AKRON, Ohio —The first patient of the day had come to Planned Parenthood for birth control, and because her daughter was waiting at the sitter’s to be taken back-to-school shopping, the patient kept her phone on her lap and watched the time while she answered the clinician’s questions.
“Any recent problems?” asked Brittney Moore, a nurse practitioner and the lead clinician for this health center in a declining industrial city in northeast Ohio.
“Last week, I had a weird pain in my ribs,” said the patient, a 24-year-old home health aide.
“Do you have any shortness of breath?” Moore asked.
“Probably from smoking cigarettes,” she said, and sighed.
There they were, in a state whose attorney general had recently opened an investigation of Planned Parenthood, in a country where House and Senate members were threatening to shut down the federal government over Planned Parenthood funding, at a time when an antiabortion group was releasing weekly videos that purported to show the organization’s employees talking about selling fetal tissue for profit — and in a universe where Planned Parenthood had again become a symbol for one of the most divisive moral battles of the modern era.
Moore wrote the prescription, then moved on to her next patient.
This clinic sees nearly 7,100 patients a year, most of them young and poor. The clinicians administer 3,400 pregnancy tests, write 2,900 prescriptions for birth control and provide 13,200 screenings for sexually transmitted infections to the women and men walking into a boxy building between a restaurant-supply store and a used-car dealership. Inside the clinicians’ office, a pamphlet on the wall reads “Bomb Threat Checklist.”
Like nearly half of Planned Parenthood’s facilities nationwide, Akron doesn’t perform abortions. Three of the organization’s 27 centers in Ohio do; the nearest is in Bedford Heights, where protesters regularly picket. When pregnancy tests come back as unwanted positives, those patients are referred to Bedford Heights, 26 miles away.
That referral had now become enough of a metaphorical tie to the organization’s more controversial mission that one patient had come in and said, angrily, “I saw those videos,” and one employee’s husband found himself defending his wife’s profession to colleagues who had never before shown an interest. Earlier that morning, at the weekly staff meeting, Stephanie Kight, the Ohio state director, told the workers that a large antiabortion demonstration was announced for the coming weekend in front of the clinic.
“I don’t think we should wear our uniforms that day,” said Harriet Schaefer, the clinic director. “To be safe.”
“We’ll get back to you with a security briefing — parking and whatnot,” Kight told the staff, and she moved to the next part of the meeting, a presentation by education manager Constance Dunlap about the stigma of working for an organization that performs abortions.
Employees should think about the risks of disclosing their workplace, Dunlap said. They also should think about the emotional risks of not telling people. Dunlap said that her own parents did not know where she works. They are in their 80s and devout Baptists. “My dad thinks I’m a teacher,” she said, and the meeting ended and it was time to open the clinic.
The next patient of the day had come because she was experiencing symptoms she’d never encountered before and wondered if her new birth control was to blame.
“Have you been stressed out at all?” Moore asked.
“I just started a new job,” the patient offered.
“The other small possibility is that it could be chlamydia.”
“I don’t think it’s chlamydia, because I’ve had that before. I hate to have to say that, but I have.”
“No, it’s not. I know it’s not.”
A patient shortly after her arrived, a young man who apologized for his coughing — “My girlfriend likes sleeping with the AC and the fan; she doesn’t understand that Geminis need to keep warm” — then submitted to the STI screening he’d come for and turned down an offer of free condoms. He was one of several clients who let a reporter write about their appointments without using their names.
The majority of the center’s services are provided at a reduced cost, funded in part through Medicaid reimbursement and Title X, a federal grant program that provides family planning and related health care. In Akron, there is no other Title X provider. The largest health provider doesn’t take Medicaid. The only federal health center has a three-to-six-week wait for appointments.
In the middle of the afternoon at Planned Parenthood, there was a pregnancy test. Those tests were walk-ins; clients didn’t make appointments. The patient was a slim 19-year-old who arrived by herself and ignored her buzzing phone as the same number flashed on the screen two times, then three.
“Have you ever been pregnant before?” asked Schaefer, the clinic director. She’d worked for Planned Parenthood for 30 years, her daughter now worked at a different branch; she had learned over time how to keep her voice neutral and calm while she read scripted questions from an intake sheet.
“No,” the woman answered, she had never been pregnant.
“Are you desiring to be pregnant, do you not want to be pregnant, or are you unsure?”
The woman’s phone buzzed a fourth time; she took it out of her bag, looked at the number and turned off the ringer. “I’m unsure.”
Schaefer nodded and told the woman, who had provided a urine sample when she first came into the clinic, that she would be right back with the test result. The woman reached for her phone again, but before she could press any numbers, Schaefer returned and said the test was positive.
“Do you know what your options are?” Schaefer asked the woman, who blinked and folded her hands under the table.
“I think so,” she said. “Like, you mean, what I’m going to do?”
“Oh. I’m going to keep it.”
“Okay,” Schaefer said. She told the woman her estimated due date and asked if she had a support system at home. She mentioned prenatal vitamins and said, “We want to make sure you have a healthy baby.” Finally, she asked if the woman had any questions for her, and the woman said no but didn’t get up to leave.
“My mom is so happy,” the woman said after a minute, explaining that she’d already taken a drugstore pregnancy test the night before and came in today for verification. “My boyfriend is happy. My friend was happy. I’m happy, too, really, but I’m also sad, because I work full time and go to school.” She started to cry, and wiped her face with the heel of her hand. “I really wanted to keep going to school, but stuff happens. I don’t know why I’m crying.”
Back in an office, down the hall from where Schaefer was giving the 19-year-old some brochures about prenatal care, Kight, the Ohio president, finished a conference call about security issues for the protest and looked at a spreadsheet on her laptop. On it was listed all of the state’s Planned Parenthood locations. The ones highlighted in yellow were where antiabortion groups said they would be holding rallies over the weekend. A state representative and a state senator had announced that they planned to come to Akron. One of them had recently proposed a bill that would tighten the restrictions and penalties for the sale of fetal tissue for research, which already was illegal in Ohio.
“It’s not like I’m worried worried,” Kight said, as she went over security plans for the event. She believed the protest would be peaceful. “But do I have an officer come? Do I not? I’m worried about staff anxiety.” Having a police officer at the clinic might feel reassuring to workers and patients, she thought, but it also could signal something unnecessarily alarming.
She is used to security briefings, and used to making public statements, and used to living in Ohio, a diverse state where abortion is polarizing and people feel their positions deeply and sincerely, where opponents argue that clinics such as the one in Akron should be defunded because they disapprove of any government support for an agency whose mission includes abortion. But it seemed to Kight as though recent events, following the release of undercover videos by the conservative Center for Medical Progress, had affected her staff in ways she hadn’t seen before. Planned Parenthood’s Web site had been hacked. Workers seemed shaken.
One supporter of the clinic had started a Facebook page to promote a counterprotest to the one over the weekend, which Kight considered well intentioned, but a complexity she didn’t need. Supportive signs sounded nice in theory, but to a patient coming in for treatment, they would just look like more overwhelming chaos. She imagined the possibility of fights and yelling.
These days, almost any spark could become a fire.
“I think I’ve decided to just get one policeman for traffic control,” Kight said, finalizing her security plan. That way, the officer would still be near the premises if anything went wrong.
It was almost the end of the day. The waiting room held an affectionate couple with matching tattoos. An older man accompanying two teenage girls. An exhausted mother of grade-school-age children who’d made an appointment to have her birth-control implant removed because she thought it was giving her headaches, although maybe the headaches were coming from her former husband, who let the kids stay up as late as they wanted and then brought them back to her house, wired and cranky. A 25-year-old man wearing gym shorts and loafers, who, after his name was called, sat down on the plastic chair in Moore’s exam room and told her that he needed an HIV screening.
“My ex just informed me that he tested positive,” he told Moore.
“It takes about 20 minutes from when we do it to get the results,” she explained, handing him a swab and instructing him to rub it across his gums. “Are you okay in here?”
When she left, he looked around for a clock and leaned back into his chair to wait for the minutes to pass. He and his boyfriend had been together for six months and broken up two weeks ago, after the news of the positive test result. That wasn’t the whole reason for the relationship’s dissolution, but it didn’t help either, and now the man was alone in an exam room with 18 minutes left to go.
“I never asked him outright if he could be positive, because I thought that was something you disclosed to people,” he said while he waited. “Like, after a couple of dates, you say there’s something important you need to talk about. But he didn’t do that.”
He reached down to the frayed hem of his shorts and twisted a thread between his fingers. “My mom is freaking out about this. I told her I would handle it, if it was positive. But she said I’m dead. She said it’s a death sentence. But even if it’s positive, I could still live for a really long time, right? A long time. It’s not how it used to be. She’s just worried.”
He pulled the thread from his shorts. “My fear is that — the pills that work, you have to take them every day and they’re really complicated. You have to do them exactly right. I used to need to take a heartburn pill every day, and I couldn’t even remember that.”
The door opened, and instead of Moore it was Schaefer, carrying a folder. She pulled a stool over to his chair and sat down on it, resting her elbows on a tray table and introducing herself as the clinic director. “Your HIV test did come back positive,” she told him.
He put his hands over his kneecaps and nodded. “Yeah,” he said. “Yeah.”
The next morning, the senior staff members at Akron arrived early. They were trying to hire a new clinician and had scheduled a candidate interview before patients arrived.
“Did you have a salary range in mind?” one interviewer asked the candidate, a middle-aged woman wearing a floral scarf.
“My last couple of jobs I was making $49 to $50 an hour,” she said.
The staff exchanged glances. “We’re not there,” said the interviewer, who had come in from the state’s headquarters. “We try to be competitive, but we have some pressures.” She asked the candidate whether she’d talked to her friends and family about working for Planned Parenthood. “I would say,” the interviewer continued carefully, “that depending on who your family and friends are, you will get a different reaction for saying you work at Planned Parenthood than you would saying you’re a clinician at the Cleveland Clinic.”
“They know I’m interviewing,” the woman said.
The waiting room had filled. One mother of three answered the nurse’s question of what had brought her to the clinic by explaining, “My husband says it only happened once and he didn’t actually sleep with her. But he lies a lot.” Another patient laughed at the question “How many children do you hope to have one day?” and answered, “None, hopefully.”
During an afternoon lull, some of the employees in the back of the clinic heard loud voices coming from the waiting area. A few minutes later, Schaefer returned to the clinicians’ office and explained to the two nurse practitioners on duty: It was a young, developmentally delayed woman who came in without an appointment. The staff recognized her — her grandmother used to drive her in for Depo-Provera birth-control injections, and she would scream whenever the needle touched her arm. Nobody had seen her in years. Now she was there alone, carrying a sheet of paper from an area hospital that instructed her to go to a Planned Parenthood.
“She’s showing like this,” Schaefer said, making a bubble gesture over her belly, “but she can’t tell me how far along she is. I asked her, and she said the hospital told her two months and five weeks.”
“She said she wants an abortion today,” Schaefer continued. “I told her that wasn’t going to happen. I told her she might be too far along, and we don’t do them here. I don’t think she understood me. She just asked, ‘Why can’t you take it out today?’ ” Schaefer shook her head, unsure of the best way to proceed. A clinician suggested asking if the woman would at least agree to an examination to determine how far along her pregnancy was, but when the clinician asked her to put her feet in the stirrups, the woman moaned in protest.
“I guess I’ll go call Bedford,” Schaefer said later, collecting her cellphone and going into the woman’s exam room, where, for the first time that day, she would explain how to travel the 26 miles to Bedford Heights, and she would spend the afternoon worrying that the patient wouldn’t be able to figure out how to get there.
The afternoon continued.
“What brings you in today?” an intake nurse asked a petite, dark-haired department-store employee.
“I just need my birth control,” the woman said. “And also I was with a guy for a year, but then he decided to cheat on me and be dirty, and so I want to make sure I’m safe.”
“How many children do you plan on having in the future?” the nurse asked, following the standard intake questions.
“When I find someone who is not dirty and cheats on me.”
“Do you have any chest pain or headaches?”
“Yeah, but that’s normal.”
The intake nurse left to go get the clinician. Another day was almost over. Earlier that afternoon, the Center for Medical Progress had released another video, this one containing a graphic interview with a former technician who said she had harvested the organs of fetuses from late-term abortions. The House Judiciary Committee had mailed letters to Planned Parenthood clinics around the country, requesting information about their abortion practices.
“You’re here for birth control?” the clinician asked, reading from a sheet as she entered the department-store worker’s exam room and sat down on a rolling stool.
“Yep, that’s right,” the woman said.