A Shot in the Dark They're dangerous, surprisingly expensive, and they don't always work. Yet for many Hispanic women, black-market injections are the contraceptive method of choice.

The names and some of the identifying details of the women who take or administer clandestine injections have been changed.

Nobody asks who she is or what she wants when Isabel Alvarez shows up on the stoop of a Cardozo apartment building on a stifling afternoon in July. Isabel, like many of the building's tenants, is Salvadoran, and her face is familiar. The people on the stoop know—or at least guess—that she is here because it's that time of the month: time to visit the woman. And so, without inquiring, one of them buzzes her inside.

Isabel is here to see Sylvia, a curandera, or healing woman, who traffics not in herbs but in an injectable pharmaceutical. Sylvia peddles the shots from an apartment on the building's first floor, a fact that's generally known to her neighbors if not to the world at large. Isabel, who has been visiting Sylvia at four-week intervals for nearly a year, heads straight for her door and knocks. Sometimes Sylvia is out, and Isabel must come back later the same day. Today, though, the door opens right away.

Hola,” says Sylvia, seeing that it is Isabel.

Hola,” Isabel replies.

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The noise from the corridor subsides as the two make their way to the back bedroom of Sylvia's apartment. Sylvia asks Isabel how she is feeling; Isabel replies that she's feeling fine. According to Isabel—who later describes the scene at my request—Sylvia then removes a slim package from a cabinet on the wall. She opens the package and extracts a needle and syringe.

Isabel removes her shorts and underwear, lies stomach-down on the bed, and braces herself as Sylvia swabs a patch of her buttock with alcohol and slips the needle into the skin. When the procedure is over, Isabel hitches up her clothing and produces a $20 bill. Sylvia pockets the bill and gives Isabel $2 in change. Then Sylvia puts the empty works in the trash, picks up a small book, and records something in it that Isabel cannot see.

Adióses and muchas graciases are exchanged, and Isabel walks home through the swampy midsummer heat. She is free to spend the rest of the day relaxing with her two children—free, as well, to enjoy what she modestly calls “relations” with her husband, secure in the belief that, for the next four weeks, she will not conceive a child.

The injectable is a powerful hormonal contraceptive that's not legally available in the United States. Black-market birth-control transactions like this one are an open secret among the D.C. area's Hispanic immigrant community. La inyección is what the women call it: That's the generic name for a variety of contraceptive injections that are widely available over-the-counter in countries south of the border. In truth, though, la inyección can contain any number of drugs, particularly when it's administered clandestinely in bathrooms and bedrooms around the D.C. area. In Isabel's case, the shot in the dark could have been Nomagest, Yectames, Topasel, or any one of a number of one-month injectables that are not approved by the Food and Drug Administration (FDA). Women who prefer a stronger shot sometimes purchase a a bootleg dose of Depo-Provera, a three-month injection that's lawfully sold here only by prescription.

The drugs are smuggled into this country—sometimes by the women who are taking them, but more often by curanderas like Sylvia. The term is used rather broadly here; traditionally, curanderas are healing women who use folk remedies and witchcraft to cure maladies of the body and the spirit. But the term aptly describes the sizable number of immigrant women who have established ad hoc, unlicensed medical clinics in their homes in the U.S. “It's a big business,” says Olga Morales Aguirre, a health worker in San Antonio, Texas. “It's like a status symbol for the women in the barrio. If you inject people, if you have the medication, it's a big deal. That woman is the most knowledgeable, the most up-to-date, the most modern. So this woman is really looked up to in the neighborhood.” The trade is illegal, of course—U.S. law forbids importing and selling drugs without a license. But neither the FDA nor local health officials have used their resources to police this subterranean medical market.

Who are the curanderas' clients? They are low-income, undereducated Central and South American women who, in most cases, are living here without legal documentation. With little English at their disposal, these women are unlikely—sometimes unable—to scan the Yellow Pages or contact a referral service to locate an aboveboard clinic. Even if they do know of such a place, they are often loath to visit it: The specter of deportation is real and ever-present, and the same fear that keeps them out of schools and police stations tells them to avoid hospitals and clinics. How much easier to purchase birth control through a casual, cultural network; how much easier to drop by a friend's house and buy an injection without facing the invasive questions of a doctor, the bewilderment of insurance forms, the indignity and discomfort of a speculum. Quicker, too: the curanderas' convenient locations and flexible hours are a mercy for women working eight to 10 hours a day as maids and baby sitters.

There's another reason these women seek out the curanderas. More so, even, than their North American counterparts, they are caught in an unsettling cross-current: The combined forces of Catholicism and machismo urge them to forego birth control, to produce baby after baby. Yet in many cases the women have come to this country to make money, an aim that pregnancy complicates. Black-market injections provide a nice compromise, allowing the women to use birth control without confronting its full significance. Catholicism is, after all, a religion in which signs are taken seriously, and if the sacrament is the outward sign of an inner faith, then birth control devices are the outward sign of an inner shame. To use a condom or the Pill is to be faced with a visible, daily reminder that one is having sex for pleasure, not for procreation. That is something these women may be uneasy acknowledging, even to themselves; the injections, being all but invisible, are most welcome.

They are also dangerous. “What's scary to me,” says Catalina Sol, patient care coordinator at La Clinica del Pueblo, a private, not-for-profit D.C. health clinic, “is that people will come to us and say, "I was given this injection, and it's supposed to do this.' The overall sense I get is of this complete distance from what's happening in your body. The women will say, "I got the injection, and I didn't have my period anymore, and then there was all this bleeding, and then there was the horrible water, and then I got a new injection.'...All the women know is that it's an injection not to have babies.”

Portia Jones, a family practitioner who works at La Clinica del Pueblo and other urban health clinics in D.C. and Baltimore, recently treated a youthful patient who had received la inyección from a friend with no medical training. The puncture site blossomed into an abscess—one of many Jones has seen.

“If you inject into fat rather than muscle, it creates an area of dead tissue, an irritation that collects and makes a pocket of fluid that has to be opened and drained,” she explains. “Injecting into the fat instead of the muscle is a common mistake by people who don't know how to give injections.”

Even if the shot is given correctly, Jones and others fear that the drug may be expired or diluted. Or, that it may arrive only on an irregular basis.

“The quality and reliability of shipments varies,” says Sol, speaking from a cramped office at her clinic, which operates out of a converted elementary school in Columbia Heights. There, each Tuesday night, scores of Hispanic men, women, and children sit patiently at wooden school desks, waiting to be treated by the clinic's volunteer physicians for everything from hypertension to ulcers. Women receiving the black-market injections sometimes appear at the clinic when side effects—such as abscesses or the unexpected cessation of menstruation—develop. But minor health complications are only one consequence of black-market medicine: pregnancy is another, and so is the danger of contracting AIDS from a communal needle.

Sol and her colleagues also worry about the women they never see—women who, thanks to the curandera, evade the Pap smears, mammograms, and other routine but crucial health care that comes bundled with contraceptive prescriptions.

It's hard to know how many D.C. area women acquire their birth control through underground channels. “We haven't done enough work in documenting exactly how many women are using it, or what the concerns should be,” says Sol. “Most people won't volunteer that information, because it has that taint of what you're not supposed to do.” But Ana Blanco, until recently a staffer at Hillcrest Women's Surgi-Center, ventures that 10 to 15 percent of the Hispanic women she treated used the clandestine injections.

Anecdotal evidence suggests that the injections are alarmingly prevalent. Over several months, I visited a number of D.C. health clinics that serve Hispanics. Each visit yielded a woman who was taking the injection, had taken it, or knew a friend who was taking it. Some women were afraid to discuss the subject further; others said they would be glad to talk, only to give me a telephone number that had been disconnected or, when rung, was never answered. Six women, one of them a curandera, agreed to be interviewed at some length. To them, la inyección is as commonplace as water—as commonplace as, well, babies.

“We know it's out there,” says Alicia Pitarque, coordinator of Planned Parenthood's Latino Outreach and Education Program. “We just don't know how and where.”

Looked at one way, these women are making an audacious gesture of independence: from husbands, from doctors, from church teachings, from their biological destiny. They are self-medicating, taking responsibility for their own physical well-being. Self-medication is far more common in Latin America than it is in this country; there, many drugs can be purchased over the counter, no prescription necessary. In San Salvador, a package of the most popular one-month contraceptive injection,Normagest, can be had from a pharmacy for 34 colones, or about $4. The package contains everything needed to administer a dose: a 150-mg ampule of liquid, a disposable syringe and needle (both sealed in plastic), some terse instructions, and an alcohol-soaked towelette. Several other one-month shots are available for slightly more. The three-month contraceptive, “Depo-Provera 150,” is a relative bargain at 75 colones.

Salvadoran women inject themselves, or pay a pharmacist 25 cents to do it. The shots, it is widely agreed, hurt like hell.

In this country—obviously—restrictions are much tighter. A woman must obtain a prescription before she may purchase the Pill or Depo-Provera, the only injectable contraceptive that's legally sold in the U.S. To get that prescription, she must undergo a thorough physical: At Planned Parenthood, for example, she receives a breast exam, Pap smear, urine analysis, blood pressure test, body-weight measurement, and blood work to determine whether she has syphilis, anemia, or (if she requests the test) HIV. She is advised of the risks of hormonal contraceptives, urged not to smoke, and, if she has come for Depo-Provera, asked to sign a form saying that she has been warned about side effects and potential health risks.

Such screening is considered necessary to ensure that the woman is capable of handling a dose of hormones; and, in the case of Depo-Provera, the “informed consent form” provides extra insurance against lawsuits.Developed in the '60s by Upjohn Co., Depo Provera is an extremely effective contraceptive that consists of a powerful progestin (or artificial form of the hormone progesterone) that works by suppressing ovulation and thickening the cervical mucus to deter the passage of sperm. The drug languished for more than 20 years before winning approval in this country: Early tests suggested that the drug could cause cancer, so the FDA twice denied Upjohn's application to market Depo-Provera as a contraceptive, in 1978 and again in 1984. At the same time, Depo-Provera gained wide use in some 90 countries, where it proved a cheap and effective means of population control.

The FDA changed its mind about Depo-Provera in 1992, most likely persuaded by a World Health Organization (WHO) study that somewhat allayed concerns about the drug's carcinogenic potential. Upjohn was invited to resubmit the drug to the FDA advisory committee, and, last October, it was approved.

But some women's health organizations failed to welcome the new addition to America's contraceptive arsenal. Instead, they reacted to “Depo” with the same hostility they showed toward Norplant, the five-year hormonal implant that won FDA approval two years ago. These groups fear that Depo's health consequences have yet to be fully measured; that, unlike the Pill, it cannot be easily purged from one's system; that low-income and ethnic groups can be coerced into taking it; and that it doesn't encourage women at risk of HIV infection to alter their sexual behavior and live more responsibly.

Long-term dangers aside, the short-term side effects of Depo-Provera are enough to make many women fumble for a condom. Chief among these is a drastic and unnerving shift in familiar menstrual rhythms: Women may bleed profusely for days, even months, once they begin taking Depo-Provera. More frequently, they stop menstruating entirely. According to the WHO report, roughly one-half the women discontinued the drug after a year; of that number, some 15 percent said they did so because they disliked the menstrual changes.

Other possible side effects include weight gain (an average of 2.5 pounds each year), depression, and an increased risk of osteoporosis. And because Depo-Provera tends to accumulate in one's system, infertility can persist for months—even years—after a woman stops using the drug. Packages of Depo-Provera marketed in the U.S. contain a list of even more side effects. Like the advisories accompanying many medicines, the warning is exhaustive, but it's worth noting that Upjohn's own researchers found that users of the drug have complained of “headache, nervousness, abdominal cramps, dizziness, weakness or fatigue, decreased sexual desire, leg cramps, nausea, vaginal discharge or irritation, breast swelling and tenderness, bloating, swelling of the hands or feet, backache, depression, insomnia, acne, pelvic pain, no hair growth or excessive hair loss, rash, hot flashes.”

“If these or any other problems occur during your use of Depo-Provera,” the packet warns, “discuss them with your health-care provider.”

What health care provider? the clients of a curandera might ask.

Strong medicine, Depo-Provera—as are the one-month shots so popular among barrio women. These one-month injections are not, as some might think, a lower dose of Depo-Provera. Instead, they're an entirely different drug, one that Ronald Gray, a professor in the department of population dynamics at Johns Hopkins University, describes as a “cocktail” of progestin and estrogen. According to a recent WHO study, the one-month injection affects menstruation less severely than Depo-Provera; it can, however, cause nausea, headaches, breast tenderness, and weight gain. Because the one-month injection has never been legally marketed—much less approved—in the United States, most North American health workers have never heard of it.

With so many questions still unresolved about these drugs, a vivid mythology has risen in the Hispanic community to occupy the place of real knowledge. At a Mount Pleasant women's center, the injection is well known to a group of immigrant women gathered for prenatal training. One woman says that she has three friends in this country who sell la inyección from their homes. Another remarks that her aunt took the injections for 10 years, every three months, back in Peru.

“Her hair, it turned white,” the woman recalled. “When she was young, around 28, it turned white.”

Another young woman said she took the injections when she lived in El Salvador. She was 16 at the time, and so skinny that the pharmacist would only sell her the one-month shot, for fear that the three-month shot would disturb her period so radically as to make her anemic. Here in the States, a friend gave her eight months' worth of birth control pills, but she prefers injections because “you don't forget.” A schoolmate, she says, takes the black-market injections and menstruates all month long, without stop.

Another woman tells me about her novel approach to self-medication. Back when she was living in El Salvador, she says, she regularly used the three-month injection. She was already raising three children, and abhorred the idea of another; so, for extra protection, she swallowed the Pill on top of the shots. When I venture that she was loading an awful lot of hormones into her system, she smiles and nods.

“Maybe it make me sick,” she says. “I don't know.”

That last comment confirms what some clinicians argue: that Latin American women—while encouraged to use la inyección by their governments—are insufficiently educated in the drug's risks and proper use. “It's my impression that a lot of the [Central American] contraceptive programs have been aimed at population control” without regard for health education, says Catalina Sol.

When this already flawed method of contraception is transported north of the border, the health problems are compounded. Here, lacking even the guiding hand of a pharmacist to oversee the supply, self-medication becomes little better than voodoo. That's why clinicians want to educate the women and persuade them to get their injections from doctors.

“They need,” emphasizes Planned Parenthood's Pitarque, “to use birth-control methods that have been approved in this country.”

But coaxing the women into the clinics is a difficult task. The fact is, many Hispanic women like the injections, despite the risks and the myths, and find it easiest to purchase the shots from the curanderas. If the curandera has smuggled in some other injectable drugs—as she often has—then so much the better. In Latin America, Sol points out, “People receive vitamin injections, liver extract, tranquilizers [by injection]—it's not at all uncommon to get medicine this way.”

“Some in the community say it won't cure them if it's not an injection,” Sol comments. “If it doesn't hurt, it's not going to work.”

Indeed, the pain is one reason why Doris Aviles liked la inyección so well. Not only did the injections hurt when they were administered; the sensation lingered for days. To Doris, this was reassuring evidence the drug was working. “The pain would shoot up and down my left leg for three days,” she recalls, stroking her leg. “You could feel it spreading.”

Doris is a 28-year-old woman who could pass for 40. Short and thickset, she sits on a folding chair in her two-bedroom apartment, explaining why she purchased injections from a Mount Pleasant curandera for three years. The apartment is dark and airless: No lights have been turned on, and there's no air-conditioning either. There is very little furniture—a couple of chairs and a table. Doris, who formerly worked as a maid but is now unemployed, lives here with her boyfriend, her three children, and another family. She has no legal documentation, no right to live in this country. But here she is: utterly isolated and quite busy. While she speaks, children drift in and out of a bedroom, peeking at her visitors—myself and a translator, Lydia Beruff. One toddler is wearing a shirt and sandals: no shorts, no diaper. Doris is wearing pink shorts and a T-shirt that says “The New Democrats.”

Long-term contraception appealed to Doris for the same reason that it appeals to many refugees: “Anyone whose life is chaotic—they're going to pick something like IUDs, Norplant, sterilization, or Depo-Provera,” says Portia Jones. “Chaotic” is a mild word in Doris' case: When she left El Salvador 10 years ago, she, like many of her countrywomen, was obliged to leave a child behind. The little boy died of anemia not long after she left. Hoping for a new baby, she quickly became pregnant again. The child was born dead. Her next pregnancy miscarried at seven months. “No doctor could tell me why I was losing these babies I wanted to have,” she says. Depressed, she put aside her hope of having a large family and began taking birth control pills, which she obtained through a clinic here.

She disliked the Pill. Rubbing her stomach, she says it made her nauseous. She went to a doctor, who informed her that she was pregnant. “I was very unhappy,” Doris says, “because rumor has it that if you have a baby with birth control pills, the baby comes out deformed.”

That was in January 1986. The baby, a boy, was born healthy. Then a friend told Doris about the injections, and, a month later, she visited a nearby curandera, a woman who claimed to have been a nurse in El Salvador.

“She has injections for everything—blood problems, heart problems, any kind of injection you want to have, she has that,” Doris says. “She goes down to El Salvador and gets them. She goes down once a month to buy up all the medicines. She even takes care of little children.”

The curandera warned Doris that some women react badly to the shots. “I said, "I don't care.' ” Doris loathed the Pill and didn't want another child just then. The woman did not tell her that the injections could delay her return to fertility.

Nor was Doris alerted to likely menstrual changes. “I kept bleeding for the first month—every day,” she recalls. “I thought this was the way it would be for the rest of my life.” She went back to the curandera, who assured her that the bleeding was normal; with the second injection, she stopped menstruating entirely.

After purchasing two of the three-month injections, Doris changed her mind and opted for the one-month shots. Does suddenly switching from one drug to another pose a health problem? Who knows? Ronald Gray believes it's a bad idea, but says that no adequate study has been done. Apart from medical dangers, a woman who is taking both kinds of shots may have difficulty remembering which shot she last received—was it for one month or three?—and, as a result, may lose track of her schedule and her fertility.

Doris wasn't worried. “I loved it—to me it was good,” she says. While some of her friends gained weight, hers stayed constant (“I already had a big appetite”) and she felt the curandera was doing her clients a great service.

“It's good because it helps them plan,” she says. “Otherwise I'd have 12 kids by now. My friends even came from Virginia to get the medicine.”

After two years, Doris stopped the injections. Nine months later, she conceived. She then returned to the shots but lapsed and became pregnant again. Here her tale becomes cloudy: After the birth of that child, she says, she went to a clinic, was diagnosed with uterine cancer, and underwent an operation at a local hospital. That was last year. Recently, she visited Planned Parenthood for a Depo injection. The doctors wouldn't give her the shot because she had entered the post-period interval of her menstrual cycle—too late to ensure that the injection, which must be administered three to five days after beginning one's period, would work. Planned Parenthood gave her a packet of birth control pills and told her to come back in a month.

“I've lost three of the pills,” she says, fetching the packet to show us. “Is that a problem?”

Fortunately for Doris, she returned to Planned Parenthood and started her Depo regimen several weeks after our interview. D.C.'s contraceptive black market—and the dangers it presents—would vanish if more women followed Doris' example. But as other interviews showed, there are many reasons why women visit the curanderas instead of the clinics.

It's commonly believed that women turn to the black market because contraception is cheaper there. It's a compelling argument: In this country, hormonal contraceptives are among the drug industry's most profitable products. Here, a monthly packet of pills fetches about $20, compared to about $1 in Central America; an implant of Norplant costs $350, compared to $23 in some other countries; Depo-Provera costs $25 to $75 at Planned Parenthood, depending on the woman's ability to pay.

And it's true that black-market contraceptives are usually cheaper—but not by much. Smuggling costs inflate the price considerably: Doris Aviles' curandera charges $25 for a three-month injection and $18 for the one-month shot. Of course, for these women, a small price differential can make a big difference: Doris' curandera also professes to sell a “one-year injection” for $50 to $60, but Doris never purchased it because she never had that much money at once. (It's a good thing Doris was broke: No one-year injection is sold anywhere in the world, so the curandera's offer was surely a fraudulent one. Most likely, she was peddling the three-month injection and making false promises about its longevity.)

Often, however, the women are drawn to la inyección not because it's the economical choice but because it is—or seems to be—the only choice. When Estella Lopez came to the States from San Salvador in 1991, she had no idea where to find contraception. But her boyfriend did, and directed her to a woman with a needle and hormones who was willing to pay house calls. Estella took the three-month shots twice; she believes the woman charged her boyfriend about $45 each time.

Estella hated the shots. They made her gain weight, she says, and caused daily headaches. Like many of her countrywomen, Estella is shockingly younger than she appears. Her tired round face, framed by shaggy hair, looks about 30, but she is only 17. She was 14 when she gave birth to her first baby, a girl, in El Salvador.

The curandera hadn't warned her about the injection's side effects, Estella complains. “When my period didn't come, I called her, and then she explained,” she says. “Really, what concerned me the most was when I lost my menstrual period. That was bad. Then when it came, it would take three days, and when it would come, it was little.”

Estella has a new boyfriend now. This one wants her to have a baby. So she stopped taking the injections. She's three months pregnant.

lot of times I would get a kind of ball in my thigh, like a cyst, but I would wear a long nightgown going down to the floor so he couldn't see my leg,” says Eva Aguillar, a 24-year-old Honduran. “He” is her husband, a Salvadoran construction worker, who ordered her to forego birth control.In this he was not unusual: Some Latinos forbid their wives to use birth control, motivated by religious scruples and by a cultural conviction that a big family offers living proof of machismo.

“If he found out that I was getting the injections,” Eva says, “he would be so furious. He would say that the woman who has a husband doesn't need birth control.”

Eva was more pragmatic. She already had two little boys—one from a boyfriend in Honduras, one from her husband. Having come to the United States in 1990, “like everybody else, to work,” she parked the boys with a neighborhood friend while earning $6 an hour as an office cleaner. Another child would complicate this arrangement. So each month, she and two like-minded girlfriends visited the curandera. The first visit, she paid $5 for a packet of pills (“they were white, with little coffee-colored ones for when you were having your period”) but found that they made her dizzy.

So she switched to the one-month injections. These were better, though not without drawbacks: the little ball that formed in her leg was one. Another was an occasional difficulty with supply. “Sometimes [the curandera] didn't have the injections—she said she had too many clients,” Eva recalls. “She said to come back the next day. And she would get them from a friend. Sometimes it was inconvenient, because I was going behind my husband's back.”

When she failed to become pregnant after several months, her husband started asking questions. “He was suspicious; he would say, "What's going on?' ” Eva says with a laugh. “I would just make things up. I would say, "I don't know—I guess my system is changing.' ”

She knew she was running a risk—but she felt the risk was worth it. And she wasn't the only one: At the curandera's, she saw “all types” of women: Salvadoran women, Honduran women, older women, teen-agers. The stealth of injections appeals to woman who, like Eva, want to hide their contraception from their relatives.

“The ones that live with their families, it's best to get injected because the family doesn't know the girl has a boyfriend,” she says. “She does not have to hide the packet of pills.”

Who knows exactly what the Mount Pleasant curandera was injecting into Eva's thigh over the two years she visited the healer on a monthly basis? The syringes were always pre-prepared; not once did Eva see the contents or the original package. Nor was she given much in the way of instruction: The curandera simply told her to come for the shot three days after the onset of menstruation. Last December, when Eva's period failed to come, she became confused and delayed her next visit, waiting for her period to begin. She waited too long. By February, she knew she was pregnant.

Eva clasps and unclasps her hands as she recounts her story at an Adams Morgan prenatal clinic. She is weeks away from her due date. Her fingernails are short and bitten; her black hair grows close to her head in thick, worried curls. “I'm suspicious that the woman may have injected me with one that was expired, or with a different liquid,” she says.

More likely, Eva's mistake was relying on her period as a signal that it was time for her next shot. Asked whether she is excited about the baby, Eva smiles—even now, she can smile, and the smile is dazzling.

“Sincerely,” she says, “no.”

Yet Eva rejected abortion: Birth control may be tacitly accepted among these women, but abortion is another thing entirely. “This is my child,” she says. “And I would never kill it.”

For Eva and her two friends, the monthly trip to the curandera was a group excursion, an act of feminine solidarity and defiance. However, other women are so secretive about what they're doing—or so isolated by life in these United States—that they decline even to visit a curandera. These are the women who obtain their drugs by mail and inject themselves.

Anita Mendez was one. For years Anita's mother shipped her the injections via the ubiquitous package services that operate out of second-floor offices in Adams Morgan and Virginia's Arlandria section. The package contained six months' worth of the one-month shots, along with a hard cheese Anita couldn't find in any District grocery. Once a month—she kept a tally on her calendar—Anita, 23, would retire to her bathroom and inject herself.

“The first time I injected myself I had a huge bruise,” recalls Anita, who lives in a one-bedroom apartment with her husband and their two children. When Anita was growing up in El Salvador, her sister, who was studying to be a nurse, would practice injecting her with vitamins. Even with this secondhand training, Anita initially had trouble assembling the syringe and needle, and then stabbed the needle into the wrong part of her thigh.

“The liquid stayed together in one place and formed a huge bruise with a ball,” she remembers. So she telephoned a doctor she knew in El Salvador.

“The doctor explained that after I put it in, I needed to massage the place,” she says. “When I put the needle in my thigh, it just stayed clumped under the skin. You have to massage it so it goes into your system.”

Anita applied a compress to the abscess, which gradually subsided. (Abscesses are not usually serious; however, if they don't shrink when moist heat is applied, they must be lanced and drained, preferably by a physician.) She continued injecting herself every 28 days for three months. The shots were painful but the pain didn't last long: “Only when I put the needle in my skin and it started going in, it was very painful.”

Anita had never used birth control before. Like many Salvadoran refugees, she comes from a rural area where she received little education about anything, including family planning. She bore one child in El Salvador, a girl whom she left with her mother when she, her father, and some of her sisters moved to the U.S. Here, her father begged her to be more careful.

“My father would tell me, "Please don't come home pregnant, because everything is so expensive—the hospital, everything,' ” Anita recalls. From a friend, she learned about the injections, and asked her mother to mail them to her. But her mother (who bore 11 children, eight of whom survived) was a stauncher Catholic than she.

“At first she said no, she refused. I told her that the hospital is very expensive, that children are very expensive, and I convinced her. I begged a lot. I said, "What is it to you if I give you the money and all you have to do is run to the pharmacy?' ”

Anita prevailed, and her mother began sending the injections. By that time, Anita and her boyfriend were engaged and living together. During her first two months on the injections, she continued to have a period; the third month she became nauseous and dizzy and stopped menstruating. She went to a clinic, but learned that she was not pregnant. “And then I did not want to use them anymore,” she says. So she stopped injecting herself—and quickly became pregnant. The decision illustrates an abiding truth about black-market contraception: Confused about or put off by the injection regimen, women fail to use the shots consistently.

But Anita returned to the shots, waiting 40 days after the birth of her baby (“at the clinic, they had told me I had to have no relations for six weeks”) before injecting herself again. The procedure took about five minutes. Her husband never participated. “I did not tell him, "I have to go inject myself now.' He knew I was injecting myself, but he did not know when I did it.”

By that time, she was taking her son to a clinic for pediatric care. Why not buy her contraception there, where the Pill can be had for $5 a month? Because she preferred the injections—and distrusted the clinic. “Once you say you're using the injection, they reprimand you....They make you take the Pill. I did not want to do anything against my will.”

Anita gave herself the shots for two years. Then, deciding that she wanted another child, she stopped using them, and became pregnant a month later. That child was born in October 1990. At that time, she says, the clinic gave her contraceptive foam and condoms, but she rejected them in favor of more injections. Then in November 1992, she and her husband became Pentecostals.

“I continued to give myself the injection one month after I was a Christian, and I felt that something was not right with me,” she says, speaking in spiritual—not physical—terms.

So Anita no longer uses any birth control at all. And she is six months pregnant.

“God says my will is his wishes,” she says placidly. “I am at his command, and if God wanted me to have children, I'll have children.”

Considering her well-demonstrated fertility, it seems possible that Anita will have a lot of children. “I'll have them,” she says. “God gives.”

At one point, Anita makes Israel lie across her lap, flips the boy over on his stomach, pulls up his shirt, and points to a scar on his smooth back. That, she says, is where a boil erupted into the sign of the antichrist: three tiny cloverleaf sixes. The boy had been sick for a long time, she says, and penicillin couldn't cure him. So church members gathered in the apartment, prayers were said, the boil burst, and the boy was healed. Another time, she asserts, a stray gunshot pierced her window and hit her in the back. By the time her husband came to help her, she says, the wound and the blood had both disappeared.

She believes that God protects her. It's a good thing He does: Outside on Sherman Avenue NW—gang territory—groups of kids are roving purposefully up and down the sidewalk.

Inside her apartment, the feeling is one of security—and abject solitude. Asked if she knows other women who use the injections, Anita says no. “It's something very private. I never said that I was doing that.”

She does maintain a commercial relationship with a woman who buys and transports knickknacks from El Salvador, which Anita resells to members of her church. She disappears into a bedroom and returns with plastic grocery bags full of assorted wares. A leather-and-cloth purse goes for $22; bolts of brightly colored napkins cost $20 and $25. Nylon underwear goes for $5, a nylon girdle, $7. There are wallets, little wooden wineglasses and coasters—all of it top dollar.

Doubtless, women buy these chatchkas not because they are cheap but because they are familiar and therefore oddly comforting—just as peanut butter may be comforting for an American living abroad.

Just as la inyección is comforting to the women who grew up with it.

ow that Depo is legal and available, there's no reason for women to have to get any of these injections on the black market,” ventures Sandra Waldman of the New York-based Population Council, which favors injectable contraceptives when properly used. “Because I'm sure that there are clinics and places like that where they can get them.”

What Waldman says makes perfect sense. And it's true that more D.C. clinics are beginning to stock Depo-Provera injections. La Clinica del Pueblo does not offer Depo, but an Adams Morgan women's clinic, Mary's Center, has just begun doing so. There, $80 buys a physical exam and a three-month shot; women who have had a physical in the past year can pay $32 for the shot alone.

Yet the culture of contraception is not always sensible. How, for example, does one make sense of the choices made by Isabel Alvarez? She came to the United States with her family when she was 7. She attended school here. Her English is almost as fluent as her Spanish. She returned to El Salvador once in her life and was appalled: “Everything was so different from here.” No stranger to America's health care system, she takes her children to a local clinic.

In short, Isabel is exceedingly Americanized—yet she obtains her contraceptives from Sylvia, the Cardozo curandera.

If she wants injections, why not visit Planned Parenthood? As it happens, Isabel says she has been to Planned Parenthood.

“They take blood and I don't like that,” she says, shuddering. “They took blood away from me, and they don't do anything. I was going to get the Norplant. First, they take your blood away from you, and then they tell you they can't do the Norplant.”

Isabel never returned to Planned Parenthood for the results of her blood test, and now she's not sure she would have wanted Norplant anyway. “My sister has the Norplant,” she confides. “My friend has the Norplant, too, and they get so skinny! They're like a bone. They get so pale. I said to my sister: "What's wrong with you? You gonna die or something?' ”

Isabel laughs at the thought of her skinny sister. (In fact, weight loss is not one of Norplant's common side-effects; if anything, it causes a woman to gain weight and, like Depo-Provera, disrupts her period.) Norplant also made her sister's menses quite heavy—so heavy that she had the device removed by the same clinic that had implanted it, in an hour-long procedure during which the six hormone-secreting rods were cut out of her skin.

“And you know what?” Isabel continues dramatically. “They couldn't find one of those things.” She means that the doctor couldn't find one of the Norplant rods. “They are bad. I wouldn't recommend it.

“I would want to be skinny,” she says, “but not that skinny.”

Lolling on a couch in her apartment on a hot afternoon, Isabel, 19, keeps an eye on her baby daughter, Angela, while her 2-year-old son, Frankie, watches Pinocchio on the VCR with a friend. When Isabel was younger, she neglected to use any birth control at all. As a result, Frankie was born when she was 16, prompting her to drop out of school. After Frankie's birth, she was given birth control pills by the clinic. But the pills made her “even more fat,” she says, and she didn't take them reliably.

“I was working, and it was hard—I was forgetting. I used to work in a part-time job from 10 in the morning to 12 at night.” She was so tired that she forgot to take her pill, not once but “a couple of times.”

She became pregnant again, and gave birth to Angela in January 1993. At that point, her Salvadoran mother-in-law told her about the curandera, and Isabel began to get the injections. She asked Sylvia for the three-month shot, “but she said to use the one[-month] because I would go out of control—I would be fading, what do you call it? Fainting. I would be fainting, I might bleed too much.”

Isabel recalls that Sylvia asked her a few questions about her health, and told her about some of the drug's side effects. “She told me that my period might come twice a month, and it is true. But not all the time. And I have gained weight.”

Isabel didn't mind. She thinks the injections are fine. “I like it better than anything,” she says. Isabel's cousin gets the injections, too, from a curandera in Rockville.

The phone rings, and Isabel disappears into the bedroom, cradling the receiver and chatting endlessly like the teen-ager she is. The bed is heaped with fragrant piles of freshly washed and folded kids' clothes. It is 6 p.m., and Isabel has been doing laundry all day, her day off work as a cashier at a fast-food restaurant. Her husband works two jobs, as a laborer and a cook. The bedroom—where the family sleeps—contains a bed, two dressers, a crib, and a window air-conditioning unit. There are more kids' clothes hanging in the closet.

When she finally returns to the living room, Frankie and his friend have emptied an entire box of baby wipes. Isabel laughs and stuffs them back into the box. Childlike herself, she obviously enjoys her children. “I usually call him Poppy,” she says affectionately of Frankie. Nodding toward Angela: “And I call her Mommy. I don't know why.”

But she's not sure that she wants to have any more children. She is under the impression that in four years, she will be old enough to be sterilized. “You know they can operate on you when you're 23. Do you think I should get the operation? Do you think that's all right?”

When I venture that she should wait, Isabel flings herself into an armchair. “That's what my aunt says,” she remarks. Her feet are bare. She apologizes for the flies that are buzzing around the apartment. “There are no, what do you call them? Screens.”

Apart from the heat and the flies, the apartment is comfortable, with wall-to-wall beige carpeting, a slipcovered couch and armchairs, an entertainment center with a television set, a galley kitchen with a gas stove. Isabel and her family share the place with two Salvadoran men. I ask her if she discusses contraception with her husband. She nods.

“He is the one who reminds me: "Remember to go and get it.' He reminds me, "You have to go get that thing.' ”

Isabel's mother-in-law reminds her, too. The older woman procures all of her medications from the curandera, refusing to visit a doctor for any reason.

“I told her, "You should go to a clinic,' ” Isabel says lightly. “She doesn't want to go.”

Culture is a powerful thing, and so is cultural alienation: Every time Isabel takes her kids for medical care, the clinicians urge her to use legal contraception. But for now—with one foot in the new world and another in the old—Isabel would rather receive the injection from an unlicensed practitioner who speaks her language, addresses her kindly, and doesn't insist upon taking blood. Isabel, in all her contradictions, suggests that the task of the health educators is not going to be easy—not as long as there are accommodating curanderas like Sylvia.

a inyección?” says a child. The child is reclining on the first-floor windowsill of the Cardozo apartment building; her feet are stretched out on an inner ledge, her face barely visible behind a window screen. Apparently it does not seem odd to her that outside, in the building's courtyard, two unfamiliar women—one Anglo, one Cuban—are standing in the dirt, asking to be let inside.

The women are myself and Lydia Beruff. Isabel has told us that Sylvia lives in this building; she couldn't remember the apartment number, but said simply to go and ask. So here we are in the courtyard, along with a motley assortment of other creatures: a tortoise-shell cat picking its way uncertainly through the weeds, a couple of men washing a car, another man peacefully rolling a joint.

,” says Lydia to the child. “Sylvia. La inyección.”

Uno momento,” says the child, disappearing.

The child reappears at the door and buzzes us inside. She ushers us to a chipped brown metal door on the right side of the dim first-floor corridor, then disappears into an apartment on the left. We knock on the door to which the child has led us. There is no answer. We knock again, a friendly rap, dum-de-dum-dum, dum-dum. Just when we are turning to go, the door is opened by Sylvia, the woman we have come to see.

She is a tiny woman, barely 5 feet tall. Behind her we glimpse an amply furnished living room, almost too small for all the things it contains. These include two upholstered couches, several hooked rugs, a wooden coffee table, a big-screen TV, and a window air-conditioning unit that blasts frigid air out the door. On the coffee table, a cordless phone rests atop an appointment book and a Macy's catalog. A little boy plays beside one of the sofas; in the middle of the wooden floor is a crib containing a baby.

Sylvia, who looks to be around 40 years old, stares at us with impassive eyes. She is wearing an orange shirt, a flowered skirt, thong sandals, and a great deal of gold: gold earrings, gold necklaces, and several gold bracelets that flash in and out of sight. She watches closely as Lydia lets loose with a flood of Spanish, I hear words like periódico and inyección, and then Lydia is asking me to produce the copies of Washington City Paper that we have brought along, as well as a City Paper T-shirt. Sylvia places these little tokens of good faith on the back of one of the couches and looks at us again, wholly unimpressed.

Lydia asks if we may come in. Sylvia says no several times, but does not dismiss us. What ensues is a polite standoff: For almost an hour we hold our positions at the door, all three of us very courteous, as the air-conditioned air gusts past us. Sylvia acknowledges that she gives la inyección to women who visit her in the apartment. She repeatedly denies, however, that she sells the injections, insisting that her clients bring the shots themselves. She charges $2 for the service, she asserts, though she will inject friends for free.

But her denial is mingled with a justification of her trade: “I was known in El Salvador as a nurse, and when I came up here people knew me,” she tells us. “I only do it for people that I know, for Salvadorans. They come here because they are familiar with me.

“When I first came here,” she says meaningfully, “my sons did not want me to do the injection. They said people are not sincere, and I was afraid to get in trouble. But my friends came to me, and they wanted me to do it.”

We ask her how she learned to inject. She says that she received her training at a Salvadoran pharmacy, from the husband of her comadre, or godmother. She didn't practice on, say, a grapefruit; she just did it. “I did it well,” she says, “but I was scared.”

She is scared now. There are little beads of sweat on her forehead. We are all sweating. Behind us there is movement: A woman and some men peep around the corner of the alcove, but Sylvia claims not to know them. Continuing the discussion about the injections, she warns that one must be very careful. “You can hit a nerve and the person can become paralyzed.” Or the injection may abscess: “If it turns red and then turns white, you have to gash it and stitch it up.”

She does not approve of the curanderas who profess to sell nonexistent six-month injections; these, she says, are merely a three-month dose. “There's a lot of lying going on,” she says direly. She also believes that some of her clients will lie to her, telling her they have had their period when in fact they are pregnant and hope the shot may end the pregnancy. And she shuns women who inject themselves. “I keep silent when women say, "I inject myself, it's so simple to do.' I just keep silent. I do not deal with women who inject themselves—you don't know what they've gotten, or when they've injected themselves.” Before she gives the injection, Sylvia says, she asks the women if they have any allergies. She will administer the shots to older women and to women who smoke, but advises “nervous” women not to take it.

“People who have nervous conditions should not get it—nervous disorders. It's not for people who are very nervous.”

About then the baby starts to cry. She picks him up, explaining that she keeps these two children all day, five days a week. Then she says we've taken up enough of her time. We ask again if she procures the one-month injections from a source in Central America, telling her that we are curious about a drug that North American women are deprived of.

“Well, then,” she says, “why don't you ask the woman who told you about me to show you hers.” It is a clever answer. She is a clever woman. She has to be.

Later that day, I talk to Isabel. She has just obtained the shot from Sylvia, purchasing the medicine for the usual $18, and having it injected in her back bedroom.

Isabel says that her skinny sister plans to start getting la inyección as well.

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