This is a fascinating, though lengthy, article on the birth control pill, menstruation, and cancer. Gladwell has an extraordinary ability to take a subject you'd never imagine you would be interested in and weave it into a compelling and insightful story. If you have the time to read this, I don't think you'll be disappointed. -- Dallas
John Rock's Error
What the co-inventor of the Pill didn't know about menstruation can endanger women's health.
by Malcom Gladwell
John Rock was christened in 1890 at the Church of the Immaculate Conception in Marlborough, Massachusetts, and married by Cardinal William O'Connell, of Boston. He had five children and nineteen grandchildren. A crucifix hung above his desk, and nearly every day of his adult life he attended the 7 a.m. Mass at St. Mary's in Brookline. Rock, his friends would say, was in love with his church. He was also one of the inventors of the birth-control pill, and it was his conviction that his faith and his vocation were perfectly compatible. To anyone who disagreed he would simply repeat the words spoken to him as a child by his home-town priest: "John, always stick to your conscience. Never let anyone else keep it for you. And I mean anyone else." Even when Monsignor Francis W. Carney, of Cleveland, called him a "moral rapist," and when Frederick Good, the longtime head of obstetrics at Boston City Hospital, went to Boston's Cardinal Richard Cushing to have Rock excommunicated, Rock was unmoved. "You should be afraid to meet your Maker," one angry woman wrote to him, soon after the Pill was approved. "My dear madam," Rock wrote back, "in my faith, we are taught that the Lord is with us always. When my time comes, there will be no need for introductions."
In the years immediately after the Pill was approved by the F.D.A., in 1960, Rock was everywhere. He appeared in interviews and documentaries on CBS and NBC, in Time, Newsweek, Life, The Saturday Evening Post. He toured the country tirelessly. He wrote a widely discussed book, "The Time Has Come: A Catholic Doctor's Proposals to End the Battle Over Birth Control," which was translated into French, German, and Dutch. Rock was six feet three and rail-thin, with impeccable manners; he held doors open for his patients and addressed them as "Mrs." or "Miss." His mere association with the Pill helped make it seem respectable. "He was a man of great dignity," Dr. Sheldon J. Segal, of the Population Council, recalls. "Even if the occasion called for an open collar, you'd never find him without an ascot. He had the shock of white hair to go along with that. And posture, straight as an arrow, even to his last year." At Harvard Medical School, he was a giant, teaching obstetrics for more than three decades. He was a pioneer in in-vitro fertilization and the freezing of sperm cells, and was the first to extract an intact fertilized egg. The Pill was his crowning achievement. His two collaborators, Gregory Pincus and Min- Cheuh Chang, worked out the mechanism. He shepherded the drug through its clinical trials. "It was his name and his reputation that gave ultimate validity to the claims that the pill would protect women against unwanted pregnancy," Loretta McLaughlin writes in her marvellous 1982 biography of Rock. Not long before the Pill's approval, Rock travelled to Washington to testify before the F.D.A. about the drug's safety. The agency examiner, Pasquale DeFelice, was a Catholic obstetrician from Georgetown University, and at one point, the story goes, DeFelice suggested the unthinkable--that the Catholic Church would never approve of the birth-control pill. "I can still see Rock standing there, his face composed, his eyes riveted on DeFelice," a colleague recalled years later, "and then, in a voice that would congeal your soul, he said, 'Young man, don't you sell my church short.' "
In the end, of course, John Rock's church disappointed him. In 1968, in the encyclical "Humanae Vitae," Pope Paul VI outlawed oral contraceptives and all other "artificial" methods of birth control. The passion and urgency that animated the birth-control debates of the sixties are now a memory. John Rock still matters, though, for the simple reason that in the course of reconciling his church and his work he made an error. It was not a deliberate error. It became manifest only after his death, and through scientific advances he could not have anticipated. But because that mistake shaped the way he thought about the Pill--about what it was, and how it worked, and most of all what it meant--and because John Rock was one of those responsible for the way the Pill came into the world, his error has colored the way people have thought about contraception ever since.
John Rock believed that the Pill was a "natural" method of birth control. By that he didn't mean that it felt natural, because it obviously didn't for many women, particularly not in its earliest days, when the doses of hormone were many times as high as they are today. He meant that it worked by natural means. Women can get pregnant only during a certain interval each month, because after ovulation their bodies produce a surge of the hormone progesterone. Progesterone--one of a class of hormones known as progestin--prepares the uterus for implantation and stops the ovaries from releasing new eggs; it favors gestation. "It is progesterone, in the healthy woman, that prevents ovulation and establishes the pre- and post-menstrual 'safe' period," Rock wrote. When a woman is pregnant, her body produces a stream of progestin in part for the same reason, so that another egg can't be released and threaten the pregnancy already under way. Progestin, in other words, is nature's contraceptive. And what was the Pill? Progestin in tablet form. When a woman was on the Pill, of course, these hormones weren't coming in a sudden surge after ovulation and weren't limited to certain times in her cycle. They were being given in a steady dose, so that ovulation was permanently shut down. They were also being given with an additional dose of estrogen, which holds the endometrium together and--as we've come to learn--helps maintain other tissues as well. But to Rock, the timing and combination of hormones wasn't the issue. The key fact was that the Pill's ingredients duplicated what could be found in the body naturally. And in that naturalness he saw enormous theological significance.
In 1951, for example, Pope Pius XII had sanctioned the rhythm method for Catholics because he deemed it a "natural" method of regulating procreation: it didn't kill the sperm, like a spermicide, or frustrate the normal process of procreation, like a diaphragm, or mutilate the organs, like sterilization. Rock knew all about the rhythm method. In the nineteen-thirties, at the Free Hospital for Women, in Brookline, he had started the country's first rhythm clinic for educating Catholic couples in natural contraception. But how did the rhythm method work? It worked by limiting sex to the safe period that progestin created. And how did the Pill work? It worked by using progestin to extend the safe period to the entire month. It didn't mutilate the reproductive organs, or damage any natural process. "Indeed," Rock wrote, oral contraceptives "may be characterized as a 'pill-established safe period,' and would seem to carry the same moral implications" as the rhythm method. The Pill was, to Rock, no more than "an adjunct to nature."
In 1958, Pope Pius XII approved the Pill for Catholics, so long as its contraceptive effects were "indirect"--that is, so long as it was intended only as a remedy for conditions like painful menses or "a disease of the uterus." That ruling emboldened Rock still further. Short-term use of the Pill, he knew, could regulate the cycle of women whose periods had previously been unpredictable. Since a regular menstrual cycle was necessary for the successful use of the rhythm method--and since the rhythm method was sanctioned by the Church--shouldn't it be permissible for women with an irregular menstrual cycle to use the Pill in order to facilitate the use of rhythm? And if that was true why not take the logic one step further? As the federal judge John T. Noonan writes in "Contraception," his history of the Catholic position on birth control:
If it was lawful to suppress ovulation to achieve a regularity necessary for successfully sterile intercourse, why was it not lawful to suppress ovulation without appeal to rhythm? If pregnancy could be prevented by pill plus rhythm, why not by pill alone? In each case suppression of ovulation was used as a means. How was a moral difference made by the addition of rhythm?
These arguments, as arcane as they may seem, were central to the development of oral contraception. It was John Rock and Gregory Pincus who decided that the Pill ought to be taken over a four-week cycle--a woman would spend three weeks on the Pill and the fourth week off the drug (or on a placebo), to allow for menstruation. There was and is no medical reason for this. A typical woman of childbearing age has a menstrual cycle of around twenty- eight days, determined by the cascades of hormones released by her ovaries. As first estrogen and then a combination of estrogen and progestin flood the uterus, its lining becomes thick and swollen, preparing for the implantation of a fertilized egg. If the egg is not fertilized, hormone levels plunge and cause the lining--the endometrium--to be sloughed off in a menstrual bleed. When a woman is on the Pill, however, no egg is released, because the Pill suppresses ovulation. The fluxes of estrogen and progestin that cause the lining of the uterus to grow are dramatically reduced, because the Pill slows down the ovaries. Pincus and Rock knew that the effect of the Pill's hormones on the endometrium was so modest that women could conceivably go for months without having to menstruate. "In view of the ability of this compound to prevent menstrual bleeding as long as it is taken," Pincus acknowledged in 1958, "a cycle of any desired length could presumably be produced." But he and Rock decided to cut the hormones off after three weeks and trigger a menstrual period because they believed that women would find the continuation of their monthly bleeding reassuring. More to the point, if Rock wanted to demonstrate that the Pill was no more than a natural variant of the rhythm method, he couldn't very well do away with the monthly menses. Rhythm required "regularity," and so the Pill had to produce regularity as well.
It has often been said of the Pill that no other drug has ever been so instantly recognizable by its packaging: that small, round plastic dial pack. But what was the dial pack if not the physical embodiment of the twenty-eight-day cycle? It was, in the words of its inventor, meant to fit into a case "indistinguishable" from a woman's cosmetics compact, so that it might be carried "without giving a visual clue as to matters which are of no concern to others." Today, the Pill is still often sold in dial packs and taken in twenty-eight-day cycles. It remains, in other words, a drug shaped by the dictates of the Catholic Church--by John Rock's desire to make this new method of birth control seem as natural as possible. This was John Rock's error. He was consumed by the idea of the natural. But what he thought was natural wasn't so natural after all, and the Pill he ushered into the world turned out to be something other than what he thought it was. In John Rock's mind the dictates of religion and the principles of science got mixed up, and only now are we beginning to untangle them.
Continue here with part 2.