Women in remote and rural parts of Hawaiʻi have long struggled to access abortion care.
Graham Chelius made it his mission to expand access to abortion pills after seeing patients make costly and burdensome trips to Oʻahu to terminate unwanted pregnancies.
The Kauaʻi family doctor was the lead plaintiff in a lawsuit that helped prompt the U.S. Food and Drug Administration to change its policy requiring women to get the medication in person from a hospital or clinic.
For the last four years, women in Hawaiʻi have been able to instead get mifepristone through the mail or at some pharmacies. But providers are worried that Robert F. Kennedy Jr. could take that hard-fought access away.
The U.S. Secretary of Health and Human Services in May ordered a review of safety regulations for the pill, a step that abortion rights advocates say could lead to more restrictions, including once again requiring patients to pick up the medication in person from a doctor.
That could have harmful consequences in a state where so many have to drive miles from rural communities or board airplanes for their medical appointments, said state Rep. Della Au Belatti, former chair of the House Health Committee.
"Every one of those trips is costly for someone who lives on the neighbor islands," she said.
In small communities, it could leave women fearful of backlash to not seek abortion care at all, said Heidi Purcell, an OB-GYN at Kauaʻi Veterans Memorial Hospital, who for the past year has been the only doctor performing surgical abortions on the island but also sees people through telehealth appointments, where she can prescribe the pills.
"There's only 70,000 people here, so your uncle, or your brother or your cousin is the pharmacist," Purcell said, "and so if I prescribe the medication in a fairly religious and conservative community, it's hard for that to be kept quiet."
One of the main arguments in the 2017 lawsuit -- which is still ongoing -- is that the FDA's regulations of the medicine are illegal and medically unnecessary.
Mifepristone, which is usually taken in combination with a second medication, misoprostol, has a better safety record than other common medicines that are not subject to so many restrictions, such as Viagra, Tylenol and blood thinners, according to the lawsuit. One of the most burdensome restrictions was the requirement that the pill be dispensed at a hospital or clinic rather than the patient being able to fill a prescription at a local pharmacy or mail-order pharmacy.
Chelius, who at the time worked for Kauaʻi Veterans Memorial Hospital, said in the lawsuit that because some of his colleagues were opposed to abortion, he would have faced difficulty stocking and dispensing mifepristone on site. He had to refer all of his patients seeking abortions to Oʻahu for care, which caused serious challenges -- especially for patients who were poor, homeless, didn't speak English or were in abusive relationships and would have trouble leaving the island.
That changed first in 2020, when a federal judge ordered the FDA temporarily suspend its in-person requirement because it unnecessarily placed those seeking abortion at risk for Covid.
Then in 2021, prompted by the lawsuit filed by Chelius and other plaintiffs, the FDA started a review of its safety regulations around mifepristone. Two years later, it formally adopted the policy allowing the drug to be delivered by mail.
"The ability to do that has broadened access," said Purcell, who took over as the lead plaintiff in the lawsuit in 2024. "It's been really good that those advancements happened."
Roughly half of all abortions in the state in 2022 were medication abortions, according to the Centers for Disease Control and Prevention -- up from 39% in 2019.
But since President Donald Trump's election last year, abortion rights advocates have feared his administration would work to roll back access to the procedure and the pill.
Emily Hilliard, spokeswoman for the Department of Health and Human Services, said in an email to Civil Beat that Kennedy has asked FDA Commissioner Martin Makary to "review the latest data on mifepristone."
"Commissioner Makary will ensure gold standard science is used while incorporating practical, common-sense considerations to its regulatory processes," the email says.
But Julia Kaye, lead attorney with the American Civil Liberties Union Reproductive Freedom Project, said the pill has already been proven to be safe.
"The Trump administration is caving to pressure from anti-abortion lobbyists by directing the FDA to undertake a complete review of its mifepristone regulations, with the obvious goal of changing FDA policy to make it even harder for people across the country to get an abortion," she said.
Kaye is one of the attorneys representing the plaintiffs in the Purcell lawsuit, which is scheduled for a summary judgment hearing on Aug. 22.
The lawsuit no longer deals with the question of whether patients can receive mifepristone by mail but challenges the federal government on other restrictions it still imposes on the medication, such as the fact that patients must sign an agreement form that states, "I have decided to end my pregnancy," before they can be prescribed the pill.
This adds administrative hurdles to accessing the medication and also can be emotionally distressing for patients, particularly those who need the drug for management of a miscarriage rather than an elective abortion, Kaye said.
She also hopes that if the judge rules in their favor, it could influence the FDA's review.
"It is more urgent than ever that a court remind the FDA that it may not restrict access to safe and effective medications based on politics or junk science," she said.
Besides pushing for mifepristone access at the national level, Chelius also advocated for changes at the hospital where he worked on Kauaʻi, Kauaʻi Veterans Memorial Hospital.
The hospital, which previously did not provide elective surgical abortions, changed its policy in June 2024 to allow for the procedure up to 12 weeks of gestation. Abortions can be performed beyond that if the mother's health or life is at risk.
The hospital is the only provider of elective surgical abortions on the island, and only one doctor there performs them.
There are no clinics that offer surgical abortions on Lānaʻi or Molokaʻi.
On Maui, patients can access surgical abortions at the Planned Parenthood in Kahului, according to the Hawaiʻi Abortion Collective, which publishes a statewide guide on abortion services. On the Big Island the procedure is available at University Women's Health in Hilo and North Hawai'i Community Hospital in Kamuela. On Oʻahu, the procedure is offered at Queens Medical Center and Planned Parenthood in Honolulu.
Chelius said he's glad that patients have access to surgical abortions on Kauaʻi, but he said having only one doctor providing them is unsustainable.
If the doctor is sick or on vacation, it can present serious problems for patients because getting an abortion is so time-sensitive, he said.
It can also be hard for the doctor to deal with any backlash from the community, he said.
"It gets awfully lonely," he said, "if you're the only person doing a controversial procedure."