The Written Line

I

In April 1956, in a social housing district of Río Piedras, two hundred and twenty-one women began taking a daily pill that did not yet have a trade name.

The trial was done there because in the United States there were legal restrictions on researching contraceptives [in several states, starting with Massachusetts] and on the island there were none. It was run on the ground by a doctor called Edris Rice-Wray, with a Puerto Rican social worker —Iris Rodríguez— doing the door-to-door work that sustains any field trial.

The pill worked. Complete protection, without a single pregnancy among those who took it as directed.

It also produced dizziness, nausea, headaches, vomiting and abdominal pain [the same five things still in the leaflet today]. Around seventeen per cent of those women reported adverse reactions and twenty-five dropped out for that reason.

Rice-Wray wrote it and signed it: she was there, counting who stopped coming. She reported that the compound gave practically total protection and that it produced too many reactions to be acceptable in general use.

The answer was to attribute those complaints to psychological causes and carry on.

Three women died during the trials. No autopsy was done on any of them.

II

Here we have to go slowly, because the difference from other files is fine and it is the whole piece.

In an ordinary pharmacological trial, what fails is that nobody asks. The form has the boxes it has, what is not in the box is not noted, and what is not noted does not exist in the report. That is a defect of instrument; it is corrected by adding a line.

At Río Piedras the line existed. Somebody wrote on it. It was signed by a doctor who was standing there, counting women who dropped out.

It was decided to take no notice.

An archive that does not record and an archive that records and discards are not the same thing. The second requires a reading, a meeting and a decision [three people at minimum, and minutes].

III

The 1956 pill carried ten milligrams of progestogen, and ten milligrams is a quantity you can see with the naked eye. The ones now carry twenty or thirty micrograms of oestrogen with their corresponding progestogen, and a microgram is a thousandth of a milligram.

The story of that pill's oestrogen is among the best pharmacology has, because nobody put it there.

The progestogen they made came out contaminated, with between four and seven per cent of a substance they did not mean to add. When they purified the product and removed that impurity, the women in the trial began bleeding out of time. So they put it back in, now on purpose and in the quantity that seemed right to them [two per cent], and the compound kept both things.

The oestrogen of the first pill in history began as a manufacturing defect. Nobody designed it. It stayed because removing it caused problems.

IV

I have never taken anything in order not to have children.

That sentence can be read quickly and has to be read slowly; it describes half the population and is almost never said. I have taken nothing, I have gone to no appointment for that reason, I have had no adverse effects, I have not paid for a box, I have not carried an alarm on my phone and I have not had to think, on any day of my life, about whether it was due today.

What I have done is be present [a comfortable position, which should not be confused with anything else].

In her house the box is in the bedside drawer, not in the bathroom, because the bathroom is shared. The alarm goes off at half past ten at night. It is a sound I have heard dozens of times in the middle of a conversation, of a film or of being inside her; she gets up, goes for the glass of water, comes back. It takes her forty seconds —I have counted them at some point, lying there, saying nothing—.

There were three months in which she came off it, because of some migraines that started with aura. Then the business began to exist for me in another way. Dates had to be talked about. There were a couple of nights when the sum did not work out; I remember both. And there was a duty pharmacy on a Sunday morning [twenty-six euros] where the one who paid was me, which is the cheapest gesture in this whole story and the only one that fell to me.

She went back on the box in March, with another brand and less dose [from thirty micrograms to twenty], and the migraines went away.

What that pill does in a house is not to prevent pregnancies. It is to take out of the way an arithmetic that used to sit on top of every night, and that still sits on top of one single body.

V

Inside, the mechanism does not deceive the body, which is how it is usually told. It sustains it.

A woman's natural oestrogen is of no use for making a pill, because the liver destroys almost all of it the first time it passes through. It is enough to add a small two-carbon piece in the right place for the liver not to know how to grab it: that is what the name of this molecule means, and it is the whole invention. A hormone that survives its own liver.

Once in the blood it behaves like the hormone it imitates, and here comes the interesting part. The body has a thermostat in the head that measures how much oestrogen and how much progesterone are going round, and that decides from that reading whether it is time to prepare the release of an egg. When the levels are high and stable, the thermostat concludes that this month is already settled and gives no order.

There is no deception. There is a correct reading of a false situation.

The rest of what it does is more earthly. It thickens the mucus of the neck of the womb until it is impassable; it leaves the inner wall thin.

There is besides a part that is not biology but design. The week off, with its bleed, has no physiological need at all: it was put there so that the cycle would look natural and so that the pill would be acceptable. What comes down on those days is not a period, it is a “withdrawal bleed” provoked by taking the hormone away. The calendar on the box is a marketing decision from sixty years ago that goes on being printed on the blister.

The body, meanwhile, responds where nobody was looking. The liver, which receives the whole dose on swallowing, adjusts what it makes, and among the things it makes are the factors that clot the blood. The more oestrogen, the greater the risk of a clot; the relation is one of dose, not of bad luck. That relation with the dose is the reason the quantity has gone on falling for sixty years, down to a hundredth.

In 1956 nobody knew that.

Three women died during that trial and no autopsy was done on them.

VI

The observation had been made. It was written, signed and dated by a doctor who was on the ground. The datum was not missing: what was missing was somebody treating it as a datum.

Turning the complaints of two hundred women into a psychological matter is not a recording failure; it is a reading of the record. It is, besides, a reading that only stands up if beforehand that report weighs less than the result being sought.

What was needed to carry on was not ignorance. It was interpretation. That is worse and it is more common.

None of this is against the pill, which seems to me one of the most important things anybody has ever made.

VII

The objection is large and it goes in two directions.

The first, against the easy denunciation. It is comfortable to write the colonial trial at seventy years' distance, and besides it is imprecise: those women wanted a contraceptive, many were asking for one, and a considerable proportion went on taking it when the trial ended. Treating them only as deceived victims takes from them the one thing nobody took from them, which was wanting that.

The second goes against me. I write this from the only body in the house that has never had to decide anything about this matter, and the part that fell to me in this whole story was paying for a box on a Sunday.

That does not disqualify me from telling it. It has to be said beforehand and not afterwards.

VIII

Of Rice-Wray's report the two sentences that matter are preserved, and they are together: that it protected and that it produced too many reactions to be acceptable.

Both were true. The first was used. The second was filed away.

The approval came in 1957 for menstrual disorders and in 1960 for what it really was. The oestrogen dose has been reduced ever since, decade by decade, on the basis of cases and of registries, down to a very small fraction of that one. Each of those reductions is, read the right way round, a belated way of proving a 1956 report right.

April 1956, two hundred and twenty-one women.

Seventeen per cent adverse reactions, twenty-five dropouts.

Three dead, zero autopsies.

1957 with one indication and 1960 with the real one.

From ten milligrams and a hundred and fifty micrograms to twenty or thirty micrograms.

Box of twenty-eight tablets, today, in a Spanish pharmacy: between two and fifteen euros according to the brand.