Democratizing Access to Birth Control
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Welcome to Stories of Impact. I'm your host, Tavia Gilbert, and along with journalist Richard Sergay, every first and third Tuesday of the month, we share conversations about the art and science of human flourishing.

If you really wanted to change the world, to leave a legacy that would support human flourishing for generations to come, what would you do? If human flourishing was at the core of your mission and purpose on Earth, how could you ensure that your contributions to the world made the greatest possible impact? Who would you serve?

We're going to jump right into the heart of today's episode with one man's answer to those questions. If you are thinking about what makes one flourish, which is the freedom to determine your choices, the freedom to create a family when and how you wish it, and the ability to put your faculties to work in your development years,

An unintended pregnancy can really slow you down. And for that, I think opening the door so that we have fewer mothers who have to carry that burden. Many of them have to carry that burden on their own because the men disappear. It really provides for those women an opportunity to change.

realize their potential, that would have been sort of whisked away from them by the events of nature. Meet Dr. Nap Hosang. He's a Jamaican-born obstetrician and gynecologist, and his long, distinguished career has focused on preventing unintended pregnancies in the United States and globally. If you think about an unintended pregnancy and what it does to, let's say, women under 20,

it significantly changes their life trajectory. And in this capitalist society, the acquisition of knowledge, further training, finished schooling, college education are important qualifying steps for people to get ahead. And for many who have an early pregnancy, especially ones that are not planned and accidental,

It puts a wrench in the spoke of the wheel because they have to stop what they're doing to attend to, you know, the important business of raising a child.

And that also has secondary impacts on their child's ability to complete a secondary education. We know that the people, for instance, get pregnant before they finish high school, their children, the children of those pregnancies actually also have difficulty completing secondary education.

That's why Dr. Hosang says he has worked to reduce pregnancy-related deaths in women and to amplify access to birth control. So when I was a youngster in my 40s, I thought I was a hotshot. And I went to my mother and had a conversation with her and was telling her how proud I was of my accomplishments.

And she had had her first child by accident when she was 16. This was long, long ago, back in the 1930s. And she said to me, I don't care what you're saying about why you think you're so good. Until you do something about preventing accidental pregnancies, I don't think you'll have made any kind of contribution at all that I would be proud of. So,

You know, she said it, I don't know if she said it in jest, she looked serious. And it sat with me for a while. I mean, I didn't take it on, but it did sit with me for the next 20 years.

Another person in Dr. Hosang's life also influenced his thinking about the importance of family planning. And then I found a colleague, Malcolm Potts, who was at Berkeley with me. And he has the fame of being the author of the 1969 Reader's Digest Quote of the Year. And you can check the exact words, but it said something like, wouldn't it be an accomplishment

if the birth control pill was sold in vending machines and cigarettes on prescription. And for 1969, that was highly prescient of what turned out to be the truth about the relative safety of each of those products. After decades in healthcare, with the voices of Dr. Potts and his mother in his head, Dr. Ho-Sang began to think more deeply about his legacy.

and what he still wanted to accomplish as a public servant in medicine. So when I turned 60, you know, it came back up as well. If you're going to leave the profession now, you're thinking about retirement, then have you satisfied all of the things that are possible with your qualifications? Dr. Hosang began a new chapter of his career as a healthcare entrepreneur.

He is the founder and co-CEO of Cadence Health, whose mission is to give people who don't want to become pregnant access to safe, effective, affordable contraceptives without a prescription wherever those people are located. Cadence Health was the answer to Dr. Hosang's question. What can we do to impact the public health situation for women in the United States? Because most of our work before that had been global. And we...

came to the conclusion that the rate of unintended pregnancies in the United States in the 21st century was really unacceptably high. Better access to effective and reliable contraception would be an avenue worth pursuing. We at Cadence are of the opinion that all pregnancies are wanted. Some are mistimed and some are unintended. So we are very careful not to cast judgment on the want or not want.

There are approximately somewhere between two and two and a half million pregnancies that are occurring every year in the United States that are unintended. Dr. Hosang thought it was unfortunate that the United States was one of the countries without an over-the-counter birth control pill. He wanted American women to have the option of birth control pills without a prescription and without having to see a doctor.

But not everyone was enthusiastic or confident about his plans. In the early days of our quest on this mission, it was very, very difficult to get audiences that would be interested in thinking this was at all possible. I mean, for most, they just thought it was never going to happen.

And it took someone who had already finished a career to be able to take it on because no young person in his 40s would take this on. It's just so risky that I think if you're sensible, you would stay away from it. At 73 years old, Dr. Hosang felt he didn't have to bow to the political or social pressures that might limit a younger doctor.

So, despite skepticism and doubt, he and his colleagues at Cadence Health persevered in their plans. We did some additional research to see the feasibility of affecting access to birth control, and we landed on the conclusion that it would require us to have better access to the most effective contraception available at the time, which was the birth control pill. And to do that,

one would have to take it off prescription. There's a process for that by the FDA. It was set up by Hubert Humphrey and others back in 1951. And we used that mechanism to gather the data that we needed to take the request to the FDA. One of the conditions was that we had to own the rights to a birth control pill to be able to put in the application.

and we proceeded to seek the purchase of a birth control pill that was going to be suitable and we found one from one of the large pharma companies. Dr. Hosang describes the thought process behind their work. Roughly less than 5% of women on oral contraception take the progesterone-only pill. We think the next logical step

is for us to get OTC permission from the FDA for the pill that more than 90% of women currently take for their birth control, which is a two-hormone pill. The second hormone in the case of the regular pill is an estrogen hormone, and that hormone actually makes the pill work more effectively because it actually mirrors the natural cycle better than the one-hormone pill does.

We differentiate ourselves by saying that we want to make available to women the same pill that they and their doctors have decided to use over the last four decades, preferentially the two hormone pill. And with that, we were off to the races. We then started to raise money from friends and family and other angels and

And slowly over the next two years, we gathered enough money and enough support and expertise to be able to put in a formal application to the FDA. The FDA was thoughtful and cautious in its response to Cadence. They required clear information explaining the product, information that anyone would be able to understand. We succeeded in creating a label

that when tested with women of all ages and of all levels of literacy, including adolescents down to age 11, that just the written label was sufficient for them to make safe self-selection decisions without the aid of a third party, namely a physician or healthcare provider. The FDA was, at the time we produced that label, still very nervous that people might not be able to

navigate a label of that complexity effectively. So what they suggested is that we consider introducing a technology-assisted label or a technology assistance to help women to make their choice even safer.

Hidden behind that was some notion that women might read the label, understand it, but still override the complications that should be avoided. So Dr. Hosang continued his careful work and preparation. And the result? Cadence would develop an app to both educate and protect the potential user of their over-the-counter birth control.

And so the technology barrier will introduce one more step to help them make a safe decision. We believe that we have applied appropriate scientific rigor and technical sophistication to the app that will allow it to perform flawlessly. In practical terms, the technology is a digital questionnaire that's administered from a web-based application.

They log into the web-based application and basically digitally fill out the questionnaire. And then the technology assesses the answers to the questions in the questionnaire and tells the person whether or not the pill is safe for them to use. When Cadence does receive FDA approval to distribute its over-the-counter birth control, what will the impact be? The impact...

Well, I think the impact will be obvious. I think you will see that there are far fewer abortions in the United States every year, primarily not because they're not allowed, but because they are prevented by the women not having an unintended pregnancy. I mean, the clearest indication that a pregnancy is unintended is the desire for termination of that pregnancy.

So that would be the major contribution. The pain and anguish and the victimization of people who have suffered an unintended pregnancy will be significantly diminished. And that would be, for me and my mother, an important accomplishment. In fact, Dr. Hosang believes Cadence's success in the U.S. will make a global impact.

I do believe that when the United States sets the example or gives its approval, that other countries, and this includes many if not all the countries in Europe,

will take note and see that it is possible to safely allow women to self-select for using birth control pills that are not mediated through a physician. And I think that the more women who are able to access their contraception without having to interact with

other intermediaries is going to be an important improvement, not just here but elsewhere. The big problem with the global push is to get permission to do it safely because that would mean that many of the illicit drugs out there that are masqueraded as birth control pills that really don't have the ingredients in them, we might be able to sort of reduce the impact of that. The other thing that will happen

is that the pricing of drugs for birth control may actually go down if it is now legal to have over-the-counter birth control pill that people want and is of the same quality as the one that's on prescription.

Dr. Hosang recognizes the many ways that birth control is kept out of reach, including cost. And he's determined to address those barriers, starting right here at home. There are about 7 or 8 million women who don't have health insurance. That includes a few million women who are undocumented. At the moment, if you don't have insurance, you can't get

a prescription unless you go to a public clinic and seek it that way. And there are understandably some significant barriers in terms of time availability and other things that relate to access in that regard.

Access to the pill disproportionately affects those who don't have access to insurance. And there are some other reasons why they don't have access to insurance that have to do with that social structure and the safety net structure in the United States.

What we are trying to do is to make the birth control pill as accessible as it is to women of middle income who have insurance for all other women. And in fact, for all people, because it's not now in these days only women who are using birth control pill because of the gender definitions that we have transitioned to in the last decade.

Some insured individuals in the United States may be able to fund the purchase of their medications through tax-advantaged accounts like health savings accounts or flexible spending accounts. However, says Dr. Hosang, For people who don't have that privilege,

They rely on the prescription because the prescription is the ticket to get the reimbursement they need for the purchases that are not prescription. And so it seems a little bit odd that to get an over-the-counter medicine, which means you don't need a prescription, that you have to actually produce a prescription to be able to get reimbursed.

There are groups working on seeing if we can have federal legislation or state legislation in certain cases that would allow reimbursement for over-the-counter purchases. There's some precedent for that, but it's certainly going to be a barrier under the current situation.

So for those women, they will have to continue using the existing mechanisms they use to make sure that their access to birth control doesn't cost them anything. The cost of birth control is not just a problem in the United States. The price of the birth control pill could still be a huge barrier because in many countries there's not an issue of insurance. It's just that there's no insurance and the medications have to be bought.

And it is the price of the birth control pill pack that would prevent many women from having access. Cadence wants to make sure their birth control is financially accessible. Right now, if you want to purchase a birth control pill and you don't have insurance, you end up paying quite a lot of money. I mean, the cheapest you might be able to get it for would be in the range of about $30 to $35.

There are pockets at times where you can get it for slightly less. And for many, it can be in the $50 and $60 and even $70 range for one pack of pills for one month's supply. And we think that's highly unacceptable given what we know about the price of producing birth control pills.

Part of our commitment in our mission is to make sure that it is at an affordable price. And we are targeting a price that is in the region of $20 because we understand that that's an affordable price for many, even when you don't have much. That will represent a significant reduction in the cost for birth control for people who currently have no other option.

If access to birth control is going to be democratized, it's not just cost that needs to be addressed, but the locations where the birth control can be acquired. The places in the country where people cannot get easy access to a birth control pill are in fact in the places where the household income is low and in rural areas as well. There is a growing use of a term called healthcare deserts where you don't have

easy access to health care of various kinds in certain parts of the country. But not only that, even in urban areas, there are pockets where it's not easy to get health care, it's not easy to get fresh vegetables either. And these are considered health care deserts.

For contraceptive deserts, that's a subset of the healthcare desert where you actually would not be able to find easy access to birth control because of the outlets or the clinics that you would be able to get those in are not located in those zip codes. A clearer example is not the same as a birth control pill, but for the emergency contraceptive,

We did a survey last year that showed that there are 8,000 zip codes in the United States in which there was not one sale of an emergency contraceptive last year. So even though it's been around for a decade, there are still pockets in the country where there is no emergency contraceptive sold. And when you do an analysis of where those zip codes is, they match very, almost like a replica of

the poorest areas in our country. The benefit of making birth control available without a prescription is that it can be made far more widely available than ever before, even in those contraceptive deserts. When we're talking to our distributors, one of the conditions we have put for them to meet is that it should be on the shelf in the store next to condoms.

And so a woman should be able to pick up a pack of birth control pills or a pack of condoms, whichever she would prefer at that moment. It's an OTC drug, so it doesn't have to be on a pharmacy shelf. It could be in a 7-Eleven or in a Wawa or in a Circle K or at the gas station. So

We'll have to decide what are the best out of this, but our aim is to make sure that it's available where everyone who wants to have access to oral contraception can get it. And there are countless reasons that individuals and families will benefit from having that broader access.

It all comes back to human flourishing, says Dr. Hosang. You know, just like the birth control pill is used ever since it was released back in the 1960s, it's been used mostly by women who are married. And today, there are many families, you know, married individuals with children who want to space their children, who want to limit the number of children that they have.

and who take a risk every time because they're uninsured, take a risk for not being able to protect themselves from an unintended pregnancy. And so I don't want to leave you with the impression that access to birth control is about preventing single motherhood. It in fact is a huge contributor to family life as well,

For those family units who don't have access to health care insurance, who would desire to have active sexual life without the fear of an unindemned pregnancy, I think human flourishing is a very important, pivotal part of life.

my thinking and my value system. And I think to a large extent, people are rushing ahead, you know, trying to be successful in life, but they often forget that human flourishing has more to do with what you share in your community and more so in your family. And that anything that the systems around us can do

to help people enjoy the existence and the sharing of the community of family and local community is a positive contribution to the well-being of humanity. I sound like an old-fashioned person when I say that, but my experience is that no matter how successful people are, it is the acting and participation in those units that make life meaningful.

And wherein we can provide and help people to have an environment in which they have the family size they need and they don't have the stress of worrying about an unintended pregnancy. That's not the total contribution to making them happy, but it's an important part of what it takes to make family units flourish. You know, they have to have shelter and they have to have food, but

They also need to not have to worry about putting food in the mouths of children that they did not intend to have. And that's entirely their choice. Wherever we can provide an opportunity for people to have a fulfilled existence, then we should be quite willing to make the contributions. And sometimes a sacrifice is necessary to make those things happen.

Dr. Ho-Sang's mother suggested that he concentrate his work on preventing accidental pregnancies. What does he think she would say if she were still alive and knew of his work? She would say, I'm glad you listened to me. It brings some measure of tears to my eyes when I think about how simple that suggestion was. You know, I have colleagues who have spent life chasing the next publication.

And we think that's important, you know, especially if you're an academic or chasing the next dollar or the next car or the next acquisitive thing. I'm not against acquisition. I mean, clearly, you know, I'm a rounded person. But sometimes it may take a little bit of hard knocks for you to just stop and think, hey, is that really necessary? And what else could I be doing with my time and effort, you know, without being a total genius?

bleeding heart liberal, as they call him in the past. I mean, just in normal behavior. Why don't we think about that? You know, kind of crazy. I love ending with Dr. Ho-Sang's humor, heart, and courage, and his willingness to follow the wise direction of his mother. Mamas really do run the world, after all. And thanks to Dr. Ho-Sang, they'll be doing it with greater autonomy and freedom of choice than ever before. ♪

Join Templeton World Charity Foundation this November 29th and 30th for the second annual Global Flourishing Conference for dynamic dialogues with leading scientists, policymakers, practitioners, influencers, and advocates working on the scientific frontiers of flourishing. The Global Flourishing Conference is virtual and free for all. Visit humanflourishing.org to learn more.

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This has been the Stories of Impact podcast with Richard Sergei and Tavia Gilbert. Written and produced by TalkBox Productions and Tavia Gilbert. Senior producer Katie Flood. Assistant producer Oscar Falk. Music by Alexander Falibiak. Mix and master by Kayla Elrod. Executive producer Michelle Cobb. The Stories of Impact podcast is generously supported by Templeton World Charity Foundation.