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that if it's going to be changing it may face restrictions that might have tremendous im- pact on the safety net . . . I thought I would be hearing more about it." Her research showed her that no one was examining how people too poor to pay for medical care might fare under Catholic management. Further, no one was looking at how end-of-life care would be handled if the hospital became Catholic. Not a single newspaper story asked how a woman with a life-threatening ectopic pregnancy would be treated in a Catholic hospital, or how she would be treated if her pregnancy endan- gered her life in other ways. Nor was anyone discussing whether women who were raped would receive medication to prevent pregnan- cy in a Catholic facility. No stories examined what happened when other hospitals merged with Catholic institutions, or examined what the Ethical and Religious Directives for Cath- olic Health Care Services, created by the U.S. Council of Catholic Bishops, led to when other hospitals merged. Eventually, all of those issues would be ad- dressed in the Courier-Journal, but not until the Board of Health made the issues public. In April, Alcalde took her concerns to her fel- low board members. (Te Board of Health is an independent advisory body to the Metro Louisville Department of Public Health and Wellness. Its members are appointed by the mayor and approved by the Metro Council but independent of both.) William Altman, board chairman and se- nior vice president of strategy and public policy for Kindred Health Care Inc., said the group immediately agreed the ramifications of merger deserved their attention. Tey ar- ranged to meet with the merger partners to discuss concerns. Tey also wrote a letter to the Courier-Journal drawing attention to the issues. It was hardly a firebomb. Te letter starts with a mention of healthcare reform, explains the role of the Board of Health, and then indi- cates there are changes afoot that could affect access to health care. Te tone throughout is reasonable, neither advocating the merger nor opposing it, simply stating its intent to "fa- cilitate a constructive dialogue" on access to health care, indigent care and the impact of the Catholic ethical directives. Its most inflammatory paragraph, if you want to call it that, states that "some com- munities around the country have faced chal- lenges in health care delivery in the aftermath of similar mergers, including loss of key re- productive health services such as contracep- tion (including in the cases of sexual assault), tubal ligations, and vasectomies." "Te board never put itself in the position of saying the merger should go through or should not go through. Tat's not our role," Altman says. "Our role is to make the com- [56] LOUISVILLE MAGAZINE 2.12 munity aware of these changes." Or maybe you thought that was the news- paper's role. Paul Simmons, a bioethicist and professor at the U of L School of Medicine, was growing alarmed at the lack of media attention to what he saw as key issues in the merger discussions. Simmons, author of several books on medical ethics and a member of the ethics committees at U of L Hospital, Baptist Hospital East and the Jefferson County Medical Society, had been watching the merger closely since its ini- tial announcement in June 2010. In April he sent an essay to Louisville Medicine, a publica- Ungar now says, until the Board of Health letter, no one would comment on the im- pacts of the merger so she could cover it. Te Board of Health letter, she says, gave her that opening. "We didn't want to create news," she says. "We responded to the news when there were complaints and concerns." In fact, however, reporters often point out potential problems before the public is aware of them, and Ungar was busy doing just that in the case of prescription drug abuse. She had only recently added the business of health care to her already hectic medical beat, as layoffs and Gannett's unpaid furloughs Not a single newspaper story (before June 2011) asked how a woman with a life-threatening ectopic pregnancy would be treated in a Catholic hospital, or how she would be treated if her pregnancy endangered her life in other ways. tion of the Jefferson County Medical Society, questioning both the merger and the lack of public discourse. Where the Board of Health letter strove to thread the needle, he snapped the needle in half and threw it away. "(Catholic Health Initiatives), of course, consistent with Vatican policy, wants all the state/federal funds it can acquire," he wrote. "It has no commitment to separation of church and state. All who benefit from its services would be subject to its moral and re- ligious restrictions." Noting the lack of public discussion, he added, "What is so amazing at this point in the deliberations is what seems to be a wide- spread indifference to this vital issue on the part of the general public. Very little has ap- peared in the local news about the project or the problems involved. Even local advocacy agencies for reproductive rights seem silent in the face of a looming deprivation of medical options and an imposition of religious dogma in a medical context." B oth Simmons' essay and the Board of Health letter were published in June, the letter appearing in the C-J on Sunday, June 12, about two weeks after the newspaper received it. Accompanying it was a letter from the merger partners, which the Board of Health urged them to send. Also on that day, the paper ran a 1,600-word "Print Exclusive" front-page story by C-J medical writer Laura Ungar covering the content of the two letters and interviewing the authors. It was the first time the impact of the merg- er on patients was explored in the local media. Ungar wrote: "Altman said officials with the three hospital systems told him they intended 'to find practical solutions' to his concerns. But when Te Courier-Journal pressed hos- pital officials for specifics beyond what they wrote in their letter, they provided none." added to the strain in the newsroom. "With a smaller staff, you have to be a jack- of-all-trades, and you have to cover a lot of things at the same time," Ungar says. As the merger story grew, reporter Pat- rick Howington, who had long covered the business of health care, began to write more frequently on the merger. He had apparently been off the health business beat when the story initially broke. Four days after the front-page story and letters from Altman and the merger partners, the C-J published the first in what would eventually become a flood of letters to the editor from readers questioning the rationale of the merger. Te call for public discussion was paying off. Te story received a big boost a month lat- er when Howington reported on July 17 that Catholic religious directives could make it impossible for women undergoing Caesarian section to have a tubal ligation at the same time. Te Catholic Church prohibits tubal li- gation, a sterilization procedure. Combining a C-section delivery with a tubal eliminates the need for two surgeries; it is also cheap- er because there is generally no additional charge for the sterilization procedure during the C-section. Te story was the first indication that promises by U of L officials about maintain- ing current services might be difficult to keep. Now, the discontent around the commu- nity coalesced. A movement was born. Te day after Howington's story ran, Honi Marleen Goldman, owner of HMG Media Relations, found herself chewing over its de- tails at a fund-raiser for Gov. Steve Beshear. She, along with Eleanor Jordan, executive director of the Kentucky Commission on Women, and former Commission on Wom- en director Virginia Woodward (acting out- side their professional capacities, Goldman