[RADIOLAB INTRO]

LATIF NASSER: Hey, this is Radiolab. I'm Latif Nasser.

LULU MILLER: I'm Lulu Miller.

LATIF: And we find ourselves, as sometimes we do, in a moment where we're thinking back to an old episode we did because the topic we covered is sparking all over the news right now.

LULU: Yeah. And that topic is the quote-unquote "abortion pills."

LATIF: Yeah.

LULU: And on April 7, 2023, which for us is also known as last Friday, a federal judge in Texas ruled that the FDA's approval of one of those drugs, Mifepristone, was invalid. According to him it should have never been approved.

LATIF: And later that day, an hour or so later in an entirely separate case in Washington state, a federal judge ruled seemingly the opposite.

LULU: Mm-hmm.

LATIF: That the FDA must continue to make mifepristone available in certain states, that same drug. And then on top of that, there have been multiple motions to appeal that first Texas ruling we talked about.

LULU: Very chaotic. A lot going on. For the time being, Mifepristone is still available, but this all means that these cases will likely work their way up the federal court system.

LATIF: Yeah.

LULU: And we will eventually see rulings that could have real staying power and real consequences.

LATIF: And so, given that there suddenly is so much attention on this pill, we wanted to share with you a story we did back in the fall of 2022, last fall, about these very pills. And—and actually in particular because this Texas judge in his ruling made an explicit argument about the safety of this drug and the approval process. And actually that's—that's exactly what we cover in this episode.

LULU: Yeah, you can think of it sort of as a profile of these pills. These pills are sort of characters, and we really  go into the science of them, their origin story, how they interact with the human body and what their real risks are—or aren't. It came to us originally from our senior correspondent Molly Webster and contributing editor and ER doctor Avir Mitra. So we'll start it off with them.

MOLLY: I don't know. I was just gonna say Avir, you start.

AVIR: [laughs] Okay.

MOLLY: Avir's gonna tell you a story.

AVIR: Yeah.

LULU: I love an Avir story.

AVIR: All right. Cool.

LULU: And we should say before we get rolling, this story talks about abortion and has some kind of graphic descriptions, so if you don't wanna hear that today, this is a good one to skip.

AVIR: Right. So, I guess this one started because for—okay, for me growing up, my mom, she's a OB/GYN, and I just remember her telling me about stories of her performing abortions back in her day. This would've been like the late '70s. So ...

LATIF: Wait, wait, wait, wait, wait. I'm just picturing, like, muppet baby Avir.

LULU: [laughs]

LATIF: ... like, even before you were a doctor, your mom would tell you doctor stories?

AVIR: Yeah, I just grew up around so many medical stories—both my parents are doctors—that we talk about things at the dinner table that a normal family would be horrified, they would be actively vomiting and I'm just like, "Oh yeah, pass—you know, pass the salt, please." So basically, you know, when she would talk to me about these procedures, they were pretty invasive. Like, it was not a small deal, if that makes sense.

LATIF: Right.

AVIR: And even now in a hospital or clinic, it's pretty safe, but it's still something we take seriously. I mean, it's safe because we take it seriously.

LATIF: Mm-hmm.

AVIR: So for the last couple of months, ever since the Supreme Court decision about abortion, I’ve been thinking about, like, what is this gonna mean for us in the emergency department ...

LULU: Hmm.

AVIR: ... now that we're living in this post-Roe world? 'Cause you know, like, regardless of what you think about abortion, if people aren't able to get them, I'm anticipating a lot more patients showing up in the ER with, like, complications, or people who've attempted to do their own abortions and ...

LATIF: Ugh.

AVIR: ... hurt themselves in the process.

LULU: Yeah.

AVIR: So basically, you know, now at my job, you know, I have to occasionally organize conferences to teach ER residents things, and so I ended up hosting this OB doctor named Laura MacIsaac where I work, who for many years has been running the division in my hospital that deals with the abortions that we do. Now what I was anticipating was sort of like this high drama, ER-type of lecture of like, "All right, when a patient comes in with a coat hanger abortion, these are the things you gotta think about. It's gonna be sepsis. Here's how you evacuate." Or, you know, "Uncontrolled bleeding. Where are you—you know, what type of blood are you gonna do? How are you gonna match the blood?" This is what I was, in my mind, picturing the lecture would be about.

LULU: Mm-hmm.

AVIR: But it actually wasn't like that at all. What she sort of talked about ended up kind of blowing my mind in a completely different way.

LULU: Oh!

AVIR: So ...

AVIR: Hey!

LAURA MACISAAC: How's it going?

AVIR: I'm good. How are you?

MOLLY: Hello!

AVIR: I emailed Molly, and I was like ...

MOLLY: I'm Molly.

LAURA MACISAAC: Hi Molly. I'm Laura.

MOLLY: Hi. Good handshake!

AVIR: ... Let's just go talk to her.

LAURA MACISAAC: I'm so glad that it was more interesting than you expected. [laughs]

AVIR: And basically, she told us while we've all been arguing about the politics, the legality and the morality of abortion, the actual practice of it has been really on its own trajectory.

LAURA MACISAAC: Since I've been doing this work, it's changed probably more than any other thing I can think of.

AVIR: For the majority of abortions happening today, we're not talking about surgeries.

LAURA MACISAAC: No. It's with the medications to induce abortions. Pills.

AVIR: And while I knew that you can take pills to induce an abortion, I hadn't really thought about, like, how much this really does change everything about what it means to get an abortion, and how much of that has really just happened in the past few years since COVID. And in a weird way, because of COVID.

MOLLY: Okay, so the story starts back in the '80s. Roe v. Wade just happened, and you have greater access to abortions. And the way that we did abortions was surgically, right? So it was like the woman, you know, was put on a table, she's given anesthesia. Someone actually had to, like, go into a woman, into the cervix, and pull out the growing embryo or the growing fetus.

AVIR: And that's just sort of the way it was.

MOLLY: Yeah.

AVIR: Until two things start happening on opposite sides of the world.

LATIF: Hmm.

LULU: Hmm.

AVIR: The first one is in Brazil. So in Brazil, abortion was illegal. And Brazilian women, you know, when they would have an unwanted pregnancy, right, they would go into a pharmacy, and they saw on these ulcer drugs that there was like a little sign that says, like, "Don't take this in pregnancy."

LULU: Oh, interesting.

AVIR: So they started taking it.

LATIF: Hmm.

AVIR: And surprisingly, it worked. It would cause an abortion.

LULU: And how does that work? How does it do that?

AVIR: Well, so that drug, it's called Misoprostol. Misoprostol is a prostaglandin. And prostaglandin is something that we make in our body, and it does a bunch of different things all over the body. One of them is healing ulcers, but another one in the uterus, it causes it to basically contract.

LATIF: Hmm.

AVIR: That's it. And so if you're pregnant, you know, that can just basically make the uterus flush the embryo out.

LULU: Huh. So it just basically physically ejects it?

MOLLY: Mm-hmm. And so it induced abortions, but no one really knew, like, how much to take and stuff, and it was like ...

LATIF: Hmm.

MOLLY: ... "Do I take it in my mouth? Should I shove it up my vagina and, like, get it near my cervix or my uterus?" No one knows.

LATIF: Sure.

MOLLY: So really what they were seeing is that sometimes it didn't work.

AVIR: Right. So that's Misoprostol, which works some of the time.

MOLLY: Okay. Right. So meanwhile while all this is happening, in France, you have a doctor Étienne-Émile Baulieu. And his whole idea was, like, well in the early stages of pregnancy and throughout pregnancy, we really need progesterone.

AVIR: Right. Because progesterone helps the uterus build up a thick layer of, like, bloody tissue that can support a possible pregnancy. And the embryo, you know, needs to implant into that tissue.

MOLLY: And so he was like, "Well, if we know that a body has to amp up progesterone in order to facilitate a pregnancy, what if I did something that, like, interrupted that?"

LULU: Oh!

MOLLY: And so he and his research team develop this drug called RU-486, otherwise known as Mifepristone.

AVIR: So Mifepristone is basically a progesterone blocker. And so when you take Mifepristone, that layer can't grow. And essentially that signals the body to shed that layer. And essentially you're just saying—like, you just say "Nope."

LATIF: No place for you to implant here. Just move along!

AVIR: Yeah. So that's mifepristone.

MOLLY: There's one problem though, which is that mifepristone will cause the uterus to be an unfriendly place for the embryo, but it won't then actually expel that embryo.

LATIF: Hmm.

MOLLY: And so you need to combine something with mifepristone to make it flush out the uterus. So then the doctors in France are like, "Wait a second, we're hearing about this ulcer drug in Brazil that's kind of doing what we need, and so what if we take that and combine the two?" So then the misoprostol would get your uterus to, like, force out the stuff that has dropped off the edges of your uterus.

LATIF: Oh, wow.

LULU: Wow!

AVIR: Yup.

LATIF: Oh, that's very vivid and clear. Okay, yeah.

LULU: Yeah.

MOLLY: And then when they combine these two, what they see is like a 95 percent success rate, and it's very safe. Et voilà, they created the abortion pill. Okay, so in 2000, the Mife-Miso pill combo comes to the market in the United States.

LATIF: Oh, wow. So that's like—that's years later.

MOLLY: Yeah. So basically, like, there was, like, scientific testing we had to do in the States, but then there was also all this politics, because it is, like, an abortion drug.

LATIF: Mm-hmm.

MOLLY: But eventually they get approved, though even then there were still all these hoops that doctors were jumping through to get it to patients.

LULU: Hmm.

AVIR: Yeah.

LULU: Like what?

AVIR: Like, for example, doctors would run all of these tests.

LAURA MACISAAC: You had to check a blood count.

AVIR: This is Laura MacIsaac again.

LAURA MACISAAC: So you have to draw blood.

AVIR: To make sure—is this person anemic?

LAURA MACISAAC: We used to do a blood type.

AVIR: Check their liver function.

LAURA MACISAAC: Do an ultrasound and make sure that it was not an ectopic pregnancy.

AVIR: Every once in a while, a pregnancy will implant somewhere outside of the uterus. If it's in a fallopian tube that as it grows, it will rupture the mom's fallopian tubes.

LATIF: And these pills do work for that or don't work for that?

AVIR: No, it wouldn't work for that.

LATIF: It would not, yeah.

AVIR: No, because, you know, you are flushing out the uterus. But if the embryo is not in the uterus, it's just gonna keep growing.

LATIF: Right.

AVIR: And so that's like a super dangerous situation that, you know, that—this situation can happen in any pregnancy, but it can also happen, you know, in this type of scenario.

LATIF: Right.

AVIR: And I should say that, you know, you didn't have to do all these tests. Doctors sort of just did them out of precaution. But there were some things that doctors had to do. Like, the FDA rule was that they had to actually give the patient the pills in the office. Like, sit there and watch the patients take the pills.

LATIF: Like, literally watch them ingest the pills in their mouth?

AVIR: Yeah, exactly.

MOLLY: Is this all in one visit? Or are we at multiple visits at this point to get all of that done?

LAURA MACISAAC: Yeah. It—initially it could take two visits.

LATIF: Wait. So why all the regulations and the testing? Was it because of politics or because of science safety stuff?

MOLLY: Well, there was a little bit—some of it was politics, but then you also have to remember, like, the day before these pills came out, the abortion was a surgery.

LAURA MACISAAC: You know, we can't forget that reproductive events: abortion, miscarriage, childbirth can be fatal, right?

MOLLY: I mean, Laura was like, "Don't get me wrong. Most of the time these things go fine."

LAURA MACISAAC: Totally. But when it doesn't, it is scary, and you have to act fast. And the light bulbs have to go on and say, "Something's not right here. Why does she have a fever? She might be septic. I'm not gonna leave her side until I figure this out." So it's not like bad shit never happens.

MOLLY: And honestly, even when everything's going right, there's, like, you—you're heavy bleeding.

LATIF: Right.

MOLLY: There's uterine contractions. There could be vomiting, diarrhea. It's a full body experience that can feel and be scary, even if it ends up being okay. And for folks where it's not okay, like, they'd have to get themselves to a hospital or a doctor or even get a surgical abortion to, like, complete the procedure. So I did find myself when I was talking to Laura, like, saying, you know, as the person who could bleed from these pills ...

LATIF: Yeah.

MOLLY: ... like, I appreciate the guardrails. Because I have just a lot—I'm a person that has a lot of questions all the time. It's why I'm in the job that I'm in.

LULU: [laughs]

MOLLY: If I could just have a little doctor living in the corner of my house ...

LULU: [laughs] You would be so happy!

MOLLY: ... I would be the happiest person ever. 'Cause I ... [laughs]

AVIR: How little do they have to be?

MOLLY: Yeah. [laughs]

LULU: Just be like ...

LATIF: Avir's applying for the job, basically.

MOLLY: I know. I was like, there's an opening. So I would be the happiest person, you know? So I understand, like, knowledge satiation.

LULU: Yeah. Totally. Totally.

MOLLY: The one thing with all these guardrails, though, is that guardrails do make it hard to get these pills to patients, right? You're missing work for all of these visits. You know, all these tests are expensive.

LATIF: Hmm, yeah.

AVIR: Yeah. So to sort of like advance the story, right? This is the state of play in 2000. And the Mife-Miso abortion is approved for up to seven weeks.

LULU: Okay.

AVIR: Now over time, like the next couple of decades, doctors are starting to—and these are OBs specifically, right? They're starting to experiment and test the boundaries of clinical practice. So ...

LULU: Someone tries an experiment, meaning a scientist?

AVIR: Yeah, like a researcher doing a clinical trial. So the initial dose of Misoprostol was 600, I think, milligrams.

LULU: Yeah.

AVIR: They try—"Maybe we—this is pretty high. Let's try 400." Same efficacy. Then they cut it down to 200. Same efficacy. So the dose is going down. The weeks are going out because remember: at first, you could only give the pills up to seven weeks. And that's not that much time considering, you know, it's typically gonna be four weeks by the time you realize you missed a period. And then you have to get all your shit together, get these labs done, come back, get the ultrasound.

LATIF: Right.

AVIR: You know, it doesn't buy us that much time. So it started at seven, then they tried eight. Still works. Tried nine, still works. 10 still works.

LATIF: Whoa.

AVIR: Meanwhile the labs that are being drawn, doctors are starting to think, "Well, do we really need this lab? The type and screen where we check the mother's blood type, do we really we need that?" And they're experimenting with taking that out. Nothing bad is happening. The CBC, you're looking for anemia. Well, turns out, you can just ask someone if they have anemia. They take the CBC out.

MOLLY: And I just want to say, a lot of this experimentation started in other countries. So it'd be like, "Oh, the UK is doing it this way now. That's interesting." And then, you know, Sweden would do something. And then France would try something.

AVIR: Right.

MOLLY: So basically what you see with these pills is just this kind of steady—steady step of progress in the science around them and the ways that we give them to people.

AVIR: And then COVID happened. And almost overnight everything about the way we use these pills changes in a huge way.

LULU: When we come back, the abortion pills and a pandemic face off. Stick with us.

***

LULU: Lulu.

LATIF: Latif.

AVIR: Avir.

MOLLY: Molly.

LATIF: Radiolab.

AVIR: Okay. So now it's the beginning of 2020, and these pills are around, they're becoming more and more common.

MOLLY: Yeah, so nearly half of abortions in the United States are happening because of these pills.

AVIR: And then COVID happens. Everything changes. Women still need to have abortions. And the ACLU ...

LATIF: Right.

AVIR: ... leads a lawsuit against the FDA basically saying that forcing patients to come into the office to get these pills poses a huge medical risk to both the doctor and the patient.

LATIF: Now. Because of COVID?

MOLLY: Because of COVID.

AVIR: Right? And they win. So now patients don't have to come into the office to get these pills.

MOLLY: Yeah. And on top of that, doctors did away with ultrasounds and testing for all but the most high-risk patients.

AVIR: So now all of a sudden, the majority of abortions are happening over video chat. They're essentially becoming, like, quote, "no touch."

LAURA MACISAAC: No touch abortions.

AVIR: That's Laura MacIsaac again.

LULU: Was that like—for people who are doing this, was that a huge moment?

AVIR: Huge. When telehealth abortions first started ...

LAURA MACISAAC: I remember my first feeling was, "Oh, some bad things are gonna happen. We're gonna miss some ectopic pregnancies, or patients are gonna estimate their gestational age poorly." I'm just used to doing it with the patient in front of me.

AVIR: In medicine, you know, it's like we're super conservative. We don't want to rock the boat. We—one mistake makes us all feel terrible.

LULU: Yeah.

AVIR: Even if 99 of the rest of the time it went fine. But it turns out ...

LAURA MACISAAC: Telehealth abortion and in-person abortion have the same outcomes.

AVIR: There's absolutely no difference.

LULU: Oh my gosh! Really? Nothing? Nothing?

AVIR: Nothing. So the efficacy rate is the same, right? The failure rate is the same. The adverse event rate is the same.

LULU: That's wild. So it's like the worries may have been legit, but the worries were in vain.

AVIR: Yes. Yes.

LULU: Wow.

LATIF: I'm kind of shocked. Like, I feel like, especially when COVID first hit, like, there were all these stories of like—like, it's like people doing Zoom funerals and Zoom weddings, and those are all—and then but, like, nobody was talking about Zoom abortions going on at the same time.

AVIR: Yeah, exactly. And I mean, Laura's take on it is that, like, all of this happened precisely because, you know, there was so much else going on, and neither the pro-abortion movement or the anti-abortion movement even got the chance.

LAURA MACISAAC: They were too distracted by COVID to be fighting these ...

AVIR: Fighting over how doctors should be doing these abortions.

LATIF: Huh. Wow!

AVIR: Yeah. But there's actually one more thing that Laura told us.

LAURA MACISAAC: ... zoning in on the US ...

AVIR: Something that almost feels like a signal of what abortions might look like in the future.

LAURA MACISAAC: So this nonprofit called Aid Access has been providing women with Mifepristone and Misoprostol through the mail. And ...

MOLLY: Aid Access is the US branch of this abortion provider that is literally mailing abortion pills all around the world.

LULU: Huh!

MOLLY: And it's run by this European doctor who has developed a company to practice essentially in other countries where access to abortion is really limited. What you do is you go online, you fill out a questionnaire, and then a doctor on the other end would read it, and if they felt like you qualified to have a medical abortion, they would mail you the pills directly to your house.

ABIGAIL AIKEN: In the first two years of the service, there were 57,506 requests from people in the United States, and they came from all 50 states.

AVIR: This is Abigail Aiken, professor at the University of Texas-Austin.

MOLLY: Abigail and her team looked at data from almost 3,000 of those patients, and ...

ABIGAIL AIKEN: We found that 96 percent of people were able to end their pregnancy without any intervention from a medical provider.

MOLLY: How does that compare to the same statistics for if this is done in a clinic setting?

ABIGAIL AIKEN: Yeah, that's a great question. So these results in terms of effectiveness are really on par with what you would see in the clinical setting.

MOLLY: Really?

ABIGAIL AIKEN: Yeah.

MOLLY: Again, same results. No greater adverse events, even when a doctor and a patient weren't speaking to each other at all. And can I just say also that there was this other result that was very interesting ...

ABIGAIL AIKEN: There were actually several ectopics—not many, a handful. Maybe five in one study, three in the other, that were diagnosed by the service at the time of consultation. So the person would share symptoms of some kind and they would say "We think that's probably an ectopic. You should go get that checked out before you proceed with this." And they would actually get into care earlier than if they had waited until they had, you know, severe abdominal pain and vomiting.

AVIR: So you mean it's like the form that they did sort of flagged them?

ABIGAIL AIKEN: Yeah, exactly.

LATIF: Wow.

AVIR: Yeah. So it's a—it's a crazy study. This is the idea that had been percolating, and Aid Access is definitely the vanguard, but it's this idea of the self-managed abortion. And I think of it like—Molly's probably tired of me hearing—saying this same metaphor.

MOLLY: Never. Never!

AVIR: [laughs] But Jenga. I just played it the other day.

LULU: Okay.

AVIR: I see this whole thing like a game of Jenga, right?

LATIF: Mm-hmm.

LULU: How?

AVIR: When—when the medicines come out, we have a perfect block of Jenga. You know, like the whole structure's there. And as physicians, we're very scared to take things out of this structure, but we start saying, "Well, you know, really, I don't know if we need this particular lab. Hepatic function? Whatever. Let's take that out." The structure still stands, you know? Boom, boom. We keep taking out different parts of this Jenga tower. With COVID, huge chunks of the Jenga tower come out, the structure's still standing. And so what's incredible is just the amount of pieces we've been able to take out of this Jenga tower and have it still stand. And really, what's the last piece that is always there is the doctor.

LATIF: Hmm.

AVIR: You know? We put ourselves at the center of this whole process. Partially out of care, but partially probably out of some hubris, I would say, you know?

LATIF: [laughs]

AVIR: And so taken to its fullest, the self-managed abortion is really saying: what if there's no face-to-face contact with a doctor at all? What if you fill out a form, and if you check the right boxes on this form, then you're just good to go? You do this completely on your own. And so that idea, I think, is subtle, but from my perspective it's profound. There is no doctor directly involved in your care. You know, it's like getting a—like, an Ikea couch, you know? It's just like "Here's the instructions."

LATIF: Hmm.

AVIR: So—so, like, what does this mean? You know, that's what—that's what I keep asking myself is like, so what? And right now, 90 percent of abortions are happening in the first trimester where you could potentially use these pills. And so the "so what" to me is that, like, what these pills are telling us is that we now have the ability to take abortions—a good chunk of them—outside of clinics, outside of hospitals, outside of institutions, and put them into the hands of people. Which I think is just such a cool and interesting trajectory. That said, you know, one thing I think important to note is that we're talking about abortions with pills, but there are a chunk of people for whom that doesn't apply at all, you know? They need to get the old-school, you know, surgical abortion. And that's fine. But the percentage of people getting an abortion using pills, it's literally just a line graph that just keeps going up every year. And it's really just happening because of the science of these pills.

LATIF: Can I just say it's, like, so funny to hear you both tell this story. Because it's like, we're so used to every story about abortion, it's all about the politics. It's, like, so politically drenched, it's like every single little detail about it is like—is like a culture war. But what you're telling is like the story that seems like there's no politics in it, really.

AVIR: Right.

LATIF: Or very little. Which is kind of surprising to me. It's like, making me do a double take, kind of.

AVIR: That's what I think is so incredible is like science moves based on science, more or less. I mean, you know, obviously there's politics involved, but in this case, I'm seeing that these pills keep moving and moving and moving in the same direction. It's bigger than politics, it's bigger than the Supreme Court, it's bigger than all of that.

LULU: Contributing editor Avir Mitra and senior correspondent Molly Webster.

LATIF: So that was the piece we played just a few months ago. At the time, it seemed to us at least like—like it really was mostly a science and medicine story, but obviously now the law and the politicians have caught up, and now this pill is sort of in the—in the crosshairs.

LULU: But we should say for the moment, this pill, Mifepristone, is still available at pharmacies and it doesn't seem to be affecting the work of Aid Access.

LATIF: Yeah.

LULU: The group we mentioned that sends patients abortion pills through the mail. So thanks for listening.

LATIF: And stay tuned.

[LISTENER: Radiolab was created by Jad Abumrad, and is edited by Soren Wheeler. Lulu Miller and Latif Nasser are our co-hosts. Suzie Lechtenberg is our executive producer. Dylan Keefe is our director of sound design. Our staff includes: Simon Adler, Jeremy Bloom, Becca Bressler, Rachael Cusick, Ekedi Fausther-Keeys, W. Harry Fortuna, David Gebel, Maria Paz Gutiérrez, Sindhu Gnanasambandan, Matt Kielty, Annie McEwen, Alex Neason, Sarah Qari, Anna Rascouët-Paz, Sarah Sandbach, Arianne Wack, Pat Walters and Molly Webster. With help from Andrew Viñales. Our fact-checkers are Diane Kelly, Emily Krieger and Natalie Middleton.]

[LISTENER: Hi, this is Tamara from Pasadena, California. Leadership support for Radiolab's science programming is provided by the Gordon and Betty Moore Foundation, Science Sandbox, a Simons Foundation initiative and the John Templeton Foundation. Foundational support for Radiolab was provided by the Alfred P. Sloan Foundation.]

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