When Smith is inside and among friends, conversation will often turn to the Kansas doctor who spent $90,000 to bombproof his car; the San Francisco friend who faces trial for murder; the incessant death threats; the hit lists; the ceaseless scorn.
"It's like life in a combat zone," says Smith, a former Green Beret, during a pause between appointments at his Bay Area practice. "You watch people on the sidewalk. You watch people out of the side of your vision. You watch people's hands."
Smith is, of course, an abortion doctor. He's a member of what has become a dwindling rogue caste within organized medicine, and he's angry and resentful. It wasn't supposed to be this way. A quarter-century ago on Jan. 22, the U.S. Supreme Court handed down the Roe vs. Wade decision legalizing abortion, and an era of shame, subterfuge, and fear was supposed to have ended. Abortion providers and their clients imagined themselves stepping out of the cold into a new epoch, where abortion was to have been treated as any other safe legal medical procedure.
While women's groups in San Francisco and elsewhere plan celebrations for the 25th anniversary of Roe vs. Wade -- often described as the defining moment of the modern U.S. feminist movement -- doctors, social workers, and sociologists concede that the availability of abortion is in a downward spiral.
For a variety of reasons, during most of the time Roe vs. Wade has been the law of the land, abortions have become increasingly difficult for women to obtain. Demographers began noting the paradox in 1982. The decline in the number of women with unintended pregnancies who received abortions is a trend that has continued more or less steadily to the present.
Last month the government's Centers for Disease Control and Prevention released figures showing that the number of abortions reported in 1995 had declined 15 percent during the previous five years to 1.2 million annually. That number is exactly the same as the high end of researchers' estimates for the yearly number of abortions performed in America during the 1950s, according to a 1958 Planned Parenthood Federation document.
"While it remains legal in the United States, access has been seriously eroded in the past decade," says Vicki Saporta, executive director of the National Abortion Federation, the professional association of physicians who perform abortions.
Dr. Smith is more adamant.
"There are cycles in history, and I'm convinced we are going back. Fewer and fewer people will be doing this. Those that do will be marginalized in such a way that fewer will be doing it at all," Smith says. "Perhaps not philosophically, but mechanically, the anti-abortion people are winning. Even the women's groups can't see this. They don't support us. They give us nothing. Oh, that's right -- they are having an anniversary dinner next week honoring us.
"Give me a break."
The reasons for the dwindling availability of abortion services are many and varied, but they all find their roots in America's odd, century-old national obsession with the procedure.In neighboring conservative, Catholic Mexico, abortion is widely available and a political non-issue -- as is the case in most of the rest of the world.
Abortion doctors' fear of violence has been much publicized, but the decreasing number of abortion training programs for physicians, the ambivalent attitudes in the medical field toward abortion, and the rise of managed medical care also have contributed to the trend toward fewer on-demand abortions in post-Roe America.
The Earthshaking Decision That Wasn't
In January of 1973, what had been a lively, state-by-state debate over abortion was stanched when the U.S. Supreme Court decided that states may not protect "fetal life" until after viability -- the point at which a baby can survive outside the womb. Supreme Court rulings in 1989 and 1992 preserved the basic tenets of the Roe decision, but they allowed for some state restriction on early abortions.
Twenty-five years later, it is not at all certain whether Roe vs. Wade has had as broad an effect as imagined. The pre-Roe era is often described as a time when back-alley butchers maimed women, and girls were cloistered to have children in secret. It's true that the Roe decision dramatically reduced the number of women who were injured and killed by botched abortions. But the extent to which the decision made it easier for women to have abortions is much less clear.
In the years leading up to Roe vs. Wade, some 600,000 legal abortions were being performed annually in states where abortion was allowed, notably New York. In states where the procedure was outlawed, however, hospitals sometimes found loopholes.
"In the days before Roe vs. Wade, in my institution, we had the 'abortion committee.' It was composed of a doctor, a layperson, a psychologist, and a minister. It was a body to whom the woman would present herself," Dr. Smith says. "They would talk with her about her reasons for wanting to do the abortion. The trump card was, she'd say she was going to commit suicide. It was a joke. All she had to do was emote, play the trump card, and she'd have an abortion. So there were a lot of legal abortions."
The Ambivalence of Doctors
To understand why abortion access has dwindled during the last decade, it helps to understand the medical profession's ambivalent attitude toward the procedure. Polls consistently show that more than 80 percent of medical doctors favor legalized abortion, says Carol Joffe, a professor of sociology at UC Davis. But ever fewer doctors are willing to perform, never mind openly defend, the procedure.
Although organized opposition to abortion is now largely associated with the fundamentalist evangelical Christian movement, it was the American Medical Association that led the late-19th-century charge against abortion in the U.S. Until then, it had been an openly advertised procedure. By century's end, most states had anti-abortion laws on their books.
The sexist tone of the AMA campaign provides the context for Roe vs. Wade's legacy as a feminist, rather than medical, landmark. A woman seeking abortion "becomes unmindful of the course marked out for her by Providence, she overlooks the duties imposed on her by the marriage contract. She yields to the pleasures -- but shrinks from the pains and responsibilities of maternity," was the AMA's 1871 assessment of the procedure, according to a document quoted in the book The Abortion Movement and the AMA.
Organized medicine remains uncomfortable with abortion to this day. Every year, fewer medical schools train doctors to perform the procedure. The portion of medical schools offering abortion training as part of their curriculum has gone from 22.6 percent in 1985 to 12.4 percent in 1991, according to the latest available figures from the National Abortion Federation.
This elimination of training programs has coincided with a ghettoization of the specialty. As abortion techniques become increasingly safe and simple, an ever greater portion of them are performed in free-standing clinics, rather than in more expensive hospitals. As a result, what was already perhaps medicine's least prestigious specialty has become increasingly isolated.
And because abortion is vanishing from doctors' palette of skills, more and more abortion clinics are forced to fly physicians in from other cities weekly to perform the procedure. Some 85 percent of U.S. counties don't have clinics, or doctors who can perform abortions.
Managed Care Manages Fewer Abortions
The spread of managed medical care has also impeded abortion access, in part because of abortion's uniqueness among surgeries: It becomes dramatically more dangerous and costly if postponed, yet it is rarely considered an emergency procedure. The prior approvals, difficult-to-get appointments, and other hassles that have become the hallmark of modern managed care programs can lead to extended postponement of abortions.
And the longer abortion is delayed, the less likely it is to be performed.
Medi-Cal, the California version of the government-funded Medicare program, has turned increasingly to managed care providers in recent years. The resulting restriction on abortion access is clear; the poor women who are beneficiaries of Medi-Cal are the women who are statistically most likely to want an abortion. Abortions are sometimes delayed so long they are no longer legally possible under Roe vs. Wade, which creates a right to abortion, but only before the fetus is able to survive outside the womb. (In California, viability is legally deemed to begin 24 weeks after conception.)
"I had an intern spend all week arguing with a managed care medical program in Sacramento County. It was delayed so long that the woman couldn't get an abortion," says Brenda Cummings, director of Access Pro Choice Information and Referral, a San Francisco organization that aids women seeking abortion and childbirth services. "It has become harder and harder to find a provider, find insurance that covers abortion, or find a doctor who will give a referral. Managed care has caused a lot of problems with getting an abortion. It's safest when soonest. And with managed care, we get delays, and we are finding fewer and fewer providers who accept Medi-Cal as payment. That's made access dwindle."
It has also dwindled because anti-abortion activists have been more numerous, committed, and inventive than their feminist counterparts. Pro-choice groups celebrate every Jan. 22; anti-abortion advocates work year round.
Crisis Pregnancy, No Abortion
Abortion opponents have set up hundreds of "crisis pregnancy clinics" that advertise in the abortion section of the telephone directory, then offer descriptions of maimed fetuses to women who take the bait. According to Betsy Powell, Bay Area director for the California Pro Life Council, there are now more such "crisis" clinics than actual abortion clinics.
"We believe strongly that women need to make a fully informed decision. Even though it's very difficult to hear descriptions of abortion methodology, or see an ultrasound, as a woman, I believe I'm going to make a better decision if I know all the facts. We provide that kind of environment," says Shari Plunkett, CEO of First Resort, a $700,000-per-year organization that has crisis pregnancy centers in Oakland and Pinole, and is now scouting for a location in the San Francisco Financial District. Plunkett says her staff manages to talk two-thirds of the women who walk through their doors out of getting an abortion.
First Resort is still advertised in the 1997-1998 Pacific Bell telephone directory under its old name, Crisis Pregnancy Services, a term now widely associated with anti-abortion counseling. "We're not a crisis pregnancy center," Plunkett says. "Please make sure you use the name First Resort."
Other right-to-life measures have been similarly subtle and effective. The right-to-life movement has toned down its fight to have abortion outlawed, and instead focused on making abortion more difficult to obtain in certain, specific circumstances. President Clinton recently vetoed a bill that would have outlawed a rare abortion technique used for late-term fetuses. Abortion opponents hope to gain the votes to override a veto this year.
The fact that the procedure, called dilation and extraction, now shows up regularly in news headlines as "partial birth abortion" is fortuitous for the right-to-life movement because it is singularly macabre. Used only in certain, rare, mid-to-late-term pregnancies, it involves partly delivering most of the fetus breech first, then removing part of its brain before the head is taken from the woman's body. Even some liberal Democratic politicians have taken a stand against the procedure, and it has served as a rhetorical jumping-off point for right-to-life arguments.
According to Dr. Smith, the procedure was developed in 1978 to replace a situation that was similarly ghoulish. "In the old days, after 16 weeks, we put a needle in the abdomen, put a solution into the water sack around the fetus. That would put the woman into labor, and she would be in labor overnight. Within 24 hours everything would come out," Smith explains. "The problem was, there were so many of these girls -- 14, 15 years old -- that we'd have a medical ward where there were 30 people screaming their lungs out all night. It was something out of an Elizabethan madhouse."
In California, the Pro Life Council and its legislative allies are promoting laws that would require parental consent for minors seeking abortions; require women seeking abortions to sign a form saying they had seen an ultrasound image of the fetus they are carrying; increase regulation of abortion clinics; require fetuses to be anesthetized before they are aborted; and reduce Medi-Cal funding of abortion.
The council is also lobbying to require television stations and other media to air paid political advertisements featuring graphic depictions of abortion.
None of these measures is specifically prohibited by Roe or its successor Supreme Court decisions on abortion. Whether they are adopted could determine whether abortion rates drop even further than they have to date.
"I really believe that the Roe vs. Wade decision is on a collision course with modern medicine and America's conscience," Powell says. "Modern medicine is allowing us to hear and see a baby's heartbeat very early. People are listening to that heartbeat."
The Violence That Chills
Then there is the violence.
The Bay Area hasn't suffered any of the shootings, murders, firebombs, and arsons that have afflicted abortion providers in Florida, Massachusetts, Kansas, Vancouver, and elsewhere.
But it does have its Brother Martin, aka Ray Temple, who, according to pro-choice advocates, so far has limited his activities to throwing salt on abortion clinic escorts, taking a swing at an abortion clinic director, and helping another group of abortion activists tackle Dr. Smith.
"There was this protester kneeling in front of the door of the clinic, writing 'murder' or something on the concrete in front of the door. I came out and said I was making a citizen's arrest: 'I am making a citizen's arrest, and I am empowered by the law to do that,' " recalls Smith. "She was struggling to get away and Brother Martin -- Ray Temple; he wears a black cassock, rosaries, all that -- she was struggling to get away, and he jumped on me. Two other men came around the corner and jumped on me. I called the police, and Brother Martin was arrested, and the woman who I tried to arrest got away."
The recent, rapid escalation of violence at abortion clinics has chilled doctors, receptionists, security guards, and anyone else who works at the clinics. Dr. Smith and dozens of his colleagues are listed on a Web page titled Abortionists on Trial, which depicts blood dripping over a hit list of doctors and clinic workers, with instructions on how to look up their addresses.
Meanwhile, Smith says, many of his associates -- the doctors old enough to remember the days when hospital trauma wards regularly served patients suffering complications from botched illegal abortions -- are retiring. And few are taking their place. For medical students, it's not worth the fear, or the ostracism from the rest of medicine.
"We don't get any support. Anti-abortionists come harass our patients all the time. I don't see anyone come and picket against the harassers. Even though I do general gynecology, many women who might support a woman's right to choose, they wouldn't want to have their baby with me. They want to go to the nice squeaky-clean doctor down the hall," Smith says. "In the same way people say that they're not going to a doctor who performs abortions, they need women to say, 'I am going to Dr. Smith for ordinary gynecology care because he gives abortions.'
"But we get none of that."
While the battle over abortion appears to favor anti-abortion forces, nobody is declaring victory, or defeat, yet.
In a December article, the New York Times reported that the number of abortions performed had recently increased in a handful of states, though it offered no suggestions as to why, or whether those numbers represented a national trend.
The Accreditation Council for Graduate Medical Education issued guidelines in 1996 that encourage medical schools to include abortion techniques in their curriculums. It is not yet clear how much effect these guidelines will have, says Patricia Anderson, executive director of Medical Students for Choice.
The prospect of approval for drugs such as RU 486, which induces abortions, could make early term abortions much easier to obtain.
But these prospects don't cheer pro-choice women.
"I think that my generation of women -- we are the second generation of feminists -- I think we have really taken advantage of what our mothers have done. We are really complacent," says Jennifer Matthews, 29, a San Francisco professional who had difficulty obtaining an abortion last summer. "Our right to have an abortion is slowly eroding away.
