LM Paltrow / Reproductive Health Matters 2002;10(19):162–170
advertisement of contraception were still on the
proved – from mandated counselling unrelated
to the patient’s needs to unnecessary waiting peri-
ods and notification requirements designed to delay
and intimidate [25]. Similarly, access to safe and
effective treatment for drug addiction is deliber-
ately limited in the USA today [4]. Methadone, for
example, is the most effective treatment for opiate
addiction, yet government regulations largely block
its prescription by primary care physicians and its
sale by pharmacies, limiting it to special clinics,
which tend to be poorly staffed and inconveniently
located [26]. Collectively, methadone programs can
accommodate fewer than 15% of those whom
methadone treatment might help [27].
Likewise, abortion services are largely limited to
free standing clinics. Although this was not the re-
sult of specific federal legislation, as in the case of
methadone treatment [28], the isolation of abortion
services from mainstream medical care similarly
leaves patients and staff without adequate access
to services. In addition, patients and staff are easily
targeted for violence and harassment [29], and
there are harrowing stories of both methadone pa-
tients and abortion patients having to travel hun-
dreds of miles to the nearest clinic to meet their
basic health care needs [30].
books in New York State and elsewhere [18]. Even
today, US Supreme Court doctrine permits speech
restrictions on the provision of information on abor-
tion by doctors in certain government programs. As
recently as 1991, the US Supreme Court upheld ‘‘the
Gag Rule’’ which, prohibits a project funded under
Title X – the federal program that funds family plan-
ning programs across the country – from engaging
in activities that encourage, promote or advocate
abortion as a method of family planning [19].
Similarly, the federal government, in response to
passage of California’s Compassionate Use of Mari-
juana Act, threatened doctors with criminal prose-
cution, loss of Medicaid and Medicare payments
and revocation of their federal prescription drug
licenses if they advised their patients about medi-
cal benefits of marijuana [20], despite extensive
evidence of the beneficial effects of marijuana
[
21]. Thus, even when it is clear that certain drugs
or contraceptive devices could improve people’s
health, the government has used control over med-
ical practice as a mechanism for preventing dissem-
ination of that knowledge and information.
While communities across the USA have been
using zoning laws to keep abortion clinics from
opening, similar laws have long been used to pre-
vent the establishment of methadone programs [31].
Moreover, efforts in both arenas, to give people
greater access to health care through private physi-
cians face serious hurdles. For example, it was
hoped that the availability of mifepristone for early
medical abortion would enable a significant num-
ber of women to get the procedure from private
physicians, but abortion restrictions on the books
may make the delivery of such services illegal [32].
Access has also been blocked to many ‘‘harm re-
duction’’ techniques that have proved effective both
in terms of public health and cost savings [33].
Making clean needles available to injection drug
users through needle exchange programs [34] and
permitting their sale at pharmacies [35] has proved
highly effective in curtailing the transmission of
HIV/AIDS and hepatitis [36]. Public health groups,
including the American Medical Association, the
National Institutes of Health, the Centers for Dis-
ease Control and Prevention and the Institute of
Medicine, have endorsed needle exchange pro-
grams [37], and government-sponsored research has
shown that such programs do not lead to increased
Access to reproductive health care and drug
treatment
In both arenas, the US government not only re-
stricts information about medically safe and useful
procedures, it also restricts access to them. In the
case of reproduction, access to abortion, contracep-
tion and other reproductive health care is deliber-
ately blocked or limited. Even though abortion is
now legal [22], access is extremely limited as the re-
sult of a wide variety of restrictive laws. As Joffe
explains:
‘
‘Some 84% of all US counties are without abortion
facilities. The number of US hospitals where abor-
tions are performed decreased by 18% between
1
988 and 1992, and less than one-third of the na-
tion’s hospitals with the capability to perform abor-
tions (defined as hospitals that offer obstetrical
services) do so [23]. The majority of ob/gyns pres-
ently in practice do not perform abortions, and most
residents in this specialty are not routinely being
trained in abortion procedures.’’ [24]
All sorts of restrictions exist in the abortion con-
text for procedures that are safe and medically ap-
1
64