The State of Last Resort

Katherine Farris has had a busy month. As the chief medical officer of Planned Parenthood South Atlantic, she supervises operations across North Carolina, South Carolina, Virginia, and West Virginia.

But in addition to her administrative work, Farris also performs abortions, a role that takes her all over the region. Over three weeks, she was in Roanoke, Virginia; Charlotte and Asheville; and then over to Charleston, S.C., before heading back to North Carolina. In between, she gave a sermon about reproductive justice at her Unitarian Universalist church.

Farris, who lives about two hours from Asheville, is a family doctor by training. She started practicing 20 years ago, and while abortion has always been part of her practice, she’s devoted more time to it in recent years.

“There are plenty of doctors willing to do other things and very few willing to do abortion care,” she said.

But soon, her abortion circuit will likely be much more circumscribed. On May 3, a leaked Supreme Court decision indicated that the court plans to overturn Roe v. Wade, the landmark 1973 ruling that legalized abortion in all 50 states.

If Roe falls, South Carolina, Tennessee, West Virginia, Kentucky, Georgia, Alabama, Mississippi and Louisiana are expected to ban or severely restrict abortions. Florida recently enacted a ban after 15 weeks’ gestation, and Republican lawmakers in the state have said they are open to banning the procedure entirely. Farris and the medical team at the Asheville clinic are preparing to step into an unprecedented position: providing abortions for patients coming from all over the South.

North Carolina has 14 clinics where abortions are performed. With a Supreme Court decision imminent, these clinics are preparing to serve many more people who do not want to be pregnant.

“All roads lead to North Carolina,” said Paige Johnson, chief program officer and vice president of patient services for Planned Parenthood South Atlantic.

And she means this literally: Interstate 40 runs across the United States and through North Carolina from west to east, and 85 and 95 pass through north to south. Overturning Roe would likely create a 4,672 percent increase in the number of women whose closest abortion clinic is in North Carolina, according to the Guttmacher Institute, an organization that researches reproductive justice. The Planned Parenthood Federation of America, Planned Parenthood’s national office, estimates that North Carolina will see between 17,000 and 70,000 additional patients seeking abortion every year. North Carolina is expected to see the greatest increase in the nation.

“It’s startling to think about being the state where people will drive thousands of miles round-trip to seek healthcare,” said Johnson.

Providers and reproductive-justice activists here are preparing to transform clinics into so-called “surge clinics.” In the Asheville clinic, which is less than an hour from the Tennessee and South Carolina borders, they are hiring more staff in preparation.

The surge has already started. The Planned Parenthood call centers in Charlotte and Roanoke, Virginia, have seen an increase from 1200 calls per week to 1500 calls per week over the last month. Asheville’s clinic had a 27 percent increase in patients in May 2022 compared to May 2021.

While the clinic has so far been providing abortions only on Saturdays, it plans to add more days in July to accommodate more patients. Johnson said other Planned Parenthood locations in the state are also adding abortion days and hiring more doctors, so that each clinic can have two doctors to provide twice the number of procedures.

They’re also planning to collaborate with facilities in other states to assist with pre-appointment services like lab testing, recording medical histories, and performing ultrasounds.

To help with the logistical snarl surrounding abortion access, Planned Parenthood affiliates in North Carolina are hiring two new patient navigators.

On a recent Friday, after closing time, Farris sat in the clinic’s cool waiting room and talked with The Assembly along with health-center manager Kat, an energetic woman in plastic-rimmed glasses. During the conversation, would-be patients tried to walk inside on two separate occasions, thinking the clinic was still open.

Three years ago, Kat was an artist working at a coffee shop, where she met a Planned Parenthood employee. They got to talking, and by the end of the conversation Kat said she was inspired to switch careers and apply for her clinic job. Today she draws on her creative background to add artwork and other touches to the facility, including a woven uterus and fallopian tubes hanging under a woven rainbow on her office wall.

Raised Catholic in the Midwest, Farris wasn’t always passionate about abortion rights. Now, with her rainbow-tipped manicure in honor of Pride Month, she’s an outspoken advocate. She appears often in news stories and photos—the rare abortion doctor who’s happy to appear in the media. Doctors who perform abortions often become targets for anti-abortion groups; fear of doxxing, stalking, and violence led most of the staff and volunteers who were interviewed for this article to request the use of first names only. And Kat wouldn’t let her brand-new staff members pose for photos. It was too soon, and she wanted to protect them from the cruelty often heaped on clinic workers.

But for Farris, putting a human face on the procedure is important.

“They can see I don’t have horns,” she said. “It is morally reprehensible to make healthcare illegal. And there is no question that abortion is healthcare. It’s terrifying and horrifying and offensive to everything I am as a physician to have healthcare treated this way.”

While Roe guaranteed the right to an abortion, it never guaranteed that it would be easy to obtain one—and it’s only gotten harder across the South in recent years. People in many areas have been living in a post-Roe reality for a while now.

Alabama has just five clinics left. South Carolina has just three. Mississippi, the state that prompted the Supreme Court case, has only one.

While abortions are expected to remain legal in North Carolina, the barriers to getting one are still high. Only nine of the state’s 100 counties have clinics. Like 32 other states, North Carolina only allows physicians to perform abortions, including the simple task of handing a patient an abortion pill and watching them take it. (By contrast, neighboring Virginia has allowed trained advanced clinicians to perform the procedure since 2019, one strategy that blue states have undertaken to expand access.)

Republican lawmakers have slowly chipped away at abortion rights in North Carolina. In 2013, the state banned physicians from prescribing the abortion pill via telehealth. In 2015, it enacted a requirement that patients undergo counseling that states the potential risks of abortion and explains to the patient that they have alternatives to getting one. Patients must then wait 72 hours before they can undergo the procedure; North Carolina is one of only five states with such a long waiting period.

Anti-abortion state legislators have also rolled out targeted regulation of abortion providers, or TRAP, laws—arcane, bureaucratic regulations specifically saddling clinics with red tape, violations, and threats of closure that other non-hospital medical facilities do not have to follow. In North Carolina, these laws dictate that clinics must provide a “nourishment station” for serving snacks; they must keep the humidity between 50 and 60 percent; the hallways must be a certain width; and ventilation systems must change the air six times per hour in some rooms, and ten times per hour in other rooms. In 2013, then-Gov. Pat McCrory signed a bill allowing the state to apply ambulatory surgical center regulations to abortion clinics. Clinics that couldn’t meet these new standards were forced to make upgrades, relocate, or close entirely.

The cost of care can also be prohibitive. At the Asheville Planned Parenthood, the procedure’s cost starts at $495 and increases after 10 weeks’ gestation. (That’s not counting additional costs like childcare, transportation, and time off work.) Because of the federal Hyde Amendment, public insurance policies cannot cover abortion. The North Carolina General Assembly passed a similar law in 2008 barring state insurance policies, such as those for public-school teachers, from covering it. There are some private abortion funds that support women, like the Carolina Abortion Fund, but they are often underfunded and stretched thin. Even patients who have private insurance often don’t want to use it, fearing a parent or partner might find out.

Abortion rights are considered safe in North Carolina for now, because the Republican majority in the General Assembly does not have a supermajority. And even though North Carolina has an anti-abortion law on the books dating back to before Roe, judicial order prohibits its enforcement, and Democratic Gov. Roy Cooper still has veto power.

But the General Assembly hasn’t been shy about introducing legislation. Last year, that included a so-called “born alive” bill, which would have put new penalties on doctors based on a faulty premise that failed abortions can lead to live births. Another bill would have restricted access based on the patient’s reasons for seeking the procedure. A third required doctors to give dangerous, false information about the possibility of reversing a medical abortion. Republicans need only three seats in the State House and two in the Senate to secure a supermajority, which could very well happen in the November midterms.

“If the anti-abortion majority gets a supermajority,” said Johnson, “we’re done.”

Like many clinics, this one on busy McDowell Street sees a cadre of regular protestors every Saturday. About 10—not counting a handful of children—were outside as the clinic opened at 8 a.m. on a Saturday in early June.

At points the protestors used a stepladder to see over the white slats of the fence surrounding the clinic, leaning over to yell down to the patients. They exhorted every car entering the clinic to stop, shouting things like “Mama” and “Let your baby live, we will help.” They begged incoming patients to think of what God would say.

Inside the clinic, Kat, her staff, the nurses, and the doctor geared up for the day. Thirty-two patients were on the schedule—slightly more than the average 25 per week the clinic usually sees. Even before the Supreme Court issues its final decision, the clinic is seeing out-of-state patients scrambling for appointments; on that Saturday, one patient had driven more than a thousand miles from Austin, Texas.

In 2021, Texas passed a six-week abortion ban. The state only had 22 clinics as of late 2019, down from 40 in 2013. Once the ban went into effect in 2021, many clinics pivoted operations to help patients get out of state. Some stopped providing altogether. Already, about 1,400 women are leaving the state every month to get care, according to a recent study.

The Asheville clinic provides two types of abortion: medical and surgical.

For a medical abortion, the patient takes two pills within 48 hours to induce bleeding. The first pill, which patients must take in front of a doctor in North Carolina, is mifepristone, which stops the pregnancy from growing. The patient can then take the second pill, misoprostol, at home; that one causes the bleeding and cramping that ends the pregnancy.

Surgical abortions take just one to two minutes. The patient sits in a chair with her legs in stirrups—a position familiar to anyone who’s had a pap smear. The doctor then unwraps a set of instruments wrapped in blue cloth, which are used to open and dilate the cervix. The doctor then inserts what is essentially a straw, attached to either a handheld plastic suction tube or a whirring, knee-high machine that provides the same suction.

While patients sat in the waiting room watching TV that Saturday morning, a struggle was brewing on the outside. Cars hurtled by on McDowell, their drivers honking or brandishing middle fingers. The three Asheville police officers that sit outside on Saturday mornings—in case the protestors block the driveway—chatted with clinic staff and volunteers.

Patients scurried or strode into the clinic while their accompanying partners, friends, or parents waited in the parking lot. The clinic’s greeters, volunteers in rainbow vests, acted as traffic directors, walked patients to the door, distributed masks and earplugs, and ran interference between patients and protestors.

Julia, who is in her early thirties, was in charge of the greeters that day. Her team usually arrives around 7:50 a.m., but today a few came late after experimenting with parking off-site to leave more spots for the influx of patients expected to arrive after Roe falls.

After strategizing on where to erect signs and sandwich boards instructing drivers to keep their windows up and drive past the protestors without stopping, Julia turned to training a new volunteer dressed in leather booties and a She/They pin, who seemed nervous but game to jump in. Julia instructed the newbie to meet patients at their cars, welcome them to the clinic, and explain that she/they would walk them to the door. She counseled against being too bubbly—getting an abortion can be a somber experience, after all—and suggested finding something to compliment about the patients’ appearance or clothes.

Julia has been a greeter for about a year and a half. She first became involved because she had an abortion at 17 at another clinic in Asheville, FEMcare. That clinic closed in 2013 after the new state law requiring clinics to conform to ambulatory surgical center regulations.

“The worst part was the cultural idea that I was supposed to feel bad,” said Julia, over the howls of protestors on the other side of the fence. “I didn’t know that you could not feel bad about it. I felt like I had to cry, feel guilty. But as I went through the process I realized I didn’t have to feel that way.”

Julia moved away to New York for a while and explored her career before coming back to North Carolina. She’s married now, and has realized she doesn’t want to have kids.

“All of that from one very easy medical procedure,” she said.

Rachel, a white-haired woman who has volunteered as a greeter for 13 years, was also volunteering that day. She got involved because she remembers 1973 and the transformative effect Roe had on women’s lives, opening doors for work and education. “I understood that this is foundational to our identities and being in the world,” she said.

In recent months, she noted, she’s seen license plates from Texas and Arkansas in the Asheville parking lot.

“I’m horrified by the burden [the Supreme Court decision] is going to place on especially the people who can’t afford to travel,” she said.

Along with the influx of patients, the greeters are also anticipating more protestors in the coming months, as abortion becomes illegal in surrounding states. Most of the current protesters are, as one greeter put it, “our local guys,” who come every week.

One regular there on Saturday was Zach, a Reformed Baptist who, like many of those on the pro-choice side, declined to give his last name. Zach has a wiry red beard and an easy, woodsy manner. He has been protesting at the clinic for more than three years, and has brought his nine children, who range in age from kindergarten to pre-teen, along with him. “We are living in an American Holocaust,” he said. “We live in a nation that discriminates against humans on account of their size.”

Another protestor, Allura, who declined to give her last name because she said she receives death threats, has been protesting at abortion clinics for 20 years. She wore a shirt that says “ABOLITIONIST,” because she believes abortion is akin to slavery. The group carried signs with gruesome images of fetuses and Nazi concentration camps.

At one point, Zach popped up over the fence to talk to a man waiting by a car, who had accompanied a woman to the clinic. The man shouted back at him, “Are you gonna pay for her funeral if she dies giving birth? Fuck off.”Since the Supreme Court opinion leaked, counter-protestors have also begun to show up. Across McDowell, three of them now sat in lawn chairs, waving at beeping cars and talking to passing joggers.

Tori, an Asheville resident who declined to give her last name because she said protestors recently harassed her on TikTok, brought bubbles and a rainbow umbrella. Hannah Foster, a nurse, was wearing a rainbow Pride flag as a cape, while Scott Meek was nearby in a rainbow tutu.

“I used to be one of those kids,” said Meek, pointing across the street. He was raised in an ultra-religious family in Michigan, and went to Christian schools and a Christian college. He’d planned to become a pastor. But he loved stars and space, and struggled to square his knowledge of the deep, ancient night sky with the idea that that universe was only 10,000 years old. That led him to an epiphany: he no longer believed.

“It was brutal,” he said. “I lost contact with most of my family.” But it was also a relief. He was longer saddled with shame and guilt.

“I look at these kids over there. It makes me sad,” he said, gazing across the street. “So many of them are going to be stuck in this life of hate.”

For Farris, all of this — the increased tension outside the clinic, the influx of patients, the states going dark one by one across the South — shows just how crucial North Carolina will be in the coming months.

“People are not waiting – people are really pressed to make their decision and make it quickly because they are so afraid they can’t access health care,” said Farris. “The patients we see will be more traumatized and more desperate and afraid. They’ll be people who are further along, who have come from a farther distance.”

Kate Medley is a photojournalist and filmmaker in the American South. Her work, which explores themes at the intersection of culture and social justice, regularly appears in publications including The New York Times, The Wall Street Journal, and NPR. She lives in Durham, North Carolina.