Red Commissar
1st July 2014, 22:16
For those of you not familiar with Texas's most recent laws passed concerning abortion, they were put into effect in Texas's session that took place last year (Texas's legislature only meets for a few weeks every other year). That year Texas sought to pass restrictive abortion standards, cynically disguised as seeking to protect women from abuses in abortion clinics (yes, that's how they were selling it), which was boosted by the media coverage of the Dr. Kermit Gosnell case.
As a summary (http://www.revleft.com/vb/texas-legislature-passes-t181949/index.html?t=181949) of the law's provisions
Abortions are banned after 20 weeks. This was under the logic of fetal pain that has become common in anti-choice circles. An amendment by a Republican legislator to exempt those who were raped or victims of incest from this was shot down by her fellow senators.
Enforces restrictions on access to abortion to minors, stipulating they need the approval of their family or other legal guardian.
Requires abortions to be administered under an outdated FDA guideline requiring a significantly higher dose of Mifeprex. Most if not all abortion providers use more recent, evidence-based techniques and standards which allow for a significantly smaller dose of Mifeprex that is more safe for the woman.
Abortion clinics must have hospital admitting privileges to clinics within 30 miles of their practice.
All abortion clinics must meet the standards of ambulatory surgical centers. Only 5 of the 42 abortion clinics in Texas are believed to meet this standard, and it's believed most of those that don't do not have the funds to upgrade their centers by the time the law takes effect. They will be forced to close if they do not meet these standards.
The last two in particular caused the most problems, as it was basically a way for the Texas government to indirectly ban abortion in the state by making it hard for providers to actually operate. A legal challenged was launched against the admission privileges portion, but this was shot down by the US 5th circuit court. Likewise, a lot of Democratic politicians avoid mentioning abortion or making it a major point of their campaign as it is a third rail in Texas politics- at least among those who routinely show up to vote. This is to such an extent that Wendy Davis, who as a state senator launched a filibuster to try and block the passage of the abortion law (and got her national recognition), has not made the issue a topic in her long-shot of a gubernatorial campaign in an attempt to appeal to the Texas electorate.
The result of this is that with no real options in the state government, that women are now seeking alternatives to seek an abortion. There is the problem with back-alley abortions, but what has been of interest is that the drug Misoprostol has started appearing more in Texas circles. Misoprostol, originally sold as an ulcer-treating drug, has been used as a DIY abortion of sorts in many Latin American countries where obstacles to abortion exist. Sales of the drug have picked up in border areas of Texas, where the new abortion laws were the harshest as there were few in those areas to begin with, and were unable to meet the new burdens the state placed on them. With remaining abortion clinics further away and more expensive, Miso is a cheaper alternative and one less visible.
Miso is safer than the alternatives that some get when an abortion clinic is unavailable, but there is still a potential problem as there is not clear instructions how to take the drug to induce an abortion, as such instructions are passed by word-of-mouth, either between individuals or through the internet.
This is a long article about the rise of Miso in Texas and how it came on the heels of successive laws passed restricting abortion. It is an interesting read, but I've highlighted some portions below
http://www.theatlantic.com/health/archive/2014/06/the-rise-of-the-diy-abortion-in-texas/373240/
As policies restricting access to abortion roll out in Texas and elsewhere, the use of miso is quickly becoming a part of this country’s story. It has already made its way into the black market here in Texas’s Rio Grande Valley (http://www.bloomberg.com/news/2013-07-11/flea-market-abortions-thrive-as-texas-may-close-clinics.html), where abortion restrictions are tightening, and it is likely to continue its trajectory if anti-abortion legislation does not ease up (http://lsrj.org/documents/factsheets/13_State_Laws_Regulating_Repro_Rights.pdf) and clinics continue to be closed.
Over the past several years, dozens of states have restricted abortions. Since 2011, at least 73 abortion clinics in the nation have shut down (http://www.businessweek.com/articles/2013-11-27/abortion-clinics-face-shutdown-spiral-as-republicans-push-restrictions) or stopped providing services; and more than 200 abortion restrictions (http://www.guttmacher.org/statecenter/updates/2013/statetrends42013.html) were legislated throughout the nation. Despite the passage of Roe v. Wade more than 40 years ago, states with pro-life politicians are still gunning to reverse the ruling—in the words of Rick Perry in 2012 (http://governor.state.tx.us/news/speech/17959/), “my goal is to make abortion, at any stage, a thing of the past.”
Ironically, misoprostol was never developed to induce abortions: Instead, it was created and marketed as an ulcer medication called Cytotec. The drug (http://www.rxlist.com/cytotec-drug.htm), a synthetic prostaglandin E1 analog, has many medical uses (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760893/): It’s taken to prevent and treat ulcers, induce labor, induce abortions, and treat post-partum hemorrhage. In 1986, misoprostol was approved for sale (http://www.ipas.org/%7E/media/Files/Ipas%20Publications/MISOLAC2E10.ashx) in Brazilian pharmacies as an ulcer medication and was distributed over-the-counter. But its use as an abortion-inducing drug spread rapidly, and slipped below the radar at first. Like many drugs, misoprostol’s label had a simple warning (http://rhrealitycheck.org/article/2013/05/28/why-arent-we-taking-advantage-of-the-potentially-game-changing-drug-misoprostol/): Do not take if pregnant.
But not everyone heeded the warning, including a number of Brazilian women who read the drug’s packaging and decided to try their luck. Or that’s how the story goes. Nobody knows exactly what happened (http://www.jstor.org/discover/10.2307/2939191). Some believe that certain Brazilian women made this discovery on their own; others say that a select few pharmacists who knew that Cytotec could induce abortions secretly spread the word. Regardless of who uncovered its power, the pill was precisely what women needed: a magic personal solution to a dreaded problem that dared not be discussed.
...
As miso became more popular, Latin American doctors from Peru to Brazil started noticing a trend: They were seeing, it seemed, a dramatic decrease in abortion-related complications. Fewer women were carted through hospital doors with gruesome infections from back-alley botched abortions, and ob-gyns saw a reduction in the grisly abortion complications that had so frequently plagued providers, including perforated uteruses, heavy bleeding, and fallen intestines, according to a 2012 study by the global health organization Ipas
...
Public pressure to regulate the drug in Brazil mounted (http://www.nytimes.com/1993/05/19/health/ulcer-drug-tied-to-numerous-abortions-in-brazil.html), and in May 1991, the state of Rio de Janeiro restricted miso’s use to hospitals, while the state of Ceara imposed a total ban on its sales. On July 17, 1991, the Ministry of Health required that the purchase of miso had to be accompanied by a prescription from a physician, and made a deal with Biolab Laboratories to reduce the availability of the drug. In 1992, miso’s public availability in the State of Sao Paulo was restricted to authorize pharmacies registered with local government authorities. Today, it’s difficult—but not impossible— (http://www.womenonwaves.org/en/page/2812/brazil)to get the drug in Brazil (http://repositorio.unb.br/bitstream/10482/14970/1/ARTIGO_CytotecAbortoPol%25C3%25ADcia.pdf). Traffickers sell it on the black market and online, but it can be prohibitively expensive (according to a recent Al Jazeera article (http://america.aljazeera.com/features/2014/5/brazil-s-abortionnightmare.html), one pill can cost up to $60 (http://america.aljazeera.com/features/2014/5/brazil-s-abortionnightmare.html)), and when it is sold online, it’s often counterfeit (http://www.womenonwaves.org/en/page/974/warning-fake-abortion-pills-for-sale-online).
But miso is still commonly used in Brazil, and it accounts for nearly half (http://america.aljazeera.com/features/2014/5/brazil-s-abortionnightmare.html) of the country’s one million annual abortions (http://bigstory.ap.org/article/brazil-doctors-urge-legalization-abortion). As these numbers reveal, many of the women in Brazil and Latin America had welcomed miso in the absence of safer options. Now, more than three decades later, the secret has made its way to the United States.
Many of these women can be found in the Rio Grande Valley, where the admitting privileges provision forced both of the county’s abortion clinics to shut down (http://www.dallasnews.com/news/state/headlines/20140305-last-abortion-clinic-in-the-rio-grande-valley-closes.ece). Now, the closest clinic for the region’s one-million-plus residents is 150 miles away. For many poor, uninsured South Texas women, that distance is beyond feasible. Few have access to a set of wheels for the long haul, and others lack the right paperwork to cross immigration checkpoints on highways that run through the state.
...
In the United States, miso is prescribed and sold legally in combination with another pill called mifepristone (or RU-486) for early nonsurgical abortion. The drug, which is also called Mifeprex, (http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandprovi ders/ucm111323.htm) was approved (http://www.guttmacher.org/statecenter/spibs/spib_MA.pdf) by the U.S. Food and Drug Administration (FDA) in 2000, can only be taken in the early stages of pregnancy (within 49 days of a woman’s last menstrual period).
The miso/mife combination is becoming increasingly popular: In 2011, it accounted (http://www.guttmacher.org/pubs/fb_induced_abortion.html) for 36 percent of all abortions before nine weeks of gestation, and it’s often considered the gold standard of medication abortion, with an estimated success rate (http://www.guttmacher.org/pubs/gpr/16/1/gpr160118.html) that is nearly 10 percent higher than using miso alone (92 to 95 percent (http://www.gao.gov/new.items/d08751.pdf) and 80 to 85 percent (http://iwhc.org/resource/abortion-self-administered-misoprostol-guide-women/), respectively). Because of this, the FDA has never approved the use of misoprostol alone. After all, some say, why promote a silver standard when the gold is available?
...
But the “silver standard” is readily available without a prescription. In Mexico, miso is sold over the counter as an ulcer medication (in the U.S., it’s only available with a prescription) creating the perfect conditions for black market sales in the United States. And while no abortion clinics remain in the Valley, the Mexican town of Reynosa is just across the nearby border. There, miso can be bought in bulk at Mexican pharmacies and snuck back over the border into Texas, where it’s sold undercover at sprawling flea markets like the one I’m searching in today.
“Ok. Um, do you have something to make your period come back? I need to bring it back,” I trail off, scrutinizing his face for expression. “Cytoteca,” I say firmly, annunciating the teca in the familiar Spanish style. “Do you have it?”
He exhales dramatically.
“Not anymore. I haven’t had it since the police came,” he huffs, referring to a Valley flea market raid last August (http://www.themonitor.com/news/local/article_52cefcb6-0541-11e3-9ea5-0019bb30f31a.html) in Donna, Texas, where sheriffs uncovered a host of counterfeit drugs, including the diet pill Redotex and Viagra.
Shortly after, a woman was arrested for illegally selling thousands of prescription drugs (http://www.krgv.com/news/police-illegal-pharmacy-operated-for-3-years-in-san-juan/) nearby. (The drugs may be over the counter when bought in Mexico, but they are prescription drugs in the U.S. and illegal to distribute.) Though miso wasn’t uncovered in any of the raids, the overall crackdowns—and amped up policing—have made vendors wary of selling the pill. Lopez, who appears to have relaxed his caution, says the market was booming up until those raids.
"When I first found out how many women were asking for it, I couldn’t believe it,” he recalls. “The market had tons of people selling the pill, and I still got asked for it so many times. Almost every time I was here, someone asked me for it."
McAllen’s [this is a city in South Texas, near the border] Whole Women’s Health stopped providing abortion services after the admitting privileges provision went into effect and shut down entirely in March.
“It’s just the beginning,” the center’s former patient advocate, Luzevlia Carreon, observes. “It’s in demand right now. It’s what our patients are doing and they’re going to continue taking it. … The fact of the matter is that women are going to get pills and are going to figure out ways to have an abortion.”
HB2 took the community by surprise, Carreon says. Many had relied on the clinic for years.
“They were so shocked when they found out we weren’t offering abortions anymore. I even have patients that call, and after we tell them that we can’t offer abortions anymore, they’ll just say, 'That’s fine. I’m going to figure out a way to do this on my own.' And imagine all the women who don’t call us at all, who are still taking [miso],” she sighs. “We have no idea how many are doing this. We just hope for the best.”
In Latin America, miso was a secretive lifeline for many women without means to have other options. Now that the same is happening in the United States, the phenomenon is even more underground here. The networks are just starting to develop and proper information about dosage is not widely available. Moreover, those in the know appear hesitant to distribute material—much of which is circulated around Latin America (http://www.womenonwaves.org/en/page/2583/safe-abortion-hotlines)—about how to safely take the drug.
...
But miso’s safety is also a function of the information that comes with it. In Texas’s Rio Grande Valley, according to Carreon and others, many women are using the drug improperly because they don’t have access to basic facts about the correct dosage. That ignorance can lead to problems.
One woman I interviewed at a Mexican restaurant in Brownsville told me her good friend nearly died after taking pills that her husband bought in Mexico. Instead of ingesting four of the 12 pills every three hours, as is recommended by the World Health Organization (http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf?ua=1), she took two pills under her tongue, then four pills vaginally, then two more under her tongue, then four more vaginally. She began to bleed profusely, doubled over in pain. But because she was undocumented, she was afraid to seek medical help at a nearby hospital or clinic. Instead, she crossed the border to Mexico with her five children—all the while hemorrhaging—in search of medical assistance. She has since recovered but is still in Mexico with her children because she can’t cross the border back into the United States.
Once I crossed over [El Paso to Juarez], I stepped inside a yellow building called Farmacia del Ahorro del Mexico and asked if I could purchase Cytoteca. “No problem,” the pharmacist said, punching a few letters into the keyboard. A couple seconds later, an estimate popped up: $48 U.S. for four pills, or around $150 for the dosage of 12. Down the street, two other pharmacists gave me similar estimates, ranging from $125 to $177, the latter two for a full bottle of 28 pills.
While I didn’t take the pharmacists up on their offer, all three were able to dispense the pills for me immediately, though none of the dosages came with instructions about how to use the pills for an abortion. Misoprostol is only sold in Mexican pharmacies as an ulcer medication, and while pharmacists are aware that women are using it for other reasons, they can’t provide information about how to terminate a pregnancy with the pill. After all, abortion is restricted outside of Mexico City.
In the late '90s, the Internet spread throughout Latin America, ushering in an era of rapid, real-time communication. Suddenly, information about miso was catapulted onto the web. Websites about the drug—where to purchase it, how to use it, and even businesses offering home delivery—began to pop up, but activists wanted to make sure that the information women were getting was correct. So they thought of a practical solution.
Activists, feminists, and abortion advocates grouped together and began creating volunteer-staffed phone hotlines (http://www.womenonwaves.org/en/page/2583/safe-abortion-hotlines). These small, often DIY networks promoted miso use and distributed information about the drug, and many of them still exist today. They’re often run by volunteers who give anonymous callers medical information about miso, like how to take the 12-pill regimen and when to be concerned about adverse reactions to the drug. Hotline workers raise awareness about their services through informal, word-of-mouth networks and social media.
The hotlines have made—and continue to make—an impact on women living in countries with some of the world’s strictest abortion legislation. In Chile, where abortion is illegal without exceptions, a hotline called Linea Aborto Libre (http://infoabortochile.org/) has had considerable success. It’s staffed by a group of young feminists who take turns passing around a compact cellphone. If they’re not careful, their work could land them behind bars: Getting an abortion in Chile—or telling a woman how to do so—is a crime punishable by three to five years in jail. To avoid legal prosecution, hotline volunteers read information about misoprostol abortions that’s publicly available on the WHO (World Health Organization) website. (http://apps.who.int/rhl/fertility/abortion/dgguide/en/)
(http://apps.who.int/rhl/fertility/abortion/dgguide/en/)
Chile’s not the only Latin American country with a hotline; similar ones exist in Argentina (http://www.abortoconpastillas.info/), Ecuador (http://jovenesdespenalizacionaborto.wordpress.com/), Peru (http://lineabortoinfosegura.blogspot.com/) and Venezuela (http://infoseguraborto.blogspot.nl/). There are well-known websites like Women on Web, an international collective that provides information about self-induction and sends misoprostol to women in countries with restrictive abortion laws. Women on Waves (http://www.womenonwaves.org/), a Dutch NGO, performs medical abortions on a ship that sails to countries where abortion is illegal.
While it appeared that the raids earlier this year had ended miso sales at the flea markets, there are other ways to get it besides crossing the border into Mexico.
Buy-pharma.com, for example, sells one 200-mcg pill for $2 (http://www.buy-pharma.com/Generic-Cytotec-Misoprostol-p-156.html) (or a package of eight for $16). On the Facebook page “Cytotec misoprostol,” (https://www.facebook.com/cytotec.misoprostol.750?fref=ts) a user can request to buy the pills from the page’s administrator, who sells 12 pills for $950 pesos ($73.05).
But often it’s nearly impossible to verify the reliability of these pills. Surfing the net for miso through search terms like “abortion pills online” yields pages of results from online pharmacies—some of which are carefully constructed to look like the buyer is in good hands.
Advocates don’t promote the use of these sites. A page on the Women on Waves website warns against buying the pills online (http://www.womenonwaves.org/en/page/974/warning-fake-abortion-pills-for-sale-online), and it outlines a long list of doctors and pharmacy websites notorious for selling counterfeit medications.
...
Despite the cautionary advertising, some still choose to purchase medications advertised as miso online. Molly, a feminist abortion advocate who preferred not to use her real name, buys miso and RU-486 (a.k.a “the gold standard”) in mass quantities from online pharmacies and sends it to women in the United States who want to use the drugs but don’t know how to go about getting them.
Back in Texas, HB2, the state’s strict new abortion law, shows no signs of letting up.
In March (http://bigstory.ap.org/article/us-appeals-court-upholds-new-texas-abortion-rules), the U.S. 5th Circuit Court ruled unanimously that the admitting privileges provision in HB 2, which led to the closures of clinics in the Valley and elsewhere, “does not impose an undue burden on the life and health of a woman." Since the law went into effect, the state’s number of licensed abortion providers dropped from 40 to 28 (http://www.texastribune.org/2014/03/19/impact-hb2-regulations-abortion-facilities-over-time/), and only 24 centers (http://www.texastribune.org/2014/03/06/whole-womans-shutters-mcallen-and-beaumont-clinics/) still offer the surgical procedure.
And in September, another portion of HB2 will go into effect, which requires all abortion providers to conform to the same standards as ambulatory surgical centers—a costly upgrade that is expected to shut down the majority of the state's remaining clinics. When this portion of the law goes into effect, the number of abortion facilities in the state is expected to drop to six.
Today in Texas things are starting to look a lot like the early years of miso in places like Brazil and Chile: The simple guidelines about miso haven't yet made it to women in the state. But eventually, in those countries, the Internet and the democratization of information prevailed. Unless, and until, abortion restrictions change again, Latin America’s DIY-abortion culture might be the future of women in South Texas.
As a summary (http://www.revleft.com/vb/texas-legislature-passes-t181949/index.html?t=181949) of the law's provisions
Abortions are banned after 20 weeks. This was under the logic of fetal pain that has become common in anti-choice circles. An amendment by a Republican legislator to exempt those who were raped or victims of incest from this was shot down by her fellow senators.
Enforces restrictions on access to abortion to minors, stipulating they need the approval of their family or other legal guardian.
Requires abortions to be administered under an outdated FDA guideline requiring a significantly higher dose of Mifeprex. Most if not all abortion providers use more recent, evidence-based techniques and standards which allow for a significantly smaller dose of Mifeprex that is more safe for the woman.
Abortion clinics must have hospital admitting privileges to clinics within 30 miles of their practice.
All abortion clinics must meet the standards of ambulatory surgical centers. Only 5 of the 42 abortion clinics in Texas are believed to meet this standard, and it's believed most of those that don't do not have the funds to upgrade their centers by the time the law takes effect. They will be forced to close if they do not meet these standards.
The last two in particular caused the most problems, as it was basically a way for the Texas government to indirectly ban abortion in the state by making it hard for providers to actually operate. A legal challenged was launched against the admission privileges portion, but this was shot down by the US 5th circuit court. Likewise, a lot of Democratic politicians avoid mentioning abortion or making it a major point of their campaign as it is a third rail in Texas politics- at least among those who routinely show up to vote. This is to such an extent that Wendy Davis, who as a state senator launched a filibuster to try and block the passage of the abortion law (and got her national recognition), has not made the issue a topic in her long-shot of a gubernatorial campaign in an attempt to appeal to the Texas electorate.
The result of this is that with no real options in the state government, that women are now seeking alternatives to seek an abortion. There is the problem with back-alley abortions, but what has been of interest is that the drug Misoprostol has started appearing more in Texas circles. Misoprostol, originally sold as an ulcer-treating drug, has been used as a DIY abortion of sorts in many Latin American countries where obstacles to abortion exist. Sales of the drug have picked up in border areas of Texas, where the new abortion laws were the harshest as there were few in those areas to begin with, and were unable to meet the new burdens the state placed on them. With remaining abortion clinics further away and more expensive, Miso is a cheaper alternative and one less visible.
Miso is safer than the alternatives that some get when an abortion clinic is unavailable, but there is still a potential problem as there is not clear instructions how to take the drug to induce an abortion, as such instructions are passed by word-of-mouth, either between individuals or through the internet.
This is a long article about the rise of Miso in Texas and how it came on the heels of successive laws passed restricting abortion. It is an interesting read, but I've highlighted some portions below
http://www.theatlantic.com/health/archive/2014/06/the-rise-of-the-diy-abortion-in-texas/373240/
As policies restricting access to abortion roll out in Texas and elsewhere, the use of miso is quickly becoming a part of this country’s story. It has already made its way into the black market here in Texas’s Rio Grande Valley (http://www.bloomberg.com/news/2013-07-11/flea-market-abortions-thrive-as-texas-may-close-clinics.html), where abortion restrictions are tightening, and it is likely to continue its trajectory if anti-abortion legislation does not ease up (http://lsrj.org/documents/factsheets/13_State_Laws_Regulating_Repro_Rights.pdf) and clinics continue to be closed.
Over the past several years, dozens of states have restricted abortions. Since 2011, at least 73 abortion clinics in the nation have shut down (http://www.businessweek.com/articles/2013-11-27/abortion-clinics-face-shutdown-spiral-as-republicans-push-restrictions) or stopped providing services; and more than 200 abortion restrictions (http://www.guttmacher.org/statecenter/updates/2013/statetrends42013.html) were legislated throughout the nation. Despite the passage of Roe v. Wade more than 40 years ago, states with pro-life politicians are still gunning to reverse the ruling—in the words of Rick Perry in 2012 (http://governor.state.tx.us/news/speech/17959/), “my goal is to make abortion, at any stage, a thing of the past.”
Ironically, misoprostol was never developed to induce abortions: Instead, it was created and marketed as an ulcer medication called Cytotec. The drug (http://www.rxlist.com/cytotec-drug.htm), a synthetic prostaglandin E1 analog, has many medical uses (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760893/): It’s taken to prevent and treat ulcers, induce labor, induce abortions, and treat post-partum hemorrhage. In 1986, misoprostol was approved for sale (http://www.ipas.org/%7E/media/Files/Ipas%20Publications/MISOLAC2E10.ashx) in Brazilian pharmacies as an ulcer medication and was distributed over-the-counter. But its use as an abortion-inducing drug spread rapidly, and slipped below the radar at first. Like many drugs, misoprostol’s label had a simple warning (http://rhrealitycheck.org/article/2013/05/28/why-arent-we-taking-advantage-of-the-potentially-game-changing-drug-misoprostol/): Do not take if pregnant.
But not everyone heeded the warning, including a number of Brazilian women who read the drug’s packaging and decided to try their luck. Or that’s how the story goes. Nobody knows exactly what happened (http://www.jstor.org/discover/10.2307/2939191). Some believe that certain Brazilian women made this discovery on their own; others say that a select few pharmacists who knew that Cytotec could induce abortions secretly spread the word. Regardless of who uncovered its power, the pill was precisely what women needed: a magic personal solution to a dreaded problem that dared not be discussed.
...
As miso became more popular, Latin American doctors from Peru to Brazil started noticing a trend: They were seeing, it seemed, a dramatic decrease in abortion-related complications. Fewer women were carted through hospital doors with gruesome infections from back-alley botched abortions, and ob-gyns saw a reduction in the grisly abortion complications that had so frequently plagued providers, including perforated uteruses, heavy bleeding, and fallen intestines, according to a 2012 study by the global health organization Ipas
...
Public pressure to regulate the drug in Brazil mounted (http://www.nytimes.com/1993/05/19/health/ulcer-drug-tied-to-numerous-abortions-in-brazil.html), and in May 1991, the state of Rio de Janeiro restricted miso’s use to hospitals, while the state of Ceara imposed a total ban on its sales. On July 17, 1991, the Ministry of Health required that the purchase of miso had to be accompanied by a prescription from a physician, and made a deal with Biolab Laboratories to reduce the availability of the drug. In 1992, miso’s public availability in the State of Sao Paulo was restricted to authorize pharmacies registered with local government authorities. Today, it’s difficult—but not impossible— (http://www.womenonwaves.org/en/page/2812/brazil)to get the drug in Brazil (http://repositorio.unb.br/bitstream/10482/14970/1/ARTIGO_CytotecAbortoPol%25C3%25ADcia.pdf). Traffickers sell it on the black market and online, but it can be prohibitively expensive (according to a recent Al Jazeera article (http://america.aljazeera.com/features/2014/5/brazil-s-abortionnightmare.html), one pill can cost up to $60 (http://america.aljazeera.com/features/2014/5/brazil-s-abortionnightmare.html)), and when it is sold online, it’s often counterfeit (http://www.womenonwaves.org/en/page/974/warning-fake-abortion-pills-for-sale-online).
But miso is still commonly used in Brazil, and it accounts for nearly half (http://america.aljazeera.com/features/2014/5/brazil-s-abortionnightmare.html) of the country’s one million annual abortions (http://bigstory.ap.org/article/brazil-doctors-urge-legalization-abortion). As these numbers reveal, many of the women in Brazil and Latin America had welcomed miso in the absence of safer options. Now, more than three decades later, the secret has made its way to the United States.
Many of these women can be found in the Rio Grande Valley, where the admitting privileges provision forced both of the county’s abortion clinics to shut down (http://www.dallasnews.com/news/state/headlines/20140305-last-abortion-clinic-in-the-rio-grande-valley-closes.ece). Now, the closest clinic for the region’s one-million-plus residents is 150 miles away. For many poor, uninsured South Texas women, that distance is beyond feasible. Few have access to a set of wheels for the long haul, and others lack the right paperwork to cross immigration checkpoints on highways that run through the state.
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In the United States, miso is prescribed and sold legally in combination with another pill called mifepristone (or RU-486) for early nonsurgical abortion. The drug, which is also called Mifeprex, (http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandprovi ders/ucm111323.htm) was approved (http://www.guttmacher.org/statecenter/spibs/spib_MA.pdf) by the U.S. Food and Drug Administration (FDA) in 2000, can only be taken in the early stages of pregnancy (within 49 days of a woman’s last menstrual period).
The miso/mife combination is becoming increasingly popular: In 2011, it accounted (http://www.guttmacher.org/pubs/fb_induced_abortion.html) for 36 percent of all abortions before nine weeks of gestation, and it’s often considered the gold standard of medication abortion, with an estimated success rate (http://www.guttmacher.org/pubs/gpr/16/1/gpr160118.html) that is nearly 10 percent higher than using miso alone (92 to 95 percent (http://www.gao.gov/new.items/d08751.pdf) and 80 to 85 percent (http://iwhc.org/resource/abortion-self-administered-misoprostol-guide-women/), respectively). Because of this, the FDA has never approved the use of misoprostol alone. After all, some say, why promote a silver standard when the gold is available?
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But the “silver standard” is readily available without a prescription. In Mexico, miso is sold over the counter as an ulcer medication (in the U.S., it’s only available with a prescription) creating the perfect conditions for black market sales in the United States. And while no abortion clinics remain in the Valley, the Mexican town of Reynosa is just across the nearby border. There, miso can be bought in bulk at Mexican pharmacies and snuck back over the border into Texas, where it’s sold undercover at sprawling flea markets like the one I’m searching in today.
“Ok. Um, do you have something to make your period come back? I need to bring it back,” I trail off, scrutinizing his face for expression. “Cytoteca,” I say firmly, annunciating the teca in the familiar Spanish style. “Do you have it?”
He exhales dramatically.
“Not anymore. I haven’t had it since the police came,” he huffs, referring to a Valley flea market raid last August (http://www.themonitor.com/news/local/article_52cefcb6-0541-11e3-9ea5-0019bb30f31a.html) in Donna, Texas, where sheriffs uncovered a host of counterfeit drugs, including the diet pill Redotex and Viagra.
Shortly after, a woman was arrested for illegally selling thousands of prescription drugs (http://www.krgv.com/news/police-illegal-pharmacy-operated-for-3-years-in-san-juan/) nearby. (The drugs may be over the counter when bought in Mexico, but they are prescription drugs in the U.S. and illegal to distribute.) Though miso wasn’t uncovered in any of the raids, the overall crackdowns—and amped up policing—have made vendors wary of selling the pill. Lopez, who appears to have relaxed his caution, says the market was booming up until those raids.
"When I first found out how many women were asking for it, I couldn’t believe it,” he recalls. “The market had tons of people selling the pill, and I still got asked for it so many times. Almost every time I was here, someone asked me for it."
McAllen’s [this is a city in South Texas, near the border] Whole Women’s Health stopped providing abortion services after the admitting privileges provision went into effect and shut down entirely in March.
“It’s just the beginning,” the center’s former patient advocate, Luzevlia Carreon, observes. “It’s in demand right now. It’s what our patients are doing and they’re going to continue taking it. … The fact of the matter is that women are going to get pills and are going to figure out ways to have an abortion.”
HB2 took the community by surprise, Carreon says. Many had relied on the clinic for years.
“They were so shocked when they found out we weren’t offering abortions anymore. I even have patients that call, and after we tell them that we can’t offer abortions anymore, they’ll just say, 'That’s fine. I’m going to figure out a way to do this on my own.' And imagine all the women who don’t call us at all, who are still taking [miso],” she sighs. “We have no idea how many are doing this. We just hope for the best.”
In Latin America, miso was a secretive lifeline for many women without means to have other options. Now that the same is happening in the United States, the phenomenon is even more underground here. The networks are just starting to develop and proper information about dosage is not widely available. Moreover, those in the know appear hesitant to distribute material—much of which is circulated around Latin America (http://www.womenonwaves.org/en/page/2583/safe-abortion-hotlines)—about how to safely take the drug.
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But miso’s safety is also a function of the information that comes with it. In Texas’s Rio Grande Valley, according to Carreon and others, many women are using the drug improperly because they don’t have access to basic facts about the correct dosage. That ignorance can lead to problems.
One woman I interviewed at a Mexican restaurant in Brownsville told me her good friend nearly died after taking pills that her husband bought in Mexico. Instead of ingesting four of the 12 pills every three hours, as is recommended by the World Health Organization (http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf?ua=1), she took two pills under her tongue, then four pills vaginally, then two more under her tongue, then four more vaginally. She began to bleed profusely, doubled over in pain. But because she was undocumented, she was afraid to seek medical help at a nearby hospital or clinic. Instead, she crossed the border to Mexico with her five children—all the while hemorrhaging—in search of medical assistance. She has since recovered but is still in Mexico with her children because she can’t cross the border back into the United States.
Once I crossed over [El Paso to Juarez], I stepped inside a yellow building called Farmacia del Ahorro del Mexico and asked if I could purchase Cytoteca. “No problem,” the pharmacist said, punching a few letters into the keyboard. A couple seconds later, an estimate popped up: $48 U.S. for four pills, or around $150 for the dosage of 12. Down the street, two other pharmacists gave me similar estimates, ranging from $125 to $177, the latter two for a full bottle of 28 pills.
While I didn’t take the pharmacists up on their offer, all three were able to dispense the pills for me immediately, though none of the dosages came with instructions about how to use the pills for an abortion. Misoprostol is only sold in Mexican pharmacies as an ulcer medication, and while pharmacists are aware that women are using it for other reasons, they can’t provide information about how to terminate a pregnancy with the pill. After all, abortion is restricted outside of Mexico City.
In the late '90s, the Internet spread throughout Latin America, ushering in an era of rapid, real-time communication. Suddenly, information about miso was catapulted onto the web. Websites about the drug—where to purchase it, how to use it, and even businesses offering home delivery—began to pop up, but activists wanted to make sure that the information women were getting was correct. So they thought of a practical solution.
Activists, feminists, and abortion advocates grouped together and began creating volunteer-staffed phone hotlines (http://www.womenonwaves.org/en/page/2583/safe-abortion-hotlines). These small, often DIY networks promoted miso use and distributed information about the drug, and many of them still exist today. They’re often run by volunteers who give anonymous callers medical information about miso, like how to take the 12-pill regimen and when to be concerned about adverse reactions to the drug. Hotline workers raise awareness about their services through informal, word-of-mouth networks and social media.
The hotlines have made—and continue to make—an impact on women living in countries with some of the world’s strictest abortion legislation. In Chile, where abortion is illegal without exceptions, a hotline called Linea Aborto Libre (http://infoabortochile.org/) has had considerable success. It’s staffed by a group of young feminists who take turns passing around a compact cellphone. If they’re not careful, their work could land them behind bars: Getting an abortion in Chile—or telling a woman how to do so—is a crime punishable by three to five years in jail. To avoid legal prosecution, hotline volunteers read information about misoprostol abortions that’s publicly available on the WHO (World Health Organization) website. (http://apps.who.int/rhl/fertility/abortion/dgguide/en/)
(http://apps.who.int/rhl/fertility/abortion/dgguide/en/)
Chile’s not the only Latin American country with a hotline; similar ones exist in Argentina (http://www.abortoconpastillas.info/), Ecuador (http://jovenesdespenalizacionaborto.wordpress.com/), Peru (http://lineabortoinfosegura.blogspot.com/) and Venezuela (http://infoseguraborto.blogspot.nl/). There are well-known websites like Women on Web, an international collective that provides information about self-induction and sends misoprostol to women in countries with restrictive abortion laws. Women on Waves (http://www.womenonwaves.org/), a Dutch NGO, performs medical abortions on a ship that sails to countries where abortion is illegal.
While it appeared that the raids earlier this year had ended miso sales at the flea markets, there are other ways to get it besides crossing the border into Mexico.
Buy-pharma.com, for example, sells one 200-mcg pill for $2 (http://www.buy-pharma.com/Generic-Cytotec-Misoprostol-p-156.html) (or a package of eight for $16). On the Facebook page “Cytotec misoprostol,” (https://www.facebook.com/cytotec.misoprostol.750?fref=ts) a user can request to buy the pills from the page’s administrator, who sells 12 pills for $950 pesos ($73.05).
But often it’s nearly impossible to verify the reliability of these pills. Surfing the net for miso through search terms like “abortion pills online” yields pages of results from online pharmacies—some of which are carefully constructed to look like the buyer is in good hands.
Advocates don’t promote the use of these sites. A page on the Women on Waves website warns against buying the pills online (http://www.womenonwaves.org/en/page/974/warning-fake-abortion-pills-for-sale-online), and it outlines a long list of doctors and pharmacy websites notorious for selling counterfeit medications.
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Despite the cautionary advertising, some still choose to purchase medications advertised as miso online. Molly, a feminist abortion advocate who preferred not to use her real name, buys miso and RU-486 (a.k.a “the gold standard”) in mass quantities from online pharmacies and sends it to women in the United States who want to use the drugs but don’t know how to go about getting them.
Back in Texas, HB2, the state’s strict new abortion law, shows no signs of letting up.
In March (http://bigstory.ap.org/article/us-appeals-court-upholds-new-texas-abortion-rules), the U.S. 5th Circuit Court ruled unanimously that the admitting privileges provision in HB 2, which led to the closures of clinics in the Valley and elsewhere, “does not impose an undue burden on the life and health of a woman." Since the law went into effect, the state’s number of licensed abortion providers dropped from 40 to 28 (http://www.texastribune.org/2014/03/19/impact-hb2-regulations-abortion-facilities-over-time/), and only 24 centers (http://www.texastribune.org/2014/03/06/whole-womans-shutters-mcallen-and-beaumont-clinics/) still offer the surgical procedure.
And in September, another portion of HB2 will go into effect, which requires all abortion providers to conform to the same standards as ambulatory surgical centers—a costly upgrade that is expected to shut down the majority of the state's remaining clinics. When this portion of the law goes into effect, the number of abortion facilities in the state is expected to drop to six.
Today in Texas things are starting to look a lot like the early years of miso in places like Brazil and Chile: The simple guidelines about miso haven't yet made it to women in the state. But eventually, in those countries, the Internet and the democratization of information prevailed. Unless, and until, abortion restrictions change again, Latin America’s DIY-abortion culture might be the future of women in South Texas.