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The Dawn of the Post-Clinic Abortion	The Dawn of the Post-Clinic Abortion
2014-08-28 19:35:29 UTC	2014-08-30 01:55:34 UTC (1 day later)
In June 2001, under a cloud-streaked sky, Rebecca Gomperts set out from the Dutch port of Scheveningen in a rented 110-foot ship bound for Ireland. Lashed to the deck was a shipping container, freshly painted light blue and stocked with packets of mifepristone (which used to be called RU-486) and misoprostol. The pills are given to women in the first trimester to induce a miscarriage. Medical abortion, as this procedure is called, had recently become available in the Netherlands. But use of misoprostol and mifepristone to end a pregnancy was illegal in Ireland, where abortion by any means remains against the law, with few exceptions.	In June 2001, under a cloud-streaked sky, Rebecca Gomperts set out from the Dutch port of Scheveningen in a rented 110-foot ship bound for Ireland. Lashed to the deck was a shipping container, freshly painted light blue and stocked with packets of mifepristone (which used to be called RU-486) and misoprostol. The pills are given to women in the first trimester to induce a miscarriage. Medical abortion, as this procedure is called, had recently become available in the Netherlands. But use of misoprostol and mifepristone to end a pregnancy was illegal in Ireland, where abortion by any means remains against the law, with few exceptions.
Gomperts is a general-practice physician and activist. She first assisted with an abortion 20 years ago on a trip to Guinea, just before she finished medical school in Amsterdam. Three years later, Gomperts went to work as a ship’s doctor on a Greenpeace vessel. Landing in Mexico, she met a girl who was raising her younger siblings because her mother had died during a botched illegal abortion. When the ship traveled to Costa Rica and Panama, women told her about hardships they suffered because they didn’t have access to the procedure. “It was not part of my medical training to talk about illegal abortion and the public-health impact it has,” Gomperts told me this summer. “In those intense discussions with women, it really hit me.”	Gomperts is a general-practice physician and activist. She first assisted with an abortion 20 years ago on a trip to Guinea, just before she finished medical school in Amsterdam. Three years later, Gomperts went to work as a ship’s doctor on a Greenpeace vessel. Landing in Mexico, she met a girl who was raising her younger siblings because her mother had died during a botched illegal abortion. When the ship traveled to Costa Rica and Panama, women told her about hardships they suffered because they didn’t have access to the procedure. “It was not part of my medical training to talk about illegal abortion and the public-health impact it has,” Gomperts told me this summer. “In those intense discussions with women, it really hit me.”
When she returned to the Netherlands, Gomperts decided she wanted to figure out how to help women like the ones she had met. She did some legal and medical research and concluded that in a Dutch-registered ship governed by Dutch law, she could sail into the harbor of a country where abortion is illegal, take women on board, bring them into international waters, give them the pills at sea and send them home to miscarry. Calling the effort Women on Waves, she chose Dublin as her first destination.	When she returned to the Netherlands, Gomperts decided she wanted to figure out how to help women like the ones she had met. She did some legal and medical research and concluded that in a Dutch-registered ship governed by Dutch law, she could sail into the harbor of a country where abortion is illegal, take women on board, bring them into international waters, give them the pills at sea and send them home to miscarry. Calling the effort Women on Waves, she chose Dublin as her first destination.
Ten women each gave Gomperts 10,000 Dutch guilders (about $5,500), part of the money needed to rent a boat and pay for a crew. But to comply with Dutch law, she also had to build a mobile abortion clinic. Tapping contacts she made a decade earlier, when she attended art school at night while studying medicine, she got in touch with Joep van Lieshout, a well-known Dutch artist, and persuaded him to design the clinic. They applied for funds from the national arts council and built it together inside the shipping container. When the transport ministry threatened to revoke the ship’s authorization because of the container on deck, van Lieshout faxed them a certificate decreeing the clinic a functional work of art, titled “a-portable.” The ship was allowed to sail, and van Lieshout later showed a mock-up of the clinic at the Venice Biennale.	Ten women each gave Gomperts 10,000 Dutch guilders (about $5,500), part of the money needed to rent a boat and pay for a crew. But to comply with Dutch law, she also had to build a mobile abortion clinic. Tapping contacts she made a decade earlier, when she attended art school at night while studying medicine, she got in touch with Joep van Lieshout, a well-known Dutch artist, and persuaded him to design the clinic. They applied for funds from the national arts council and built it together inside the shipping container. When the transport ministry threatened to revoke the ship’s authorization because of the container on deck, van Lieshout faxed them a certificate decreeing the clinic a functional work of art, titled “a-portable.” The ship was allowed to sail, and van Lieshout later showed a mock-up of the clinic at the Venice Biennale.
As the boat sailed toward Dublin, Gomperts and her shipmates readied their store of pills and fielded calls from the press and emails from hundreds of Irish women seeking appointments. The onslaught of interest took them by surprise. So did a controversy that was starting to brew back home. Conservative politicians in the Netherlands denounced Gomperts for potentially breaking a law that required a special license for any doctor to provide an abortion after six and a half weeks of pregnancy. Gomperts had applied for it a few months earlier and received no reply. She set sail anyway, planning to perform abortions only up to six and a half weeks if the license did not come through.	As the boat sailed toward Dublin, Gomperts and her shipmates readied their store of pills and fielded calls from the press and emails from hundreds of Irish women seeking appointments. The onslaught of interest took them by surprise. So did a controversy that was starting to brew back home. Conservative politicians in the Netherlands denounced Gomperts for potentially breaking a law that required a special license for any doctor to provide an abortion after six and a half weeks of pregnancy. Gomperts had applied for it a few months earlier and received no reply. She set sail anyway, planning to perform abortions only up to six and a half weeks if the license did not come through.
When Gomperts’s ship docked in Dublin, she still didn’t have the license. Irish women’s groups were divided over what to do. Gomperts decided she couldn’t go ahead without their united support and told a group of reporters and protesters that she wouldn’t be able to give out a single pill. “This is just the first of many trips that we plan to make,” she said from the shore, wrapped in a blanket, a scene that is captured in “Vessel,” a documentary about her work that will be released this winter. Gomperts was accused of misleading women. A headline in The Telegraph in London read: “Abortion Boat Admits Dublin Voyage Was a Publicity Sham.”	When Gomperts’s ship docked in Dublin, she still didn’t have the license. Irish women’s groups were divided over what to do. Gomperts decided she couldn’t go ahead without their united support and told a group of reporters and protesters that she wouldn’t be able to give out a single pill. “This is just the first of many trips that we plan to make,” she said from the shore, wrapped in a blanket, a scene that is captured in “Vessel,” a documentary about her work that will be released this winter. Gomperts was accused of misleading women. A headline in The Telegraph in London read: “Abortion Boat Admits Dublin Voyage Was a Publicity Sham.”
Gomperts set sail again two years later, this time resolving to perform abortions only up to six and a half weeks. She went to Poland first and to Portugal in 2004. The Portuguese minister of defense sent two warships to stop the boat, then just 12 miles offshore, from entering national waters. No local boat could be found to ferry out the women who were waiting onshore. “In the beginning we were very pissed off, thinking the campaign was failing because the ship couldn’t get in,” one Portuguese activist says in “Vessel.” “But at a certain point, we realized that was the best thing that could ever happen. Because we had media coverage from everywhere.”	Gomperts set sail again two years later, this time resolving to perform abortions only up to six and a half weeks. She went to Poland first and to Portugal in 2004. The Portuguese minister of defense sent two warships to stop the boat, then just 12 miles offshore, from entering national waters. No local boat could be found to ferry out the women who were waiting onshore. “In the beginning we were very pissed off, thinking the campaign was failing because the ship couldn’t get in,” one Portuguese activist says in “Vessel.” “But at a certain point, we realized that was the best thing that could ever happen. Because we had media coverage from everywhere.”
Without consulting her local allies, Gomperts changed strategy. She appeared on a Portuguese talk show, held up a pack of pills on-screen and explained exactly how women could induce an abortion at home — specifying the number of pills they needed to take, at intervals, and warning that they might feel pain. A Portuguese anti-abortion campaigner who was also on the show challenged the ship’s operation on legal grounds. “Excuse me,” Gomperts said. “I really think you should not talk about things that you don’t know anything about, O.K. . . . I know what I can do within the law.” Looking directly at him, she added, “Concerning pregnancy, you’re a man, you can walk away when your girlfriend is pregnant. I’m pregnant now, and I had an abortion when I was — a long time ago. And I’m very happy that I have the choice to continue my pregnancy how I want, and that I had the choice to end it when I needed it.” She pointed at the man. “You have never given birth, so you don’t know what it means to do that.”	Without consulting her local allies, Gomperts changed strategy. She appeared on a Portuguese talk show, held up a pack of pills on-screen and explained exactly how women could induce an abortion at home — specifying the number of pills they needed to take, at intervals, and warning that they might feel pain. A Portuguese anti-abortion campaigner who was also on the show challenged the ship’s operation on legal grounds. “Excuse me,” Gomperts said. “I really think you should not talk about things that you don’t know anything about, O.K. . . . I know what I can do within the law.” Looking directly at him, she added, “Concerning pregnancy, you’re a man, you can walk away when your girlfriend is pregnant. I’m pregnant now, and I had an abortion when I was — a long time ago. And I’m very happy that I have the choice to continue my pregnancy how I want, and that I had the choice to end it when I needed it.” She pointed at the man. “You have never given birth, so you don’t know what it means to do that.”
Two and a half years later, Portugal legalized abortion. As word of Gomperts’s TV appearance spread, activists in other countries saw it as a breakthrough. Gomperts had communicated directly to women what was still, in many places, a well-kept secret: There were pills on the market with the power to end a pregnancy. Emails from women all over the world poured into Women on Waves, asking about the medication and how to get it. Gomperts wanted to help women “give themselves permission” to take the pills, as she puts it, with as little involvement by the government, or the medical profession, as possible. She realized that there was an easier way to do this than showing up in a port. She didn’t need a ship. She just needed the Internet.	Two and a half years later, Portugal legalized abortion. As word of Gomperts’s TV appearance spread, activists in other countries saw it as a breakthrough. Gomperts had communicated directly to women what was still, in many places, a well-kept secret: There were pills on the market with the power to end a pregnancy. Emails from women all over the world poured into Women on Waves, asking about the medication and how to get it. Gomperts wanted to help women “give themselves permission” to take the pills, as she puts it, with as little involvement by the government, or the medical profession, as possible. She realized that there was an easier way to do this than showing up in a port. She didn’t need a ship. She just needed the Internet.
Gomperts no longer works from a boat. Eight years ago she started Women on Web, a “telemedicine support service” for women around the world who are seeking medical abortions. She and a small staff share a one-room office in Amsterdam on a residential street, where red-and-pink flowers bloom on the balconies of brick buildings. Early in July, I went to visit the space, which has six workstations with computers, a few shelves and a filing cabinet with the sticker “Trust Women.” A large window opens onto a courtyard, where a Cupid fountain bubbles.	Gomperts no longer works from a boat. Eight years ago she started Women on Web, a “telemedicine support service” for women around the world who are seeking medical abortions. She and a small staff share a one-room office in Amsterdam on a residential street, where red-and-pink flowers bloom on the balconies of brick buildings. Early in July, I went to visit the space, which has six workstations with computers, a few shelves and a filing cabinet with the sticker “Trust Women.” A large window opens onto a courtyard, where a Cupid fountain bubbles.
On the morning I arrived, Gomperts — who is 48 but looks younger, with freckles and black hightop sneakers — was talking with one of her help-desk staff members, Renata, about an email she recently received from a 22-year-old woman who lives in Brazil, where abortion is legal only in cases of rape and to save the life of the mother. “I need help please,” the woman wrote. “I’ve tried to get other information” about how to get an abortion, she added in another message later that day. “But I could not. I’m desperate.”	On the morning I arrived, Gomperts — who is 48 but looks younger, with freckles and black hightop sneakers — was talking with one of her help-desk staff members, Renata, about an email she recently received from a 22-year-old woman who lives in Brazil, where abortion is legal only in cases of rape and to save the life of the mother. “I need help please,” the woman wrote. “I’ve tried to get other information” about how to get an abortion, she added in another message later that day. “But I could not. I’m desperate.”
Almost 40 percent of the world’s population lives in countries, primarily in Latin America, Africa, Asia and the Persian Gulf, where abortion is either banned or severely restricted. The World Health Organization estimated in 2008 that 21.6 million unsafe abortions took place that year worldwide, leading to about 47,000 deaths. To reduce that number, W.H.O. put mifepristone and misoprostol on its Essential Medicines list. The cost of the combination dose used to end a pregnancy varies from less than $5 in India to about $120 in Europe. (Misoprostol is also used during labor and delivery to prevent postpartum hemorrhage, and global health groups have focused on making it more available in countries with high rates of maternal mortality, including Kenya, Tanzania, India, Nepal, Cambodia, and South Africa.) Gomperts told me that Women on Web receives 2,000 queries each month from women asking for help with medical abortions. (The drugs are widely advertised on the Internet, but it is difficult to tell which sites are scams.)	Almost 40 percent of the world’s population lives in countries, primarily in Latin America, Africa, Asia and the Persian Gulf, where abortion is either banned or severely restricted. The World Health Organization estimated in 2008 that 21.6 million unsafe abortions took place that year worldwide, leading to about 47,000 deaths. To reduce that number, W.H.O. put mifepristone and misoprostol on its Essential Medicines list. The cost of the combination dose used to end a pregnancy varies from less than $5 in India to about $120 in Europe. (Misoprostol is also used during labor and delivery to prevent postpartum hemorrhage, and global health groups have focused on making it more available in countries with high rates of maternal mortality, including Kenya, Tanzania, India, Nepal, Cambodia, and South Africa.) Gomperts told me that Women on Web receives 2,000 queries each month from women asking for help with medical abortions. (The drugs are widely advertised on the Internet, but it is difficult to tell which sites are scams.)
Responding to the 22-year-old woman in Brazil, Renata — a 54-year-old artist who moved to Amsterdam from South America 26 years ago and who asked me to use only her first name because of the controversial nature of her work — wrote to ask how far along she was in her pregnancy. Women on Web will open a new case only if a woman is less than nine weeks pregnant, to ensure time for delivery of the medication before the end of the first trimester. In filling out the online consultation Women on Web provides, the woman in Brazil dated her pregnancy at seven weeks. She reported no signs of an ectopic pregnancy — a condition that, while rare, can be fatal and cannot be treated with a medical abortion.	Responding to the 22-year-old woman in Brazil, Renata — a 54-year-old artist who moved to Amsterdam from South America 26 years ago and who asked me to use only her first name because of the controversial nature of her work — wrote to ask how far along she was in her pregnancy. Women on Web will open a new case only if a woman is less than nine weeks pregnant, to ensure time for delivery of the medication before the end of the first trimester. In filling out the online consultation Women on Web provides, the woman in Brazil dated her pregnancy at seven weeks. She reported no signs of an ectopic pregnancy — a condition that, while rare, can be fatal and cannot be treated with a medical abortion.
On July 5, three days after the Brazilian woman’s initial query, her consultation was sent to a doctor to review. Five physicians work for Women on Web part time; some of them also have jobs in abortion clinics doing surgical procedures. Gomperts wouldn’t tell me where the doctors were based, only that she consulted with a law professor to determine that “everyone is operating in a legal setting.” Despite her earlier defiance on the ship, she decided on this front not to court controversy. “We are trying to demedicalize abortion, but the reality is the doctors are liable,” she said.	On July 5, three days after the Brazilian woman’s initial query, her consultation was sent to a doctor to review. Five physicians work for Women on Web part time; some of them also have jobs in abortion clinics doing surgical procedures. Gomperts wouldn’t tell me where the doctors were based, only that she consulted with a law professor to determine that “everyone is operating in a legal setting.” Despite her earlier defiance on the ship, she decided on this front not to court controversy. “We are trying to demedicalize abortion, but the reality is the doctors are liable,” she said.
At the Amsterdam office, Renata followed the Brazilian case. After reviewing and approving the woman’s consultation, the doctor wrote a prescription for mifepristone and misoprostol and sent it electronically to a drug exporter in India. The exporter would fill the prescription and send the medication to the woman, in a package with a tracking number, so she and the help desk could follow its progress. Renata sent the Brazilian woman an email telling her how to take the pills, once they were delivered, in a series of doses over 24 hours. The instructions explained what to expect when the medication takes effect — bleeding, cramping and discomfort. When taken together, the pills are 95 to 98 percent effective.	At the Amsterdam office, Renata followed the Brazilian case. After reviewing and approving the woman’s consultation, the doctor wrote a prescription for mifepristone and misoprostol and sent it electronically to a drug exporter in India. The exporter would fill the prescription and send the medication to the woman, in a package with a tracking number, so she and the help desk could follow its progress. Renata sent the Brazilian woman an email telling her how to take the pills, once they were delivered, in a series of doses over 24 hours. The instructions explained what to expect when the medication takes effect — bleeding, cramping and discomfort. When taken together, the pills are 95 to 98 percent effective.
Gomperts designed her program — based on the radical idea of providing abortions without direct contact with a doctor — for women in countries where abortion clinics are nonexistent or highly restricted. But her model is invigorating abortion rights activists in the United States, where the procedure is simultaneously legal and increasingly hard to access. In their eyes, medical abortion, delivered through a known, if faraway, source, could be a transformative response: a means of access that remains open even when clinics shut.	Gomperts designed her program — based on the radical idea of providing abortions without direct contact with a doctor — for women in countries where abortion clinics are nonexistent or highly restricted. But her model is invigorating abortion rights activists in the United States, where the procedure is simultaneously legal and increasingly hard to access. In their eyes, medical abortion, delivered through a known, if faraway, source, could be a transformative response: a means of access that remains open even when clinics shut.
Medical abortions take place over hours instead of minutes and can be more painful than surgical abortions. One Dutch woman I spoke with who had an abortion through Women on Web while she was living abroad in 2012 told me about her experience. “When the cramps started, I felt horrible,” she said. At the time, she was 40 and living in Burkina Faso in West Africa. She hadn’t meant to get pregnant; she wasn’t in a serious relationship, and she had a 7-year-old son she was raising on her own. During the abortion, she sent him to a friend’s house for the weekend and “cocooned” herself, making tea and putting on music. “I’d vomit, take a warm bath, feel the cramps, get into bed, have diarrhea, go back to the bath,” she said. “I was in pain. It really hurt. But I knew what was happening.”	Medical abortions take place over hours instead of minutes and can be more painful than surgical abortions. One Dutch woman I spoke with who had an abortion through Women on Web while she was living abroad in 2012 told me about her experience. “When the cramps started, I felt horrible,” she said. At the time, she was 40 and living in Burkina Faso in West Africa. She hadn’t meant to get pregnant; she wasn’t in a serious relationship, and she had a 7-year-old son she was raising on her own. During the abortion, she sent him to a friend’s house for the weekend and “cocooned” herself, making tea and putting on music. “I’d vomit, take a warm bath, feel the cramps, get into bed, have diarrhea, go back to the bath,” she said. “I was in pain. It really hurt. But I knew what was happening.”
When women take the pills and feel uncertain — worried, for example, about whether they are bleeding too much or not enough — they can write to Women on Web with questions. The help-desk staff is trained to send a standardized list of warning signs but not to weigh in about the severity of anyone’s particular symptoms. “We cannot judge your situation over a distance, so we advise you to visit your doctor,” Gomperts said. “This is the limitation of the service.” She argues that it’s not a constraint that puts women at risk. “If you think something is wrong, what’s crucial is to be able to recognize it. Women can do that. The help desk makes sure they’ll go to a doctor if there is an indication that they might have a problem.”	When women take the pills and feel uncertain — worried, for example, about whether they are bleeding too much or not enough — they can write to Women on Web with questions. The help-desk staff is trained to send a standardized list of warning signs but not to weigh in about the severity of anyone’s particular symptoms. “We cannot judge your situation over a distance, so we advise you to visit your doctor,” Gomperts said. “This is the limitation of the service.” She argues that it’s not a constraint that puts women at risk. “If you think something is wrong, what’s crucial is to be able to recognize it. Women can do that. The help desk makes sure they’ll go to a doctor if there is an indication that they might have a problem.”
When women do seek medical attention, Women on Web also counsels them about how to avoid criminal charges if they live in countries where they have reason to fear prosecution. To ingest the mifepristone and misoprostol they are told to place the drugs in their cheek or under their tongue, where the medicine cannot be detected in the body. (If they are inserted vaginally, they may leave fragments.) Gomperts says there is no medical reason for women to tell anyone that they’ve used pills. Treatment, if needed, is the same as it would be for a spontaneous miscarriage. “Women shouldn’t be afraid to look for care when they need it, and at the same time they shouldn’t do anything to incriminate themselves,” Gomperts said.	When women do seek medical attention, Women on Web also counsels them about how to avoid criminal charges if they live in countries where they have reason to fear prosecution. To ingest the mifepristone and misoprostol they are told to place the drugs in their cheek or under their tongue, where the medicine cannot be detected in the body. (If they are inserted vaginally, they may leave fragments.) Gomperts says there is no medical reason for women to tell anyone that they’ve used pills. Treatment, if needed, is the same as it would be for a spontaneous miscarriage. “Women shouldn’t be afraid to look for care when they need it, and at the same time they shouldn’t do anything to incriminate themselves,” Gomperts said.
In Brazil, the legal risk is acute. This summer, some women who were sent drugs through Women on Web reported that custom officials were confiscating their packages. Gomperts and her staff started telling Brazilian women to look for help elsewhere, sending links to resources in other places, like public clinics in Mexico City that provide abortions inexpensively. The 22-year-old in Brazil told Renata she couldn’t travel. Renata warned that the delivery wasn’t guaranteed, saying, “You understand the situation: You need to keep looking for help because there is a chance the package won’t arrive.”	In Brazil, the legal risk is acute. This summer, some women who were sent drugs through Women on Web reported that custom officials were confiscating their packages. Gomperts and her staff started telling Brazilian women to look for help elsewhere, sending links to resources in other places, like public clinics in Mexico City that provide abortions inexpensively. The 22-year-old in Brazil told Renata she couldn’t travel. Renata warned that the delivery wasn’t guaranteed, saying, “You understand the situation: You need to keep looking for help because there is a chance the package won’t arrive.”
“I’m trying,” the woman wrote back. “But everyone here is misusing women. They are selling four pills” — an incomplete dose — “for three times my monthly salary. Thank you very much for what you’re doing. It is very important for many people.”	“I’m trying,” the woman wrote back. “But everyone here is misusing women. They are selling four pills” — an incomplete dose — “for three times my monthly salary. Thank you very much for what you’re doing. It is very important for many people.”
On July 13, the woman reported a new problem: The tracking number for her package had disappeared from the online system for international mail. “I wonder if the order was made,” she wrote. “Please help me! I am very worried!”	On July 13, the woman reported a new problem: The tracking number for her package had disappeared from the online system for international mail. “I wonder if the order was made,” she wrote. “Please help me! I am very worried!”
Gomperts took that plea to the person who is the last crucial link in the Women on Web delivery chain: Mohan Kale, a 44-year-old businessman in India who exports the pills.	Gomperts took that plea to the person who is the last crucial link in the Women on Web delivery chain: Mohan Kale, a 44-year-old businessman in India who exports the pills.
Kale and Gomperts met two years ago when she went to India in search of a new supplier. His was one name on a long list, but when Gomperts went to his office, Kale’s relaxed way with his workers put her at ease. When they sat down to talk, Kale told Gomperts that his wife was a social worker and that he was involved with local charities. “He wasn’t showing off,” she said. “It was the opposite of that. He just felt a lot of responsibility for the suffering in his country.”	Kale and Gomperts met two years ago when she went to India in search of a new supplier. His was one name on a long list, but when Gomperts went to his office, Kale’s relaxed way with his workers put her at ease. When they sat down to talk, Kale told Gomperts that his wife was a social worker and that he was involved with local charities. “He wasn’t showing off,” she said. “It was the opposite of that. He just felt a lot of responsibility for the suffering in his country.”
When I spoke to him over Skype last month, Kale told me that his company, Kale Impex, supplies 1,500 drug compounds, including mifepristone and misoprostol, and has $4.5 million in annual revenue. He said he understood why it was important to Gomperts to partner with a drug exporter. “It’s a simple pill and still not freely available,” he told me. At one point over Skype, he asked me to turn on my camera. “Can you see this?” he said, holding up a sheaf of papers that Gomperts gave him. “These are notes from women we sent the packages to.” I asked him to read one, and he chose a message from Malaysia. “Me and my boyfriend are not really fluent in English, but you guys at Women on Web really did a great job,” it read. “We are grateful for the help and support and thank you for all that you do.” I had seen other notes like this in Gomperts’s office. One message from Kenya read: “I retrieved the medicine from the post in Nairobi yesterday. I kissed the pills when they fell into my hand.” Another from Northern Ireland read: “I used your service a few months ago. Today I finally found out I was back to normal, whatever that really means, seems strange to say really, but I wanted to say a HUGE thank you.” Kale paged through more notes, reading off a list of the places they came from: Costa Rica, Malta, Pakistan, New Zealand, Chile, India, Uganda, Ireland, Brazil, South Korea, Saudi Arabia, the United Arab Emirates, Poland, Algeria. “So many countries,” he said, with a note of awe.	When I spoke to him over Skype last month, Kale told me that his company, Kale Impex, supplies 1,500 drug compounds, including mifepristone and misoprostol, and has $4.5 million in annual revenue. He said he understood why it was important to Gomperts to partner with a drug exporter. “It’s a simple pill and still not freely available,” he told me. At one point over Skype, he asked me to turn on my camera. “Can you see this?” he said, holding up a sheaf of papers that Gomperts gave him. “These are notes from women we sent the packages to.” I asked him to read one, and he chose a message from Malaysia. “Me and my boyfriend are not really fluent in English, but you guys at Women on Web really did a great job,” it read. “We are grateful for the help and support and thank you for all that you do.” I had seen other notes like this in Gomperts’s office. One message from Kenya read: “I retrieved the medicine from the post in Nairobi yesterday. I kissed the pills when they fell into my hand.” Another from Northern Ireland read: “I used your service a few months ago. Today I finally found out I was back to normal, whatever that really means, seems strange to say really, but I wanted to say a HUGE thank you.” Kale paged through more notes, reading off a list of the places they came from: Costa Rica, Malta, Pakistan, New Zealand, Chile, India, Uganda, Ireland, Brazil, South Korea, Saudi Arabia, the United Arab Emirates, Poland, Algeria. “So many countries,” he said, with a note of awe.
Kale ships the mifepristone and misoprostol at cost; this helps Women on Web remain in the black. Women who request medical abortions are asked for a standard donation of 90 euros, which goes toward staff salaries and overhead. If women say they can’t afford this — the 22-year-old from Brazil said she couldn’t — they are still sent the medication. Last year, about two-thirds of the women made the suggested contribution; the others gave a small donation or none at all.	Kale ships the mifepristone and misoprostol at cost; this helps Women on Web remain in the black. Women who request medical abortions are asked for a standard donation of 90 euros, which goes toward staff salaries and overhead. If women say they can’t afford this — the 22-year-old from Brazil said she couldn’t — they are still sent the medication. Last year, about two-thirds of the women made the suggested contribution; the others gave a small donation or none at all.
After working smoothly with Kale for two and a half years, Gomperts started running into delivery and tracking problems last spring. Last year, the United States began an investigation into the export of generic drugs by Indian companies, claiming patent violations. Though the Indian government denied the allegations, Kale said the regional authorities in Mumbai forced companies like his to reroute their deliveries. Since then, tracking numbers and deliveries were getting lost.	After working smoothly with Kale for two and a half years, Gomperts started running into delivery and tracking problems last spring. Last year, the United States began an investigation into the export of generic drugs by Indian companies, claiming patent violations. Though the Indian government denied the allegations, Kale said the regional authorities in Mumbai forced companies like his to reroute their deliveries. Since then, tracking numbers and deliveries were getting lost.
Kale knew this was causing heartache for women who were waiting for their pills. “The anxiety level of the women goes up,” he said. “It’s painful.” He and Gomperts agreed to send a second shipment to anyone whose package appeared to be lost. Like any web-based small business concerned with customer satisfaction, the Women on Web help-desk staff was trying to trace the packages as they traveled from India to their global destinations. It was time-consuming work, and it underscored the tenuous nature of sending abortion pills around the world in an effort to circumvent the law. In the office, Gomperts sat with a staff member who was trying to track down a shipment that Kale Impex sent 10 days earlier to Nicaragua. She found a record of the tracking number on the Indian post-office website, but it wasn’t clear how to plug it into the Nicaraguan system. Gomperts emailed one of Kale’s assistants asking if the company could send the shipment again.	Kale knew this was causing heartache for women who were waiting for their pills. “The anxiety level of the women goes up,” he said. “It’s painful.” He and Gomperts agreed to send a second shipment to anyone whose package appeared to be lost. Like any web-based small business concerned with customer satisfaction, the Women on Web help-desk staff was trying to trace the packages as they traveled from India to their global destinations. It was time-consuming work, and it underscored the tenuous nature of sending abortion pills around the world in an effort to circumvent the law. In the office, Gomperts sat with a staff member who was trying to track down a shipment that Kale Impex sent 10 days earlier to Nicaragua. She found a record of the tracking number on the Indian post-office website, but it wasn’t clear how to plug it into the Nicaraguan system. Gomperts emailed one of Kale’s assistants asking if the company could send the shipment again.
Next, they looked for another package that had been mailed to Chile on June 6 and found that it had arrived at a Chilean airport on June 30. The staff member looked at the recipient’s records to find out how many weeks pregnant she now was. “O.K., she’ll get this by 11 weeks,” she said with relief. Gomperts said, “Send her the details — the tracking number and that it’s at the airport.” The staff member typed the note in Spanish. “Please let us know when you receive the package,” she wrote at the end.	Next, they looked for another package that had been mailed to Chile on June 6 and found that it had arrived at a Chilean airport on June 30. The staff member looked at the recipient’s records to find out how many weeks pregnant she now was. “O.K., she’ll get this by 11 weeks,” she said with relief. Gomperts said, “Send her the details — the tracking number and that it’s at the airport.” The staff member typed the note in Spanish. “Please let us know when you receive the package,” she wrote at the end.
That evening after work, Gomperts and I bought rotis for a picnic she was having with her family. We walked to a park and met her children, a son who is 8 and a daughter who is 9, Gomperts’s sister Miriam, who is also a doctor, and Renata, who is Miriam’s wife. They all live in a communal house with a couple of other families. At one point, Gomperts’s children ran up to show her the pink-and-blue bracelets they had woven at school, then spotted friends wearing face paint and went off with them.	That evening after work, Gomperts and I bought rotis for a picnic she was having with her family. We walked to a park and met her children, a son who is 8 and a daughter who is 9, Gomperts’s sister Miriam, who is also a doctor, and Renata, who is Miriam’s wife. They all live in a communal house with a couple of other families. At one point, Gomperts’s children ran up to show her the pink-and-blue bracelets they had woven at school, then spotted friends wearing face paint and went off with them.
Surrounded by other families who brought food, music and soccer balls, Gomperts lay on her back and told me about an organizational struggle that exploded in the spring when most of the staff — about 20 people, many of whom worked remotely — as well as a majority of the board quit over her management style. I talked to one former staff member, who said that for years Gomperts trusted her and other longtime workers to give women comprehensive counseling, including medical advice, in response to questions about possible complications. But, she said, several months earlier Gomperts had abruptly put a stop to this to make the system more efficient and assert her own control.	Surrounded by other families who brought food, music and soccer balls, Gomperts lay on her back and told me about an organizational struggle that exploded in the spring when most of the staff — about 20 people, many of whom worked remotely — as well as a majority of the board quit over her management style. I talked to one former staff member, who said that for years Gomperts trusted her and other longtime workers to give women comprehensive counseling, including medical advice, in response to questions about possible complications. But, she said, several months earlier Gomperts had abruptly put a stop to this to make the system more efficient and assert her own control.
Gomperts said she has been accused of having founder’s syndrome: being good at starting organizations but bad at running them. She was worrying about managing the new staff she hired. “If someone is working for you, can’t you just tell them what to do?” she asked. “Am I being too bossy?”	Gomperts said she has been accused of having founder’s syndrome: being good at starting organizations but bad at running them. She was worrying about managing the new staff she hired. “If someone is working for you, can’t you just tell them what to do?” she asked. “Am I being too bossy?”
I asked Gomperts why, as a Greenpeace activist, she chose abortion as her cause. She thought for a minute. Her philosophy, she said, was about the “reduction of suffering” but also about self-determination. She said she was “interested in finding the blind spots of the law.” She liked upending the system. “I enjoy that,” she said. “If I was interested in money, I’d have a company in the Cayman Islands, getting all the tax deductions I could to get rich.”	I asked Gomperts why, as a Greenpeace activist, she chose abortion as her cause. She thought for a minute. Her philosophy, she said, was about the “reduction of suffering” but also about self-determination. She said she was “interested in finding the blind spots of the law.” She liked upending the system. “I enjoy that,” she said. “If I was interested in money, I’d have a company in the Cayman Islands, getting all the tax deductions I could to get rich.”
Of the thousands of emails that come to Women on Web, 40 to 60 a month now originate in the United States, Gomperts said, double the number from two years ago. On the first day I was in the office, she showed me a recent email from Florida. “Please tell me where I can get miso without a prescription,” the email read. “I live in the United States and have no health insurance. I have two children and I am currently out of work, there’s no way I can afford another child. Please help. I’m desperate.”	Of the thousands of emails that come to Women on Web, 40 to 60 a month now originate in the United States, Gomperts said, double the number from two years ago. On the first day I was in the office, she showed me a recent email from Florida. “Please tell me where I can get miso without a prescription,” the email read. “I live in the United States and have no health insurance. I have two children and I am currently out of work, there’s no way I can afford another child. Please help. I’m desperate.”
Gomperts is sympathetic but firm in her refusal to get involved in the United States. “We’re sorry, the doctors of Women on Web cannot provide the service in any country with safe abortion services,” reads the response American women receive from the help desk. She told me: “I know that it’s difficult, because abortion is not accessible to them. But this is not our work. I think this is a problem the U.S. has to solve itself. There are so many resources, so much money available there for abortion rights groups, I think they should be able to work on this. Starting on paper, with changing the laws.”	Gomperts is sympathetic but firm in her refusal to get involved in the United States. “We’re sorry, the doctors of Women on Web cannot provide the service in any country with safe abortion services,” reads the response American women receive from the help desk. She told me: “I know that it’s difficult, because abortion is not accessible to them. But this is not our work. I think this is a problem the U.S. has to solve itself. There are so many resources, so much money available there for abortion rights groups, I think they should be able to work on this. Starting on paper, with changing the laws.”
The laws regarding access to medical abortion have been contested in the United States since the drugs became available in the 1980s. Mifepristone was initially licensed in France in 1988. Abortion opponents lobbied to keep the drug out of the United States, and in 1990, the administration of George H. W. Bush made it illegal to bring the drug into the country for personal use. In 2000, however, after a long Clinton-era fight, the Food and Drug Administration approved mifepristone under the name RU-486. Doctors could dispense the drug, but the F.D.A. imposed restrictions that persist to this day. Before doctors can order the medication, they must provide information about their qualifications. Patients have to be given the medication at a doctor’s office instead of picking it up at a pharmacy. Mifepristone also carries a black-box label, the F.D.A.'s strongest alert for life-threatening effects. It has been used in 2.3 million procedures resulting in 11 reported deaths of women. Misoprostol, which is 85 percent effective on its own, is available in the United States by prescription.	The laws regarding access to medical abortion have been contested in the United States since the drugs became available in the 1980s. Mifepristone was initially licensed in France in 1988. Abortion opponents lobbied to keep the drug out of the United States, and in 1990, the administration of George H. W. Bush made it illegal to bring the drug into the country for personal use. In 2000, however, after a long Clinton-era fight, the Food and Drug Administration approved mifepristone under the name RU-486. Doctors could dispense the drug, but the F.D.A. imposed restrictions that persist to this day. Before doctors can order the medication, they must provide information about their qualifications. Patients have to be given the medication at a doctor’s office instead of picking it up at a pharmacy. Mifepristone also carries a black-box label, the F.D.A.'s strongest alert for life-threatening effects. It has been used in 2.3 million procedures resulting in 11 reported deaths of women. Misoprostol, which is 85 percent effective on its own, is available in the United States by prescription.
The F.D.A. approved mifepristone through the seventh week of pregnancy. Many doctors, though, prescribe the medication off label through 10 weeks, based on recent research showing it remains effective. Medical abortion now accounts for approximately a third of all abortion through that period in this country. Ohio and Texas require abortion providers to follow the more restrictive F.D.A. protocol; a similar law will go into effect in Oklahoma in November.	The F.D.A. approved mifepristone through the seventh week of pregnancy. Many doctors, though, prescribe the medication off label through 10 weeks, based on recent research showing it remains effective. Medical abortion now accounts for approximately a third of all abortion through that period in this country. Ohio and Texas require abortion providers to follow the more restrictive F.D.A. protocol; a similar law will go into effect in Oklahoma in November.
A medical abortion in the United States usually involves two office visits. At the first, a woman often has an ultrasound, to date the pregnancy. She is given mifepristone in the office and misoprostol to take at home 24 hours later. Then, at a follow-up visit, the woman has an examination to make sure the abortion is complete. (The F.D.A. protocol, however, calls for three visits and recommends that the misoprostol be taken under medical supervision; Texas requires four visits.) Some clinics in the United States and abroad are experimenting with cutting the number of office visits by making the follow-up visit optional — if the woman isn’t sure whether an abortion is complete, she can either take a home pregnancy test or return for an examination.	A medical abortion in the United States usually involves two office visits. At the first, a woman often has an ultrasound, to date the pregnancy. She is given mifepristone in the office and misoprostol to take at home 24 hours later. Then, at a follow-up visit, the woman has an examination to make sure the abortion is complete. (The F.D.A. protocol, however, calls for three visits and recommends that the misoprostol be taken under medical supervision; Texas requires four visits.) Some clinics in the United States and abroad are experimenting with cutting the number of office visits by making the follow-up visit optional — if the woman isn’t sure whether an abortion is complete, she can either take a home pregnancy test or return for an examination.