The Birth of the Pill: How Four Crusaders Reinvented Sex and Launched a Revolution (23 page)

Gamble was born in 1894 in Cincinnati. His father, David Berry Gamble, was one of the last in the family to play a key role in the family company, Procter & Gamble. Clarence Gamble was a Harvard Medical School graduate who became a professor of pharmacology and decided to devote his great wealth to the cause of birth control. Though they often worked together, Gamble and Sanger did not always agree. While Sanger wanted to build the birth-control movement around doctors, believing it would add legitimacy to the cause, Gamble understood that most women did not have private physicians and would never visit a birth-control clinic. He wanted every child born to be a child desired by responsible and qualified parents, and he believed that the only way to make that happen was to find a cheap, simple contraceptive that could be distributed without doctors and nurses getting involved. Gamble wanted to re-engineer the world, making it safe for his kind of people—white, prosperous, and hard working—by reducing the fertility of those he deemed less desirable.

In Puerto Rico, thanks to the work of Gamble and others, women who delivered their babies in hospitals often requested sterilization before being discharged. One American doctor working on the island said she was “horrified” at how common the sterilizations were in the 1950s. “It was a habit,” the doctor said. “I mean, it was a thing that they did . . . and the women were
determined not to have more children
.” The more the Catholic Church complained about the sterilizations, the more Puerto Rican women tended to request the procedure. The Church was only helping to spread the news of the procedure’s availability. To Pincus, that meant Puerto Ricans might reject or ignore the Church’s instructions and embrace a birth-control pill—assuming, of course, that it worked. In the end, both Rock and McCormick agreed to try it Pincus’s way.

They were about to launch one of the boldest and most controversial field trials in the history of modern drugs.

SEVENTEEN

A San Juan Weekend

A
S PINCUS BEGAN
planning Puerto Rican trials for the birth-control pill in 1954, another scientist, Jonas Salk, was launching the first trials of his polio vaccine. At first glance, the men had little in common.

Pincus was working somewhat clandestinely on a project that was almost certain to stir controversy and provoke fear, a project that he could not have dared undertake on American soil. Salk was a national hero out to vanquish a common enemy. The nation was riveted by his quest. Polio was killing and crippling American children at a rate of 50 per 100,000. It was a disease that hit without warning and seemingly at random, leaving its survivors in wheelchairs and leg braces. Even when polio cases peaked in the 1940s and 1950s,
ten times as many children
were killed in car accidents. But conquering the virus became a national priority of the highest order. More than two-thirds of all Americans donated money to the March of Dimes, a charity formed to fight the disease. In 1954, more Americans knew about Salk’s clinical trials than knew the full name of the president of the United States, Dwight David Eisenhower. There had never been a medical experiment like it.

Salk would spend tens of millions of dollars on his vaccine trial, while Pincus would operate with a first-year budget of less than twenty thousand dollars. Salk would go on to test his drug on
six hundred thousand children
during field trials, while Pincus was hopeful that he would round up three hundred subjects.

But Salk and Pincus were not as different as they might have seemed. Both men were willing to overlook potential risks for the sake of speed. Both men were willing to step outside the cloistered world of academic research and engage with advocacy groups that sought to guide and hurry along their work. Finally, both men were unconcerned with profiting from their inventions. In 1954, as Pincus negotiated with Planned Parenthood for support and funding and arranged with Searle and Syntex for supplies of the necessary progesterone compounds, he too focused on the scientific work ahead, not on the money. As he said to the leaders of Planned Parenthood and to members of his own Foundation’s board, he was operating on the assumption that the drug companies producing the compounds would hold patent rights if his experiments did, in fact, produce a birth-control pill.

Not since the 1930s, when he had been dabbling with
in vitro
fertilization, had Pincus been so close to a discovery that had the potential to change human lives. And while the public clamor for birth control hardly equaled the clamor for a polio vaccine, the growing concern about population growth lent legitimacy to the work of those studying human reproduction.

“
The earth’s population will double
to 5,000,000,000 in the next 70 years if the present birth-death rate continues,” warned a United Press story in what would turn out to be a conservative estimate. While birth-control campaigns and legalized abortions were reducing the rate of population increase in some of the world’s more affluent nations, Asian and Latin American countries were still growing more rapidly than ever. At the same time, penicillin and other medical innovations were helping people live longer.

In 1954, the first United Nations Population Conference was held in Rome, with representatives from almost every country attending, prompting still more headlines in the American press. In the United States, where land was abundant and the economy strong, few people worried about overcrowding. But there was a great deal of concern in Puerto Rico, and that concern was becoming a topic of conversation in the United States, especially in New York City, where Puerto Rican immigrants were arriving in extraordinary numbers. Puerto Rico’s population doubled between 1900 and 1950, making it
one of the most densely populated countries
in the world. The island was twelve times
more densely packed than the United States
, and the crowding would have been even greater if so many Puerto Ricans were not fleeing to American cities such as Chicago, Philadelphia, and especially New York. In 1950, New York City was home to 246,000 Puerto Ricans. Three years later, the number was 376,000 and still rising. By 1953, nearly
one in every ten residents
of Manhattan was Puerto Rican. The arrival of so many Puerto Ricans in the United States helped bring attention to problems on the island, where 2,245,000 people lived in an area
one hundred miles long
and thirty-four miles wide. As Puerto Ricans left home for better jobs and better lives, the crowding became more than a Puerto Rican problem; it became an American problem, and perhaps a sign of things to come.

In Puerto Rico and many other developing countries, birth rates were holding steady but death rates were declining. Malaria was being wiped out. Water supplies were improving, which meant fewer deaths from intestinal diseases. And new drugs were stopping the spread of tuberculosis. But better health did not translate into a better economy. Despite a massive American push that opened hundreds of new factories on the island after the war, one in six Puerto Ricans remained unemployed, and the industrialization pushed more people to the island’s cities,
only heightening the sense of crowding
. The issue was so pressing that 8.5 percent of married Puerto Rican women under the age of fifty had volunteered for sterilization. There were no reports on how many men underwent vasectomies, although the number was certainly much smaller. Courts sometimes ordered the sterilization of men who were deemed insane or criminally dangerous, but few men volunteered for the procedure in order to prevent pregnancy. Responsibility to control reproduction fell to the women, and women were taking action as best they could. In a 1952 study, 80 percent of women said the ideal number of children for a woman was
less than four
.

“There is no advantage in having more children,” one Puerto Rican woman said.

If one is poor one shouldn’t have more than two. The rich can have more because they have the money to educate them and are not sacrificed or even killed working as the poor do. . . . The rich care better for the sons, but it is great work for the poor to rear them, and the wife of the poor gets sick with many children because she can’t feed herself well nor have the medicines if she needs them.
So, two is enough
.

A social revolution was
underway in Puerto Rico
. Poor women were doing everything they could to have fewer children, believing that there would be no escape from poverty otherwise. Investment on the island after the war had made more jobs available (mostly to men), but factory jobs still didn’t pay enough to support families of ten. In 1951 and 1952, as Pincus was beginning his progesterone research in Worcester, a young sociology student at Columbia University, J. Mayone Stycos, went to Puerto Rico to interview women for his doctoral dissertation. At one point he asked some of the women if they were quick to have children after marriage because they were afraid of being branded
machorras
, or barren women, in Stycos’s translation. Their response surprised him. Most of the women said they didn’t care, and five out of fifty-six said they would be happy to be infertile.

“In older times,” one woman said, “women were ashamed not to have children. . . . Women of today even expose themselves to death trying to avoid children.”

Some of the men in Puerto Rico told Stycos that they were sleeping with other women to avoid getting their wives pregnant after their families had reached what they considered desirable sizes. “One has to look for other women,” one man said, laughing. “That is the most suitable method, and the handiest.” He went on to say his wife was jealous but that when he explained his logic, “she made up her mind and agreed with me.”

But not all women were so compliant. One told Stycos about her own method of birth control. “You know what I do?” she asked. “I hit him with my legs and throw him out of the bed. We have quarreled about it for nine years and he even threatened to kill me.”

Some women said the fear of pregnancy had crushed their desire for sex.
“How could I enjoy it, thinking of what would become of me if I have another child?”
one woman asked. In a few cases,
women said they intentionally married men
who were rumored to be sterile because they preferred not to have children. One or two children might have been acceptable, perhaps even three or four, but the women felt as if they had no choice. Once they married and began having sex, they feared they would wind up with more children than they could handle, despite the fact that Puerto Rican women had greater access to birth control than most American women.

A court decision in 1937 had legalized the distribution of birth control for medical purposes, and in response about 160 clinics had opened across the island by the 1950s. The devices handed out didn’t work well, often because the women used them only intermittently. Between 1945 and 1950, condom distribution increased by 50 percent, and Stycos found that 72 percent of families practiced
birth control at some point
. Four percent of the women he interviewed admitted having one or more abortions, but Stycos suspected that the abortion rate was actually much higher because women were reluctant to discuss the subject. Though abortion was illegal, it became so commonplace in the 1950s that Puerto Rico developed an international reputation as a place where the procedure could be obtained, no questions asked. For Americans, it was a quick enough flight yet far enough away to offer anonymity. They called it a “San Juan Weekend,” with an appointment at the abortion clinic on Friday and
a return flight home on Monday
. The whole thing, including airfare and hotel,
would cost about six hundred dollars
.

Despite the high rates of abortion and the widespread acceptance of birth-control devices, Puerto Rican birth rates declined only slightly in the first half of the twentieth century. Women in rural areas had an average of 6.8 children and women in urban areas had an average of 4.8. Stycos believed that concern over pregnancy wasn’t translating to action for many women, or at least not consistent action. Some men and women said they were reluctant to use birth control because the Catholic Church rejected it, but most offered more practical excuses. Men and women both complained that condoms were not always handy when needed. Many men refused to use condoms because they didn’t like the way they felt, and some women rejected them because they had heard rumors that they might cause cancer or hemorrhages. Men said they were unconcerned about birth control because it was the wife’s responsibility to raise the children no matter how many were born. One man told Stycos that when he felt his wife had too many children, “I will have her sterilized.”

Why did birth control efforts in Puerto Rico fail? Stycos cited male dominance in Puerto Rican society, poor communication between spouses, modesty among women, and misinformation about how birth control worked. He complained of a shortage of personnel at health clinics, apathy among doctors, and the failure of government to educate women about their options even in a country with one of the most ambitious and widespread birth-control programs in the world. Rapid population growth in Puerto Rico, he said, “
imperils the whole society
,” and nothing short of widespread social change would save it.