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Article of the Month

 , August 01, 2019

SGIM in Alabama: Making Our Mark in Controversy

Sirisha Narayana, MD, and Erin Dunn Snyder, MD

Dr. Narayana (sirisha.narayana@ucsf.edu) is an assistant professor of medicine at the University of California, San Francisco, and a former SGIM Leadership in Health Policy and Advocacy (LEAHP) Scholar. Dr. Snyder (edsnyder@uabmc.edu) is an associate professor of medicine at the University of Alabama, and has lived and worked in Alabama for most of her life.

On Tuesday, May 14, 2019, the Alabama State Senate approved a measure to ban abortions in the state, except when the mother’s life is at risk, with no exceptions for rape or incest. Abortion would be considered a crime, thus holding physicians accountable. Since that time, other states have enacted similarly strict abortion laws, many of which would not allow abortion once a fetal heartbeat is detected (as early as six weeks gestation). However, other states are now passing laws that expand or protect access to abortion. Long a hot button political issue, the United States is on the cusp of a major policy shift around abortion. It is not clear which way the country will move.

Legislation around abortion and contraception have real and lasting consequences for our patients. As internists, we often care for women of childbearing age and counsel patients on pregnancy and contraception. Many of us help manage complex medical issues during pregnancy. As members of the Society for General Internal Medicine (SGIM), we pride ourselves in this organization’s core values, to “[lead] the way to better health for everyone” and establish a “just system of care in which all people can achieve optimal health.”1 We are concerned that legislation limiting access to abortion will create inequities and injustices, making it harder for women to receive care they need.

The 2020 SGIM National Meeting is being held in Birmingham, Alabama. The national meeting is designed to promote collaboration, share research and educational successes and failures, and motivate each other to practice the best medicine and provide the best care for all. Every year, we return from this meeting inspired to think more creatively and collaborate more effectively to create the just healthcare system our patients deserve. Hosting our national meeting in the same state that is attempting to eliminate a critical health care option for women is controversial. Some have called for SGIM to consider moving the location of the 2020 meeting away from Alabama, saying this law does not model our professional values.

We are writing today from inside and outside of Alabama to share our perspective on a more meaningful and impactful response. While SGIM leadership has articulated financial reasons for not moving the meeting, the abortion law in and of itself is all the more reason we should go to Alabama in 2020. We can capitalize on our presence in Alabama and the fervor around the abortion law to 1) learn from local and community stakeholders, 2) execute programming around contraception, family planning, and medical abortions, and 3) partner with colleagues in local advocacy—all to ensure we continue to champion women’s health.

The SGIM meeting in Alabama would allow many members to learn from a community quite different from their own. Abortion is an issue around which many have very deeply held beliefs, us included. While bridging differences may sometimes appear intractable, conversation is often a powerful tool to move forward. By engaging with colleagues, trainees, and community stakeholders living and working in Alabama, we may be able to better understand the broader context of the abortion discussion. We can explore the nuances of how we may weigh our underlying values, witness the depth and breadth of our own organization, and ideally find some common ground to promote research, education, and advocacy that can foster informed, civic solutions. These open conversations are challenging but are necessary for SGIM to develop unifying policy statements around women’s health. Some SGIM members do agree that restricting access to abortion is appropriate, whether or not they support the extent to which these recent laws restrict it. SGIM, and Alabama, are not monolithic cultures. There is, and should be, space for many opinions.

As a professional network, SGIM should demonstrate to trainees the importance of engaging in a dialogue with those with contrary opinions, whether it be with patients, colleagues, or policy-makers. We should not abandon institutions just because their state(s) enacted a law many in the medical community oppose. We will continue building academic connections and creating academic projects regardless, and we will be more empowered to study pregnancy, abortion, and family planning needs in our patients, engage in political discourse, and improve women’s health overall, because we faced the issue head on. Even if women in Alabama feel abandoned, we have not abandoned them. We will remain their physicians and help them get the health care they deserve.

A unique form of protest would be to capitalize on the dialogue around abortion laws by aligning the meeting programming with the theme of “Transforming the Medical and Social Determinants of Health.” Invited local community practitioners and patients could share their perspectives on delivering and receiving health care in a state that limits healthcare options for women, including obstetric care. Alabama, along with 13 other states, has not yet expanded Medicaid under the Affordable Care Act. In the years since, Alabama’s rural hospitals have struggled to stay open. Currently, fewer than half of the counties in Alabama have a hospital with obstetric services, leaving many Alabamians to drive for hours to find care. Many organizations are learning how to do more with less, a struggle that may sound familiar to internists everywhere.

Workshops teaching practitioners about contraception counseling and medical abortions should be prioritized. We should consider hosting a special symposium on family planning options in the internal medicine setting, especially since primary care may be an optimal avenue for patients to receive this care due to Title X changes.2 We could add a special oral presentation session specifically highlighting pregnancy-related cases or contraception. A debate on the ethical, legal, and policy issues related to abortion could be a welcome addition to the program. SGIM’s leadership would be wise to take this issue by the horns and make it front and center in the meeting.

Ultimately, the key to broader change is local advocacy. Physicians play an influential role when engaging with policy makers. During a recent advocacy effort in Sacramento, California, physicians testified on the value of stricter vaccine exemption laws. One of the most powerful statements came from a formerly unvaccinated medical student who was now advocating for vaccinations herself. Another student was able to provide language to a junior assemblyman on how to respond to his constituents who were concerned about seizures after vaccinations. We can likewise provide that counter-voice for lawmakers in Alabama. Conceptualizing stories and articulating key points are critical for lawmakers when they consider their votes, what bills to prioritize, and how to best influence their colleagues and constituents. As internists, we have the unique ability to catalogue and share the stories of our patients whose lives are affected by pregnancy. SGIM has capitalized on advocacy as a professional responsibility by sponsoring Hill Days and regional events, as well as creating the Leadership in Health Policy and Advocacy (LEAHP) program. SGIM can likewise facilitate meetings with policy-makers in Montgomery and allow members from around the country to partner with those from Alabama to deliver important commentary. Additionally, SGIM should consider forming coalitions with other medical organizations and speak out in favor of women’s health. It is time for SGIM to take a vocal and formal stand.

We have a golden opportunity in 2020 to embolden our role in supporting women’s health. Unifying disparate feelings around health care does not start with sticking to our sides, whether we are a “West Coast liberal elite” or an “Evangelical Southern conservative.” It begins with learning from each other. We cannot learn unless we show up. As a medical society, we need to show up in Alabama. We must talk to our colleagues, people in the community, and policy makers. We must champion the rights of women. We should not be deterred from our mission.

References
1. Society of General Internal Medicine. Vision and values, https://www.sgim.org/about-us/vision--values. Accessed July 15, 2019.
2. Beaman J and Schillinger D, Responding to evolving abortion regulations—The critical role of primary care. N Engl J Med. 380:e30 DOI: 10.1056/NEJMp1903572. Published May 2, 2019. Accessed July 15, 2019.



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