Woman of Valor (61 page)

Without the support of governments or of broad-based international institutions, IPPF could only struggle to stay alive, yet sadly enough, Margaret herself came to be viewed as part of its problem. So long as she chose to remain active, no one in the organization was willing to challenge her openly, but almost everyone indulged her schemes and paid her bills while complaining bitterly to each other in private that she was too erratic and no longer had the capacity to make things happen. Even Dorothy Brush lost patience and accused Margaret in a moment of pique of becoming uncharacteristically self-absorbed—“bitchy, ruthless and cruel”—as the conversation was later reported. Margaret responded by becoming only more convinced that she was being pushed out. “The big heads that grow bigger & bigger with the growth of the movement just sicken me!” she later complained to Dorothy, confirming her observations.

Increasingly frail during these years, Margaret would recuperate from her intermittent bouts of angina long enough to scurry across the country looking for money, but even then she could only manage to come up with a handful of $5,000 checks from longtime supporters like Doris Duke, Mary Lasker, Martha Rockefeller, Amy Dupont, and Mary Scaife of the Mellon family in Pittsburgh, who conveniently spent part of her winters in Tucson at the Arizona Inn. Until Margaret officially retired in 1959, IPPF's annual budget never exceeded $35,000, nowhere near the millions needed for a serious undertaking, and, of course, nowhere near the money available to the Population Council.

A successor generation filled with talent and good intentions was eager to take charge—such women as Elise Ottesen-Jensen of Sweden, Dhanvanthi Rama Rau of India, Dr. Helena Wright, a prominent sexologist in England, and Eleanor Pillsbury and Frances Ferguson of Planned Parenthood in the United States. These women, however, were all divided in their loyalties between international work and competing domestic obligations. Even as they disparaged Margaret, they acknowledged the difficulty of identifying substantial resources for foreign work, and the indignity of having to grovel before a handful of interested and wealthy men for what little money they could raise. Yet she, in turn, always found a reason to criticize them, and grew especially harsh in her condemnation of family advocates who were supporting marriage counseling, sex education, and infertility programs contributing to baby booms in the West, while trying to advocate population decline elsewhere. Once it became clear to her that activities she had long tolerated as enhancements to her central program might actually be subverting it, she refused to have anything to do with them whatsoever.
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The struggling IPPF found itself at the mercy of entrepreneurs like Clarence Gamble, who was willing to underwrite its initiatives abroad, but only under the condition that he be given a measure of control. Long grateful for what little credibility he had provided her among fellow physicians and philanthropists, Margaret for a time staunchly defended the eccentric Gamble among a widening circle of skeptics. In 1955 she sent him off to Ceylon with IPPF's imprimatur, but he immediately set off a fracas there by treating local women with unabashed insensitivity and arrogance, allegedly addressing them with terms of derision like “coolie” and “native.” His obdurate defense of the contraceptive utility and cost-effectiveness of a simple rag soaked in salt water was viewed under these circumstances as the symbol of an elitist contempt for the poor women of the developing world. Although she continued to defend his good intentions and his personal generosity, Margaret had no choice but to repudiate him, while taking pains not to alienate him altogether from the organization. The situation underscored the complexity of reconciling the diverse constituencies supporting birth control.
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Her newest and most sympathetic benefactor, Hugh Moore, then stirred up even more trouble the following year with a pamphlet called
The Population Bomb
, distributed as a fund-raising vehicle on behalf of a group of men in business and the professions to some 10,000 notables identified in
Who's Who in America
. Claiming concern over the spread of Communism in underdeveloped countries, the document encouraged support for population control with the rationale that a hungry world “may quite likely succumb to the blandishments of Moscow” and with a specific disclaimer of any interest in the “sociological or humanitarian aspects of birth control.” The original language was so insensitive that the new president of Planned Parenthood of America, Loraine Campbell of Massachusetts, wrote along with other irate recipients to demand that it be changed.

Moore's Cold War zealotry did succeed in generating popular interest in the subject, but at the same time it shocked and offended the more seasoned activists, who despaired that incendiary American rhetoric would stir up Communist and Roman Catholic propaganda and threaten the little progress that had been made in building indigenous constituencies for family planning abroad. A prolonged fracas over the pamphlet helped scuttle Margaret's own plans for a population conference in Washington in 1957, which she reluctantly canceled on the advice of Frederick Osborn of the Population Council. Pointing to developments in India, Japan, Egypt, and even mainland China, where Socialist and Communist governments were already supporting birth control clinics, Osborn convinced her that Washington was no place to meet, because the United States, as he put it, was becoming “backward” on population issues compared to other countries in the world.
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As these developments unfolded, Margaret found herself in and out of the hospital once again. She suffered two more acute heart attacks in 1956, and under these circumstances, what may have been nothing more than the inevitable fits and starts of institution-building left her simply weary and confused. She took everything personally and was especially distressed, as she put it, by having to listen to the opinions of “young men too lazy to read history…who sound as though the BC movement began with their arrival as paid and hired hands.” She summoned what little sense of humor she could muster, however, and admitted in another letter to Dorothy that “all this is enough to
give
you a heart attack, but I am getting better.”

During the early winter months of 1957, she then took herself off to Hawaii to recuperate as the house guest of Ellen and Goma Watumull in Honolulu. Meanwhile, far away in New York and London, IPPF officials concentrated their attentions on the slow and largely unheralded work of developing solid regional structures for family planning in central Africa, the Soviet Union, Australia, Asia, and the Carribbean. A conference was held in the Virgin Islands in 1958 with support from Laurance Rockefeller, who had demonstrated a strong interest in the controlled development and conservation of the islands there. These were not initiatives in which she had any significant role to play, and although she retained her title as president, she became little more than a figurehead.

Back in Tucson, she continued to wrangle small contributions out of old friends like Mary Lasker, who sent her money with few questions asked, allowing her to hire a pandering young secretary by the name of Jonathan Schultz, who at her direction then drafted a series of memoranda that offered elementary suggestions about policies and operations to IPPF members all over the world. Margaret disputed the wisdom of decentralizing IPPF along regional lines, since neighboring countries like India and Pakistan or Japan and China were often at odds. She disparaged marriage counseling and infertility services and designated as the movement's primary goal the integration of contraception into public health programs. These controversial proposals were handed down in an imperious tone, with only the most elementary analysis of Margaret's thinking. Few paid them any heed, though several did try to respond out of respect and courtesy. C. P. Blacker, Margaret Pyke, and others at the headquarters in London found the situation “impossible…and tragic,” and it only grew more and more troubling through the following year as Margaret's health deteriorated further, and her memory began to fade. Dorothy Brush sadly reported the precipitous deterioration and its unfortunate consequences to Margaret Grierson, the librarian at Smith College, who was assembling the Sanger archive. Brush attributed the extreme insecurity and vanity to Margaret's age, illness, and loss of physical appeal. “The collection ought to have letters which show the unfortunate change in character of old age,” she added wistfully. “But I hate to spoil the otherwise remarkable picture of the most selfless woman I ever knew.”
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As it turned out, however, there was no need of betrayal on Dorothy's part. Hungry for recognition of just about any kind, Margaret did all the damage she could possibly do to herself when she went on national television in September of 1957 as the guest of Mike Wallace, who was just beginning his long career as a combative investigative journalist. The format was a half-hour interview show on ABC offering, as Wallace promised in the promo, “an unrehearsed, uncensored…free discussion of an adult topic…that we feel merits public examination.”

Wallace certainly got what he was looking for. Intent on uncovering the titillating story of how the old—and shockingly wizened—woman who sat across from him had become involved in a life of controversy, he spent far more time trying to expose Margaret's psyche than ferret out her thoughts. It was not recent developments in birth control that interested him, but, rather, his guest's attitudes toward divorce, infidelity, promiscuity, and God, and he put her through a cross-examination for which she was wholly unprepared.

What prompted the inquiry was Wallace's reading of Lawrence Lader's biography, from which he baldly quoted material out of context. The interview began with nothing less than the accusation that Margaret had abandoned her husband and children when she was a young woman, because the birth control movement gave her “joy and interest and freedom.” “Now, what was this joy, this freedom, that you craved?” Wallace demanded to know. She responded meekly that simple humanitarian motives had been enough to justify her calling—that she hated to see women suffer or children starve—but he then countered with statistics suggesting that the world's agricultural resources were plentiful, and she didn't seem to know what to say.

Following a commercial interruption, the discussion turned to religion and went further downhill. Margaret challenged Catholic attitudes toward love, marriage, and contraception, and questioned why celibate clergy were empowered to instruct married people on how to live their lives, allowing her host to respond with a defense of the integrity of natural law doctrine, as though he actually believed in it.

Is birth control a “devastating social force, which tends to weaken the moral fibre of the community,” he inquired abruptly, quoting a recent article in a popular magazine? Did Margaret really just advocate it as a way “for single women to avoid bearing illegitimate children”? What, exactly, were her religious beliefs? Did she believe in a God “who rewards or punishes people after death”? Did she believe in sin?

She tried to punch back by responding that the greatest sin she believed in was the sin of bringing children into the world who would never have a chance. “But sin in the ordinary sense that we regard it,” Wallace insisted. Is infidelity a sin? And what about murder? And what about America's high divorce rate?

“May I—may I ask you this,” he admonished haltingly, perhaps betraying an uncharacteristic reluctance to say what was clearly on his mind: “Could it be that women in the United States have become too independent—that they have followed the lead of women like Margaret Sanger by neglecting family life for a career?”

The interview was nothing less than a knockout. Margaret's teenaged granddaughters were watching with their parents in Tucson and remember being floored, hoping that she would fight back—astonished that a woman who had once been so powerful now seemed so submissive and overwhelmed. Bill Sanger, watching in New York with his daughter Joan, began to cry. Writing in
The New York Times
the next morning, the television critic Jack Gould attacked Wallace for his determination to explore Margaret's personal life rather than the significant aspects of her career—for trying to trap her in inconsistencies, at the cost of the more important story.

But Gould may have missed the point. Wallace got exactly the interview he intended. For more than forty years, Margaret had been trying to posture birth control as a scientific and social issue, but she could never escape its moral dimension, because the truth was that her own life engaged it. For all her efforts to conceal herself—for all the compromises she had made in order to get ahead—she could never wholly escape her own past.

With the same unforgiving clarity that the television camera gave to his guest's wrinkled old face, Wallace explained just why Margaret Sanger's life really did make a compelling story, but not necessarily one that a new generation of professional leadership in the family planning field wanted told.
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H
ad Mike Wallace actually been interested in reporting on developments in family planning, there was quite a bit to say. In the waning years of the 1950s, basic assumptions that had long constrained movement activists were finally being altered in a manner that would allow for dramatic gains during the following two decades.

The big news, of course, was scientific. Planned Parenthood's own clinical experience had long demonstrated the limitations of the diaphragm and jelly and provided the most convincing rationale of all for better technology, if birth control was to be truly democratized. It was hardly surprising, therefore, when the preliminary findings on the pill published by Gregory Pincus and John Rock in 1956 led immediately to expanded field trials. Within a year, the Population Council had agreed to joint meetings with the International Planned Parenthood Federation to discuss technology and was directly supporting field research on a small sample of pill takers in Los Angeles. And a larger experiment was begun in Puerto Rico, under the direction of a local public health physician by the name of Edris Rice-Wray, whom Pincus had met while giving a lecture in San Juan.

As a legacy of Ernest Gruening's and Clarence Gamble's quiet cooperation during the Depression, the Puerto Rican legislature had legalized birth control in 1937, over the strident objections of the Catholic Church. Sixty-three family planning clinics remained in operation on the island, one of them in a housing project for indigent families where Dr. Rice-Wray worked. A tradition of sexual modesty and the absence of reliable methods prevented the island's women from practicing conventional contraception effectively, however, and sterilization had instead become their contraceptive of choice. Promoted by private physicians eager for the business and inadvertently by Catholic pastoral letters condemning it, sterilization was not just reliable but had the distinct advantage of requiring only a one-time absolution in the confessional. In a pattern that the United States mainland would begin to replicate in the 1970s, one third of all women ages twenty to forty-nine were having the operation. Yet the Puerto Rican birthrate still remained twice as high as the United States national average.

Under these circumstances Dr. Rice-Wray had no trouble finding recruits for her pill research and no compunction about recommending that they take a risk on experimental medication. In one year she collected data for several hundred patients, aggregating forty-seven years of pill-taking, without a single pregnancy. Problems with side effects such as nausea, fluid retention, and dizziness caused a quarter of the original sample to drop out, but eager substitutes were found, and experiments with placebos then demonstrated that at least some of these reactions were psychological, while the administration of the actual medication in lower dosages resolved even more problems, with still no effect on contraceptive reliability.

Anxious officials in the local public health ministry, nevertheless, put a stop to the research when they learned of it, and Dr. Rice-Wray left the country for a position in Mexico. A second field trial was then arranged privately in the village of Humacao as the result of a proposal by Clarence Gamble to Dr. Adaline Pendleton Satterthwaite, a Quaker medical missionary there. Having spent years delivering babies and then sterilizing desperately poor women, she too had no trouble defending her work on humanitarian grounds and wound up providing a fourth of the case histories on which Gregory Pincus would base his successful argument for the safety and effectiveness of Enovid before the United States Food and Drug Administration three years later.
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Physicians and policymakers in the continental United States were, at first, considerably more cautious. During the summer of 1957, Planned Parenthood officials in New York issued a tentative statement of support for the Pincus-Rock studies in Brookline, but admonished enthusiasts who were already proclaiming the dawn of a new era that it was still much too soon to regard the medication as safe. Dr. Carl Hartman, then chairman of the organization's medical committee, expressed many reservations about the possible consequences of altering the body's natural hormonal chemistry and predicted a fifteen-to-twenty-year period before the drug's safety could be assured. (This prompted Margaret to pencil in the comment on her copy of the statement that he was simply “jealous.”) In fact, Planned Parenthood would take close to two years after FDA approval before authorizing the pill's use by its affiliates, during which time Searle and Ortho Pharmaceuticals, its first major competitor, substantially reduced the drug's progestin and estrogen content, further diminishing reported side effects and enhancing safety.

Private physicians who had never liked the diaphragm, because prescribing it was neither medically challenging nor terribly remunerative, turned out to be a good deal more enthusiastic about the pill, and within five years it became the most popular contraceptive in America, used by 29 percent of married, non-Catholic women under the age of forty-five and by more than half of all women with a college education. It would soon revolutionize contraceptive practice among Catholics as well. Close to 50 million women around the world would be taking oral contraceptives by the 1970s, a population more than adequate to establish their reliability and safety for women of normal health—outside a small and readily identifiable group of high-risk users. Sixty million use it today. Periodic alarms about the relationship of the pill to embolisms, cancers, and other serious complications have been sounded, but never substantiated in large enough numbers to dissuade use. From a medical standpoint, the potent drug, whose actual physiological effects to this day remain poorly understood, has proved remarkably benign, even as women have continued to question the wisdom of taking it over long periods of time.
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The demographic consequences of oral contraception have also been substantial, though never enough so to satisfy population planners. The pill's early and rapid success did demonstrate the motivation of large numbers of women, across a broad spectrum of classes, creeds, and cultures, and helped undermine prevailing assumptions about who would use contraception and who would not. But because it remained a relatively costly medication, requiring prescription by a doctor and individual daily administration, it never lived up to the hopes of its early patrons. International population professionals have continued to look for an inexpensive technology that does not depend on the regular cooperation of the people using it—something on the order of the inoculations against epidemic disease that have more successfully revolutionized maternal and child health around the world.

These inherent liabilities were, in fact, recognized from the start. In 1957, while field trials on the pill were still underway, officials at the Population Council continued to despair over the prospects for ever bringing about meaningful change through voluntary family planning initiatives. A long-term experiment with conventional barrier and chemical methods of contraception in Khanna, a rural district of India, was resulting in poor compliance and negligible changes in fertility. And even in the United States, where knowledge of contraception was nearly universal, and its use controversial only among a few groups, national fertility surveys were still uncovering substantial numbers of unwanted births. Accidental, unplanned pregnancies in and out of marriage remained a problem of statistical significance, especially among the poor, who appeared to have more difficulty anticipating the need for contraception, and less access to pharmacies or health care services that could provide it.

In 1958, the Population Council decided to invest in the development of a contraceptive device that could be left in place for a long period of time. Alan F. Guttmacher, M.D., then chief of obstetrics at Mt. Sinai Hospital in New York, and a member of the council's medical advisory board, recommended the support of preliminary research by Lazar Margulies, a German-trained physician on his staff, who was experimenting with a variation on the Grafenberg ring that Margaret had promoted years earlier and then been pressured to reject. The new intrauterine device substituted a pliant plastic material for the metal components that had always been difficult to insert and more likely to cause uterine punctures and infection. The once controversy-shy organization then contracted with Christopher Tietze, M.D., another German émigré who had become the protégé of Robert Dickinson and had continued working on his own with a shoestring budget at the National Committee on Maternal Health following Dickinson's death. During the early 1960s several million dollars would be channeled through Tietze for the refinement, testing, and evaluation of various intrauterine devices. And the organization would reserve to itself the international marketing rights for a loop-shaped apparatus developed by the Buffalo physician Jack Lippes, that gained the highest rate of acceptance and caused the fewest side effects. By 1967, when the success of the pill had legitimized active intervention in family planning on a broad international scale, the Population Council would incorporate this research and technical assistance capacity as its own Bio-Medical division, where further testing and refinement of various IUDs, injectable contraceptives, and other experimental medications have continued.

IUDs were widely distributed in the 1970s and 1980s, but their use has declined subtantially in recent years as a result of concerns about safety. IUDs have been associated with an increased risk of pelvic inflammatory disease, which, if left untreated, can cause sterility. The fear of malpractice liability has left many physicians in the United States unwilling to insert the devices, and they are also less frequently recommended anymore for use in countries where adequate follow-up medical care is not available to women. More successful in recent years has been the Population Council's investment in research on subdermal contraceptive implants that slowly release an ovulation inhibiting synthetic hormone containing progestin, and can remain in place for up to five years. Close to a million women in the rest of the world are currently using this procedure, and it has recently been approved for use in the United States by the Food and Drug Administration.

In the United States and many other countries, however, barrier contraceptives are still widely employed, sterilization remains a preferred option of married women who have completed their desired childbearing, and legal abortion is a widely utilized backup. This is likely to remain the case, so long as all artificial methods pose the risk of any side effects or more serious complications. As a result, the primary objectives of family planning policymakers today must be to promote additional research to ensure that existing services are tailored to the individual needs of women in disparate cultures and circumstances.
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Political barriers to change were also eroding in the late 1950s. As Margaret had long complained, Planned Parenthood, after rejecting her own flamboyant, confrontational tactics, never formulated a coherent strategy for combating, or even neutralizing, the power of Catholic opposition to family planning and instead more or less accommodated to its marginal political and legal stature in this country. Something of a turning point, however, came in 1955 when Agnes Meyer of Washington admonished new recruits to the organization to be less cowardly and encouraged them to articulate a positive vision in opposition to Catholic absolutism, thus demonstrating that they could no longer be intimidated.

The ideal circumstances for putting this advice into practice developed several years later, when a doctor in a municipal hospital in Brooklyn found that he could not get permission from New York City's health commissioner to fit a diabetic patient with a diaphragm. Hospital administrators and city officials sensitive to New York's large and powerful Catholic constituency had never challenged the unwritten but widely acknowledged policy that kept contraceptives out of publicly assisted health clinics, despite the legal protection state law provided birth control when prescribed for medical reasons. Indigent women could only find medical birth control through a handful of Planned Parenthood facilities and clinics in voluntary hospitals or settlement houses.

Working behind the scenes, Planned Parenthood staff in New York, under the direction of Frederick Jaffe, then a young and savvy public relations specialist, assembled a broad coalition of support from non-Catholic medical, social, and religious institutions. They also brought the situation to the attention of the local press, where it received extensive coverage, especially from Joseph Kahn, a crusading investigative reporter for the
New York Post
, who helped frame the issue as a matter of freedom of information, medical discretion, and religious tyranny. After months of concerted lobbying, the policy was overturned with the quiet acquiescence of Democratic Mayor Robert Wagner, Jr., though he remained neutral in public. Contraceptive services were subsequently incorporated into postpartum clinics in the city's three largest municipal hospitals, though only physicians, of course, not social workers or other nonmedical personnel, could legally give information.

The New York City confrontation raised popular awareness of the substantial political constraints on birth control in this country. Editorial opinion was nearly unanimous in its approval of government's taking a more assertive role and gave Planned Parenthood professionals the courage to assist similar confrontations elsewhere. The victory also exposed emerging divisions of opinion within the Catholic Church itself. “It should be clear,” suggested an article in
Commonweal
, by then considerably more liberal editorially than it had been in the past, “that there are many sound and compelling reasons why Catholics should not generally strive for legislation and directives which clash with the beliefs of a large portion of society…they almost inevitably strengthen in the minds of non-Catholics the already present worries about Catholic power.” Two years later a Planned Parenthood poll of lay Catholics would establish that more than half believed public officials should respect freedom of religious belief in all medical institutions. An editorial in
The Pilot
, the publication of the Boston Archdiocese, then acknowledged that although Catholic principles remain constant, “the social, political, economic, legal and cultural context in which these principles are applied is itself in flux and they must be applied differently.” No longer would the church be able to present itself as a monolith, absolutely resistant to change.
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