The phone still rings at the Whole Woman’s Health clinic in McAllen, Texas, not 15 miles from the Mexican border in Texas’ fertile Rio Grande Valley. Robin Hood: Prince of Thieves plays on the waiting room television, a few feet from a wall stocked with brochures detailing the stories of Chicana activist and writer Sandra Cisneros, seminal Mexican artist Frida Kahlo, Black scholar Audre Lorde, and other feminist heroines. A purple coffee maker stands at the ready, near neatly stacked magazines.
But the chairs are empty. No one is here to idly watch Kevin Costner plead for his intended’s affections or read about Molly Ivins’ relentless crusade against tomfoolery in the Texas legislature. And for the first time in nearly 40 years, no one is coming to this building to get an abortion.
The stillness belies the many duties recently taken on by the skeleton crew of clinic workers left to manage the phone line and pre-operative counseling, seeing patients who are now facing a 300-mile round-trip drive to Corpus Christi, or a 500-mile round-trip drive to San Antonio, to the nearest safe, legal abortion providers.
Sex. Abortion. Parenthood. Power.
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“Now I can actually hear my echoing footsteps,” said Lucy, one of two remaining full-time clinic workers who are keeping up with day-to-day operations at Whole Woman’s McAllen in the wake of the enforcement of HB 2, Texas’ restrictive new anti-abortion law. It is late November 2013, and the doctor who performs abortions at the clinic hasn’t been able to secure admitting privileges at a local hospital, ending the abortion care that the clinic provided for the past nine years under Whole Woman’s Health name, and for 30 years before that under a prior owner.
Lucy periodically jumps up from our interview to take phone calls and direct the trickle of patients to exam rooms. Two women stand at the inside receptionist’s desk, discussing procedure costs and paperwork in hushed tones.
The clinic’s security entrance buzzer is still in operation, and a sign attached to a church counseling center next door still points an oversized arrow to its neighbor, under a sign that reads, in partial capital letters: “ABORTION Clinic.” Lucy says she’s even continued to see protesters on the sidewalk outside. Inside, everything appears quietly preserved, a museum-like memorial to a time when legal abortion was available in the Rio Grande Valley.
The empty waiting room at Whole Woman’s raises a question for everyone who sees the new, grim reality of reproductive choice in the Valley: Where have all those patients gone?
It seems unlikely that the 2,600 or so Texans who once sought legal abortion care each year in the Valley will, suddenly, find the means to support or continue unplanned pregnancies they would otherwise have terminated. None of the three of HB 2’s four provisions that are currently in effect provide funding for prenatal care, mandate workplace child care, or expand enrollment in Medicaid or food- or work-assistance programs.
Instead, HB 2 requires physicians to have admitting privileges at a hospital within 30 miles of where they perform abortions, restricts the prescription of medication abortions according to a 13-year-old Food and Drug Administration protocol, and bans abortion after 20 weeks. And if the final provision of HB 2 remains unchallenged in court before September 2014, all abortion providers in Texas will, at that time, have to meet the standards of ambulatory surgical centers, leaving a total of six legal abortion facilities in operation in the entire state.
If Valley residents seeking an abortion cannot afford to drive hundreds of miles to Corpus Christi or San Antonio, they will have no choice but to do one of three things: continue their pregnancies, schedule later, more expensive abortions once they find the means to pay for them, or attempt to self-induce abortions using occasionally dangerous and often ineffective means.
For Lucy at Whole Woman’s Health, there is no question that some patients who can no longer come to her clinic for legal abortion care will attempt to self-induce. “Women are going to have an abortion,” she said. “They’re going to find a way. Which means there might be an increase in infection, infertility, in death.”
Whole Woman’s Health has tried to get admitting privileges for its doctor in the Valley, to no avail. Whole Woman’s Vice President Andrea Ferrigno, who has overseen the group of clinics’ attempts to obtain privileges, testified in federal court in October, saying that oftentimes hospitals want their doctors to generate business, and with abortion’s low complication rate, it’s unlikely they’ll be admitting many patients, if any at all.
And the privilege-obtaining process itself is lengthy, Ferrigno told Rewire: The clinic must first send a doctor’s information to local hospitals, then the hospitals do background checks
to decide if they want to allow the doctor to formally apply.
“It seems our doctors would qualify for privileges,” said Ferrigno, but “ultimately, it comes down to the [hospital] board.”
Evidence suggests that self-induction was already more common in Texas than elsewhere in the country, even before the implementation of HB 2. According to University of Texas researchers at the Texas Policy Evaluation Project (TxPEP), self-induction appears to be an even more likely choice for those living along the U.S.-Mexican border.
TxPEP’s lead researcher, Dr. Joseph Potter, testified in a 2013 federal court affidavit that the rate of attempted self-induction was “significantly higher” in Texas; while a 2010 nationally representative study by the Guttmacher Institute found that 2.6 percent of 9,493 respondents reported trying to self-induce an abortion, 7 percent of 318 patients surveyed at Texans abortion clinics in 2012 reported attempting the same. At clinics near the border, 12 percent of those patients reported attempts to self-induce.
Indeed, one young Rio Grande Valley woman I spoke to, who asked not to be identified, said that she and a friend crossed the border into Mexico as teenagers to obtain abortion-inducing drugs. Already, they felt the heavy weight of abortion stigma in the deeply socially conservative area.
The two friends “got pregnant around the same time,” she told me. “I took pills from Mexico. I was so young.”
Dr. Potter expects attempts at self-induced abortions to become “even more common” in Texas as the state further limits access to legal abortion.
But being able to travel back and forth across the border is a luxury many undocumented Texas residents in the Rio Grande Valley do not have. Neither can they make the drive to San Antonio or Corpus Christi without passing through interior border checkpoints on the highways that connect the Valley to the rest of the sprawling state.
The checkpoints are tailor-made for intimidation. At Falfurrias Station, as south-bound travelers breeze toward McAllen, border patrol agents guide drug- and people-sniffing dogs around bumper-to-bumper cars heading north on Highway 281, inspecting trunks and back seats. A giant black-and-white sign proudly advertises the number of “illegal aliens” detained.
But for anti-choice proponents of HB 2 and their allies, there is little sympathy for people whose access to legal abortion is blocked by border patrol. During a Fifth Circuit Court of Appeals hearing on the constitutionality of the law, Judge Edith Jones quipped that the Valley highway leading to San Antonio is “peculiarly flat and not congested,” with a speed limit of 75 miles per hour.
Congestion on the highway is hardly the problem. Many people who live and work in the Valley have visas that require them to stay in the area, while others live as undocumented Texans who travel north at their own peril. Valley residents told me it is not unusual to see people hurl themselves from moving cars before they reach border patrol stations in hopes of escaping detection by agents at the northbound checkpoint. They’d rather venture through farmland on foot than risk the trip in a vehicle.
“I got to see firsthand. They’re driving the car in front of you, and they swerve to the side, the door opens, and people start flying out,” said Paula Saldana, a community health educator who lives in Brownsville. The first time she saw this happen, she was in the car with her husband, and she was sure someone had just committed a terrible, violent crime.
“I’m like, ‘Oh my God, he pushed her out of the car!’” she said. But her husband told her to just keep driving, pretend like you never saw it. Still, she says she worries about people who get lost in the brush surrounding the highway, and wonders if they are attacked by animals.
Having lived and worked in the Valley her whole life, Saldana knows the challenges faced by undocumented residents. She lost her job with Planned Parenthood in 2011 in the wake of statewide family planning budget cuts that have, so far, caused 76 clinic closures in Texas. Now, Saldana volunteers with the National Latina Institute for Reproductive Health, educating people in her area about birth control
and cancer screenings, and talking to their kids about sexual health.
In the course of her work, Saldana comes face-to-face with the people who will be most negatively affected by restrictions on access to abortion.
“The ones that do have papers, yes, they’ll be able to cross the checkpoint, but there’s also just the cost,” she said, of making the trip to San Antonio or Corpus Christi for a legal abortion. “Travel cost, lodging if they have to stay, meals, plus the cost of the procedure.”
Even if border checkpoints were to disappear tomorrow, financial barriers to obtaining even basic reproductive health care, not to mention abortion, are particular concerns for the estimated 275,000 women of reproductive age who live in the Valley.
The counties that make up the Rio Grande Valley are among the very poorest in the United States, and TxPEP research estimates that two-thirds of those 275,000 women are “in need of subsidized contraceptive services.” But two years ago, conservative state legislators drastically reduced funding for long-acting reversible contraceptive methods like intrauterine devices (IUDs) and implants, and now Valley residents often have to decide between buying a $30 pack of birth control pills or putting food on the table for their families.
Because of this, Saldana says she knows that there are “back-alley procedures” happening; she even partially blames herself for a recent raid on a Donna, Texas, flea market, where shoppers could obtain the abortion-inducing drug Cytotec—the brand name for the stomach ulcer drug misoprostol—without having to visit a physician or clinic.
When the national media turned its attention on the Valley after Texas’ 2013 legislative session, Saldana says she spoke to reporters about the illicit sale of Cytotec; sheriffs soon raided the Donna market and found Cytotec, along with a host of other drugs, including Viagra, Cialis, and the diet pill Redotex. A woman in neighboring San Juan was also arrested for illegally selling prescription drugs, including abortion-inducing pills.
Now, Saldana wonders whether the fear of future raids has pushed illegal abortion even farther underground.
“I feel responsible for that, a little bit,” she said. “But I know they’ll find a way.”
With the near-full implementation of HB 2 underway in Texas, there are many people who want to help Valley residents who are seeking an abortion find a way to not “find a way.” I joined ten or so of them on an unusually cold and rainy November evening at McAllen’s MoonBeans cafe, where we squeezed tables together and ordered hot drinks—along with a couple of cold beers—to fuel an hour-long discussion of strategies that could help people access the comprehensive reproductive health care they’d lost weeks before.
I found myself surrounded by familiar faces, Twitter avatars come to life, recognizing people like activist Nancy Cardenas, a Valley native who’s taken the reproductive justice fight with her to school at the University of Texas at Austin, as well the meeting’s organizer, NARAL Pro-Choice Texas’ Heather Busby, who carpooled to the Valley with an Austin birthing center activist. We joined up with a local professor and students from UT Pan-American in nearby Edinburg, and Valley-dwelling members of the grassroots Rise Up Texas movement.
Their first question proved to be one of the hardest to answer: Where to start? With organized caravans and ride shares from the Valley to San Antonio? With message boards or clinic liaisons, finding out who needs to travel, and on what days? Would anyone ever try to disseminate information about how to take abortion-inducing drugs without causing hemorrhaging or infertility, or warn women against dangerous herbs? More broadly, what could be done in the long term to elect legislators who wouldn’t try to further block access to abortion and put yet more Texans in dire straits?
The trouble with answering any or all of these questions is that, almost by definition, the populations who are the most affected by legislation like HB 2, and cuts to family planning funds, are the hardest to track through institutional or organizational means.
The most recent and comprehensive study focusing specifically on reproductive health care in the Rio Grande Valley has come from the National Latina Institute for Reproductive Health (NLIRH) and the Center for Reproductive Rights (CRR), which jointly produced a report and human rights campaign called Nuestro Texas, released two weeks before our meeting at the McAllen cafe.
NLIRH and CRR built Nuestro Texas out of interviews with Valley Latinas, conducted through focus groups and conversations with people like Paula Saldana, who have been directly affected, in both positive and negative ways, by health policy and budget changes in Texas.
Saldana can remember a time, in Texas, when she and women like her had access to resources that enabled them to make informed, empowered decisions about reproductive health care and pregnancy. Saldana herself, pregnant as a teenager, was able to continue her schooling and raise her child thanks in part to the help she got at her local Planned Parenthood.
“Planned Parenthood helped me a lot,” Saldana told me. “I considered abortion, I considered adoption, and they gave me my options. They educated me on them, and they told me, ‘You make the decision.’”
Conversations about abortion can be difficult for Texans in the Valley, because of the strong Catholic culture, said Saldana. Her mother, she says, “supported [her] 100 percent,” but her grandmother threatened to write her out of her will if she aborted her pregnancy.
Through a Planned Parenthood program called Positive Directions, Saldana was able to finish school and find a job right out of high school, even enroll in college.
“I was fortunate enough to have help at that time,” she said. Her little sister and her mother helped her raise her child, who is now 19 years old. Saldana went on to a career in community health, but members of her own family continue to be affected by state cuts to family planning funds.
When I met Saldana at her home in Brownsville, Saldana’s sister Tina was on hand to help watch Paula’s younger son. Tina had her own infant in tow, a child conceived after Tina lost access to the low-cost birth control she’d been able to get from a local Planned Parenthood clinic; Tina was suddenly looking at paying $80 per month for her contraception.
“The cuts came,” said Saldana, referring to the $66 million reduction in family planning funds enacted by conservative Texas legislators in 2011. “She had to pay, and was like, ‘OK, it’s my light bill or my birth control.’”
“In between her deciding,” her sister conceived, she said. “She got another one.”
Like Paula Saldana, Nuestro Texas pulls no punches; the report openly puts the responsibility for the deteriorating state of reproductive health care in Texas on the policymakers and legislators who reduced family planning funds and who failed to allocate much-needed transportation resources to the state’s poorest residents. It reads, in part:
Yet, rather than allocating a greater share of reproductive health resources to underserved areas like colonias, or addressing the structural barriers such as poverty and transportation that prevent women from accessing timely and appropriate care, Texas has implemented reproductive health policies that will further undermine access to care and exacerbate health disparities.
Whenever she can, Saldana says she tries to teach her community health groups about the importance of voting and participation in local government, along with giving them the basics of contraception and explaining female anatomy.
“I always incorporate the importance of voting, the importance of getting these programs back,” she told me. “But the only way we can do that is through mobilizing. Getting these women worked up!”
According to the Texas Cancer Registry, in Starr, Willacy, Cameron, and Hidalgo counties—the four counties that make up the Lower Rio Grande Valley—the incidences of invasive cervical cancer among Latinas are almost twice those of non-Latina white women. What’s especially heartbreaking for people who do the kind of work Saldana does is the knowledge that even when they give their fellow Latinas the health-care information they need, it will do nothing for them if clinics are closed, or if they are so far away that no bus can take them there—if a bus exists at all.
“During presentations, they’re like, ‘You’re telling me it’s very important to get a pap smear, but where do I go?’” said Saldana. “There’s no services, there’s no transportation. It’s very expensive.”
Seeing conservative and anti-choice legislators’ resistance to funding family planning services, a group of reproductive health-care providers in Texas decided to take fiscal matters into their own hands and applied directly for the federal Title X family planning grant that has, for years, gone directly to the State of Texas. The group, Women’s Health and Family Planning Association of Texas, won the grant. With it, they are now reopening closed clinics in the Rio Grande Valley.
A few miles from Whole Woman’s McAllen, the scene at the newly reopened Planned Parenthood clinic in Mission is markedly more upbeat: Pop country music pipes through the office speakers while busy receptionists file paperwork and patients sit, whispering to friends and with kids in tow, waiting to be seen. The building even smells like a fresh coat of paint.
As staffers sing along to Darius Rucker’s cover of “Wagon Wheel,” Planned Parenthood’s Hidalgo County community services director, Kathryn Hearn, explains the importance of the clinic’s reopening after a two-year shutter due to the state funding cuts: “When we opened again, [our patients] were really sick.”
“For two years,” said Hearn, “they had not gone anywhere.”
Often, in low-income communities and areas where people are under- or uninsured, Planned Parenthood is the only viable option for affordable health care of any kind. Community clinics and federally qualified health centers are overbooked, and undocumented residents frequently fear going to emergency rooms or hospitals where they worry their immigration status will be questioned.
Now that the Planned Parenthood in Mission is back to serving clients—but for the closure, the clinic would have been going on 50 straight years operating in the Valley—patients can return for reproductive health screenings as well as referrals for mammograms or outside treatment of high blood pressure and diabetes; what clients cannot get at this Planned Parenthood, or any Planned Parenthood clinic in the Rio Grande Valley, however, is an abortion.
A full well-woman exam at Planned Parenthood in the Valley costs around $60, but many patients don’t even pay that much, taking advantage of the income-based fees that the Mission clinic offers through the Title X grant.
“Most patients live at or below 100 percent of the federal poverty level,” said Hearn. That’s about $23,000 per year for a family of four, and at that level, patients pay nothing for services. Title X patients with a higher income might pay 10 or 20 percent of the service cost—about $20 or less. And if patients don’t qualify for Title X, Planned Parenthood offers extremely low fees for them as well.
On this particular November day, two months after the Mission clinic reopened, a 28-year-old woman named Christina has come in for an appointment. She’s two-and-a-half months pregnant, and says she’s “still coping” with the news of her pregnancy, but appreciates being able to come to Planned Parenthood and talk with staffers who are good listeners with lots of answers.
“If you have any concerns about your body, you can come here,” she said. “They let you know what your options are.”
Perhaps most importantly, says Christina, Planned Parenthood lets her know up front what she’ll pay for care, and they’re “willing to work with you.” At regular doctor’s offices, she says, “they just want to know if you have any insurance.”
In Texas, insurance can be hard to come by. In 2013, Texas had the highest rate of uninsured adult residents in the country, and the highest number of uninsured children. State leaders, Gov. Rick Perry the most vocal among them, have refused to address the situation by expanding Medicaid coverage provided to them by the federal government under the Affordable Care Act.
The result is what’s been called the “coverage gap.” It prevents an estimated one million Texans who live at up to 138 percent of the federal poverty rate from being able to buy affordable insurance under the new health-care exchanges, while their neighbors in other states are able to take advantage of the new offerings. Once again, Valley residents are some of the most likely Texans to fall into that gap.
It is no wonder, then, that many people in the Valley turn to getting their medication across the border in teeming Reynosa and sleepy Progreso, Mexico. Or they can stay a little closer to home and visit places like the Alamo Flea Market, just off Interstate 2 outside McAllen.
I convinced a group of people from the MoonBeans meeting to join me at the Alamo market on a drizzly Saturday morning, and from the get-go, our mission was a challenge: The market spans acres and features multiple entrances, where patrons pay a quarter to access a maze of stalls. After a flurry of text messages trying to determine which booth full of cowboy boots, pet rabbits, or soccer scarves everyone had entered near, we found each other at a nest of picnic tables near a food stand selling hot coffee and tortas.
The task at hand
—to find out whether we could purchase any abortion-inducing drugs—was no small feat when faced with row after row of vendors selling faded packages of Monistat, crates of deodorant, and socks in bulk.
Two of our Spanish speakers, both men, disappeared into the maze to see what they could find, while I—a giveaway white woman—talked transportation tactics with NARAL’s Heather Busby and a local high school teacher. After an hour or so of searching, the guys returned empty handed, but not without news. “One of the vendors told us there wasn’t that kind of thing for sale here anymore,” they reported.
After a San Juan, Texas, woman was arrested in November for selling prescription drugs, including abortion pills, out of her home, a San Antonio FOX affiliate made a similar attempt at a South Texas flea market last fall, but vendors declined to sell undercover producers abortion-inducing drugs directly.
A San Juan police spokesperson told me that the San Juan woman, Maria Garza, is the only arrest they’ve ever made on charges of selling abortion pills illegally; they believe she operated out of flea markets before she moved her business to her home. When Rewire inquired with other local law enforcement agencies in the Valley and along the border, none besides San Juan reported ever arresting anyone for illegally selling, or ingesting, abortion-inducing drugs. Many seemed surprised to have been asked the question.
But the focus on drugs like Cytotec/misoprostol may be too narrow. While illegally obtained stomach ulcer drugs like these have been the primary subject of media reports on self-induced abortions, university researchers have found they are not the only, or necessarily the most common, means by which women attempted to end their own pregnancies.
“There is a misconception among abortion providers and some advocates that self-induction is all about misoprostol,” Dr. Dan Grossman, an assistant clinical professor in obstetrics and gynecology at the University of California at San Francisco, told Rewire via email. Grossman is also part of the Texas Policy Evaluation Project, and has led some of the only research on self-induced abortions in the United States.
“Women are using a lot of other methods, most of which are not effective,” he wrote. In in-depth interviews with 30 women who reported that they had tried to end their own pregnancies, his group found that women reported using, variously, herbs, vitamin C, laxatives, fermented beverages, and more physically invasive methods like inserting objects into their vaginas or exerting external trauma on their bodies to try and end their pregnancies.
Misoprostol use, however, was especially common among women who had more recently attempted to terminate their own pregnancies, and among women in McAllen, four of the five survey respondents there used the drug. Dosages taken by women who chose misoprostol varied greatly, and of the 30 respondents Grossman’s team spoke with at length, just three reported having a “complete abortion without additional clinic care.”
In an interview with Al Jazeera, a straight-talking Harlingen, Texas, doctor named Lester Minto, who owns a reproductive health clinic about 40 minutes from McAllen, said he saw around 100 patients who needed him to complete their own self-induced abortions in the month-and-a-half period between when HB 2’s admitting privileges provision went into effect and mid-December.
Minto hasn’t been able to obtain admitting privileges in the Valley, but he told the news outlet that he keeps his clinic open to help the patients who have to turn to him after their self-inductions have failed. The North Texas-based doctor who formerly performed abortions at Whole Woman’s Health in neighboring McAllen, however, has stopped providing care altogether.
Now, it appears as though the only people performing abortions in the Rio Grande Valley are the pregnant Texans who are unable to receive an abortion because they lack the funds or documentation needed to travel to Corpus Christi or San Antonio for safe, legal abortion care provided in a clinical setting by a licensed physician. They are Texans who now must take matters into their own hands, or continue their pregnancies in a state where the maternal mortality rate has quadrupled over the last 15 years.
At Whole Woman’s Health, Lucy says she misses her patients and can’t imagine leaving, though she knows now that in the wake of HB 2, she’ll almost certainly have to, unless administrators at local hospitals have a change of heart about granting admitting privileges to physicians who intend to provide abortions in the Valley. She says she can see the value and quality of comprehensive reproductive health care that Whole Woman’s once provided in McAllen through the patients who returned there, year after year, for more than just abortion procedures.
“A lot of patients that were previous patients, whether it was years ago or recent, wanted to come back to have their pap smear with us,” Lucy said with a smile. “We were there for their abortion, which is very personal, intimate.”
“I don’t see myself,” she said, “working anywhere else.”