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What’s in a Pill?

An inside look at the shifting risks to safe abortion providers

The people in this story are all anonymous. They must remain so because they are doing illegal things with abortion pills—at least according to police, prosecutors, and government agencies. Their opinion is the one that matters now, two years after Roe v. Wade was struck down, triggering a cascade of state-level abortion bans and restrictions. As abortion pills cross state and federal borders, they also cross conceptual boundaries, shifting in status between legal and illegal. Any drug can acquire the label of a fake or falsified product, not because of problems in manufacturing but because of irregularities in packaging, distribution, regulatory authority, and mobility. Depending on its geography and the logistics of its journey, the same medicine can be considered licit or illicit, inexpensive or costly, even safe or dangerous. Several of the individuals introduced below have been prosecuted or threatened with legal action because of their relationships to abortion pills.

The Buyer is a woman living in the American South who bought abortion pills online twice. Or, she tried to, at least—once, she got them, and once, she got scammed.

The Seller is a woman living somewhere else in America who sold abortion pills online until she was prosecuted and her operation was shut down by federal authorities.

The CEO runs a pharmaceutical company that markets abortion pills. His company’s pills are stocked in clinics and pharmacies where abortion is legal and sold illicitly online where abortion is not.

The Activist is a woman living in the American West who works to spread information about how and where to buy abortion pills.

The Buyer

We begin with the Buyer. This story is about her and people like her. The first time the Buyer tried to get abortion pills, it was 2016. She was living in Texas, where abortion was legal but hard to access because restrictive laws had shuttered so many clinics. She found a blog with its own online store that promised to sell her abortion pills. It seemed too good to be true, but it worked. She placed an order for one package of abortion pills through the online store for $85. When she got to PayPal, she was confused to see her purchase described as a “gold necklace.” The envelope that arrived a week later did indeed contain a necklace—and hidden inside some bubble wrap, the blister pack of pills. She used them and ended her pregnancy.

Where abortion is legally available, abortion pills are often the most common method.

Two years later, the Buyer was living in Florida and needed an abortion. Abortion was legal enough, and there were plenty of clinics around, but they wanted $500 for the procedure. She simply couldn’t afford that. She already had two children, and her boyfriend had promised to help her pay for the abortion, until he went and changed his mind. The Buyer went back to the website where she bought pills the first time, but it had been closed when federal authorities prosecuted the woman behind it for illegally importing pills. In the comments section of a blog post there, people were posting in a panic. Could they still buy abortion pills elsewhere? Which were the most reliable websites? Could they get in trouble? The Buyer made her own post and found someone who offered to sell her pills. She paid her through Cash App and then . . . nothing. It was a scam. But what could she do? “I figured I was doing something illegal anyways,” she told me, “and I didn’t need to dig myself any deeper, I just left it alone.” She managed to pull together the money for the abortion at a local clinic. By that point, the procedure cost her $800.

Long before Roe v. Wade was overturned, people in the United States had abortions in secret, outside of clinical spaces. Since the 1980s, self-managed abortion outside of a medical setting has increasingly involved abortion pills. The “abortion pill” is the common name for two different medicines: mifepristone (also known as Mifeprex or RU-486) and misoprostol. These pills are usually used together, although misoprostol is used on its own where mifepristone is unavailable. In many countries, including Mexico, misoprostol is sold over the counter for the treatment of ulcers—but can often be obtained for its alternative purpose. Mifepristone, by contrast, is much harder to get in pharmacies and must be ordered online for someone managing an abortion without a doctor’s prescription. Where abortion is legally available, abortion pills are often the most common method: in 2020, 53 percent of abortions in the United States were done with medication (as opposed to a surgical procedure). Elsewhere, there are fewer obstacles to prescribing these pills, so they are used in the vast majority of abortions: 87 percent in the United Kingdom and as high as 98 percent in the Nordic countries.

With abortion, there lies an enormous gulf between what is legal and what is accessible. Roe v. Wade offered a constitutional guarantee that abortion would be legal, to some degree, in every American state, but not that it would be practical to access or afford. Both times she sought abortion pills online, the Buyer had been priced out of an in-clinic abortion. The other women she encountered seeking abortion pills from the blog reported the same: “At five weeks along, I would have thought going to the clinic would be more affordable for me. Instead, I got a quote for $730! And only up-front, no payment plans available.”

The cost of an in-clinic abortion is a substantial reason that people seek out abortion pills online, according to a 2021 study. That was before Dobbs, and costs have risen dramatically in the two years since. At the time of press, fourteen states have banned abortion altogether, three have bans blocked by courts, and seven have added other restrictions. Demand for abortion pills online has spiked—unsurprisingly the biggest increase in demand comes in places with the harshest antiabortion laws. In Texas, for example, requests for abortion pills increased over 1,000 percent in the week after SB8, a six-week abortion ban, was passed.

Abortion pills scramble the way that abortion is regulated. Historically, antiabortion laws have been enforced by regulating doctors: which doctors can do what, to whom, where, and under what conditions. Abortion pills, meanwhile, don’t require surgical expertise. Abortion pills make the abortion seeker the abortion provider. And as such, they circumvent the kinds of regulations most governments have relied on to restrict the procedure. What’s more, the availability of unregulated medication abortion online means that abortion seekers need not rely on medical gatekeepers to prescribe. Abortion pills are cheap, plentiful, and mobile.

The Seller

The Seller, who ran the online store where the Buyer first bought abortion pills, got into selling them almost by accident. Back in 2010, she had an abortion with pills in an abortion clinic. Two years later, when she needed an abortion again, she decided to manage it herself at home because she knew it would be less expensive and allow her more privacy. Online, she found pharmacy sites that sold abortion pills from India. (If you knew where to look, there were so many pharmacy sites selling pills.) She read reviews on Reddit to help her choose the best place to buy, and she figured out what doses to use by reading a medical journal abstract. When she wrote a blog post reflecting on her experience, the commenters came in fast. As she recalled to me, “People were just like, ‘Do you have extra?’ And I was like, ‘Wow! No, but try these sites . . .’”

A few years later, in debt and struggling to pay her bills, she started selling the pills herself. “Women were still asking me, ‘Do you have pills?’” so she started to plan: “I said, OK . . . misoprostol is cheap, so I’ll start with that. I’ll make a bulk order and put up a little PayPal page and see what happens.” It started out with small quantities at first, and then the Activist posted information about the Seller’s online store. Buyers came flooding in.

The Seller went back to the Indian pharmacy that sold her the abortion pills and negotiated to order in bulk. Eventually, she began buying up to one hundred mifepristone pills with each order. “I was ordering very regularly. I was doing a lot of business.” The pills came through customs labeled as “personal medical supplies.” The mifepristone she bought was not FDA-approved Mifeprex, but it was the chemical equivalent: a generic mifepristone product made for the Indian market. By the time federal authorities intercepted her packages and took her to court the Seller was filling orders for up to twenty customers per day. If she’d kept going, she says, it would have been closer to five thousand customers a year.

For two years, she had no trouble getting bulk orders of pills through customs and sent to her P.O. box, which she would repackage into individual shipments and send out to customers through the domestic mail. It is not illegal for Americans to import personal-use quantities of their prescription medications from outside the United States, so long as the medications are FDA-regulated products that come from FDA-approved manufacturers. Personal-use importation of medicines that are not FDA-regulated exists in more of a gray zone; drugs only approved abroad are not legal to import, but enforcement is decided on a case-by-case basis. The “personal use” exemption dates to 1989, when HIV/AIDS activists wanted to import medicines that were not FDA-approved: Americans may bring in small quantities of medicines, not for resale, as long as they don’t present a health risk. In practice, prohibitions on importing medications for personal use are rarely enforced, at least when shipments are “normally small, both in size and value,” and many people rely on foreign pharmacies to get cheaper prescription medications like insulin. And regardless of its legal position on prescription medications entering the country, the FDA lacks the enforcement capacity to stop them.

The FDA estimates that it can inspect less than 0.18 percent of the packages assumed to contain drugs that pass through international mail facilities. In 2017, when an estimated 275 million packages came into the country through the U.S. Postal Service, the FDA had only twenty-two import investigators responsible for covering its nine international mail facilities. Even as the use of the mail to import opioids has generated alarm in recent years, regulatory agencies are already overwhelmed by the number of incoming packages. Still, because they cross so many political and regulatory borders on their journey, it takes know-how to get abortion pill packages safely from sender to recipient. Creating pathways for abortion pills to move and informing people about how to get their pills (and avoid being caught in the process) is the work of a transnational network of abortion pill activists.


The CEO leads a nonprofit that markets contraceptive devices and abortion pills. His company doesn’t manufacture the abortion pills, but they market Indian-made products across the world. When the FDA issued a memo in 2019 naming his products as “violative drugs” that were illegally entering the U.S. drug supply chain, the CEO had to respond even though there was little he could do. “We let them know: we can’t control it,” he told me, “We can’t control who buys those products in India and puts them in a bag and ships them across the ocean.”

Legislation and judicial rulings on mifepristone have less impact on abortion access than we might assume.

Feminist networks had been buying the abortion pills marketed by his firm and sending them to abortion seekers in the United States. His difficulty was this: the products were legally manufactured in regulated pharmaceutical plants and sold to legitimate pharmaceutical distributors. It’s not a crime to export abortion pills from India because they are not banned substances. For the CEO, it’s further down the chain that things get murky: “We’re selling to a distributor in India or to a pharmacy in India, and someone’s walking in off the street and buying those products off the shelf in India and then doing what [they’re] doing.” This sounds like complex regulatory geography, but it presents a simple and familiar dilemma for people seeking treatments: you need a medicine, which is safely made, cheaply sold, and readily available, but not in your home country. Luckily, pills can usually move more easily than people.

India is known as the “pharmacy to the world” because its large pharmaceutical industry has specialized in the production of inexpensive generic medications. It’s now such an important source of medicines for American consumers that the FDA maintains an office in New Delhi specifically to monitor Indian products headed for the United States. Abortion—although deeply stigmatized—is not illegal in India, and abortion pills are not a controlled substance. Neither of the two FDA-approved mifepristone products are made or marketed by Indian firms, although the mifepristone made in India is chemically equivalent. Dozens of Indian pharmaceutical manufacturers make their own brands of mifepristone.

Abortion pills are by no means the only medication to cross borders illicitly. Nor are they the only medicine to have transnational activist groups organizing their movements. For decades, community-led organizations known as buyers clubs have worked to make medicines accessible for their members. Buyers clubs came to prominence in the 1980s, when activists in the HIV/AIDS movement organized to spread information and import experimental and untested medicines. When the FDA blocked access to experimental drugs and threatened to crack down on drug imports, the People With AIDS Health Group organized its own parallel systems. “In the absence of adequate health care,” their director explained in 1986, “we have learned to become our own clinicians, researchers, lobbyists, drug smugglers, pharmacists; we have our own libraries, newspapers, drug stores, and laboratories.” HIV/AIDS activists continue to organize buyers club information and distribution networks for pre-exposure prophylaxis drugs like Truvada. Other contemporary buyers clubs, like those for treatment of hepatitis C or cystic fibrosis, exist because drug prices vary so dramatically between countries. (A course of sofosbuvir for hepatitis C costs $84,000 in the United States and $539 in India.) Through networking, they’re able to source medications from one country and distribute in another, circumventing pharmaceutical pricing structures.

Unlike other drugs that are moved by buyers clubs, mifepristone and misoprostol are cheap, generic medications that are manufactured around the world. But the obstacles to getting mifepristone are political: although the World Health Organization lists mifepristone as an essential medicine, the U.S. regulations imposed on it are more akin to restrictions placed on narcotics. Meanwhile, deaths and injuries from unsafe abortion are concentrated in low-income countries where it is illegal or economically inaccessible. Yet, decades of research have shown medication abortion to be a safe abortion method, and to such a degree that additional studies suggest increasing the use of pills as an abortion method in low-income countries would drastically reduce deaths from unsafe abortion.

The Activist

The Activist never sent out pills herself. Living in the United States, where antiabortion violence is commonplace and abortion laws are draconian, the risks were too high. Instead, she pointed people to reliable suppliers online. Her site directed many people to the Seller’s online store, as well as the sites where the Seller bought her products. It also linked out to a variety of online pharmacies and international networks who shipped abortion pills. After years of campaigning on abortion and contraception, she was demoralized. Things in the United States always seemed to be moving in the wrong direction. “We started noticing everywhere we went,” she told me, “you could go to pharmacies in these places, like the highlands of Ethiopia, and you could get mifepristone and misoprostol or ‘the abortion kit’ as they called it.” Back in the United States, the Activist and her colleagues saw state after state rolling back abortion rights. Another activist puts it simply: “There’s absolute outrage! Our strategy is: let’s build on that outrage, let’s take advantage of that outrage. Let’s spread the knowledge, and people are going to take it into their own hands.”

Luckily, pills can usually move more easily than people.

The Activist works as part of a transnational movement for self-managed abortion. Philosophically, this movement is motivated by a feminist refusal to comply with unjust laws. Emma Campbell, an activist who spent years supplying pills in violation of Northern Ireland’s abortion ban, explains: “The law is an ass, so we’ll do whatever we can around, above, and beyond it.” Feminists know it’s dangerous to invest too much in the power of law. Even the most liberal abortion laws result in rules that exclude some abortion seekers because criminal laws governing abortion are incompatible with the medical complexities of the issue. Abortion laws that permit exceptions to protect life and health are instructive examples; interpreting and implementing such exceptions are practically impossible for doctors, creating chilling effects that keep people from obtaining abortions that are nominally legal. Activists and thinkers from the influential reproductive justice movement add a further reason to be skeptical of law’s power: what’s legal is not necessarily accessible. A law that allows the right to “choose” is meaningless without the allocation of resources to realize it. The right to choose abortion, for instance, is purely theoretical if it requires several hundred dollars and a journey of several hundred miles. Activists in this movement see tinkering with the law as insufficient at best and, in the words of sociologists Zakiya Luna and Kristin Luker, a “dangerous preoccupation” at worst.

Activists in the movement for self-managed abortion are committed to creating immediate practical abortion access on the ground. Even where it’s against the law, they believe that making abortion available will challenge stigma, change public attitudes, demonstrate to governments that antiabortion laws are unenforceable, and, eventually, lead to progressive reforms. This strategy is rooted in the idea of “social decriminalization,” which originated in the Latin American feminist movement, and works on parallel tracks: the methodology provides clandestine abortions, regardless of abortion’s legal status, while simultaneously mobilizing public opinion against restrictive abortion laws, especially where abortion seekers are prosecuted and jailed. Long before the Green Wave of activism that catalyzed abortion reforms across Latin America, feminists there operated information networks that educated abortion seekers on which pills to buy, where to get them, and how to use them safely.

Broadly speaking, people in the United States who need abortion pills—quietly, outside of formal medical spaces—have two options. First, they can go to feminist activist and community groups who get abortion pills to buyers, usually sourcing them from abroad and delivering by mail or by hand. Perhaps the best-known activist group who does this work is Aid Access, the American-focused sister organization of safe abortion nonprofit Women on Web. Before the Dobbs decision was leaked in May 2022, about eighty people per day contacted Aid Access to request pills; after June 2022, when the Dobbs decision was formally announced, 213 requested pills on a daily basis. Before 2023, Aid Access operated abroad and shipped pills from Indian distributors into the United States; in the last year, the group has used shield laws to allow American doctors in abortion-protective states to mail pills into states with abortion bans. The second option for those looking to buy abortion pills is to go online for a range of foreign pharmacy websites or vendors like the Seller—intermediaries between the pharmacies and people like the Buyer. Those foreign pharmacy websites, often based in India, sell generic medicines that fall between regulatory cracks. For the U.S. government, they present a threat to the integrity of national borders. For abortion seekers, they present a lifeline.

Postlude: The Courts

Because abortion policymaking is so often a fact-free zone, the safety of abortion pills is still an active question in the United States. It’s a question that the U.S. Supreme Court heard arguments on in March and will rule on later this year: whether the FDA was right to loosen restrictions on mifepristone in 2016 and again in 2021, when it made abortion pills easier to use outside of clinical settings. If the Supreme Court decides to roll back mifepristone’s approval, all abortion providers, even those in blue states, will be barred from prescribing abortion pills without an in-person consultation. It looks as though the Court will maintain mifepristone’s current regulations, for now at least.

Would a Supreme Court ruling that restricts mifepristone matter, really? Not as much as antiabortion activists hope, and not as much as pro-choice commentators fear. Legislation and judicial rulings on mifepristone have less impact on abortion access than we might assume because abortion pills are so widely available and moved through international borders across the world, by activists and foreign vendors.

The Activist will continue to collect and spread information about where to buy abortion pills, how to ship and how to use them, and what to say to your doctor so they don’t turn you into the police. The CEO’s firm will continue to manufacture and distribute them. The Seller, or sellers like her, will continue to import and distribute abortion pills through the mail. And the Buyer, with millions of others, will look for a safe way to get an abortion even when her state legislators tell her it’s a crime. Antiabortion laws do not stop abortion. As Irish politicians became fond of saying when they finally realized how futile abortion pills had made their abortion ban: “The genie is out of the bottle.”