On centering reproductive health and access in the public health agenda

Thoughts on the possible overturn of Roe v. Wade and public health’s responsibilities in this moment.

A few days ago, Politico obtained a draft majority opinion written by Supreme Court Justice Samuel Alito. If the draft becomes the Court’s final opinion, it will end the constitutional protection of abortion access, first established by the 1973 decision, Roe v. Wade. If that happens, decisions about abortion access will fall to the states. Even recognizing that this leak is not yet the settled opinion of the Court, the news is heartbreaking. This leak suggests there could soon be a seismic shift around this issue, as federally protected abortion access—a fact of life in this country for nearly 50 years—reverts to a status quo not seen since before many Americans were born. The implications of this decision are enormous. 19 states will effectively ban abortion, immediately affecting access for more than 40 million women, and abortion rights will no longer be protected in a majority of states.

This possibility is simultaneously shocking and expected. It is shocking that access to a foundational right could be suddenly restricted for so many. It is expected because we have long known this was likely coming. Roe v. Wade was always fiercely contested. For decades, the push for its fall has been an animating principle of the country’s conservative movement. The shift to a majority of right-leaning Justices on the Court has for many months now made the overturn of Roe seem inevitable.     

It is important to state unequivocally that abortion is inextricably linked to the health of the public. As such, our ongoing engagement with abortion and the broader issue of reproductive health is at the heart of our mission as a field. Reproductive health is public health, and abortion access is core to how we address reproductive health in this country. Throughout our history, generations of scholars have engaged with the issue of abortion—its social, legal, economic, medical, and political implications. I have also engaged with this issue in my own writing and thinking. This work, as with the work of many others in the public health community, has long aimed to address the many challenges at the heart of the abortion debate, while keeping a core focus on health.

Central to our concern with the consequences of this moment needs to be an acknowledgement of who the abortion debate—and the potential overturn of Roe—most affects. Abortion rates are deeply influenced by the structural factors that shape all aspects of the health of populations, with race and socioeconomic status playing a central role. Black women are five times more likely to have an abortion than white women. 49 percent of abortions are concentrated among women below the federal poverty level (Figure One).  Restricting access to abortion is a quintessential regressive act that harms the health of populations overall, but also widens health gaps through harming the health of those who need health protection the most.

Figure One

Source: Abortion rates by income. Guttmacher Institute Web site. https://www.guttmacher.org/infographic/2017/abortion-rates-income. Accessed May 3, 2020.

The future of Roe, then, is intertwined with the future of marginalized populations who have long borne the brunt of health gaps. In particular, recognizing that access to healthcare is already more limited for people of color than it is for White Americans, further limiting access perpetuates and exacerbates our shameful national history of structural racism. Engaging with the issue of abortion access and reproductive health then is inextricable from public health’s mission of placing the health of marginalized groups at the heart of all we do.

In keeping with public health’s engagement with these issues, we have a role and a responsibility to work towards a just status quo around abortion and reproductive health, regardless of the Court’s decision about Roe. I offer here three actions that might help support our engagement going forward.

First, we can state clearly—as I am here—that abortion is both a right and a health issue. While I realize that there are legal challenges to the first of these statements, it is hard to countenance that something as intimate as an abortion can be separable from the foundational right to bodily autonomy. On the latter, even those who are inclined to oppose abortion access should be able to see there are times when the context of health makes such an option necessary, and that a individual and their doctor should be free at those moments to pursue that option without state interference. There is abundant evidence that criminalizing abortion results in complications—including death—due to illicit abortions; estimates of the number of worldwide deaths due to unsafe abortions range from 20-68,000 women annually. By contrast, there is little evidence that banning abortion reduces its incidence. While the availability of safe, at-home abortion pills have increased via telehealth, its access could also be in jeopardy. We should therefore continue to argue for legal abortion access as the health issue it is, appealing to the fundamental human right to health and the principle of universal access to healthcare. The same is true of the broader range of issues that inform our support of reproductive health, from making contraceptives more available, to providing sex education, to advancing a more equal, egalitarian world in which women no longer face disproportionate burdens due to outdated attitudes about sex, birth, and childrearing.     

Second, we should maintain and deepen our partnerships with organizations that share our commitment to reproductive health. Such partnerships help us advance the provision of necessary services and they help us engage, at the political level, with the legal underpinnings of health. The problem posed by the opinion that may soon come from the Supreme Court is not one that public health can solve on its own. It will take working with a broader movement, as we organize towards a healthier world. For my part, I have for several years now had the privilege of serving on the board of the Planned Parenthood League of Massachusetts, following the lead of many colleagues who have worked with such organizations. Thank you to all who engage in these partnerships.

Finally, this moment calls on us to return to the fundamentals of our field. I realize that abortion is a highly emotional issue, intertwined with morality, philosophy, religion, and intimate lived experience. But I have often found a focus on the foundational principles of public health can be clarifying, helping ground our efforts in core values. Guided by our values, it strikes me that our responsibility in this moment is to bring clarity to and inform the public conversation around abortion and reproductive health, as we work to advance the public health practice that shapes a healthier world.  Perhaps this is always our responsibility, and now, in a time of challenge, more so than ever.