Repackaging the Pill

Roman Mars:
This is 99% invisible. I’m Roman Mars.

Roman Mars:
In 1960 a new wonder drug hit the US market and while a lot of new drugs promised dramatic results, this one would actually transform millions of lives and radically shift American culture. It was called Enovid. It was the first oral contraceptive.

Archive Tape:
“Drugs for many seem the answer to all the problems when a government agency approves the first birth control pill in 1960, it helps set in motion forces that will soon change the social mores of the world.”

Lila Cherneff:
In just two years 1.2 million American women were taking the birth control pill.

Roman Mars:
That’s reporter Lila Cherneff.

Lila Cherneff:
Within five years the pill would become the most popular form of birth control and the country. It let women choose if and when they wanted to have children. It gave them more freedom to pursue careers and it helped usher in the free love era of the late. It was a big deal.

Roman Mars:
And even if you’ve never taken the pill, you can probably picture its packaging. There’s the round plastic package that opens like a shell and looks kind of like a makeup compact. There’s also the more low-key rectangular pill sheets with each pill or arranged in four neat rows for every day of the month. It’s hard to think of other prescription drug packages that are as widely recognizable as those of the birth control pill

Lila Cherneff:
But the pill didn’t always have special packaging. The first birth control pill to hit the market came in a simple glass bottle of loose tablets, like any other prescription drug.

Archive Tape:
‘They come in big bottles for a year’s supply, smaller bottles for a month supply…’

Roman Mars:
As the pill went from nondescript bottles to the iconic pill packages, it came to represent larger trends in American Medicine. Women were beginning to take more control over their own bodies and their demands for a new standard of patient autonomy would go on to affect prescription packaging of all kinds. It all started with a family in Illinois.
In 1961 David and Doris Wagner were a middle-aged couple with four kids. They didn’t want any more of them, and so they were thrilled to learn about the pill. Doris got a prescription.

Lila Cherneff:
The pills came in a big bottle. The instructions said to begin the pill on the fifth day of her period and to take one pill every day for 20 days followed by a five-day break for menstruation.

Roman Mars:
If Doris lost track of her cycle or if she forgot whether or not she had taken her pill that day, she was instructed to pour all the pills out of the bottle count, count how many pills were left, subtract that from the original number of pills and consult Carolyn Eiserta calendar. Not a super user-friendly design and if she missed a pill, she risks getting pregnant again.

Carolyn Eisert:
So David Wagner noticed that his wife Doris was often sort of concerned about taking her pills and he was also concerned about whether or not she was taking her pills.

Lila Cherneff:
The Wagners have since passed away, but this is Carolyn Eisert, a women’s health expert who’s researched the Wagners and their role in the history of birth control packaging.

Carolyn Eisert:
So he thought, “hmm, why don’t I do something about this.”

Roman Mars:
David Wagner was an engineer for a tool company in Illinois, and he was used to solving mechanical problems. He figured he could create a packaging system that would make the pill-taking process easier for his wife. First, he tried something really simple.

Carolyn Eisert:
He took a piece of paper and he wrote out the days of the week and put the pills on the piece of paper along with the days of the week to sort of make it into a bit of a calendar.

Lila Cherneff:
And that worked pretty well, at least for a few weeks.

Carolyn Eisert:
Then, I guess the story goes, something fell on the dresser and the pills got scattered and fell on the floor and that was that. That made him think, ‘maybe I can make a package that, say, you could throw in your purse, throw in your bag, take with you and it would keep everything in order.

Diane Wendt:
So what he came up with is today, very familiar to anyone who’s probably used the birth control pill.

Lila Cherneff:
Diane Wendt is a curator of the extensive birth control archive at the Smithsonian Museum of American History.

Diane Wendt:
And we actually have some of the prototypes over here.

Roman Mars:
Wagner’s original prototype was made out of two discs of clear plastic and a snap fastener that he borrowed from a child’s toy. The bottom disc held 20 pills, the top disc had one hole drilled through it which could be rotated each day to expose the correct pill along with the corresponding day of the week.

Lila Cherneff:
Having this system that made pill-taking more intuitive helped Doris and David feel a lot more comfortable.

Diane Wendt:
This is David Wagner writing in, let’s say, January 16th 1995.

Lila Cherneff:
This is a letter Wagner sent the Smithsonian Museum for their birth control archive.

Diane Wendt:
Both Doris and I could tell at a glance whether a pill had been taken on a given day. This did wonders for our relationship.

Lila Cherneff:
Wagner successfully received a patent for his design, but he had trouble convincing pharmaceutical companies to get on board.

Diane Wendt:
He actually took it around to some of the big companies and most of them said sort of things like ‘well, we don’t need that kind of gimmicky and everything’.

Roman Mars:
At the time drug companies were known for the boring sameness of their prescription packaging. Wagner was told that a special package just for birth control sounded kind of commercial and flashy. His design was turned down by every company he approached, but then just a few months later, one of the companies he’d met with called Ortho Pharmaceuticals released their first birth control pill.

Lila Cherneff:
And these pills came in a circular plastic container with a dial then moved each day to reveal the next pill it was called the ‘dialpack’. To David Wagner, the dial pack looked very familiar.

Roman Mars:
Maybe a little too familiar. Wagner threatened a lawsuit and in December of 1964, he signed an agreement with Ortho Pharmaceuticals for $10,000 and a promise not to sue. Another company called Searle soon began paying Wagner royalties for the rights to produce a similar pill container and pretty soon all birth control manufacturers were coming out with a version of this circular design.

Lila Cherneff:
Here’s Diane Wendt again reading from the letter Wagner wrote to the Smithsonian.

Diane Wendt:
He said some people have wondered how I made out financially I spent about $30 on the six models I made in my basement and the rest of my costs were legal fees over the life of the patent. He says he netted about $100,000 in royalties.

Roman Mars:
Eventually David Wagner got tired of chasing royalty obligations from pharmaceutical companies and he sold the patent rights to Ortho Pharmaceuticals. He returned to his quiet life in Illinois, but his design became a national sensation.

Lila Cherneff:
As pharmaceutical companies began marketing these new birth control pills, they faced a couple of obstacles. Obstacles that the packaging design would help overcome.

Roman Mars:
First of all, the pill marked a big turning point in the pharmaceutical industry. Before birth control, only sick people took pharmaceutical drugs. The birth control pill was one of the first prescriptions intended to be taken by healthy Americans.

Lila Cherneff:
And so pharmaceutical companies design the packaging to look not like medicine but instead like an ordinary everyday object. They began packaging the pills in circular plastic cases that looked a lot like makeup compacts. They were decorated with bright colors and graphics.

Diane Wendt:
I would say flowers and butterflies are probably the most common on them. I always kind of wonder about that. Why they didn’t get a little more edgy, at least at times.

Lila Cherneff:
Pharmaceutical companies also experimented with packaging gimmicks to make daily pill-taking seem normal and unremarkable. One pill company went so far as to bundle a toothbrush and a bar of soap with each prescription.

Diane Wendt:
You know, brush your teeth, wash your face, take your pill. It’s kind of, you know, another part of a daily routine.

Roman Mars:
The other challenge that pharmaceutical companies faced as they rolled out this groundbreaking new medication was the conservative outlook of some doctors. In the 1960s, doctors were overwhelmingly male and some were wary about the revolutionary impact the birth control pill would have on sex and gender roles.

Archive Tape:
“The subject for this afternoon’s continuing discussion of the pill is the power to prescribe.”

Lila Cherneff:
In 1967, a group of doctors gathered in San Francisco at a symposium called ‘The Pill and the Puritan Ethic’ where they explored the moral implications of the birth control pill. Here’s Dr. Donald Minkler, a leader in Women’s Health and Family Planning, describing the challenges the pill presented for physicians who might be uncomfortable with changing attitudes towards premarital sex.

Dr. Donald Minkler:
“How can he maintain his emotional neutrality? In the face of rapidly changing values among his younger patients whose code of conduct often will differ markedly from his own. The ethical dilemmas posed by the demand and the obvious need for contraceptive advice among the young and unmarried has generated a good deal of anxiety and discomfort in the minds of physicians.”

Roman Mars:
Not only were physicians grappling with stuff that was actually not their business, they also thought that some of their young female patients might not even be responsible enough to manage their daily pill-taking regimen. Here’s another doctor at the symposium, Dr. Albert Long.

Dr. Albert Long:
“The girl who can’t remember to take a pill every morning is in trouble and this is one of the problems with the pill. We have to have a patient who will understand how it is used use it correctly.”

Roman Mars:
Pharmaceutical companies needed to market the pill to skeptical doctors who might not be totally comfortable with the idea of women taking control of their reproductive health. And once again, they use the pill’s packaging to help them do that. Pharmaceutical companies produce dozens of ads that targeted physicians. They marketed the new pill packages as a way to help female patients take the pills correctly.

Lila Cherneff:
They advertise the device as ‘the package that remembers for her’ or ‘the foolproof method’. Each company insisted their pill package design would help the female patients stay on schedule.

Roman Mars:
Which was true. The packaging did help women stay on schedule but the marketing of these so-called ‘compliance packages’ played into some doctor’s struggles for control at a time when their cultural authority was weakening. Here’s medical historian, Dominique Tobbell.

Dominique Tobbell:
Prior to the introduction of oral contraceptives, the image of the physician-patient relationship is really one in which patients, whether male or female, would really kind of just do what the physician said. It was like this period of medical paternalism that ‘physician knows best’. With the introduction of the pill, the idea that a woman would go to the doctor’s office and demand a particular prescription, that was something that was quite new.

Roman Mars:
As the 60s progressed, more and more women began taking the pill and a series of Supreme Court cases also helped establish that women, both unmarried and married, had a legal right to contraceptive medications. The invention of the pill and the subsequent legal victories were hailed as feminist milestones, but there was a darker side to the pill too. And this darker side would lead to one more major revolution in pharmaceutical packaging.

Lila Cherneff:
The pill of the 1960s is not the same people we have today. The old pill had about seven times more estrogen. And this high dose of estrogen causes some negative side effects like dizziness and nausea, as well as more serious problems like blood clots high risk of cancer.

Roman Mars:
Some of these problems have been apparent in early birth control trials but the trials have been conducted in the 1950s in Puerto Rico where the pill was primarily tested on low-income women, many of them were not even aware they were participating in a medical trial. Researchers mostly ignored their complaints.

Lila Cherneff:
As the pill moved into the mainstream, most women did not hear about these health risks from their doctors and it was hard to fathom that the pill that came in pink plastic compacts – the pill that millions of women carried around in their purses – that those pills could be dangerous.

Roman Mars:
Then in 1969, a book was published.

Dominique Tobbell:
Barbara Seaman who was a journalist at the time wrote ‘The Doctor’s Case Against the Pill’ which documented what she and others believe was really kind of egregious treatment by drug companies and physicians and the FDA, the failure to kind of acknowledge these serious risks around the pill.

Lila Cherneff:
As women learned about these risks, they got angry. Most didn’t want the pill to be taken off the market, but they did want more transparency about the side effects.

Roman Mars:
In 1970, Barbara Seaman’s book inspired Congress to hold hearings to investigate the safety of the birth control pill, but no women were invited to testify at these hearings.

Dominique Tobbell:
It was a panel of men – white men – and this, not surprisingly, was really alarming to Seaman and other feminists at that time. And so they protested that those hearings and demanded that their voice be heard about the pill.

Lila Cherneff:
Each morning of the hearings, a group of women from the activist group ‘DC Women’s Liberation’ convened at the Capitol with prepared questions and bail money tucked into their socks. The woman strategically placed themselves in the middle of audience rows and repeatedly interrupted the hearings demanding more transparency.
“Why have you assured the drug companies that they could testify. Why have you told them they will get top priority. They are not taking the pills, we are.”

Dominique Tobbell:
It was a really remarkable show of activism and kind of showcasing the paternalism of medicine at that time.

Feminist Activist:
“We are not going to sit quietly any longer. You are murdering us, for your profit and convenience.”

Congress Member:
“I’m not going to permit the proceedings to be interrupted in this way. If you ladies would sit down-”

Feminist Activist:
“Our lives have been interrupted by taking this pill.”

Roman Mars:
These hearings reveal that some doctors had long been aware of the negative side effects of the pill and many had failed to adequately alert their female patients.

Lila Cherneff:
The situation left many women feeling torn. They were grateful for the freedom and autonomy the pill gave them but they also felt betrayed by the doctors and pharmaceutical companies that had failed to warn them about the possible risks. At this point, the pill had been on the market for nearly a decade.

Feminist Activist:
“We will no longer tolerate intimidation by white-coated God’s antiseptically directing our lives.”

Dominique Tobbell:
I mean this really had a different kind of transformative impact on the physician-patient relationship because the health risks around the birth control pill. These really raised the issue of does the physician knows best. Do they know best and do they act in the best interests of patients.

Lila Cherneff:
Over the years the hormonal dosage of the pill was gradually lowered and it became much safer for women. Although there are still some negative side effects.

Dominique Tobbell:
The longer-term legacy is that now we have a healthcare environment in which patients and pharmaceutical consumers are really much more willing to kind of raise questions and raise concerns.

Roman Mars:
The scandal also led to one more enduring innovation in pill packaging. Feminist health activists successfully changed FDA policy to require a typed warning of side effects to be included in every birth control package. This laid the groundwork for the side effects warnings that come in all prescription packages today. So today when you pick up a prescription – any prescription – that little typed sheet you get that lists every side effect from the mild to the terrifying, you have birth control to thank for that. Of course, these inserts present their own design challenges. If you’ve ever tried to read one, you’re familiar with the tiny font, the medical jargon and the completely overwhelming amount of information.

Birth Control Warning Ad:
“Common birth control side effects include Intermenstrual spotting, nausea, breast tenderness, headaches, weight gain, mood changes, mysterious hirsutism, decreased libido…”

Roman Mars:
Let’s hope there’s a good designer out there to make sense of all that information for us.