Sex, Politics and Markets
We know that the "invisible, wise hand" of the free market sometimes fails to work properly -- when buyer and seller do not have equal information, or one or both are dishonest or corrupt. Things get even more complicated, however, when ideology, politics and sex get added to the mix. Consider the current controversy about emergency contraception.
Recently the FDA refused to approve the application of Barr Laboratories to change Plan B from prescription to "over the counter" status (Plan B is an emergency contraception pill that can reduce the chance of pregnancy by 89% if taken within 5 days of unprotected intercourse). This refusal occurred in spite of the fact that the Agency's own Advisory Committees on Reproductive Health and on Over the Counter Drugs had both voted in favor of the proposal by a 23-4 margin.
It appears that the FDA was bowing to election year political pressure in its decision. Some factions within the extreme rightwing, who are a crucial component of President Bush's electoral base, have long opposed EC. Some see the medication as an "abortafacient," that is, a drug that causes abortion (in fact, EC, while preventing pregnancy from occurring, cannot disrupt an established pregnancy). Another argument of these conservatives is that too easy access to the drug will cause promiscuity and irresponsibility, particularly among teenage girls.
The FDA's official reason for its decision was that Barr had not demonstrated that the pill could be used safely by teenagers, 16 and under. This assertion, however, was undercut by testimony at the FDA hearing that reviewed scientific evidence on this precise point -- and found no such safety problems. In addition, internal FDA memos have revealed that Agency staffers did not find this argument credible or consistent with FDA policies used in assessing other over the counter drug applications. To the outraged and frustrated reproductive health community, which has worked for years to make EC more accessible, the FDA's action therefore represents yet another instance of the Bush administration's efforts to undermine scientific expertise -- and the integrity of the regulatory function of government. In short, science has once again been trumped by a political agenda.
But there is another element of the recent EC saga which has gone largely unnoticed. That is the peculiar role that the market -- in this case, the pharmaceutical industry -- plays in these showdowns in the highly politicized world of reproductive health. The threat of boycotts and other disruptive activities by conservative groups (not to mention high-profile lawsuits by dissatisfied consumers) has been enough to make many mainstream drug companies wary of investment in this field. Thus, in the case of EC, as in the quite similar case of Mifeprex (also known as RU-486 or the "abortion pill"), it was reproductive rights advocates who persuaded a small firm to take on the production and initial marketing of a controversial new product. These advocates took the quite unusual step (for the pharmaceutical world) of helping these companies to obtain some of their funding from foundations.
But as we have seen, even though Barr played by the rules--that is, it marshaled all the scientific evidence necessary to prove the safety and efficacy of its product--the system ultimately failed to work properly. Regrettably, one likely effect of this high profile FDA setback will be to further discourage needed investment in the field of reproductive health by the private sector.
What are the lessons to be drawn from this story? First, no attempts to make reproductive health services in the U.S. more accessible can presently be expected to work in an orderly, "normal" way. Given the presence of a politically strong rightwing movement that is opposed to nearly all forms of contraception, and which aggressively promotes "abstinence until marriage," EC will inevitably be bitterly resisted, in spite of the fact that it potentially has the capacity to prevent thousands of abortions.
Second, the EC story is a particularly vivid example of a larger pattern -- the failure of the "market" to meet basic human needs for adequate health care. EC will remain inaccessible to many American women because its controversial nature makes it difficult to sell to consumers in the most efficient way. But other drugs are inaccessible because they are priced out of reach for many, both in the U.S. and globally, as we see in with AIDS medications; some drugs are never even developed, as in the case of so-called "orphan diseases", because not enough (wealthy) people have a particular condition to make developing and marketing a drug profitable. And of course the poor, and the uninsured, cannot afford the more mundane drugs the rest of us can. The recent EC debacle is a powerful illustration of how both partisan politics and uncertain market forces compromise necessary health care services.
Carole Joffe is a Longview Senior Fellow. Felicia Stewart M.D. is adjunct professor of obstetrics, gynecology and reproductive science at UCSF and co-director of the Center for Reproductive Health Research and Policy at UCSF.