning really gets popular in the 1910s and 1920s with Margaret Sanger's activism.

That makes sense. By the 20th century, every state in the United States has classified abortion as a felony.

That's correct. Again, it's physicians who drove that campaign. They're the ones who lobbied state legislatures to criminalize abortion. Those criminal abortion statutes were really serious. In a lot of states that made providing or even seeking an abortion was a felony offense. More abortion providers were prosecuted than women, and the reason for that are twofold. One, often the thing that triggered these prosecutions was a woman dying, so there wasn't a woman there to prosecute. The second reason is when a woman did leave, let's say there was a dragnet and the police where criminal abortions were being performed, they would often offer women a plea deal if they agreed to testify against the person who performed the abortion.

They were always after, like in the drug trade, they're after the supplier.

Right. Yeah, they're getting the little guy to slip.

Exactly.

Culturally and, I guess, politically, what propelled us from this place where every state has classified abortion as a felony to Roe v. Wade?

One thing that plays a big role in abortion access is the state of the economy.

When the economy was not doing well during the Great Depression, authorities for the most part turned a blind eye and the abortion rate spiked. This was true globally, people, in todays terms, were attempting to practice family planning when they could not put food on the table. Abortion was still illegal, but authorities really diminished prosecutions because they understood that if people are suffering and then they go after this source of relief, it would be enormously unpopular. Conversely, when the economy was doing well, there tends to be this renewed emphasis on promoting family. Think about the baby boom of postwar America. There was a renewed crackdown on criminal abortion in the 1950s and 1960s. That's really when we see the underground market, the unregulated market really taking off in the United States.

When prosectutions start ramping off, doctors stopped providing abortions because they're afraid of going to jail or losing their practice, so this teeming criminal enterprise opened. Low and behold, you see the death rate just spike because instead of turning to physicians, women are increasingly turning to underground, unlicensed people. This is where you hear these horror stories, or if you've ever seen that photo of the woman who's lying in a pool of her own blood on the floor, that's taken in this era in the 50s and 60s. Hospitals end up having to open up entire wards called septic wards to treat women dying of blood infections, like bacterial infections from using knitting needles or ingesting Lysol, trying to throw themselves down stairs.

It is also coinciding with more women going to college, so they're wanting to delay their pregnancies in order to maybe go to law school or medical school. Women's lives were changing so much after the war, and yet these laws remained unchanged. Suddenly, affluent white people started to see their daughters dying, friend's daughters dying, so there was real public outcry.

One additional factor is that there was an outbreak of German measles. When women contract German measles when they're pregnant, it can result in birth defects or a loss of a pregnancy. Americans came into contact with women who had wanted pregnancies, were mothers, and then were suddenly in this position to want an abortion and couldn't get them. There's something about being, again, affluent white middle-class mothers who want another child need an abortion that suddenly makes Americans more sympathetic to the issue. This propelled state legislatures at the state level to begin liberalizing abortion laws.

During this time, 50s, 60s, I feel like the prespective on abortion was divided along religious lines. There was a section of Catholic voters opposed to abortion access that were a really big part of the New Deal Democratic coalition. You look back at Barry Goldwater, who was staunchly pro-choice. How did it become then contentious along the party lines as we see it today where it seems the GOP takes the conservative, anti-choice stance? I can't really imagine a Democrat being elected to state legislature or senate or anything with a non-pro-choice perspective.

No, absolutely. You hit the nail on the head. There's such a profound realignment that is kind of stunning if you look back at it.

In the early 1960s, in general, Democrats were slightly more anti-abortion than pro-choice. Republicans were slightly more pro-choice than anti-abortion.

This was due to the fact that the Democratic party was the home for many Catholics. How did this all change? A large part of that story has to do mostly with the realignment of the Republican party. In the late 1960s, several of Richard Nixon's strategists knew they had a very close reelection coming up. Their goal was to try to animate new voters to come out and vote for Richard Nixon.

At the time evangelicals were somewhat of an afterthought politically, but Nixon's team figured out if they could mobilize Evangelicals to come out and vote Republican, that would be a significant enough wedge of voters that it could enable Nixon to win. They had to craft Nixon into somebody that could be considered to champion their values. They argued that school prayer was under assault, they decried the legalization of birth control as leading to changes in gender, they pointed to the feminist movement as changing families away from the traditional American family, and they argued that “traditional” America was being upended by programs meant to promote desegreagation. Abortion became one of these issues. An issue that Nixon previously didn't seem to care about suddenly became pretty central.

After Nixon was impeached, Gerald Ford represented the more typical Republican politician over there. He was deeply uncomfortable talking about abortion. That wasn't part of partisan politics, so he signaled a return to how it had been. Some people within the Republican party looked at Ford and his unwillingness to embrace this more Moral Majority right position, and say, "Aha, look what happens when you step away from this emerging coalition. You lose." They made sure that wouldn't happen again, so one of the most robust parts of Ronald Reagan's campaign was to very aggressively court the Evangelical right and the Moral Majority. The Moral Majority was happy to align with him. They saw if they could get out the vote for him, they could maybe help select judges. It's in 1979 that the Republican party for the first time adopts a pro-life plank as part of the Republican platform.

It's so late. That's so crazy.

Yeah, but it took a while to get there. It starts with Nixon, it's really uncomfortable, it gets to Reagan. Even in that time, it's still deeply uncomfortable within the party because you have all these Ford-type people and George H. W. Bush-type people who were either pro-choice or thought it was uncouth to talk about abortion that way.

Right. You deal with that in private, please.

Exactly, that's a private issue. There were a lot of Republican politicians who openly identified as feminists and it wasn't a cynical feminism. They promoted gender equality. They were deeply uncomfortably with what was happening. You just basically see a reckoning unfold in the Republican party. Basically, that very conservative faction won. By the time you get to George W. Bush, there is no question. If you want to win a primary, you basically have to be anti-abortion. As part of that reckoning, they were basically able to take conservative Catholics away from the Democratic party. The degree to which the Democratic self-consciously became the party of choice, one could make that argument, but there's almost a way in which that's what they were left with. They were almost a reactionary party to the party that was taking the oxygen out of the room, which was the Republican party through its realignment.

The Democrats, they then affirmed a pro-choice plank one year after the Republicans did. I want to say it's '79 is the Republican party, then 1980 is the Democratic party. You just see them following suit or following the lead of the Republican party.

Right. The Republican political line, by this time, it is morally reprehensible and it's a moral religious argument that they're making.

Absolutely. In this time period, in the '70s and '80s, you're not hearing as much about abortion is a horribly dangerous thing. You hear that a little bit in the grassroots, but as far as major politicians, they're definitely just using very moral religious rhetoric to make these arguments that they are saving babies.

That makes a lot of sense. Again, by this time, what is the women narrative? How are women talking about abortion and access to abortion and what it means to the feminist movement, obviously, during the same time period?

Right. The feminist movement is just so radically altered by this time, by the 1960s and 1970s. One of the major things we have to remember historically is that the pill had just been made available, an effective form of birth control in the 1960s. Women began to see how the ability to control reproduction meant the ability to complete college. It meant the ability to go to law school. It meant the ability to go get on the career track maybe to becoming a manager in a company. They very clearly saw the links between that ability to control reproduction, the ability to control one's body, and the ability to control one's destiny. You weren't destined to have to get married in order to survive economically.

Abortion in the 1960s became embedded in this rising feminist consciousness in a way that it just wasn't part of the imagination of the 19th century.

By this time, what's the physicians' stance? Has that changed?

That's changed dramatically. Whereas physicians led the movement to criminalize abortion in the 19th century, they were among the groups that were calling for the decriminalization of abortion by the late '60s.

What changed?

They were doing so for two reasons. One was they were getting that uptick in women coming into the emergency room dying of criminal abortions. They were first-hand responders watching criminal abortion was doing to young women, so they were horrified by what they were seeing. But a second reason why they led this campaign is that they were so afraid of being prosecuted for making the wrong decision. For example, if a woman came in suffering from a miscarriage and needed a D&C, there was always this specter of worry, "Will people think I'm really just performing an illicit abortion and using this as a cover?" or, "What do I do when my state only has an exception for the life of the mother, but I know her health may suffer, and I go ahead and perform this. I'm technically not complying with the law. Am I vulnerable to being prosecuted?" Because the law just didn't match ordinary human experiences, these physicians believed that they weren't able to exercise their professional judgment. They resented that and they were afraid, so they worked with the American Law Institute to try to reform state criminal abortion codes so they didn't feel as nervous just doing their profession.

Right. Where do the nurses come in and fit between the two groups. As an overwhelmingly female dominated industry in the medical field, it seems that they would be staunchly pro-choice. But that is not the case at least in the 1970s, could you elaborate on why that is?

When I was writing my first book, I kept coming across all these images of pro-life nurses, or anti-abortion nurses. They formed some of the first anti-abortion groups. I was just so stunned by this because there were all these physicians who were advocating for the decriminalization of abortion. Why were nurses so different when they were working in the same hospital, working with the same group of women? One of the things that I discovered was that in the late '60s and early '70s, many nurses did not have bachelor's degrees. Instead, after high school, they entered 3-year hospital-based nursing programs, like a nursing school. There's a really strong corelation between the amount of education a person has and their attitude about abortion. The more education one has, the more likely they are to be pro-choice. That's one possible explanation for why nurses tended to be more anti-abortion than women in other professions, like social work or teaching, or compared to men in healthcare.

As I investigated more, I learned that it was more commonplace for women to get a second-trimester in the '60s and '70s; that's for a lot of reasons. It's something that's gone down a lot. But at the time, the procedure for performing a second-trimester abortion was called a saline abortion. Among the things that I learned is that the way that that was administered is the physician would often inject a woman's uterus with a saline solution and then leave the room and basically have minimal or no contact with that woman ever again. It was left to the nurse to stay with woman while she labored and eventually had a miscarriage, so delivered a baby that was stillborn, or was dead from the saline. There were ways in which this could be... if a person is not trained to deal with this, it was stressful. Some of these nurses weren't even trained, like given directions about how to dispose of these fetuses. It's not totally shocking that they found this to be upsetting. They resented this new workload that they had because, again, there was a massive influx of women as soon as abortion was decriminalized initially.

These women felt overworked, overburdened, and they were doing traumatic work. I came to be more empathetic to these women who just felt they were left without a net.

Yeah, no. That makes a lot of sense.

Okay.

Do you see a way to decouple the moral religious grievances that come with the abortion conversation from the conversation entirely? Is there a way that this can be something that is less polarized, that is less extreme, that is less difficult? Ultimately, is this always going to be a central stance of the Republican party? Do you see a way that that changes?

In the short term, I don't see the Republican party abandoning this because it's been such a successful strategy for ensuring that they have a very stable, loyal base. Think of Donald Trump. A lot of people wonder how is it that a person who is a philanderer, in many regards pretty immoral in his personal life, definitely not religious, how was he able to garner the support of so many Evangelical Christians? It's because of his promise to nominate anti-abortion judges.

Because there's such a quid pro quo in this relationship, it would be foolish for someone running for Republican office to abandon that loyal group of people who can help push them over the edge and win.

From just a very cynical political calculation, I cannot imagine why a Republican would abandon that base. One thing I often find myself thinking about is, if we're being honest about this issue, in many ways, opposition to abortion is a religious belief.

It's a belief about morality and when life begins. If we were to value a strict separation of church and state, I think it's possible to have political discourse that isn't about this issue. For example, if we agree that this is a moral religious issue, it's then inappropriate for us to have it at the focal point of public policy... to regulate it, to make it go away. Conversely, if we think about the right to abortion as a public health issue, it's inappropriate to take it away on grounds that are religious, right? If we're foregrounding the ways in which this is key to keeping women's health safe, a moral argument is inappropriate. Again, if we can think about our obligation to separate personal moral religious beliefs from issues of the state secular issues about health, I think that would be tremendously helpful and important.

Right.

If we're going to keep our attention on like the medical reasons for abortion, there really are not really compelling reasons to regulate it.

And is that something that you can see happening or are we too sort of...

I do not see that happening because in a variety of contexts, including gay rights, the courts had been more permissive of religion and The Affordable Care Act.

There is more emphasis placed on people protecting religious freedom than there is on protecting freedom from religion.

So, I do not really see there being an end in sight to this so long as the courts continue to value religious expression over the ability to be free from religious controls.

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