PHILADELPHIA -- If pioneering physician Kermit Gosnell set out to offer women safe, legal abortions in the 1970s, that's far from what drug investigators say they found inside his West Philadelphia clinic in 2010.
By then, Gosnell had gone years without health department inspections, perhaps because state officials preferred a hands-off approach to a political misstep in the abortion quagmire.
The result, according to a grand jury report, is that Gosnell's patients received the equivalent of the back-alley abortions that advocates of legalized abortion had hoped to eradicate.
Gosnell, now 72, goes on trial Monday for murder in the deaths of a woman patient and seven babies allegedly born alive. Eight clinic workers charged with him have pleaded guilty, including his wife, a beautician accused of helping him perform stealth third-term abortions on Sundays.
The devastating 2011 grand jury report describes nearly unfathomable conditions: fetal body parts stored in glass jars and staff refrigerators; filthy, blood-stained operating areas; women and teens maimed after Gosnell perforated a uterus or colon.
"Anybody walking into that clinic should have known immediately that it should have been shut down," said Bernard Smalley, a lawyer for the family of Karnamaya Mongar, the 41-year-old refugee who died after being given too much anesthesia and pain medication during a 2009 abortion.
Philadelphia prosecutors accuse state and local authorities of turning a blind eye to laws requiring regular inspections. And they say the occasional complaints that trickled in, one after an earlier patient death, went nowhere.
"Bureaucratic inertia is not exactly news. ... But we think this was something more. We think the reason no one acted is because the women in question were poor and of color, because the victims were infants without identities, and because the subject was the political football of abortion," said the 2011 grand jury report, released by the district attorney.
The case drew national attention and prompted state lawmakers to tighten clinic regulations. Pennsylvania abortion clinics now have to meet the same standards of care required by ambulatory surgical facilities, and other states are also adopting that rule.
Planned Parenthood and other providers complain that the cost of updating facilities to meet ambulatory clinic rules can be prohibitive and further restricts women's access to abortions. Pennsylvania already required parental or judicial consent for minors, a 24-hour waiting period and a ban on abortions after 24 weeks gestation.
The Guttmacher Institute, which supports abortion rights and tracks women's health laws, believes abortion foes are capitalizing on the Gosnell case. Pennsylvania's 2012 changes to the law came under Republican Gov. Tom Corbett, who opposes abortion.
"They're using the Gosnell example in the argument to promote clinic regulations," policy analyst Elizabeth Nash said. "But in the past couple of years, the heat has been turned up under abortion restrictions in general."
Despite the new rules, which took effect in June, nearly all of the state's abortion centers have remained open, state health officials said. The most recent state data shows that 36,280 abortions were performed in 2011, down somewhat from 37,284 in 2009. The highest annual total on record is 65,777 in 1980; the lowest is 34,494 in 1999.
Mongar had fled Bhutan and spent 19 years in refugee camps, some in Nepal, before arriving in the U.S. in 2008 with her husband and three children. When she discovered she was pregnant, she went to a clinic in Virginia, where she lived, but was referred to Gosnell because she was in her second trimester. She was 19 weeks pregnant when her adult daughter brought her to Gosnell's Women's Medical Center.
The thin, 4-foot-11 Mongar, who spoke no English, was allegedly given a lethal dose of Demerol and other drugs before Gosnell, the only licensed doctor on staff, ever arrived.
"She was older, with grown children and grandchildren, and that clearly was the basis for her decision to ... terminate the pregnancy," said Smalley, who filed the family's civil suits against Gosnell, city health officials and others. "If it's legal, people have an opportunity to pursue it if they believe it's in their best interest and in the best interest of their family, especially for my client, given all they had been through before they ever got to this country."
Smalley grew up in the West Philadelphia neighborhood as Gosnell and recalls the Gosnell family's good reputation. Gosnell earned kudos by returning to the area after medical school, when he could have set up shop in the suburbs. He worked out of a storefront he bought in the run-down Mantua section.
But Gosnell came to operate under the radar, relying on unlicensed medical school graduates, untrained clerical staff and even a teen working after school to administer anesthesia and help perform abortions, usually on poor and immigrant women paying a few hundred dollars in cash, the grand jury found.
"At some point, he made a left-hand turn," Smalley said. "But somebody should have known about it long before my client died."
Gosnell also ran what federal drug investigators call a pill mill, allegedly making millions of dollars over the years by selling prescription painkillers to addicts, drug dealers and others. Federal drug charges await him after the murder trial, which is expected to last six to eight weeks.
"Even though everything points back to Gosnell himself, to me it's a mystery why so many people that he hired on as staff would be complicit in what he was doing," said Thomas Shaheen, vice president of the Pennsylvania Family Institute, which opposes abortion. "He was the one profiting, but it puzzles me that during that whole time and that whole tragedy, no one blew the whistle."