Avoiding Another American Tragedy: Lessons from 3801 Lancaster

By Matthew Wagner

3801movie83I recently watched the movie “3801 Lancaster: American Tragedy” about the house of horrors that was Kermit Gosnell’s abortion center. There were a number of striking elements to the film (enough to fill several more blogs, so stay tuned). What struck me the most, however, was how much of his horror could have been prevented.

The fact of the matter is, there was plenty of evidence that Mr. Gosnell was not just committing horrible acts of infanticide, but also that he was a terrible doctor. Going back as far as 1972 Gosnell participated in what is known as “The Mother’s Day Massacre,” when 15 women were bused from Chicago to Philadelphia where Gosnell performed abortions on them using an experimental device called a “super coil” without their knowledge.

Sadly, 9 of the 15 women suffered serious complications (including one who had to have a hysterectomy). Yet it was another 37 years before Gosnell was put out of business (and only then because he was caught selling drugs illegally). Here are some of the signs during those 37 years that something wasn’t right:

–Reports from a former employee of Gosnell that he had unlicensed workers giving anesthesia, that he was using unsterilized equipment from one patient to another, that his facility was filthy, and more.

–Complaints from another doctor in the area (who ironically went on to become the head of the city’s health department) who referred several patients to Mr. Gosnell who all came back with the same venereal disease…one they didn’t have before going to see Gosnell.

–The death of a 14-year-old girl at the hands of Gosnell in 2002, and the subsequent lawsuit which the insurance company settled for $1 million dollars.

–One city employee did the right thing, and when she discovered Gosnell was scamming the citywide vaccination program, reported him and even filed a report identifying some of his most egregious transgressions. Sadly, her report went into a black hole.

–Only a few weeks after the employee filed her report, Gosnell’s sloppy practice killed female patient Kamamaya Mongar in 2009.

–Ironically, shortly after Mongar’s death, Gosnell applied to join the National Abortion Federation. However the NAF denied Gosnell’s facility membership citing records that weren’t being kept properly, risks not being fully explained to patients, patients being left unmonitored, anesthesia being misused, and other violations. In fact, the NAF evaluator called it the worst abortion clinic she had ever inspected (although she never reported any of the violations to the proper authorities).

Let me be clear. Gosnell is not the only one with blood on his hands. Certainly you can find fault with his staff who participated in his misconduct. Furthermore, you can look at the regulators at the city department of health, who were in Gosnell’s facility regularly collecting blood samples for testing and somehow magically didn’t notice anything amiss…or the PA Department of Health and the Department of State, both of which closed multiple complaints throughout the year against Gosnell and his facility after very little investigation and no further action.

The real question is, with the damage so broad, and so many to blame, what is being done to make sure it doesn’t happen again? In 2011 Pennsylvania passed common sense legislation which requires abortion centers to meet certain basic conditions of cleanliness and allows for random, unannounced inspections from the Department of Health.

Winston Churchill famously said, “Those who do not learn from history are doomed to repeat it.” Pennsylvania learned some difficult lessons from the Gosnell tragedy—but we must remain ever vigilant to ensure that would-be Gosnells do not set up shop in our Commonwealth again.