In this episode, host Megan Hall sits down with the co-directors of Brown University’s new AIM Lab, emergency physician Dara Kass and legal expert Liz Tobin-Tyler, to discuss the chaotic intersection of medicine and law three years after the Dobbs decision. As state abortion bans create a "chilling effect" that leaves clinicians paralyzed by legal fear, the AIM Lab is stepping in to provide a practical roadmap for emergency care and maternal health. Kass and Tobin-Tyler share how they are moving past the political noise to solve the public health crises on the ground, offering a harm reduction approach that protects both doctors and patients while training a new generation of advocates to value the lives of pregnant people in every state.

In the past few years, the field of public health has become more visible than ever before, but it's always played a crucial role in our daily lives. Each month, we talk to people who make this work possible. Today, Dara Kass and Liz Tobin-Tyler.

So to help doctors continue to provide care, Brown's School of Public Health announced the creation of the AIM Lab last November. The lab brings together medical and legal experts. They’ll work together to answer the questions that doctors are facing all over the country. We're joined today by the lab's co-directors. Professor and lawyer Liz Tobin Tyler, and Professor and emergency medicine physician Dara Kass.

[00:01:12] Dara Kass: Thank you.

[00:01:18] Liz Tobin-Tyler: I'm a lawyer by training and I went to law school really initially out of an interest in women's rights.

[00:01:36] Liz Tobin-Tyler: But of course now with all of the legal changes and all of the policy changes that are affecting women's health broadly, but in particular reproductive and maternal health, it's just a passion of mine to really think about how we do this work better and how we affect policy change.

[00:01:55] Dara Kass: So I'm an ER doctor by training. I work in an emergency room– have for 20 years. I did a lot of work on gender equity in medicine and the careers of women about 10 years into my career. And then I actually was in the government at Health and Human Services when the Dobbs decision came down.

[00:02:25] Dara Kass: When the decision came down, I was like, “this is foundational to my ability to do my job as an emergency physician.” This is gonna change so much of access to care for people around the country. It's going to redefine how we take care of people, because we have never before had a medical decision that was so politicized. But more importantly, you've never removed treatment options from doctors before for things like emergencies, not just elective terminations, but things like miscarriage management or ectopic pregnancy.

And so my mind immediately blew up with all of the people that were gonna be affected by this decision, who weren't the kinds of people, quote unquote, that the judges and the Supreme Court were thinking about when they wrote this decision.

[00:03:17] Dara Kass: So I think it's really complicated. I think that one of the things that we did very early after the decision was inform a lot of people, not just doctors, about the other ways to get care now that didn't exist in like 1972. And so if you think about things like medication abortion, right? That didn't exist when we heard stories from the seventies about sepsis and infections and back alley abortions.

And so it's actually a very different landscape now than the previous time abortion was illegal in America, and more importantly, getting physicians and advocates and community members and family members up to date has actually been the work of the last three years.

[00:04:00] Dara Kass: At the time I was giving lectures nationally and I would have a map, you know, that would highlight the abortion laws in every state. And I would literally have to change that map weekly. Because a state that had a six week ban, that would get enjoined by the court, and then it would have a 20 week viability standard. And then that would get enjoined, and then the legislature would pass a total ban.

And so you would see that the laws were changing so fast that it actually is one of the reasons why doctors and lawyers had to get on the phone, right? And be like, “wait, what exactly is the law in my state?”

[00:04:50] Liz Tobin-Tyler: I do a lot of work on the connection between intimate partner violence and reproductive health care access. And I sort of immediately drafted a piece that was in the New England Journal about the implications of the Dobbs decision because there's a clear connection between access to reproductive health care, including abortion, and escalating violence. Pregnancy is the most dangerous time for people that are experiencing intimate partner violence.

And I have to say, you know, the Dobbs decision came down a day apart from another decision, the New York Rifle vs. Bruen case, which expanded vastly people's access to firearms. So I could see the writing on the wall. So, you know, I think those of us that have studied reproductive health care access, we could see multiple dimensions of the problem,

[00:05:39] Dara Kass: The creative ways that people wanna restrict care by chilling, so by scaring physicians or scaring patients or scaring community members, has been so disastrous for access to care. Even today, there's news from Texas about whether or not a random person can sue another random person on the suspicion that they may have facilitated pills from another state coming into Texas.

[00:06:17] Dara Kass: Right. So I spent a lot of time talking to doctors across different states about what is actually legal in their state. And this actually is the beginning of the doctors and lawyers working together. And so for example, the treatment of an ectopic pregnancy, which is a pregnancy that implants not in the uterus, functionally, but it is a pregnancy that could not continue—there is no state in the United States where treating that is illegal. And yet doctors, we've seen data, we actually just published a paper a few months ago about the decision making and that they're delaying decisions because they feel like they need more evidence, they need a better ultrasound, they need better-convincing data, so that if in a hypothetical world, an attorney general comes after them and says, “I don't agree with your care, I'm gonna charge you with a crime.”

Well, the truth is, no emergency physician who has taken care of a patient in an emergency room has been charged with a crime anywhere in the United States, taking care of a patient who is pregnant and needs a termination as part of their treatment, including ectopic pregnancy and miscarriage management. And so we need to remind doctors that the care you need to provide in an ER is often not illegal.

And part of that is that lawyers and I think, particularly in states that have abortion bans, the legal counsel in hospitals are very risk averse, right? They are trained to protect the hospital from liability, and that's very different than thinking about how do we best take care of the patient?

When you think about this, especially from a medical malpractice perspective, right? There is a standard of care that we expect should be delivered by clinicians. So in this context, what is the standard of care? What would an OBGYN do in this situation, in an emergency? What does that patient need? What do we need to do to protect her life and her well-being? And that's not impossible in states with abortion bans, which I think is our kind of framing of the work that we wanna do, which is kind of a harm reduction, right? How can we use existing systems and policies, that we wanna change, but in the meantime, how can we protect people's lives?

[00:08:49] Liz Tobin-Tyler: Yeah, so AIM, it stands for Advancing Impact in Maternal and reproductive health. And as we've started to talk about, I think the goal of this lab is that we wanna address the issues on the ground right now that are having the most impact on pregnant people and mothers, because we have horrific statistics on maternal mortality and morbidity. And we have of course, more people, who are pregnant, that don't wanna be and are facing consequences.

And so we want to use the lab as an opportunity to synthesize research on the evidence base on these different issues that are directly affecting people's outcomes on a daily basis. But really to use the lab as a promotion of policy and practice change that can affect what happens to people on the ground.

So some of that will be academic papers that we hope will be effective in demonstrating the research base, but also really doing on the ground practical guidance. And Dara's done really terrific work on this in emergency care settings already. But I think we really wanna expand on that.

So again. We want to work towards the goal of changing policy over the long term, but really focus on these three issues: emergency care, intimate partner violence and homicide, and substance use disorders during pregnancy.

[00:10:16] Liz Tobin-Tyler: Absolutely. I mean, I think what it comes down to is that right now with our policies and practices, we don't value the lives of pregnant people. And I think, what we wanna do is demonstrate that we care about those people and that when they are suffering health consequences that they shouldn't be suffering, that we're valuing their lives, and I think that's, you know, one of the things that inspires me in this work is that right now I feel like there's so many forces that are telling pregnant people, and mothers and women that, that their lives are not that valuable.

[00:11:04] Dara Kass: There's a reason that we're doing this out of the School of Public Health. This is a public health crisis. This is about health care. This is about making sure that people get the care that they need, where they show up, as long as it is legal. And again, there are plenty of times I have conversations about better laws to affect access to health care across the country. This lab isn't gonna do that, but it will say, if we have a different administration at a state level or federal level, these are the opportunities to change access to care. These are the things you could do. This is what we've seen is working and in collaboration, with much larger institutes that have been working on this for a long time, this could be really, really impactful and it's very exciting.

[00:11:48] Dara Kass: We are both getting an unbelievable amount of incoming from graduates of the program, from current college students, current public health students who are all like A: if I was at Brown when this existed, my entire career could have been different, right? This would be amazing for me. But then existing students, who are like, how can I get involved?

And so you realize that there's a hunger to be part of a solution at a time when you're paralyzed, with inaction and anxiety and fear. And so if you can be part of a solutions-based lab that's looking to reduce the harm while helping to build a blueprint for the future, you don't feel so bad every day.

[00:12:29] Liz Tobin-Tyler: Exactly.

And so I think about that a lot when I look at how many patients come to my ER but can get access to care because I work in New York City, and what other things that could be done across the country to increase access, but also understanding what we can put in front of governors, doctors, health systems chairs, to be part of that solution.

[00:13:18] Dara Kass: To me it would be this kind of self-perpetuating lab that is looking at the problems in front of us and saying, ‘Okay, what is the next thing we need to solve?’ We hope that in a few years we'll be able to say, okay, we've kind of gotten through this moment of what was a devastating time for access to care, but we've gotten on the other side of it. Maybe we'll see access protected at the federal level. Maybe we'll see more innovations with, you know, telehealth or access to medications we don't know, right?

But that this will be a hub where we will look around and say, and now that we have gotten through that, let's look back at that maternal health crisis for Black women in America and say, what things could we start doing right now to help continue to increase access to midwives or doulas or other kind of autonomous birth processes that we know reduce Black maternal mortality, right? What can we do to increase access to the newborn baby kits that we know decrease postpartum depression for Black mothers? There are so many things we know work.

But over the next 10 years, like you said, if we're continuing to look for, identify and then address these urgent issues, we will not fall short of them, I promise you that. But we will see a continued energy around solving problems. And that's what, to me, this lab is about. It's giving a forum and a home to address problems we can solve right now

Because it can be overwhelming for many students right now, understandably, with all that's happening. But if we can model for them how to take the bull by the horns and try to work on these issues now in real time and demonstrate to them how to do that, and give them those skills, you know, going forward then we're gonna have a whole generation of reproductive health, and maternal health advocates out out there that are gonna do great work in the future.

[00:15:38] Liz Tobin-Tyler: Thank you for having us

[00:15:43] Megan Hall: Liz Tobin-Tyler is a Professor of Health Services Policy and Practice at the Brown University School of Public Health,  She's also the co-director of the AIM Lab.

Dara Kass is Adjunct Professor of Health Services, Policy and Practice  at the Brown University School of Public Health. She's also the other co-director of the AIM Lab.

Humans in Public Health is a monthly podcast brought to you by Brown University School of Public Health. This episode was produced by Nat Hardy and recorded at the podcast studio at CIC Providence.

I'm Megan Hall. Talk to you next month!