Dr. Knox is also one of just a handful of abortion providers in the South. She is a young woman in her early thirties - defying the statistic that the majority of abortion providers are over the age of fifty.
"I am a young provider and I am also an academic. I am interested in integrating abortion into academics rather than sidelining it," she says.
The murder of Kansas abortion provider Dr. George Tiller on May 31 brings into sharp relief the gravity of Dr. Knox's decision to be a provider.
Despite the fear of violence that has for decades cloaked their work, providers like Dr. Knox are scattered throughout red and blue states, quietly doing their part to make good on the promise of Roe v. Wade.
Overall the number of providers in the United States remains staggeringly low. Approximately 87 percent of all American counties do not have an abortion provider.
The low number of abortion providers in the United States is the result of a number of factors. There is the political factor: several states have passed restrictive laws and policies, including ones that prohibit any medical professional other than physicians from performing abortions. This precludes physicians' assistants or other qualified medical professionals from being providers.
There is the fear factor, crystallized by the murder of Dr. Tiller.
And, there is the professional factor: abortion is often marginalized within major medical institutions and teaching hospitals. Most medical school curricula do not include any discussion of abortion. In 1996 the Accreditation Council for Graduate Medical Education required that all American ob-gyn residency programs include at least an elective abortion training option, but training is not mandatory. A survey published in Family Planning Perspectives in 2000 found that less than 50 percent of all ob-gyn residency programs included routine abortion training.
Further, residency training alone does not ensure that ob-gyn programs will yield abortion providers. According to the American Journal of Obstetrics and Gynecology, of the residents who express an interest in being an abortion provider upon beginning their residency, 52 percent actually become providers.
Defying these odds requires a deep commitment to reproductive freedom and health care. Dr. Knox's passion for her work becomes clear after just a few minutes of meeting with her. She is proud of how receptive students have been to her abortion lecture, and how she has worked with her department chair to mainstream training.
"I am pleased with how much I've been able to accomplish in a short time," she says.
Her commitment may lead one to assume that Dr. Knox was raised in a politically liberal family, or at least in a "blue state." In fact, she grew up and attended college in the conservative South. "I never discussed the issue with any women in my family or any other family members," she says. "I came to the conclusion on my own that I am pro-choice."
Dr. Knox worked on feminist issues like domestic violence awareness as a college student, but she did not grapple with the question of abortion until her third year of medical school, when a student organization that called itself Medical Students for Reproductive Health educated her class about the issue. (At the time, the student group was discouraged from using the word "choice" in its name.)
This student group is a chapter of a national organization, Medical Students for Choice (MSFC). Formed in1992, MSFC aims to educate and engage medical students so that Dr. Knox can become the rule rather than the exception. On its website, MSFC says it is committed to "de-stigmatizing abortion provision among medical students and residents, and persuading medical schools and residency programs to include abortion as a part of the reproductive health services curriculum." There are currently 134 active MSFC chapters throughout the United States and Canada.
"I have seen a number of classes of students move into their careers and many of them are providing abortions," says Lois Backus, Executive Director of Medical Students for Choice. "But they are doing it by and large quietly, especially in communities in the southeast and Texas and the West where it is a little less accepted."
As an ob-gyn resident Dr. Knox saw first-hand the problems caused by the dearth of providers in the United States. She was stunned by how difficult it was to arrange abortions for her patients, even when doctors had recommended abortions due to patients' health concerns.
"I was setting up my patients' abortion treatment, and it was often hard to find a provider. The difficulties and delays involved caused me to wonder, how could it be that there were no networks in place to ensure these women had providers?" she says. "Those experiences solidified my resolve to become a provider and work on research in the field of abortion."
Dr. Knox went on to complete a family planning fellowship where she could focus on reproductive health care. In the early nineties, only one university offered such a fellowship. Now, approximately 20 medical schools across the country offer family planning fellowships, which collectively support 15-23 doctors per year. Some of the fellowship graduates become providers, while others work in health policy.
The fellowship program offers Dr. Knox and other graduates support and a sense of community, which their work environments often lack. The challenges she faces at work are shared by most providers: increasing access for as many women as possible; navigating office politics and colleagues who disagree with legalized abortion; ensuring compliance with laws and regulations; tuning out angry, shouting protestors on her way to work; and, of course, looking out for her own safety.
Different challenges permeate her personal life. Every day Dr. Knox negotiates how to discuss her job with family and close friends. Providers often grapple with questions like, what will my family think if I become an abortion provider? Writer Patricia Meisol discussed some of these more personal struggles in her November 2008 Washington Post piece, "A Hard Choice," which follows a medical student who is trying to figure out whether she wants to become a provider.
Dr. Knox's own journey has led to revelations within her family. When she told her family that she would specialize in reproductive health care, she learned for the first time that her mother, a conservative Southern woman, is pro-choice.
Dr. Knox's husband first balked at her interest in being a provider, but has since become a source of great support. When they first discussed it, she printed out facts from the Guttmacher Institute's website about the lack of providers. He was shocked to read the statistics. While he still felt concerned about his wife taking this on professionally, primarily for safety concerns, he began to understand her passion for the issue.
Her husband, a businessman and a fellow Southerner, relocated with Dr. Knox when she accepted her family planning fellowship, and the two continued to discuss the implications her career decision could have on their lives. "The conversation evolved over the course of a year with a lot of questions about how this would affect our family and our careers."
"Many of our questions still remain unanswered," she says, but it is clear that she and her husband are in this journey together.
They both still feel concerned about her safety. "If my safety was ever in jeopardy, we'd be back to square one in our conversation, deciding whether we can really do this," she says.
Her husband's support is particularly important given that Dr. Knox often feels she cannot discuss her work with some family members or close childhood friends who disagree with her. "I used to think I needed to spread the gospel with everyone. Now, I think it would create an unnecessary divide that would not further the cause at all."
So, she reserves the gospel for her job, and to good effect. While legislators and activists can change policies and the political climate, the power to actually provide comprehensive reproductive health care lies in the hands of medical professionals like Dr. Knox who choose not to be deterred by fear.
"When we know something is important enough, we can't wait for others to do it," she says. "We have to do it ourselves."
*The provider's name has been altered to protect her privacy.
]]>Instrumental to this message development was the work of Denver-based Colorado Organization of Latinas for Opportunity and Reproductive Rights (COLOR). Led by workers' rights activist Daniel Gonzales, COLOR's No on 48 campaign developed messages addressing the rights of families and the hardships Amendment 48 could pose to working people.
Gonzales polled 608 likely Latino voters in Colorado and found that about half were staunchly against abortion, while the other half were pro-choice but supported some regulation of abortion. Voters represented in his poll responded positively to messages framing Amendment 48 as an affront to the rights of families and working people, whereas messages that focused on individualistic reasons for rejecting Amendment 48 did not resonate as well.
Based on this poll, COLOR's No on 48 campaign literature included the following messages:
Even if I would not have an abortion myself I respect and support other families' decisions to do what is right for them, and
Families should be in charge of their own healthcare decisions. Amendment 48 would allow the government to make these decisions instead, and
Amendment 48 would grant constitutional rights to fertilized eggs. It would eliminate a family's right to make personal private decisions about their future and their health care.
"We knew we needed to use empathetic messages that emphasized family decision making over the individual," Gonzales said. "We also used those messages when talking to union leaders and union members, and that helped us get labor unions on board."
By contrast, mainstream reproductive rights groups developed messages about Amendment 48 that focused on individual rights, such as:
Amendment 48 affects important life decisions that should be made by individuals, their doctors, and families, not extremists rewriting the state constitution; and
Amendment 48 would eliminate a woman's right to make personal private decisions about her own body and her health.
The coalition to defeat Amendment 48 was broad, consisting of both mainstream reproductive rights organizations like Planned Parenthood of the Rocky Mountains and NARAL Pro Choice Colorado, Republican Majority for Choice, religious groups like the Colorado Interfaith Initiative, as well as COLOR.
If passed, Amendment 48 would have amended the Colorado State Constitution to define the term "person" as "any human being from the moment of fertilization." The amendment and would have given zygotes, embryos and fetuses "inalienable rights, equality of justice and due process of law" and would have resulted in the criminalization of hormonal birth control, emergency contraception, and all abortions, even in the case of incest or rape.
Personhood initiatives like Amendment 48 have not yet succeeded in part because they tend to divide pro-lifers. Colorado's Amendment 48 failed to gain support of Republican United States Senate candidate Bob Schaffer, and the Catholic Church refused to weigh in on the measure. Colorado and Georgia are the only states that have acquired enough signatures to qualify personhood measures for the ballot.
Though Amendment 48 did seem menacing to the pro-choice community initially, having received over double the required petition signatures in order to secure a spot on the ballot, and having survived a legal challenge under Colorado's single subject rule, it was defeated 77% to 23%.
According to Gonzales, pro-family messaging as well as the extreme nature of the measure helped the No on 48 campaign acquire unlikely allies in the Latino and labor communities, which evolved into a coordinated get out the vote effort.
COLOR, along with Denver workers' rights groups 9 to 5 and FRESC for Good Jobs and Strong Communities, persuaded the Service Employees International Union (SEIU) to sign on the No on 48 campaign. One key message COLOR posed to labor unions explained the implications Amendment 48 could have on their own members, such as unionized first responders.
"We explained to union groups that their own members like EMTs and fire fighters would have difficulty doing their jobs since Amendment 48 could force them to assume that every woman they treat is pregnant," Gonzales said.
Labor unions also agreed to
support the No on 48 campaign because mainstream reproductive rights
groups signed on to defeat anti-union initiatives.
"When meeting with unions we pointed out that COLOR and other reproductive rights organizations have already been working hard to defeat anti-union initiatives," said Carmen Rhodes, Executive Director of FRESC, pointing out that Planned Parenthood of the Rocky Mountains gained permission from its board of directors to help defeat at least one anti-union initiative. "It was clear that if we wouldn't have come together, we may not have won on any of our initiatives."
Despite its success in securing SEIU support, the No on 48 campaign fell just two votes shy of receiving an official AFL-CIO endorsement. Had it formally endorsed the No on 48 campaign, the AFL-CIO's campaign literature would have included a No on 48 message.
Nevertheless, COLOR and its labor allies engaged in aggressive door-to-door canvassing with campaign literature that grouped the No on 48 message with no-vote messages about four workers' rights initiatives: Amendment 46, an anti-affirmative action measure; Amendment 47, a right to work initiative; Amendment 49, which prevented employees from taking paycheck deductions to contribute to their labor unions; and Amendment 54, which prohibited unions from contributing to political causes. All five of these Colorado initiatives were listed in the Ballot Initiative Strategy Center's Top Ten Worst Initiatives. All but Amendment 54 were defeated.
COLOR's pre and post election polling shows that Latinos shifted from 31% no on 48 to 51% no on 48. There are currently no such statistics reflecting turnout among union voters. However, the joint literature and canvassing effort bolstered turnout on all of these initiatives.
"A lot of the initiatives on the ballot were bad for our community," Rhodes said. "As a community, we focused on how to create synergy around issues that weren't core to our work but attack our common values."
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