(Garcia in Anonymous 1978:55) AN ISLAND LABORATORY
The ultimate choice of Puerto Rico as the testing ground was shaped by a complex set of factors which illustrates the ways in which the development of new medical technologies takes place. Medical innovation requires the creation of contexts to establish the required links between the technology-in – the-making and its new audiences and consumers. If such a context does not exist, scientists have to create it. The making of the pill required the creation of what might best be described as “a laboratory in the field.” The test location had to provide the same controlled conditions that were present in the clinical setting. It was quite clear that the field location had to meet specific requirements so that these trials would not fail altogether.
The prerequisite was that the location had to guarantee that women would not easily drop out of the project. But where could one find such a”cage of ovulating females,” as McCormick bluntly put it (Ramirez de Arellano and Seipp 1983:107)? In this respect an island seemed a perfect solution since its population tends to be rather stable. Pincus again opted for Puerto Rico, a “miniature world” which seemed to be an ideal location for the testing of progestins (McLaughlin 1982:28) 28 The island’s people were stationary, with hardly any opportunity to move elsewhere. Pincus’s colleague Garcia explained the choice of Puerto Rico:
The basic aspect was trying to find an area where there were large numbers of fertile women that were in need of contraception; look, it was a question of the law of supply and demand and where you could carry out these studies under a close supervision of the individuals concerned…. The object was to set up a program in an area where you would have better control over the particular population that you are dealing with.
(Garcia in Anonymous 1978)
Pincus selected a location in one of the suburbs of the capital, San Juan, where large slum-clearance operations were being carried out, involving a new housing project. Many of the families who had just moved into these new houses had previously lived in hovels. This situation promised to minimize the risk that women would become lost to the continuous checks and examinations of the trials. Or, as Garcia put it:
The particular sites that were selected were the so-called Parcellas, the housing projects that were considered the elite amongst the indigent. They considered it a prize to have been selected to be living in those homes, in those apartments and therefore once they got into them, they never left. Their kids did but they didn’t. And therefore we had the equivalent of a captive population which in the United States you would never have had.
(Garcia in Anonymous 1978:66)
Puerto Rico thus promised to meet one major requirement of the laboratory. But an island in itself is, of course, not enough to make a “laboratory in the field.” The development and introduction of new technologies requires an organizational infrastructure within which this testing can take place. Puerto Rico also met this requirement in the form of its Family Planning Association. In the early 1950s the family planning movement had a well – established base in Puerto Rico. The Family Planning Association, as the direct successor to the Population Association and other previous birth control organizations in Puerto Rico, was founded in 1953 and had inherited a widespread network of family planning workers and clinics. The aim of the association, continuing the work of previous organizations, was “to provide contraceptive services, stimulate interest in family planning, and carry out research concerning the efficacy and acceptibility of different birth control methods” (Ramirez de Arellano and Seipp 1983:102, 128).29 The association could rely on a well-trained and medically sophisticated staff. Because of its previous status as a US colony,30 Puerto Rico had a well-developed university at its disposal, including a Medical School. The University of Puerto Rico, situated in San Juan, maintained frequent exchanges with the continental American universities, facilitated by a direct air service between New York and San Juan (Ramirez de Arellano and Seipp 1983:74). Celsio – Ramon Garcia, for example, who cooperated with Pincus and Rock in the progestin trials and founded the Department of Gynecology and Obstetrics at the Medical School of the University of Puerto Rico, received his training as a gynecologist at the State University of New York. (McLaughlin 1982:118; Ramirez deArellano and Seipp 1983:74). Consequently, the medical staff of the Family Planning Association was familiar with the “American approach,” to use Pincus’s words. The Puerto Rican Family Planning Association thus provided the local organizational infrastructure required for the testing of the progestins.31 The medical profession did not show any interest in the trials of the new contraceptive. According to Garcia “the medical profession, the whole health care field in Puerto Rico, while it accepted and tolerated sterilization, just paid minor attention initially to the field trials that we set up in the Planned Parenthood organization” (Garcia in Anonymous 1978:49).
A third requirement for creating “a laboratory in the field” was a population willingly available for examinations and interviews with the field trial staff. Where could women be found who would be motivated to participate in the trials? Again, Puerto Rico seemed very promising. Its colonial history had resulted in a well-established public health system. Puerto Ricans were thus accustomed to a reliance upon public health workers rather than family doctors (Maisel 1965:128-129), a situation which might facilitate their participation in the progestin trials.
By choosing Puerto Rico as the test location, hormone research became inextricably intertwined with birth control politics. This choice clearly illustrates how scientists do not operate outside political contexts, but actively select these contexts. The making of the pill was an overtly politically inflected endeavor based on a very specific ideology concerning its potential users. In 1950, Sanger described this underlying ideology: “the world and almost our civilization for the next 25 years is going to depend upon a simple, cheap, safe contraceptive to be used in poverty stricken slums, jungles, and among the most ignorant people.”32 Sanger’s expression reflects the then dominant ideology with respect to population control and economic development. After the Second World War, the problems of assisting what were then first identified as “underdeveloped countries” became of increasing international concern (Ramirez de Arellano and Seipp 1983:88). In this period birth control was perceived as a prerequisite of development. Puerto Rico, given its status as one of the most densely populated and impoverished regions of the world, was considered a prototype underdeveloped country, right at the USA’s doorstep (Maisel 1965:129; Ramirez de Arellano and Seipp 1983:88).33 In the late 1940s overpopulation came to be considered as the basic cause of what was called the “Puerto Rican problem,” with birth control as its major cure (Gordon 1976:336).34
This population control ideology was shared by Pincus and Rock. In this respect the previous tests were not sufficient. Thus far the oral progestins had been tested only among a selected group of well-educated white women. These tests did not yet answer the question of how well educationally limited populations in Third World countries could be disciplined to take the pills regularly (Maisel 1965:127). Consequently, Pincus and Rock sought a test location with a less-educated population than in the previous trials. Puerto Rico, whose population included a high proportion of semi-literate and illiterate women, met this need as well as the other requirements. Puerto Rico thus became the stage for testing the progestins.35 It was on this island that Pincus and Rock began their final quest: the organization of field trials.