Big global challenge: Men don't like condoms

Employees inspect condoms on a production line in South Korea.
SeongJoon Cho | Bloomberg | Getty Images
Employees inspect condoms on a production line in South Korea.

Global scarcity is intrinsically linked to population growth. Apocalyptic talk of looming food shortages, limited fresh water, and wars over diminishing natural resources can't be divorced from the fact that in many developing countries, populations are booming.

When discussion turns to the role of population growth in scarcity-linked global challenges, though, one shortage that underlies it all is lack of access to contraception for more than 200 million women in sub-Saharan Africa and south Asia (primarily India). And it's not talked about enough outside the circles of nongovernmental organizations and government ministers of health.

"There are more than two hundred million women in the world today would like to avoid getting pregnant and yet aren't able to use modern methods of contraception," said Judy Manning, an expert on reproductive health at the U.S. Agency for International Development (USAID).

"This is a top-five global issue, and it's still an afterthought," said Saundra Pelletier, CEO of WomanCare Global, an international non-profit healthcare company, structured using a hybrid business model that draws from strategies of the commercial and non-profit sectors.

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The 2012 London Summit on Family Planning, co-hosted by the Bill & Melinda Gates Foundation, received a $2.6 billion commitment to serve at least 120 million women worldwide and address the issue of 80 million unintended pregnancies a year, 30 million unplanned births and 40 million abortions..

But a global family planning policy guided by donations alone won't get the job done.

"NGOs having been doing great work, but it needs to be escalated to a higher level. When we are talking about scarcity, if we don't include this, we are just putting a Band-Aid on the problem," said Pelletier, who was formerly an international franchise leader for Searle Pharmaceutical. The company was ultimately by Pharmacia, which eventually merged with Pfizer.

As with many other medications, the lack of contraception in the developing world has long been neglected by major drugmakers for a variety of reasons. The bottom-line assessment is that there is no profit motive in such an effort. Developing countries also have particular challenges—from corruption to a dearth of infrastructure—that make marking and distribution problematic.

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"These markets are fragmented, and you have to be ready to figure out the layers, and levels of corruption," Pelletier said. That's where WomanCare Global is ahead of the global pharmaceutical companies.

The nonprofit markets a range of contraceptive products. Its current business model redirects revenue from sales of its products in developed countries to developing markets.

WomanCare Global serves as a middle agent in underserved global regions, creating supply chains in places where the role of the government and private health-care players is still evolving. Its aim is to move beyond the model of redirecting revenue and develop a distribution network in developing nations that attracts the interest of pharmaceutical players.

"Now we have to go into the profitable markets, but we will be able to create market demand and sustainable markets, and fund ourselves in each country, and eventually, just focus on the developing world," Pelletier said. "We will never become a huge global marketing organization or NGO ... but we will be sustainable five years from now," she said, adding that creating the global supply chain makes the difference.

The reproductive health sector has been slow to adopt new technologies in response to the needs of women and girls. Experts cited the fact that the women worldwide have a major compliance issue with oral contraceptives and do not like the side effects of hormonal approaches.

Some long-term methods of birth control, including certain intrauterine devices (IUDs), are hormone-based, require clinical training that's not always available, or are too sustained by design for some women.

In terms of getting male partners to use condoms, Pelletier said that for many of the world's women, "you never can negotiate with a partner."

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In fact, reproductive health is one area in which innovation is being spurred by the needs of the developing world rather than those of richer populations. While big pharma has stepped back, NGOs, groups such as WomanCare Global and niche manufacturers such as Qpharma in Sweden have stepped up.

"Studies show that if you provide women with a method that their friend or family member is using or when you enable choice, women are far more likely to use contraception," Manning said. "Just meeting the needs of those women and girls reaching reproductive age would have a huge impact on slowing population growth, and it can be a completely voluntary approach.

"When a woman has ability to have two kids instead of 10, she can invest in the health care and education of the children," she added.

Hormonal therapy is not being abandoned, but USAID and WomanCare Global are trying to bring it into the 21st century, with a range of vaginal rings that last from three months to five years. USAID and the Population Council have a one-year ring on track to begin the FDA approval process in 2014, a process that could take up to two years.

The one-year time horizon for the ring was chosen because a concept known as "healthy timing" shows that if women wait 18 months to two years between pregnancies, they and the child will be healthier. Currently, the conventional ring lasts from one month to three months.

While successful, IUDs require clinical training and followup, and access to clinics is a typical stumbling block in the developing world. "IUDs are terrific for women who are ready to limit their family but aren't ready to make a permanent decision, but do require advanced training for a clinician," Manning said.

USAID has invested in an early-stage project to create a biodegradable contraceptive implant that can last from one to three years and degrade under the skin so a woman would not have to go back to a clinic to have it removed.

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Even more cutting-edge, the Gates Foundation and National Institutes of Health have invested in a vaccine that could make women "immune" to sperm, either for a defined period or permanently. Such efforts are in early R&D, and the time horizon to market could be two decades, according to Manning.

Pelletier is also co-CEO of a privately held biotech company in partnership with WomanCare Global, Evofem, which is working on a hormone-free contraceptive gel.

"In the next 10 years, we will see a lot more excitement and financial support," she said. "The gel concept isn't new and sexy, but being hormone-free makes it exciting. You don't have to worry about side effects.

"There are so many new ways to talk to girls and women," Pelletier said.

And most of those conversations are probably easier for women than talking to their partners about using condoms.

By Eric Rosenbaum,