As Joseph points out, ob/gyn doctors are not likely to be very familiar with the neurovascular properties of the arm, where Norplant is inserted and removed. In its literature, Wyeth states that both insertion and removal can be accomplished in a matter of minutes, yet it can be a deceptively complicated process, particularly if the doctor has little or no experience with the procedures, or is removing a device implanted by somebody else. If the device is inserted too deeply, the capsules are more apt to travel away from the site; a too-shallow implant increases the risk of infection and rejection by the body.

The issue of doctors' lack of expertise with Norplant goes beyond insertions and removals. "Originally, [Wyeth] wanted all the providers to go through a training program to learn about Norplant," says Dr. Marilyn Joseph (no relation to attorney Jane Joseph), medical director of Boynton Health Services on the University of Minnesota campus. "But there was a lot of resistance among the clinicians to have to go through the training, so the company, for PR purposes, abandoned it." Joseph, who has gone through the training and says she "almost tries to dissuade people from using Norplant, because of the bleeding and to make sure they really want it," claims that "many doctors didn't tell their patients anything other than it was an effective form of birth control for five years, and they don't have to worry about any bleeding or anything." There are some Norplant-related lawsuits that seek damages against the physician as well as (or instead of) Wyeth; this is not the case among the largest group of Minnesota plaintiffs, whose attorneys believe, as Jane Joseph puts it, "that the doctors were duped [by Wyeth's claims of safety] as much as the patients."

There is still a chance that there won't be a class action suit certified against Norplant's makers after all, but in the meantime Wyeth is playing the "nuisance litigation" theme to the hilt. And it's having an impact: In Congress and on Main Street, a heavily, if surreptitiously, promoted corporate campaign to restrict product liability and rein in tort lawyers has been gaining momentum for a few years now. The movement is boosted by learned articles in media such as the The New York Times, Newsweek, and Family Planning Perspectives arguing that overregulation and the fear of lawsuits is stalling research and development on innovative new contraceptive products.

That's one way to spin it. But according to a 1993 report by the Program for Appropriate Technology in Health (or PATH), many drug companies view mature markets such as the United States as containing little additional profit potential. Ironically, proven options in this market include products like the Pill and IUDs, which were made safer and more effective as a result of celebrated lawsuits against them. Short of creating an altogether new form of contraception with broad appeal--like the long-heralded promise of a male oral contraceptive--most companies feel that new products would simply prey upon, and thus disrupt, the existing market for already developed, already profitable products.

When they do want to introduce a major new product into the market, they often find nonprofit or public groups to underwrite much of the research, as Wyeth did with the Population Council in the course of developing Norplant. A 1995 Rockefeller Foundation report estimated that pharmaceutical companies were raking in as much as $2.9 billion annually on contraceptive products while spending a paltry $22 million on research. With specific regard to Norplant, which reportedly sells for as little as $23 per unit in some parts of the world, Brosnahan says that Wyeth (which is a division of the multi-billion-dollar American Home Products Corporation) determined it would have a 90 percent gross profit if Norplant sold for $285 per unit four years ago. It currently retails in the United States for $365 per unit, a sum that Wyeth spokeswoman Audrey Ayers defends by saying it still makes Norplant one of the most cost-effective birth control methods available. Unless you're one of the unlucky few for whom the matter of side effects becomes more than a footnote in product literature.

Ryan Peck and Jon Segal contributed research to this story.

Norplant, the Law, and Social Engineering

by Britt Robson

JUST TWO DAYS after Norplant received FDA approval for use in the United States, the Philadelphia Inquirer published an editorial headlined "Poverty and Norplant--Can Contraception Reduce the Underclass?" It advocated the promotion of the device for welfare mothers and other poor women. The editorial writer, Donald Kimelman, acknowledged that he was "perhaps raising the specter of eugenics. But it would be worse to avoid drawing the logical conclusion that foolproof contraception could be invaluable in breaking the cycle of inner city poverty."

Norplant surfaced at a time when the United States was bringing eugenics out of the closet again. The country has a long and dishonorable, if seldom told, history of coercing "undesirable" people not to have children. Historical studies such as Philip Reilly's The Surgical Solution and Allan Chase's The Legacy of Malthus point to more than 60,000 cases of involuntary sterilization between 1907 and 1964. In view of the fact that some states (including Virginia and North Carolina) had sterilization programs that continued into the 1970s, and because sterilizations have also occurred in an illegal, clandestine fashion throughout this century, the actual number is probably much higher.

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