The Clinicians

On a Friday night in August 2013, someone put a ladder against the wall of Cristina Villarreal’s nonprofit in Bogotá, Colombia.

He — Villarreal assumes it was a he, but the culprit was never identified — tiptoed over the Spanish tiles on the roof, stopped at the second-floor window to Villarreal’s office, put a fist-size hole through the glass, unlatched the window, and crawled beneath the gaze of a security camera. At the opposite end of the room, he ripped the drawers from Villarreal’s desk, scattering their contents — billing statements, medical records, printed emails, spreadsheets, family photographs — across the floor. The only items he took were an external hard drive, an audio recorder, a small collection of chocolates, and a bottle of wine that he snagged from the fridge on his way out.

Villarreal got the phone call on Saturday morning. As the director of the Fundación Oriéntame, a network of abortion resources that could be described as Latin America’s equivalent of Planned Parenthood, she has grown accustomed to vandalism and violent threats. The worst of the incidents have always happened on the weekends, while she is at home, working from her couch. She immediately thought of the organization’s medical records and her personal files. The wives of several well-known public figures had visited her suburban clinics; if the history of their abortions got out, they’d face humiliating scandal. “I was trembling,” Villarreal says a few days later. “The alarms were set! Somehow they didn’t go off.”

She figured that there were two possibilities: Either it was a random act of burglary by a petty thief, or, much more frightening, it was an anti-abortion activist looking for something very specific, something he may have found on that audio recorder. If that were the case, she would find out on the evening news.

By Monday, nothing had surfaced. She drove to a mid-city police station, where an officer in a fluorescent-lit room punched her report into a computer, typing with one finger. Nothing will come of this, Villarreal thought. It’s only for the insurance. Better to remain silent and avoid the media. That has been her family’s strategy for close to 40 years, dating back to when her father, Jorge Villarreal Mejía, founded the first Oriéntame clinic.

Oriéntame is renowned among reproductive-rights advocates around the globe for helping to create more than 600 clinics in ten Latin American countries and for reshaping abortion politics across the continent. Villarreal sits on the board of the Guttmacher Institute, the largest reproductive-rights think tank in the United States, and her international work is funded by several major American and European foundations. Young researchers and physicians travel from Harvard, Emory, the University of California, Berkeley, and other elite universities to train and conduct research within her network. Daniel Grossman, the vice president for research at Ibis Reproductive Health and a clinical professor of obstetrics at the University of California, San Francisco, says that Villarreal has “transformed the panorama of reproductive health in Latin America. Literally the entire trajectory.”

Despite this wide-ranging influence, few outside the small and tightly knit pro-choice medical community know the Villarreal name.

Oriéntame’s headquarters are located in the Teusaquillo neighborhood of Bogotá. Once an expensive enclave with manicured streets and gated homes, the area was gradually abandoned to an influx of rural poor. When Villarreal’s father, Jorge, opened the first Oriéntame clinic in 1977, he took advantage of plummeting real estate prices in Teusaquillo to purchase a rambling Tudor-style mansion. He converted the living spaces into a labyrinth of exam rooms, operating rooms, and administrative offices. As crime in the area worsened, Jorge topped the brick wall surrounding the mansion with loops of barbed wire. Today, homes are marred by graffiti and peeling paint, and on most weekday mornings, an old man and his donkey pull a ramshackle wooden cart full of vegetables toward the city center.

Jorge was affluent and well-educated, born to a cattle-ranching family with mostly secular habits and traditions. He graduated medical school in 1952 and traveled to the United States for advanced training in obstetrics at the University of Pennsylvania and the University of Kansas. (Villarreal credits her father’s choice of specialty to the loss of his mother to uterine cancer while he was young.) Within a few months of his return to Colombia, Jorge became head of the department of obstetrics at the national university. At his hospital, there was a special ward for women suffering from the aftermath of at-home abortions and failed back-alley procedures. “The most common thing,” says Villarreal, “was that women in the slum areas were putting the sonda (catheter) inside of them without any sonography. They used ganchos de ropa (coat hangers), anything.” In those years, 38 percent of maternal deaths in Colombia were caused by botched abortions.

The seeds of Oriéntame were planted in 1973, the year the U.S. Supreme Court decided Roe v. Wade and when Jorge met a man named Harry Levin at a seminar on population health at the University of Chicago. Levin was a pioneer in the field of reproductive rights. Before Roe v. Wade, four U.S. states had legalized abortion; in the rest of the country, the procedure was legal only when recommended by a hospital review board. For women arguing their cases before these committees, “the whole experience was humiliating, infantilizing, and terrifying,” says Rickie Solinger, a historian of reproductive politics. “There was no dignity.” After the Supreme Court decision, Levin saw an opportunity to expand access to abortion beyond hospitals. Over a few years, he built a network of East Coast clinics staffed with specially trained medical personnel and counselors. Levin’s Preterm Clinics, which treated women with respect and discretion, set the standard for abortion care across the country.

Jorge was inspired by this model and saw an opportunity to provide better care to the women in his hospital’s “special ward,” who were generally regarded as immoral filth worthy of pity, basic medical attention, and little else. He returned home, quit his job, and purchased the mansion in Teusaquillo.

But unlike Levin, Jorge did not have the law on his side. At that time, Colombia banned abortion, even when the mother’s life was endangered. Instead of fighting the law directly, Jorge opted to approach politicians about creating a stand-alone clinic for women who were already bleeding from failed attempts, which he took to calling “incomplete abortions.” This phrase became the wedge he used to open the abortion debate in Colombia, culminating in a 2006 law legalizing the procedure to protect the mother’s health. “It was our magic sentence,” says Villarreal.

Jorge called his clinic Oriéntame, roughly translated as “guide me.” He addressed his patients with a respectful “mi señora,” hired counselors to help them navigate the stigma of abortion in a deeply Catholic culture, and offered them birth control with every visit. The goal of the clinic, as he explained it to his staff, was to empower women. Jorge ran ads on the radio that a former employee remembers as saying “something like, ‘Woman, hey, if you already happen to have a pregnancy, and if you are bleeding out of your pregnancy, don’t risk your health; we can help you.’”

By the time Villarreal witnessed her first police raid, her father had developed a routine. Villarreal remembers several officers, accompanied by a priest from the neighboring church, demanding to speak with him, and Jorge calmly descending the spiral staircase in the old mansion to meet them.

“Do you conduct abortions in this facility?” one of the officers asked.

“Yes, we treat abortions,” Jorge responded. “Let me explain.” Using anatomical drawings showing a cervix opening and blood flowing out, Villarreal remembers, he explained what an incomplete abortion was, and how he “treated” it.

“My first reaction was that it was too much,” Villarreal says. “Why is he giving so much information to the police? He is not understanding anything; he doesn’t understand a uterus.”

But her father’s approach worked: After an hour or so, the officers and priest left the clinic.

Jorge had been strict with his two sons, but with his only girl, he was softer, more tolerant, even doting. He let her accompany him to the office, where she sorted files and designed presentations. “He paid me directly from his own salary,” Villarreal says.

Still, neither father nor daughter had planned for her to take over the organization, which had expanded to include clinics in other parts of Bogotá. Villarreal went to school for psychology, not medicine. Her father didn’t want her working at Oriéntame; he worried that it would look like nepotism. He agreed only when a counselor job opened at a clinic in a northern suburb, far from his day-to-day activities. Villarreal, who has always suffered from intense social anxiety and considers herself timid, even humorless, enjoyed working behind the scenes. But three years after she took the counselor job, her father’s health began to flag, and, urged by Oriéntame’s board of directors, she acclimated to the idea of taking on a leadership role. Then 31, she began four years of training, shadowing her father through every moment of his day. She sat silently next to him in meetings and held patients’ hands while he conducted procedures.

One weekend in the winter of 1994, while her father was on vacation in Patagonia, Villarreal received a phone call. On orders from the municipal health authority, a gang of ten armed, off-duty police officers had rushed the outside gates of Oriéntame, and one of them had struck a pregnant woman in the belly with the butt of a rifle. For the next ten hours, they held everyone in the facility hostage while they searched the premises for health violations that would give the minister — a religious fundamentalist — reason to shut down the clinic.

While camera crews from local news organizations lined the streets outside Oriéntame, Villarreal spoke with her father over the phone. Even as her insides roiled with self-doubt, she told him that it was time for her to assume control of the organization. He had weathered his own trials. This one would be hers. Villarreal waded into the crisis as the new director of Oriéntame, taking the lead in contentious talks with government officials.

The inspectors found only exposed wires, tripping hazards, and spots of moisture in the drywall — nothing out of the ordinary for a busy clinic. Yet for a three-month stretch, municipal health authorities managed to keep Oriéntame closed on the grounds of safety violations. (A similar tactic has been used by state legislatures in the U.S., several of which have passed laws requiring abortion clinics to comply with logistical regulations so burdensome that many clinics have been forced to shut down.) Even after Villarreal managed to reopen the clinic, she was drawn into a ten-year legal battle over alleged health-code violations; once the statute of limitations ran out, the case was dismissed. Despite this turbulent start, Villarreal went on to not only sustain her father’s network but to expand it — she has replicated the Oriéntame model across Latin America and turned the organization into a political force.

Villarreal, now 55, lives with her husband and teenage son in an urban high-rise overlooking Bogotá’s boundless sprawl. Their two-bedroom apartment is modestly decorated, with floors and furniture of cherry wood and oak.

She claims to share few characteristics, outward or inward, with her father, who died in 2001. Jorge had blue eyes that appeared to turn gray when he grew passionate or angry; Villarreal inherited her mother’s brown eyes. Her skin is lighter than Jorge’s, her manner less formal. Where he was stone-faced, Villarreal cries easily. Where he had a vertical style of leadership, hers is more horizontal. “I don’t like conflict,” she says. “If I have to identify with an object, I am a pillow — putting the pillow between two people fighting.”

On the third day of my visit to Bogotá, Villarreal leads me beyond the frosted-glass doors of the Teusaquillo clinic and introduces me to Dr. Mejía, a young, assured clinician with pale skin, freckles, and strawberry-blond hair who lets me shadow her for an afternoon. Sitting inside the first exam room we enter are a teenage girl I’ll call Teresa and her boyfriend. Teresa wears a black T-shirt with a punk-rock-band logo and blue jeans. She tells Dr. Mejía that she is pregnant and that she also has thrombocytopenia, a condition that can lead to frequent, unpredictable, and often uncontrollable bleeding. Her doctors have told her that she could bleed to death during delivery. “Still, they didn’t want to help me,” Teresa says. “They showed me pictures of children and told me to manage the risks.”

“How could this have happened if I was on the pill?” she asks.

“Nothing is 100 percent with birth control,” Dr. Mejía tells her, sending her behind a curtain to undress. Teresa comes out cinching a paper drape around her waist like a sarong. Her boyfriend sits next to the exam table on a metal stool.

“This will be very short, easy, and without pain,” Dr. Mejía tells her, before conducting a physical exam and transvaginal ultrasound. Teresa’s boyfriend tries to hold her hand; she brushes him off.

“It’s a small pregnancy,” Dr. Mejía tells her. “Only a few weeks along.”

Until eight years ago, Colombia’s laws prohibited helping Teresa unless she arrived at the clinic “incomplete.” With her bleeding disorder, she very well might have died before she ever made it to Oriéntame. But in 2006, due to the efforts of a coalition that included Villarreal, Colombia legalized abortion in cases that threaten women’s physical or emotional health. Together, these categories can be interpreted to encompass most women seeking abortions — Oriéntame considers being forced into an unwanted pregnancy a threat to emotional health.

In its years under Jorge’s leadership, Oriéntame relied on a policy of nonconfrontation. The organization worked with existing laws and defended itself in court, not on TV or at public protests. Feminists in Bogotá criticized this apolitical strategy. They believed that, by widening a loophole within Colombia’s draconian abortion laws, the Villarreals effectively enabled the status quo. Some went so far as to claim that they were only in it to make money.

“It’s the idealist-pragmatist divide,” says Ndola Prata, the director of U.C. Berkeley’s Bixby Center for Population, Health & Sustainability. It’s a common dilemma for those seeking to advance reproductive rights in countries with restrictive laws: Protest for sweeping change or silently work toward safer and more accessible abortions? Prioritize women’s rights or women’s health? (In the U.S., interestingly, the dynamic is flipped. Forty years after Roe v. Wade established a federal right to abortion, anti-abortion activists have resorted to a pragmatic strategy, seeking opportunities to restrict access in practice, if not on paper.)

Making it through the decade-long legal morass after the 1994 raid emboldened Villarreal. In the early 2000s, she and her feminist critics came together to support a young lawyer making the case that abortion was a basic health care right. This argument culminated in the 2006 law, which, at the time it passed, was the most progressive abortion policy in all of Latin America.

Because of this new law, Teresa is able to end her pregnancy. Dr. Mejía gives her a medical abortion, meaning she administers a pill that will induce Teresa’s uterus to slough its contents, including the unborn fetus, a feathery wisp of cells at this stage of gestation. “It will feel like a heavy period,” Dr. Mejía tells her. Outwardly, Teresa shows no signs of anxiety or sadness. She and her boyfriend leave the exam room, with Teresa leading the way.

Laws change, governments fall, fashion evolves, and abortion remains constant. The best estimates show the annual number of illegal and legal procedures in Latin America increasing from 4.1 million to 4.4 million between 2003 and 2008, roughly on par with population growth. The same research, by the Guttmacher Institute, estimates that 95 percent of these procedures were unsafe. Of the women who received them, at least 800,000 per year were eventually hospitalized from complications.

While abortion access has expanded in certain parts of the region in recent years, for every political action, there seems to be an equal and opposite reaction. When Mexico City legalized abortion for any reason in 2007, 16 of the 31 Mexican states subsequently passed legislation defining life as beginning at the moment of conception. While Uruguay largely legalized abortion in 2012, Nicaragua revised its laws to ban the procedure, even when the mother’s life is in danger. This hostile political climate makes Oriéntame’s success, both in Colombia and beyond its borders, all the more unlikely.

In the 1980s, doctors from Mexico, Peru, Argentina, Venezuela, and other Latin American nations began visiting Bogotá to observe Jorge at work. They came to learn how to perform safe procedures and also how to navigate Latin American abortion politics. In 1985, several Peruvian doctors tried to replicate Oriéntame in Lima. Jorge trained them in the most up-to-date medical techniques, walked them through his method of bookkeeping, and shepherded them through political roadblocks. But after three years of red tape and social pressure, the doctors gave up.

Disappointed by this failure, the Villarreals decided to take a more hands-on approach to expanding their model. In 1990, their board of directors formed a second nonprofit called Fundación Educación Para la Salud Reproductiva (ESAR). They designed it to function somewhat like a franchise, helping doctors, nurses, and midwives in other Latin American countries set up their own Oriéntame clinics. They went only where locals asked for help. In addition to funneling money to new clinics for basic supplies, either Jorge or his daughter would parachute in for an initial consultation, and Oriéntame counselors would train staff in how to offer patients emotional and psychological support. The Villarreals would keep in touch with the clinics via teleconference meetings.

By 1991, ESAR served clinics in Mexico, Peru, Bolivia, and Ecuador. Today, the organization has expanded to Guatemala, Paraguay, El Salvador, Nicaragua, and Argentina.

In December of 2001, Jorge fell down the stairs of his Bogotá home and was paralyzed. After an invasive neurosurgery neither saved nor killed him, he was left on a breathing machine. His family watched in horror. “I went to the director of the hospital,” Villarreal remembers. “‘Please let him go,’ I said. ‘We have talked about this for years and years and years.’ He couldn’t breathe. He couldn’t talk. He slept all the time with tubes, trying to throw them out.” Finally, the director intervened, and Jorge, then 73, was removed from life support.

Not long after, Villarreal received another blow. At that point, most of ESAR’s roughly $500,000 budget came from private donors, including the Packard Foundation; in 2001, following a shift in organizational strategy, Packard announced that it would cease all funding. Villarreal was panicked.

She had frequently accompanied her father on fundraising trips to the United States. She thought of how, only a few years earlier, a donor had sent a limousine to pick them up at the San Francisco airport. “We were kidding the whole time during that trip,” she says. “We were like, ‘Oh! We are millionaires now!’” Knowing that her organization depended on her ability to secure more funding, she traveled alone to a fundraising conference in Santa Cruz, without anyone to ease her fear of public speaking or her anxiety around strangers. “I was so nervous, and I needed a drink and wine and smoking,” she remembers. She did succeed in finding a few small grants to help ESAR stay afloat, though it was another six years before she landed on a more comprehensive solution. One of her donors introduced her to a large American foundation spending hundreds of millions of dollars on international reproductive-health work. (The foundation donates on a condition of anonymity.) Several years of courtship followed. Finally, in 2008, the foundation came through with a multimillion-dollar grant, increasing ESAR’s budget tenfold. “We went from a little propeller plane to a Boeing jumbo jet,” Villarreal says.

Flush with cash and out from under the oppressive laws that restricted Oriéntame in its early days, Villarreal was able to open new clinics and expand her international collaborations. Today, 150 employees coordinate surgical supplies and medications for 640 Oriéntame outposts, train new counselors and doctors, and put together marketing materials tailored to each country. Villarreal has transformed her father’s modest family of clinics into a politically powerful international health care agency. She should be celebrating her success.

“I am very, very worried. Very worried,” Villarreal tells me in her office in 2013, a few days after the mysterious break-in. For most of Oriéntame’s history, the network of clinics within Colombia earned enough in revenue to be self-sustaining (Villarreal relied on philanthropy only to fund her international work). The clinics offered a sliding pay scale and treated a high volume of both wealthy and impoverished women; on some days, clients lined the streets for appointments. But little by little, Villarreal says, “this balance was lost.” Throughout the 2000s, those who could pay for services — middle-class and well-to-do women from Bogotá, mostly — stopped scheduling appointments. Only poor women continued to show up at Oriéntame’s door, and by 2012, even as ESAR was swimming in funding, Oriéntame was half a million dollars in the red.

The reason for the exodus of paying clients, Villarreal eventually figured out, was a drug called misoprostol. Originally developed to prevent ulcers, misoprostol was found to cause spontaneous abortions. In the late 1980s, word spread among women in Brazil and then across national borders, and black markets began to emerge. Today, Latin American women can buy misoprostol and similar drugs in many pharmacies, via telephone hotlines, and on the internet. Of the roughly 100,000 abortions that take place each year in Bogotá, according to a 2008 Guttmacher Institute study, 50 percent are performed using misoprostol. It’s not just Latin America; black-market misoprostol has made its way into other parts of the world where abortion is difficult to come by, including some regions of the United States.

Misoprostol is considered safe when administered at the correct dose. Less than 1 percent of women experience more than minor side effects, such as excessive bleeding or infection. Most misoprostol abortions in Colombia occur in private, but the drug has also changed how abortions happen in clinics; Oriéntame uses it for roughly half of the abortions its doctors perform. Teresa, the young woman I met at the Teusaquillo clinic, was given misoprostol by Dr. Mejía.

For Villarreal, the drug is a mixed blessing. Even as it’s expanded access to abortion, it has eroded her clinics’ business model. Her bigger concern with it, though, is that clandestine use of the drug is rolling back years of progress in women’s rights. When women go to the pharmacy and ask for misoprostol, they use euphemisms and code words, never having to explicitly reference abortion. “They don’t feel they are pregnant,” Villarreal tells me. “They feel that they have menses delay. And psychologically it is much different; it avoids all the stigma of the Catholic church.”

Misoprostol has also exacerbated the socioeconomic gap that Oriéntame, with its sliding scale, has fought so long to close. Despite its proliferation, misoprostol is difficult for poor women in Colombia to obtain. Along the sidewalks outside of Oriéntame, Villarreal points to corner stores where women can buy the compound for about $50, a sum beyond the reach of many Colombian women. Ordering the drug over the phone or online requires an international cell-phone plan, an internet connection, or, at the very least, an address where it can be shipped. Wealthy families have always had access to abortions, whether through a flight to another country or by paying a private obstetrician for a covert procedure. Misoprostol could become just another option for well-connected, well-off women.

As Oriéntame’s revenues began to dry up, Villarreal tried advertising, cost-cutting, and improving efficiency, even hiring a business manager from the private sector. But none of it worked. Today, she has acquiesced to the possibility that Oriéntame’s clinics may never be solvent again, and that they may become a last resort for women who cannot afford misoprostol. She is also shifting her focus from on-the-ground care to bigger-picture advocacy. In essence, she finds herself inching across the aisle from pragmatist to idealist.

A few years ago, in an attempt to educate women about the abortion rights they already have and how misoprostol fits into that picture, Villarreal launched a grassroots campaign. Her team visits pharmacies in Bogotá and elsewhere, distributing referral cards and educational materials for women who come in looking for misoprostol. On the weekends, vanloads of Oriéntame workers travel to schools and community centers in slums and poor neighborhoods to speak to women directly.

I meet Elvira, one of Oriéntame’s health workers, on a Saturday morning a few days later for one such trip. It’s late August. We drive with six other educators across Bogotá’s central valley toward Ciudad Bolívar, a slum in the city’s western hills. The area has no plumbing or running water. Houses are stacked in tightly packed rows butting up against the sidewalks in shades of concrete, brick, and dirt, like a dystopian version of San Francisco. We stop at a high school. In a small courtyard between the classrooms, Elvira, wearing blue denim and a blue coat, looking and sounding like a Detroit labor organizer, addresses a circle of 14 women.

“Can you tell me why a woman could have an abortion in Colombia?” she says.

There is an expected silence; a few eyes scan the room. A 20-something woman in a pink sweater with matching pink shoes pipes up, “For the woman’s life.” Another says, “Malformations.”

“You left out the mental health,” Elvira says. “And this is a big category, more so than bodily health. If you are depressed, sad, traumatized, you have the right. In Colombia, women have the right. Women have the right to interrupt the pregnancy. Health is not just physical.”

Oriéntame, she tells them, asks women to pay only what they can. She hands out glossy pamphlets. On the front, an orange dove flies through the orange “O” of “Oriéntame.”

More women file into the courtyard. They are accompanied by teenagers, toddlers, and newborns. Inside the classrooms, Elvira and her co-workers have set up tables with condoms and birth-control pills. Of the dozens of women gathered, about a third go to the bathroom with pregnancy tests, including one 13-year-old girl.

Elvira speaks to several different groups of women that day. Each time, she ends her talk the same way. “Lots of women die from unsafe access,” she says. “But not at Oriéntame. You can count on Oriéntame.”