Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman

You're listening to The Nocturnists. I'm Emily Silverman. Today we have a very special guest on the show. But before I introduce her, I want to provide a little bit of context. So, here at The Nocturnists, we were really rocked by the Supreme Court decision to overturn Roe vs. Wade. And really upset and disturbed by the reports that were coming out from the physician community about the moral distress of having to withhold abortion care from patients. Stories out of Texas and Oklahoma of women being asked to go home and come back after they're septic. Physicians and other clinicians being criminalized for the work that they do, widespread confusion about what can and can't be done, what is legal, what is not. It's just a catastrophe, to be honest, and part of our goal as an organization is to serve our community, and to document history, and to stand up for what we believe is right.

And so that's why we are launching this new storytelling project, The Nocturnists: Post-Roe America. So, our goal is to collect the voices and stories of any clinician who takes care of pregnant patients. Whether you're an OB-GYN, or a nurse or a doula or a primary care doctor or family medicine doctor, whether you are a pharmacist or a rheumatologist or an oncologist, we want to hear your stories. We want to hear it all. And so much of this conversation is dominated by media personalities and politicians who have really variable medical literacy. And part of our goal with this project is to amplify the voices of healthcare workers who can speak to the reality of what is going on on the ground.

Our plan is to publish this series next summer on the one-year anniversary of the Dobbs decision. And we invite you to contribute. If you know anybody who you think might be interested in adding their voice to this project, sponsoring this project, supporting it in any way, shape, or form, please, please let us know we are eager and hungry for collaboration. And if you want to learn more, visit our website: thenocturnists.com/post-roe-america. With that, we want to kick off this project with today's interview.

Today I'll be speaking to Dr. Alison Block. Ali is our Executive Producer here at The Nocturnists. She's also a family medicine physician and abortion provider, and the author of a recent Op-Ed in the New York Times that was called, "Why I Learned to Perform Second-Trimester Abortions for a Post-Roe America." She's an amazing person, and just has so much to say about this topic and what we can do moving forward. And I'm thrilled to be putting out this conversation that I had with her recently, which covers a lot of ground ranging from Ali's personal journey to a career in reproductive health, to how we think and talk about the political polarization around this issue, and so much more.

Before I spoke with Ali, I asked her to read an excerpt from her Op-Ed in the New York Times. So without further ado, here is Ali.

Alison Block

When I walked into the Trust Women Clinic in Oklahoma City on the first day of my training, I felt a little scared. We get anti-abortion protesters outside my clinic in California, but the environment in Oklahoma feels more intense. There's a truck parked outside that's plastered with graphic images of fetuses, analogizing abortion providers to ISIS fighters. During my clinic tour, I'm shown the emergency exit in case something crazy goes down–code for anti-abortion violence.

You have to be dedicated to work in an abortion clinic anywhere, but those on the Trust Women's staff are among the most dedicated I've met. They're up against some of the most restrictive laws in the country–laws that disproportionately affect poor people and people of color. The governor just signed a Texas-style ban on most abortions this week. When I was there, the clinic’s patients had more than doubled since Texas's SB8 went into effect, outlawing abortion in that state after six weeks of pregnancy, before many women know they're pregnant. The clinic was getting about 500 calls a day with only a few people available to answer the phone.

Despite these hardships, the clinic is as welcoming as any I've seen. Smiles are detected everywhere, even behind masks. Posters on the wall say, “You can cry here.”

As of recently, some 90 percent of abortions in America occurred in the first trimester, but that number seems likely to change as states restrict abortions and it takes people longer to get their procedures. In this way, what would-be first-trimester procedures that are outlawed in one state become second-trimester procedures in another.

The vast majority of abortions that I perform in my California practice are at six, seven or eight weeks of pregnancy — a period during which the gestational sac, a tiny piece of tissue that resembles a cotton ball, is about the size of a coin. While California has its own issues with health equity, my patients are largely able to get access to care so early because California has a large number of abortion clinics that are easy to get to. And, unlike in many states, including Oklahoma, it has a medical insurance structure that covers the cost of abortion.

In Oklahoma, the patients I saw were often one to two months further along than my patients in California typically are. They had driven five hours, sometimes ten, to visit the clinic. They had sometimes been to crisis pregnancy centers that may have intentionally misled them with false information about abortion, or given them inaccurate pregnancy dating. They often spent weeks arranging childcare, getting time off work, raising funds, finding a place to stay, arranging rides.

I asked the Trust Women staff members where they send patients whose procedures can't be done in the clinic. I was thinking about patients with complicated surgical histories, or those who want general anesthesia. They smiled wearily at my naïveté. There's nowhere else, they said.

Emily Silverman

Thank you for reading that Ali. And thanks for coming on to the show today.

Alison Block

Thank you so much for having me. This is such a treat being on this side of the mic.

Emily Silverman

So, Ali, why don't you start by telling the audience a bit about your involvement with The Nocturnists?

Alison Block

Yeah, I would love to. So, I guess it was back in 2016 that you held the first-ever Nocturnists event with just a few of your co-residents. And my husband actually attended because he was your chief resident at the time. And he came home and he was totally blown away and he just said, “Ali, this is totally your thing. You should meet with Emily, you should talk about it.” And then we met. I remember where we met, and it was at that little coffee shop off of Haight Street. And we got together and we just sort of talked about the problem that we saw in medicine, and the sort of hole that we wanted to fill with The Nocturnists, and how we might do it. And we said, “Let's do it. Let's make a partnership. Let's make this happen. Let's have events.” And it just, sort of, has grown and grown from there. So, we started with the live events and switched to the podcast. And I've had the pleasure of being involved ever since.

Emily Silverman

And I remember at that coffee shop you mentioned reproductive health, because that was your content area of passion and expertise. And along the way, we did do a show focused on the theme of reproductive health. And that show was especially close to your heart. And I was wondering if you could tell us a little bit about why reproductive health is an area that you've decided to focus in. Tell us about your journey to reproductive health.

Alison Block

So, I have just always been passionate about reproductive health and healthcare and advocacy. I think it started from a young age. My family has always been, you know, they're sort of typical Jewish New Yorkers. They donate to Planned Parenthood, they're very involved in the cause. It was something that we always talked about in my household. My mom is, was a big second-wave feminist, and reproductive health and Roe v. Wade was hugely important to her. So, it was always just sort of part of the air that I breathed. And then when I went to medical school, it became clear to me that being a provider was something that I really wanted to pursue. So, I decided to go into family medicine, because I love taking care of the whole person, the whole family, the whole community. And, to me, providing abortion care is just a very integral part of providing health to families and communities, the same way that obstetric care or caring for sick kids with ear infections is. I mean, it's something that affects about half the population. About a quarter of women will get an abortion at some point in their lifetime. So it just feels really important from a medical standpoint. And then, of course, also from a social justice perspective. I think, you know, there can't really be any advancement for women without access to contraception and reproductive health. And that includes abortion care.

Emily Silverman

I'm thinking back to when I was in medical school, and I did my OB/GYN rotation, and it was an eight week rotation. And we had one or two weeks where we could pick an elective. And one of the elective options was a family planning elective, where students had the opportunity to go to a family planning clinic and see abortions, and things like that. I somehow ended up in another elective. I actually don't even remember what it was. But because I hadn't been put in the family planning elective, I actually ended up graduating from medical school without ever seeing an abortion, doing an abortion, really even learning that much about abortions–what they are, how they work, the statistics around, you know, how far along are women typically when they get abortions. So, lately, I've been reflecting back on just my medical school experience and what I learned and what I didn't learn. So you mentioned that it was in medical school that you decided that you wanted to be a part of this. Was your medical school experience different? And how was abortion taught? Was it something you had to seek out aggressively? Or passively? Did everybody get that education?

Alison Block

It was different. I went to UCSF for medical school. And I was really fortunate to get a lot of exposure to both sort of didactic education about abortion, and also hands on clinical experience. I'm not totally sure about this statistic, but I think I remember learning that, in medical school, we had an entire lecture that was dedicated to abortion and all the kinds of things that you're saying–explaining what medication abortion is, explaining how surgical abortions work, some of the epidemiology and demographics. It was only one lecture, but it was a lecture that was part of the regular core curriculum, it was not an elective. And I think I remember hearing at the time that it was the only medical school in the country that did that. Hopefully, that has changed since then. But that was an amazing opportunity. UCSF, of course, is a leader in family planning, so there were a lot of wonderful mentors available. So, I had that early introduction to, sort of, the medical side of abortion in the setting of medical school. And then as a fourth-year medical student, I did an elective at the Women's Options Clinic, which is a very well-known and wonderful abortion center that's located at San Francisco General. So I spent two weeks there, again, learning some more hands-on skills.

And then, sort of, for the next phase of my medical training for residency, I was very intentional about choosing a program that had abortion care baked into the curriculum. So in family medicine there's about, I think, about 500 residency programs across the country. And I think there's about 30 that include abortion care as part of the curriculum. They're dedicated as RHEDI Programs. And that's Reproductive Health Education Initiative. And they are very few but they are considered opt-out programs. So the idea is that you have abortion care baked into the curriculum through clinical rotations, through didactics. And of course, if there are residents that don't want to participate and don't want to perform abortions they don't have to. But, again, the only residency programs that I applied to were programs that included abortion care.

Emily Silverman

You've interacted with a lot of abortion care providers throughout your career. How do they get educated in how to provide abortions? Do they all come from, you know, the same medical schools that provide really good education on it? Or do some of them come from schools more like mine? And do they have to go outside to get that education? And how is the skill set transferred from generation to generation of providers?

Alison Block

That's a really good question. And it's something that is an active area of conversation, particularly as we need to think about increasing the number of abortion providers in some places in the post-Roe era. How to educate abortion providers is always a big area of concern for medical educators. And there's a couple of different reasons. In answer to your question of who are abortion providers, obviously it's a very diverse and heterogeneous group. But I would say that the common thread is that there are always people that have always been very passionate about abortion care. I guess once in a while I meet someone that had sort of a seminal moment or event that really changed things for them in medical school or residency. But for the most part, abortion providers that I meet went into medical school knowing that this was something that they wanted to do. And part of the reason for that is that there's a lot barriers to becoming an abortion provider.

A number of years ago, in an effort to really increase abortion education, there was the hope that everybody would be get educated in abortion care, and people would really be able to integrate it into primary care settings. It's become clear that that's not really feasible because of so much legislation and restriction at the state level, both for education and for providing. So, it's hard to become an abortion provider. I mean, when I said I was, you know, lucky that I went to UCSF, but then I had to be intentional about going to a residency program that included it. I also during my third year of residency, paid out of pocket to go to Mexico City and do an additional two-week elective to get sort of higher volume training. So, it's sort of a hodgepodge of ways.

But one of the issues right now is that abortion numbers actually have been declining somewhat. There's a number of factors. One of them is that medication abortion has really increased and now makes up about 50% of procedures. So there's just not as much opportunity to train in procedural abortion. And of course, often all of the learners that are highly motivated to learn the abortion procedure are sort of clustered in certain coastal, liberal regions. And so then they're all sort of competing for the same resources. So, you have these vast areas of the country that maybe have plenty of abortions to perform but no learners, and then places like San Francisco, New York, Seattle, Boston, where there are sort of tons of learners and not enough opportunity to learn.

So, essentially, people find a way. A lot do it through OB/GYN and learn during their residency. Some go on to do family planning fellowships out of OB/GYN, some learn during residency. But there's usually some sort of extra-educational opportunity that needs to be pursued outside of the usual training. And then that, of course, brings up a lot of issues around diversity, equity and inclusion, because who are the people that can pay to fly to Mexico and find a place to stay and get those extra opportunities?

Emily Silverman

As we all know, abortion is a very tricky topic. It's highly charged. It's very politically controversial. And I'm wondering, as a physician who's really active in this area, really passionate about it, how do you navigate the healthcare space around this issue? For example, even among physicians, opinions can be diverse about abortion, and, kind of, how far along a woman should be for it to be legal, and things of that nature. So, over the last decade, or however long you've been doing this, what is it like to navigate the healthcare community with this area of expertise?

Alison Block

Almost all, well, all of my life as a healthcare provider has been in the San Francisco Bay area. So, I've been in sort of a uniquely privileged situation in which pretty much everybody that I've interacted with has been very pro-choice and has responded very well and very positively to what I do. So, it was really eye opening when I did this training in Kansas and Oklahoma to see how people did have to balance to some extent their own personal comfort and safety, but also doing the work of advocacy, a large piece of which, I think, is normalizing and de-stigmatizing, and saying the word, and not being afraid to say to people, “I'm an abortion provider. This is part of what I do.”

So, I have, to some extent, often stepped out of my comfort zone, and tried to just work it into everyday conversation with new people that I meet. When they ask me what I do include the fact that I'm an abortion provider, again, in an effort to just talk about it, and normalize it, and kind of bringing it out into the fold. The place that I was working in the Bay Area, there was certainly some staff members that were not as comfortable with providing abortion care, and I had some very patient, diligent, heroic colleagues that had those hard conversations with them. For the most part, I have always worked in spaces where people were on the same team.

Emily Silverman

In the media, the conversation about abortion tends to be really sensationalized. And I've been reading a bit about this and listening to some podcasts about it. And it seems like there's actually more common ground than we might expect. So, for example, if you're on the left, you might think that someone on the right wants abortion to be totally illegal from the moment of fertilization, full stop. No abortion allowed. When in reality, it's actually not true. And a lot of people on the right are flexible and actually okay with abortion being legal up to a certain point, whether it's 12 weeks, 15 weeks.

I recently was Twitter DM-ing with a conservative pro-life Christian guy. I know I shouldn't do that, but sometimes I do end up getting into these Twitter conversations. And I was talking to him because he was tweeting all of this anti-abortion stuff, and then once we got in the DMs, he was actually open to a federal protection to abortion up to 12 to 15 weeks, which is actually more than I expected. So, on our side, maybe we think that the right, you know, is anti-abortion more than they are. And then similarly on the right, it seems like a lot of people think that those on the left are wanting to do abortions super, super late, you know, from the, you know, the moment right before the baby is born, that abortion is okay, up until that moment, which is actually not the case. So, as somebody in this space, like, how do you navigate all of those extremes and try to kind of pull people back to the middle, keep the conversation reasonable and realistic, and just educate people about the realities of what this work is?

Alison Block

Well, I think that, right, there's a problem just on Twitter, in general, with people being crazy. There's a problem in our country right now, with the legislators really not representing the people. So, I think that's, kind of, one of the things that you're alluding to is that 70% of the population supports the right to abortion, and somehow we just wound up with a situation where the right to abortion is not protected across the whole country. And probably a federal ban will be coming down the pike, and there'll be plenty of people supporting it. So, there's this huge disconnect between what, I think, it's, you know, it's fear mongering, it's Fox News. I don't know. Everybody's being manipulated, I think, by misinformation and inaccuracies that the people in power, for the most part, have motivation to spread.

So, I think that you're absolutely right, that it's just about education, it's about good journalism, it's about having open and honest conversations with family and friends. So I, for example, again, I live in a very rarefied bubble of the world. I grew up in New York City. I lived in San Francisco for many years. Almost everyone that I knew, was pro-choice. I have one friend who I know to be very anti-choice. And I reached out to him at some point and said, “Hey, I know this is something that you believe. You know, this is something that I do professionally. And I just want to be a resource for you, if you have any questions and if you want to talk about it.” And we wound up having a very productive conversation, I think, along the lines of what you're saying–that you realize that your positions are maybe a lot closer together than you thought.

So, I just, again, sort of tried to make myself available. There's a wonderful organization called Physicians for Reproductive Health, whose whole mission is to get abortion providers out into the media connected with journalists, have them publishing op-eds, have them doing interviews. So, organizations, organizations like that, that are really making sure that the people that are spreading information have good sources for the information that they're spreading.

Emily Silverman

There have been a lot of changes in the laws around abortion lately. So, first, we saw some news out of Texas. There were some, you know, statewide changes that were made. And then we had the leak about the Supreme Court. And then we had the official Supreme Court decision, the Dobbs Decision. So as all of these changes were, kind of, tumbling out of the news, what was going on in the minds and hearts and souls of the reproductive healthcare community? Like, I imagine, maybe you have a Facebook group or, you know, some way of all, kind of, talking to each other. Was this a surprise? Was this not a surprise?

Alison Block

Right. I mean, I can't speak for everyone, of course, but I think I can speak for a lot of people in my community, which is basically, that this was 0% surprise to anybody that has been working in the field of reproductive health care or paying attention to what was going on at state levels across the country. Basically, the day that Trump was elected, every abortion provider that I know, was mourning the loss of Roe v. Wade. That was back in 2016. So, it's been a slow rollout since then. But I think I can speak personally that it has been, I mean, of course, it's been sad, it's been infuriating to actually see these things happen. To actually watch Roe being overturned is so devastating. I would say that I didn't have a lot of grief on that day, because I had been processing it for so long. I will say that I had a lot of frustration towards a lot of well-intentioned, well-meaning, like-minded liberals that were sort of saying for the last bunch of years, “Oh, they'll never do that. The Court’s never going to overturn Roe. This is never gonna happen.” But the right has been very diligently working for the last 50 years to make it happen. And they succeeded.

So, I think that, again, if you were really paying attention, this was extremely predictable. And I think at every beat–so Trump being elected, Merrick Garland being denied a seat, all of Trump's appointees, especially with Amy Coney Barrett. You know, a lot of people who sort of think of themselves as feminists would say, “Oh, but she's a woman, she would never do that.” Again, you're just not paying attention. So, I think that there's been a lot of frustration among abortion providers and, sort of, the reproductive health communities that I know, that all of a sudden now people are outraged. All of a sudden, now people are paying attention.

I have a colleague who said something that I found to be very poignant on the day or two after Roe was overturned. We were on a text chain. And people were in distress and making plans and trying to talk to journalists. And she said, “Don't forget to take care of yourselves. Now is the time to rest. The emergency was years ago.” And I think that really struck me because that's true. We are really at square one now and need to start from scratch. And you can't undo what just happened overnight, because it took 50 years to happen.

Emily Silverman

I grew up pro-choice. My mom was an adoption social worker. And she was also a huge advocate for women and having access to abortion. And I remember when I was little, my mom would volunteer for an organization called WEN–Women's Emergency Network. And I still remember her sitting at the computer in the office and taking these calls from women and helping link them to resources. And she would just say to me, “Emily, it's so important that a woman is sovereign over her own body, her own future, her own choices. And after she died, I actually found a letter to the editor in my old computer that she wrote to the local newspaper, arguing for why some new piece of legislation was inhumane, you know, forcing women to look at the heartbeat, that kind of thing, and how that wasn't going to solve anything. And, anyway, so my mom isn't here anymore. But as all of this news is coming out, I can't help but think of what she would have thought of all of this and I actually feel really connected to her.

And the other thing I wanted to share is, as you know, I recently got pregnant and had a baby. I was very nervous about getting pregnant. I had a lot of, kind of, fear and anxiety about losing control of my body. And I have to say that that fear was well-founded. The experience of being pregnant was really, really challenging. And then the recovery and you know, postpartum, with a C-section scar and breastfeeding. It was just, it was so much, and nature has entrusted us with this process. And as I mentioned, I've always been pro-choice, but nothing solidified that pro-choice stance more than carrying to term and delivering this very-much-planned and very-much-desired pregnancy, because I saw firsthand how just all-encompassing it is. And the idea of that experience being forced upon a woman without her consent was so so just deeply disturbing to me. Since we're a storytelling podcast, are there any, like, stories–maybe it's a de-identified patient anecdote or something from your personal life, that highlights for you why, why is it just so important that women have this sovereignty over their bodies?

Alison Block

I have a lot of thoughts and feelings about this. The first is that I totally agree. I have three children. I love them to death. They were all planned and highly desired. And nothing has made it more clear to me what an enormous load of work it is to carry and birth and care for a human being. And the idea that that wouldn't be a choice just seems patently absurd. On the other hand, in terms of this idea of specific anecdotes and stories, I'm always torn on that. On the one hand, obviously, stories are compelling to humans, they're really important in journalism, they're really important for the work that we do. On the other hand, I think that a lot of abortion storytelling winds up feeling like exceptionalism. You tell the heart-wrenching story about the woman who had this highly desired pregnancy and then found out at 22 weeks that there was a fetal anomaly incompatible with life and she had to get an abortion. Or the woman who's the victim of rape or incest, or whatever it is. And I think that the problem is that that really gives people sort of a level of protection and an out and an ability to say, “Of course, of course, we need to protect it for these specific people, for these specific categories. But that's different. That's not your average woman who's getting an abortion.” So, I think that it just winds up–and of course, what we're seeing now in all of these states that are passing abortion bans is that they don't really care about those exceptions anyway. Which is–I think the reason not to emphasize them is that, you know, we talk a lot in the abortion advocacy world about sharing the stories about the normal, boring abortion. The problem is that those are normal, boring stories that no one wants to hear about. But the majority of patients that I see in my practice, the bottom line is that they're just people that don't want to be pregnant.

So, there are a million reasons because humans are a very diverse species. And we all have our own very specific and particular life circumstances. And sometimes they have to do with money, and sometimes relationships, or educational goals, or safety, or health–so many reasons. But I think that's kind of my big takeaway. And something that I've really learned in educating residents in this work is, like, pushing them to think about how much we've really internalized this idea of the good abortion and the bad abortion. The person who, you know, deserves to end their pregnancy because they're whatever characteristic that you identify with or support, and the person that was just reckless and irresponsible and got pregnant and shouldn't have. And I think that those wind up being often very classist, very racist, very problematic distinctions in the first place. And again, I think it really distracts from the idea that this should just be a basic human right. The idea, like you're saying, Emily, is it's a big deal to have a baby.

I was recently on a podcast talking about how to talk to kids about abortion. And that was kind of the big takeaway, is that this is going to be really intuitive to kids. Because as much as we think that abortion is this scary, stigmatized thing that we shouldn't be talking about with kids, if you ask a kid, “Should a person have to have a baby if they don't want a baby?” Any kid is gonna be like, “No, that's crazy.” So, I think that that's kind of, I mean, again, I could come up with specific stories. But when it comes to providing abortion, honestly, I'm not getting into the story too much. Patients come in. They don't really want to talk to me about it. They just met me. They want me to do their abortion so they can go home and get back to the rest of their life. So it's not really my job to find out what their justification is or make them explain it. To me, it's enough. They show up, they're in my room, they're pregnant, they don't want to be pregnant, I can help them not be pregnant.

Emily Silverman

One question that's coming up for me is this thing about abortion being “safe, legal and rare.” And just focusing on that word, rare. How connected or not connected is the abortion care community with things like contraception and education? Because I think all of us would like for abortions to be rare. But are the same people who are seeing patients and doing abortions also counseling patients on contraception, and actually preventing abortions from happening in the future? Like, is the goal to kind of put yourself out of a job so that there aren't as many abortions to do or, like you said, sometimes the rates of abortion dip so low that people actually have to go out of the country to get this experience? So, should our goal be to put ourselves out of a job and have abortions just not happen? And just really, like, hammer home the contraception and education and things like that?

Alison Block

I think that that messaging, I guess it came out of the 80s and 90s, of “safe, legal and rare” was a huge mistake for the pro-choice movement. Obviously, the pro-choice movement has made a lot of mistakes, which led us to this point. It didn't work. The other side has really co-opted the narrative and won. I think that that was one of them. And I think you see this when you see sort of shifting demographics of abortion providers. I think that the sort of more old-school way of talking about feminism and about abortion was this idea of “safe, legal and rare.” And that was sort of the same category of people that were really aggressively pushing contraception onto patients, and particularly the long-acting, reversible methods of contraception–so, like IUDs and Nexplanons. And there was sort of a whole generation of providers that was trained with this idea of, well, everybody should have an IUD, and it's basically your job to convince somebody to have an IUD. And that has really fallen way out of favor as the pendulum has swung much more towards a new generation of providers that are much more reproductive-justice-minded, and much more interested in promoting and protecting patient autonomy.

So, I think that the conversations around contraception with patients need to be patient-centered. And we absolutely need to have much more funding, much more education, much more protection for contraception for those who want it and a lot of education available. And our providers need to have the information so that when patients come to the office, if they want it they can have it. And it kind of goes back to that same conversation around judgment of people and their choices. And the idea of the good abortion or the bad abortion. We should be fighting for a world where people can have children or not have children and can raise them in safe, healthy communities, full stop. And I think everybody in the world of reproductive health and advocacy and justice would agree that we need to make contraception widely and readily available to people. But I think the idea that you're ever going to eliminate the need for abortion is, again, very problematic for the movement, because then all someone on the pro-life or anti-choice side has to do is say, “Well, let's just provide all these protections, and then nobody will need abortions anymore anyway, so we can make abortion illegal and nobody will care.” And I think the reality that we've seen throughout human history is that for many different reasons, like I was saying, whether it's fetal anomalies, or the contraception failed, or that someone just doesn't like any of the contraceptive options that are available, or that someone was raped, like, again, there are just so many reasons that people wind up pregnant and don't want to be pregnant. And I think the idea of saying that should be a very rare occurrence feels a little bit like harping on abstinence-only education. Like, it's just not going to happen. It's just not sufficient.

There are going to be a lot of people that have unwanted pregnancies that need abortions. And so of course, we should do everything that we should, along all the other policy levels– make contraception available, make childcare better and more available, parental leave, like, all those things, so that all of the options are available. None of those things, of course, are on the agenda of the right. But I think that idea of really protecting abortion, as its own medical necessity that's going to happen and going to be needed no matter what, is really important.

Emily Silverman

I recently came across the story of a woman who got pregnant, it was a desired pregnancy. And she found out along the way that it had a fetal anomaly that was incompatible with life. And she said that her physicians just sort of assumed that she would want to have an abortion. And that was the way they were talking. That was the way that they were posturing. The vibe was kind of, like, “So when are we going to set up your abortion?” And she actually thought about it and for whatever reason–personal, religious, I don't know–made the decision that she actually did not want to have an abortion. She wanted to carry the pregnancy to term. She wanted to bond with that baby, even if it was only going to survive for hours, days, and that was her choice. But she said that every time she showed up for her OB/GYN appointments, she would ask the doctor to please check the heartbeat and, you know, check on the baby. And the vibe from the doctors was kind of like, “Well, why would I check the heartbeat?” Like, “Your baby's just gonna die.” And so the feeling she got was that the medical system was treating her baby as if it was already dead. And this is actually what spurred her to become very pro-life and to be a pro-life advocate.

And so that narrative actually got me thinking a lot about what does it really mean to be pro-choice? We have to support women who want to have abortions. But how do we think about supporting women who maybe don't want to have an abortion, even if it's a scenario where maybe we personally would choose to have an abortion? Is that piece of the conversation missing? Is that a place where maybe we can tap into some empathy on both sides and find some common ground, and also just critically look at ourselves as healthcare providers, and how we might orient ourselves to patients whose views differ from our own?

Alison Block

I think that anecdote makes a lot of sense. I can totally see that happening. And I think this is sort of, again, almost a generational issue. The new generation of providers is very attuned to, again, that sense of reproductive justice. It's not just about giving people abortions who want abortions. It's also about letting people have babies who want to have babies, and it's really about patient autonomy. And I think we see this in a lot of places in medicine that used to be a lot more paternalistic. And, certainly, abortion care and reproductive health care is not immune to the sins of the past in terms of, again, things that are really rooted in racism and white supremacy and the approach to patients of who should and shouldn't be having babies. There's a lot of bad historical legacy there that we need to work towards getting away from. But I think we already are.

There are a lot of people, again, it sounds like this woman had a really unfortunate experience. And hopefully, there's a lot of providers that can learn from that and do better. But I think that idea of just genuinely, I mean, it's what we learned in med school from day one about just meeting patients where they're at and really taking into account their wishes and their desires and their humanity and who they are, and not just making assumptions and not imposing our agenda on them. So, I think that is really important. And I think that I do a lot of values-clarification work with the residents that I train, where we sort of play out different scenarios and test and probe our reactions to them, because there's a lot of bias that we have built in, that just comes out. And sometimes it's things like that–it's assuming that somebody should have an abortion who maybe doesn't want one. And I think anytime that your own personal beliefs and biases are affecting the way that you're treating a patient in the room, that's something that needs to be more deeply explored and excavated and worked on.

Emily Silverman

Let's talk about your Op-Ed in the New York Times. You wrote this, it was published on May 6, 2022. What inspired you to write this? What inspired you to come forward and go public as an abortion provider? What was the experience writing that piece? Having it edited? Having it published? What was the response? Tell me about that.

Alison Block

I did this second trimester abortion training in Oklahoma and Kansas in the spring, partly because I was anticipating this shift, in a post-Roe era, of a need for a lot more second trimester providers, as patients had to wait longer and longer and travel further and further for abortions, and partly because I was moving to a new region, where there was more of a need for providers that could provide both first- and second-trimester abortions. So I went and it was a really eye-opening and wonderful and affirming experience, learning there and being there. And I just felt like I had something to say as somebody that, again, had been living and providing in this Bay Area bubble. And I had this new experience right at this critical moment in American history of seeing what it was like providing abortions in this, these places where access to abortion was going away, literally in that moment.

So, I have for a long time debated whether or not to write about the issue of abortion. I love writing and doing advocacy journalism. And I also, obviously, I'm really passionate about abortion care, but have not done it for a long time because of issues of privacy and safety. And I just sort of got to a point where I talked to a lot of colleagues and felt like this was the right thing to do. And, I mean, I love that anecdote that you shared about your mom and seeing her on the phone making these calls and writing letters to the editor. And I think I want to be that person for my kids. I want to be brave. And I want to fight for what I believe in and write about what I believe in.

So, I decided to write the piece. And then it was a really terrific experience. I immediately heard back from the editor at the Times in charge of the, sort of, reproductive health opinion section, and she was wonderful to work with. She gave me a lot of great feedback and was extremely mindful of my desire for accuracy and just making sure that we got it right, that we really got it right. And she was terrific to work with. And I was certainly nervous about publishing it. And the outpouring of incredible love and support after the article came out, I mean, it honestly felt like the day of my wedding! It was just people from every corner of my life, reaching out by email and texts and phone calls, just saying how much they appreciated it and how much it resonated with them. And that felt obviously good, and also just gave me a lot of hope that people do care, they are reading, they are listening, they are paying attention. And again, most people in this country are not happy with the direction that things are going. So, hearing that feedback from people was really affirming.

Emily Silverman

Do you want to talk a little bit to our audience about The Nocturnists, and our idea for how to do some storytelling around this moment?

Alison Block

So, yeah, basically, we have been talking about doing something around reproductive healthcare for a long time, but particularly in the wake of the recent Supreme Court Dobbs decision, we felt like this was an incredibly important moment in the history of healthcare in America, and that there are going to be a lot of stories happening all across the United States that we want to document. And I think we want to be a venue for healthcare providers and other people that work in the healthcare field to share those stories. So, what we decided is that we're going to put out a call and just gather as many stories as we can. I think we would love some audio diarists to explore what they're experiencing on both sides of the political divide. So, things are changing for everybody. People in red states who used to be providers, who are now really dealing with the tremendous moral distress of having to turn away patient after patient after patient. People in blue states who are maybe experiencing an influx of patients are having to totally rework and rethink their clinic flows. And then of course, people in between, that have been doing this work for a long time. And, sort of, the canaries in the coal mine that saw it coming and nobody was listening. Our providers in Texas that have been dealing with this since SB8 went into effect last September and have been trying to sound the alarm and nobody's really listening.

So, we want to hear from everybody. I know that there are a lot of people out there that have relationships with the colleagues that they're referring to. So, people in Texas or Oklahoma that are referring to their colleagues in Kansas, or in all the states around Illinois, where abortion is going to be illegal, that are referring to centers in Chicago. And I think there are going to be some really interesting stories that come out of those relationships among providers. And just doing what we do, which is trying to care for patients and get them the health care that they need, and the fact that now it's going to require really Herculean logistical efforts. So we just want to hear everything about it.

Emily Silverman

So, if you're listening to this, and you are a health care provider who takes care of pregnant people, or maybe you're somehow adjacent to taking care of pregnant people but you have something to say about this, visit our website, thenocturnists.com, and find the page about our new storytelling project, which is Post-Roe America. We would love to hear your voices. And we just want to document the fallout of…how is the healthcare landscape changing in the wake of this new Supreme Court decision. I think rarely in my life have I seen a single legal decision have such an abrupt and immediate and jarring and high stakes impact on the practice of healthcare workers across this country. I can't think of another example of a time that things have changed overnight, so quickly. So, we want to understand what that is like for you and hopefully amplify the voices of clinicians in a landscape where it's the politicians’ voices that are usually amplified. And their medical literacy around this issue is variable. We really want to make sure that we get voices that are telling it like it is and being accurate, and so on and so forth.

Alison Block

And I think part of, one of my goals with this project is like with everything that we do–to just be a place of catharsis and healing for the health care providers that are going through this. Because, again, it's obviously a huge tragedy for all the pregnant people that are not going to be able to access abortions, but it also has huge ramifications for the providers and is really a trauma. And so, being a place not only where we can capture and document those stories, but also, in the meantime, just a place to share what you're experiencing, and unload, and have an experience of community with others that are going through the same. I think we want to provide that as we always do, as we have since our first live event.

Emily Silverman

Dr. Ali Block, thank you so much for coming onto the show today, for the amazing work that you do taking care of patients, for your Op-Ed, your advocacy, and everything else. It's been really wonderful to chat.

Alison Block

Thank you for having me, Emily, I'll see you soon.