By Mike Cummings
Millions of people visit Dubai each year on business and for pleasure. While Dubai has emerged as a global hub city for commerce and tourism, it also is becoming an international center for medical care, including in vitro fertilization (IVF). People who cannot access safe, affordable, or effective IVF services in their home countries travel to Dubai by the thousands on a desperate quest to conceive.
Marcia C. Inhorn, the William K. Lanman Jr. Professor of Anthropology and International Affairs, describes the experiences of reproductive travelers in her latest book, “Cosmopolitan Conceptions: IVF Sojourns in Global Dubai.”
The book features the voices of people Inhorn interviewed who had traveled to Dubai at great expense to seek IVF treatment. The stories of these “reprotravelers” provide insight into the frustration, pain, fear, and financial burden shouldered by those who are compelled to travel across borders for IVF services.
Inhorn recently spoke to YaleNews about her research.
Do you know about the Iranian IVF (In Vitro Fertilization) Revolution?
Marcia Inhorn (pictured) does … because she was alive to see it, and has studied it since in detail.
A medical anthropologist at Yale University, she witnessed a massive shift in the Middle East — and specifically Iran — as Ayatollah Khomeini embraced the reproductive technology in the 1990s. He proclaimed that IVF was fine for Muslim couples and he even allowed donor egg and donor sperm to be used. Thus, Iran has become a hub for so-called ‘reproductive tourism’ in the Muslim world.
Sound a little complicated? It was, and still is. But it stirred something deep and pressing within her nonetheless.
In honor of Father’s Day, let’s see what Yale Anthropologists have to say about dads in their ongoing research. Dr. Marcia Inhorn is a specialist on middle eastern gender and health issues and founding editor of the Journal of Middle East Women’s Studies. Her investigations in infertility clinics lead her to study concepts of emerging masculinity in countries like Egypt and Lebanon. In 2012 she published The New Arab Man, and co-authored Globalized Fatherhood in 2014.
by Ezra Klein
I. Bill Gates is an optimist.
Ask him, and he’ll tell you himself. “I’m very optimistic,” he says. See?
And why shouldn’t Bill Gates be an optimist? He’s one of the richest men in the world. He basically invented the form of personal computing that dominated for decades. He runs a foundation immersed in the world’s worst problems — child mortality, malaria, polio — but he can see them getting better. Hell, he can measure them getting better. Child mortality has fallen by half since 1990. To him, optimism is simply realism.
But lately, Gates has been obsessing over a dark question: what’s likeliest to kill more than 10 million human beings in the next 20 years? He ticks off the disaster movie stuff — “big volcanic explosion, gigantic earthquake, asteroid” — but says the more he learns about them, the more he realizes the probability is “very low.”
Then there’s war, of course. But Gates isn’t that worried about war because the entire human race worries about war pretty much all the time, and the most dangerous kind of war, nuclear war, seems pretty contained, at least for now.
But there’s something out there that’s as bad as war, something that kills as many people as war, and Gates doesn’t think we’re ready for it.
“Look at the death chart of the 20th century,” he says, because he’s the kind of guy that looks at death charts. “I think everybody would say there must be a spike for World War I. Sure enough, there it is, like 25 million. And there must be a big spike for World War II, and there it is, it’s like 65 million. But then you’ll see this other spike that is as large as World War II right after World War I, and most people, would say, ‘What was that?'”
“Well, that was the Spanish flu.”
II. The most predictable threat in the history of the human race
No one can say we weren’t warned. And warned. And warned. A pandemic disease is the most predictable catastrophe in the history of the human race, if only because it has happened to the human race so many, many times before.
In a 1990 paper on “The Anthropology of Infectious Disease,” Marcia Inhorn and Peter Brown estimated that infectious diseases “have likely claimed more lives than all wars, noninfectious diseases, and natural disasters put together.” Infectious diseases are our oldest, deadliest foe.
And they remain so today. “In a good year, flu kills over 10,000 Americans,” says Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention. “In a bad year, it kills over five times that. If we have a pandemic, it will be much worse. People think the H1N1 flu wasn’t so bad. But more than 1,000 American kids died from H1N1!”
Each new year seems to bring its own sensational candidate for the next pandemic. In 2014, of course, it was the Ebola outbreak — which killed more than 10,000 people, and sent much of America into hysterics. This year, a particularly infectious form of bird flu has ripped through 14 states, killing or forcing the slaughter of 39 million birds. Public health authorities are forcing the grisly massacre because the more birds around for the flu to infect, the more chances the flu has to mutate and reassemble itself into a form that can infect humans.
It isn’t just the news that carries warnings. The culture is thick with our fear of infectious disease. Zombies, for instance, are everywhere — World War Z was a best-selling book and a blockbuster movie; The Walking Dead has become one of television’s most popular shows. And zombies are a metaphor for infectious disease.
“When I was a kid, I watched AIDS go from an obscure, arcane curiosity to a global pandemic,” Max Brooks, author of World War Z, told the CDC. “What drove me crazy was that unlike the Black Death or the Spanish Influenza, AIDS could have simply been stopped by a pamphlet: A couple dos and don’ts, a little education and clear-headed leadership and it might have ended up as a footnote in a virologists’ medical text. If that’s not zombies, I don’t know what is.”
The CDC has even released a document titled “Preparedness 101: Zombie Apocalypse.” The point, obviously, isn’t that the CDC expects a zombie apocalypse around the corner; it’s that since a zombie apocalypse is simply an infectious disease apocalypse, talking about how to avoid becoming a zombie is a safe way for people to talk about how to protect themselves from pandemic disease.
“When confronted with real anxiety, a lot of people shut down,” Brooks said. “For them, planning for an actual crisis is just too scary, too paralyzing to think about. Make it a zombie attack, though, then there’s some psychological padding.”
Pandemic disease is something our culture thinks about, knows about, fears. It’s so topmost on our minds and in our nightmares that we’ve created an elaborate metaphorical architecture so we can talk about it even with people who are too scared to talk about it. We think about it so much, it seems almost ridiculous that we aren’t ready. But we’re not. Not even close.
Just look what happened with Ebola.
III. The “luck” of the Ebola outbreak
Ron Klain was an odd choice for Ebola czar.
Klain entered the Obama administration as Vice President Joe Biden’s chief of staff. This was, itself, notable: Klain was chief of staff to Vice President Al Gore, too, making him the only person to serve in that position for two different vice presidents.
He quickly proved himself an exceptional fixer for the Obama administration, with a mix of policy, political, and bureaucratic chops that everyone agreed was rare. And so when President Obama needed someone to coordinate the US government’s response, he turned to Klain. And Klain did his job. After a few early, botched cases, the Ebola outbreak ended on American soil. Ebola became what Americans were used to it being: someone else’s problem
But talk to Klain today, and he doesn’t sound like a guy exulting in victory. He sounds scared. He doesn’t think Ebola showed that America’s response can work. He thinks it showed how easily it could fail.
“You can’t use the word lucky or fortunate about something like Ebola that killed 10,000 people,” Klain says. “But it was the most favorable scenario for the world to face one of these things. Ebola is very difficult to transmit. Everyone who is contagious has a visible symptom. It broke out in three relatively small countries that don’t send many travelers to the US. And those three countries have good relationships with America and were welcoming of Western aid.”
“With a pandemic flu, the disease would be much more contagious than Ebola,” Klain continues. “The people who are contagious may not have visible symptoms. It could break out in a highly populous country that sends thousands of travelers a day to the US. It could be a country with megacities with tens of millions of people. And it could be a country where sending in the 101st Airborne isn’t possible.”
Ebola, Klain thinks, shows how unprepared the world was for a disease that it’s known about for decades and that, comparatively speaking, spreads pretty slowly. A person infected with Ebola can be expected to pass the disease on to two people, barring effective countermeasures (epidemiologists call this the “reproduction number”). Two is not that high, as these things go. The SARS virus had a reproduction number of four. Measles has a reproduction number of 18.
What happens when the world faces a lethal disease we’re not used to, with a reproduction number of five or eight or 10? What if it starts in a megacity? What if, unlike Ebola, it’s contagious before the patient is showing obvious symptoms?
Past experience isn’t comforting. “If you look at the H1N1 flu in 2009,” Klain says, “it had spread around the world before we even knew it existed.”
IV. How human beings have helped infectious disease
Behind Gates’s fear of pandemic disease is an algorithmic model of how disease moves through the modern world. He funded that model to help with his foundation’s work eradicating polio. But then he used it to look into how a disease that acted like the Spanish flu of 1918 would work in today’s world.
The results were shocking, even to Gates. “Within 60 days it’s basically in all urban centers around the entire globe,” he says. “That didn’t happen with the Spanish flu.”
The basic reason the disease could spread so fast is that human beings now move around so fast. Gates’s modelers found that about 50 times more people cross borders today than did so in 1918. And any new disease will cross those borders with them — and will do it before we necessarily even know there is a new disease. Remember what Ron Klain said: “If you look at the H1N1 flu in 2009, it had spread around the world before we even knew it existed.”
Gates’s model showed that a Spanish flu–like disease unleashed on the modern world would kill more than 33 million people in 250 days.
“We’ve created, in terms of spread, the most dangerous environment that we’ve ever had in the history of mankind,” Gates says.
V. Underdeveloped health systems threaten developed countries
The science fiction writer William Gibson has a good line: the future is already here, it’s just not evenly distributed. And nowhere is that truer than in health care.
According to the World Health Organization, the United States spends more than $8,000 per person, per year, on health care. Eritrea spends less than $20. Traditionally, Americans thinks of that as Eritrea’s problem. But if a highly infectious, highly lethal new disease presents in Eritrea, and the world is slow to learn about it, then it will quickly become America’s problem.
This is, of course, what happened with Ebola. If it had made its first appearance in the United States, it likely would have been caught, and contained, quickly. But as my colleague Julia Belluz wrote, the countries where the 2014 outbreak began “happen to be three of the poorest in the world, and it took them at least three months to even realize they were harboring an Ebola outbreak.” By the time Ebola was recognized, it was already out of control — and so, for the first time, it made its way to American shores.
When I ask the CDC’s Frieden what’s needed to catch these diseases early, he doesn’t hesitate. “The most effective way to protect people is basic public health infrastructure,” he says. “That means laboratories for finding specimens, getting them tested, and discovering what’s spreading. It means field epidemiologists. It means emergency operation centers. And you need to have that available day in and day out. If we’ve learned anything, it’s that you want an everyday public health system you can scale up for an emergency, not a system you only use in case of emergencies.”
The good news is this kind of system isn’t all that expensive. Basic public health infrastructure is fairly cheap — around a dollar per person, per year. “There’s no magic here,” says Frieden. “In Uganda, you have motorcycle couriers picking up specimens from hundreds and hundreds of health-care centers all over the country. They then send them to centralized centers. The expense isn’t huge.”
The difficulty often isn’t money; it’s priorities. These aren’t sexy investments. “It doesn’t cost nearly as much as building a fancy hospital in your capital,” says Frieden, with evident frustration.
But if you can find the disease and test it, then modern technology really does come into play. We can rapidly decode the basic structure and pathways of new diseases in ways that were unimaginable even a few decades ago — and that means we can come up with a response much more rapidly.
That’s the good news.
The bad news? “You need a government that works,” sighs Frieden.
VI. “Are we sure [the WHO] can do better next time? No.”
Pandemic infections present three basic problems of governance. The first is countries that don’t want to admit they need international help because they don’t want to admit they have a problem in the first place.
“Guinea did not want to declare an Ebola epidemic,” Gates says, “because in terms of investors and travel, it’s a death sentence.”
And it wasn’t just Guinea, or even just Ebola. As Michael Specter wrote in the New Yorker:
If SARS had been more contagious, it would have created the new millennium’s first grave public-health crisis. And yet, in 2002, after it first appeared, Chinese leaders, worried about trade and tourism, lied about the presence of the virus for months—insuring that it would spread. In 2004, when avian influenza first surfaced in Thailand, officials there displayed a similar reluctance to release information.
The second is countries that can’t admit international help, either because the state is too weak and fragmented to effectively coordinate with international actors or because the state is hostile to the organizations that would need to come in and offer relief. Imagine an outbreak that begins in Syria right now, and you get the idea.
The third problem is that no one really trusts the efficacy of the international institutions that would most naturally coordinate the response.
There is no other way to say this: the World Health Organization’s Ebola performance was a disaster. “The WHO’s slow response to Ebola has been universally condemned,” reported the Guardian. “The director general’s committee — which can declare a public health emergency — was not convened until August, eight months after the first cases and five months after public warnings from Médecins Sans Frontières, whose doctors were on the front line.”
Germany’s Chancellor Angela Merkel is now leading an effort to reform the organization. But similar mistakes during the SARS crisis and H1N1 have led to similar calls for WHO reform, and little has happened.
This isn’t just an issue of bureaucratic incompetence. The WHO is underpowered for the problems it’s meant to solve. About 75 percent of its funding comes from voluntary donations, and there’s no mechanism by which it can quickly scale its efforts during an emergency. The WHO’s member countries could fix this by giving the WHO more reliable, permanent funding — or even more reliable emergency funding mechanisms. But so far, no suggestions along those lines have gained much traction.
The result is that the WHO that will face the next major disease outbreak is likely to be quite similar to the WHO that faced Ebola, and H1N1, and SARS. As a senior US delegate to the World Health Assembly told Vox, “Are we sure [the WHO] can do better next time? No.”
Whether through the WHO or some other mechanism, most experts agree that the world needs some kind of emergency-response team for dangerous diseases. But no one knows quite how to set up that team. “That’s what we’re lacking in the global system — a battalion of people in white helmets,” says Klain. “But who will own it? Control it? Pay for it? Deploy it? Those are the tricky things.”
This is in stark contrast to war, which is not necessarily more deadly to the human race, but is much better planned for. “When you talk about war,” Gates says, “there are all these rules about how the government can seize various ships. But when an epidemic comes along, who is supposed to survey the private capacity and go out there and grab all these things?”
Look at what happened during Ebola, Gates continues. “Where was the equivalent of the military reserve, where you get on the phone and you said to people, Now come! And they had been trained, and they understood how to work together. People who want to volunteer, do we pay them? What do we do with them after they come back, when people might have this fear that they’ve been exposed? Are employers going to take them back? What are the quarantine rules? It was completely ad hoc.”
This is what’s so maddening about the modern fight with epidemic disease. Unlike in past eras, humanity has the tools it needs to protect itself. But global travel has far outpaced global governance — or even global disease response. Diseases move much faster than governments. “This is the hole in the global system,” Klain says, and no one really knows how to fix it.
The Journal of Middle East Women’s Studies is pleased to announce that Marcia C. Inhorn’s The New Arab Man: Emergent Masculinities, Technologies, and Islam in the Middle East is the winner of the 2014 JMEWS Book Award. This marvelous ethnography is exemplary in its theoretical, empirical, and methodological approach to and exploration of the complex issues of infertility, gender, religion, and power in Arab societies. The book’s true strength lies in Inhorn’s meticulous analysis, using the lens of infertility, to illuminate the fundamental changes taking place in the institutions such as family, marriage, and kinship, which underpin society and which, in turn, are transforming the younger generation of the Arab men and women. Moreover, with moral courage, Inhorn challenges current stereotypes of Middle Eastern manhood, masculinity, and patriarchy and redefines the shape and meaning of manhood, family, and relationships.
The Journal of Middle East Women’s Studies Book Award has been established by the Association for Middle East Women’s Studies to recognize and promote excellence in the fields of Middle East women’s or gender studies, broadly defined. It is given to an author whose work is judged to provide the year’s most significant and potentially influential contribution to Middle East women’s or gender studies. The 2014 award is sponsored by Yale University’s MacMillan Center for International and Area Studies and Council on Middle East Studies.
Marcia C. Inhorn also received 2014 AMEWS/JMEWS Distinguished Scholarly Service Award for leadership as two-term editor and founding editor of the Journal of Middle East Women’s Studies (JMEWS).
The article “Defining Women’s Health: A Dozen Messages from More than 150 Ethnographies,” published in 2006, is reprinted in Open Anthropology, A Public Journal of The American Anthropological Association.
Marcia Inhorn is author of the next article included in this collection. Inhorn is Professor of Anthropology and International Affairs at Yale University and author with Emily Wentzell of Medical Anthropology at the Intersections: Histories, Activisms, and Futures among many other publications. Her article in our collection is titled “Defining Women’s Health: A Dozen Messages from More than 150 Ethnographies,” which appeared in the 2006 edition of Medical Anthropology Quarterly.
The Islamic Republic of Infertility Treatment? All eyes have been on Iran’s uranium enrichment programs – but they’ve overlooked the country’s baby-making programs. We look at how Iran is leaps ahead of its Sunni neighbors when it comes to fertility.
- Azadeh Moaveni @AzadehMoaveni (Cambridge , United Kingdom) Journalist; Author
- Marcia Inhorn (Branford, CT) William K. Lanman Professor, Anthropology and International Affairs, Yale University
- Shereen El Feki @shereenelfeki (London, United Kingdom) Author of “Sex and the Citadel”
Society for Medical Anthropology, January 2014, Vol. 2 No. 1
Mary Read-Wahidi (U Alabama)
Jonathan Stillo (CUNY Graduate Center)
Each year, a committee of SMA student members reviews nomination letters for the annual Graduate Student Mentor Award. Each year we are encouraged and inspired as we read about professors who place student mentoring at the forefront of what they do. We see a clear connection between outstanding mentors and the successful career paths of their students.
Professor Marcia Inhorn was awarded the title of 2013 Outstanding Graduate Student Mentor. Those who’ve had the honor of being mentored by her have gone on to pursue successful careers, which they strongly link to Dr. Inhorn’s mentoring. As one of her former students declared, “Marcia Inhorn’s mentorship has changed my life.”
One reviewer wrote to the award committee, “What I found so striking about Inhorn is that many of her supporters are now junior faculty all over the country and even the world.” It is clear that despite Inhorn’s institutional moves over the years, she has supported her students even after her departure, enough so that her file includes her students from Emory, Michigan and Yale. These students found her supportive from the classroom, to grant writing, publishing and even in their tenure reviews.
Inhorn has been a strong mentor to her students from grad school to well beyond. One of her students even commented that she had been a mentor for more than twenty years! Another former student wrote, “Marcia was my doctoral advisor at the University of Michigan, my postdoctoral supervisor at Yale, and, now that I am a junior faculty member, continues to offer career mentorship and is also a collaborator.”
Another former students wrote, “Perhaps the reason that Marcia is most deserving of this award is not that she has provided such amazing mentorship and opportunities for me, but the fact that she has done similar things for many generations of students.” Echoing this, one reviewer commented that it was clear that Professor Inhorn was a mentor not only to individual students, but also to the academy at large.
Nearly every letter mentioned that she was always accessible, and gave prompt and meaningful feedback. One writer shared: “Everything about Marcia’s relationship with me and her other students demonstrated the highest level of respect and concern for our success. When sending her drafts of work, she sent back comments promptly; if she was going to be delayed, she’d tell us in advance. And, it’s worth repeating, her comments, and the way she discussed our papers in person, made clear her great passion for teaching. Marcia is extremely passionate about her research, but she’s just as passionate about her students.”
Not only is she recognized as a successful researcher and an amazing teacher, but also as someone who genuinely cares— simply “an amazing human being.”
“On one occasion, she mailed the pages [of my dissertation] to me with a toy camel packed in the box,” shared one letter. The writer continued, “She had read the chapters on her flight to the United Arab Emirates and bought the stuffed animal for my daughter, then a year old. I recall being grateful equally for her comments and for the camel.”
The appreciation that Professor Inhorn’s former and current students feel was especially evident by their presence at the SMA business meeting where she was presented with the MASA mentor award. A large number of them gathered by the stage to personally congratulate her as she received the tremendously well-deserved honor.
Special thanks are due to Misty Clover Prigent and Britt Dahlberg for joining Mary Read-Wahidi and Jonathan Stillo on this year’s selection committee, to all those who took time to nominate their outstanding mentors and to write support letters on their behalf, and to all the outstanding mentors who share so much of their time and wisdom with their students. We will circulate a call for nominations for 2014 Outstanding Graduate Student Mentor Award later this year, and we encourage all readers to nominate graduate medical anthropology professors whose mentorship has made a difference in their lives.
One writer shared: “Everything about Marcia’s relationship with me and her other students demonstrated the highest level of respect and concern for our success. […] Marcia is extremely passionate about her research, but she’s just as passionate about her students.”
Dr. Marcia Inhorn is the recipient of 2013 MASA Graduate Student Mentor Award of the AAA’s Society for Medical Anthropology
Dear Dr. Inhorn,
It is my pleasure to inform you that you have been chose to receive the Medical Anthropology Student Association (MASA) 2013 Graduate Student Mentor Award. Of all of the awards supported by the Society for Medical Anthropology, the Mentor Award represents the qualities that students hold most valuable in the way of support and mentorship by recognizing individuals who have diligently met those needs for their own students. Your commitment to mentorship, and the fruitful results that your students have experienced, is clearly conveyed in the multitude of nomination letters we received on your behalf.
Mary Rebecca Read-Wahidi
Biocultural Medical Anthropology
University of Alabama
Chair, Medical Anthropology Student Association
Student Representative, Society for Medical Anthropology
This award recognizes excellence in graduate student mentorship, and is aimed at senior or mid-career scholars who have demonstrated an ongoing commitment to teaching and mentorship throughout their careers, particularly those who have taken the time to successfully guide their MA and PhD students through field work and the thesis or dissertation writing process. Previous recipients of the MASA Graduate Student Mentor Award are Peter Brown (2012), Frances Barg (2011), Mary-Jo DelVecchio-Good and Byron J. Good (2010), Carole Browner (2009), Joe Dumit (2008), Lenore Manderson (2007) and Mac Marshall (2006).
This biennial award was established in 2006 to recognize the efforts of “a senior scholar in Middle Eastern anthropology who is an outstanding academic in terms of scholarly publications and service to Middle Eastern anthropology.” The 2013 award will be officially granted at this year’s AAA meeting in Chicago.
“Our committee greatly values your efforts as a scholar, a mentor, and a leader who has been deeply invested in the anthropology of the Middle East. We very much value your impressive pioneering and important work on medical anthropology, science and reproductive technologies, the anthropology of gender, and religion in the Middle East. Your thick ethnographic accounts of the lives of men and women who struggle with infertility and how they appropriate different discourses and technologies in their quest for conception as well as your engagement with broader theories and concerns in anthropology have been very valuable contributions to our field. We also greatly value your service to the anthropology of the Middle East and leading role in making our discipline more visible in different institutions and organizations, including MESA as well as your committed work with the Journal of Middle East Women’s Studies. In addition, we deeply appreciate your mentoring of students and junior faculty. As was communicated by one of your students, you are renowned among graduate students and recent PhDs “as one of the best mentors in the field” for your “support, enthusiasm, and warmth.”
“On behalf of MES Distinguished Scholar Award Committee, I would like to offer our heartfelt congratulations and warmly invite you to give our Distinguished Lecture at the MES Business Meeting during the AAA’s 2013 Annual Meetings, and we look forward to celebrating your work and contributions to our field.
Farha Ghannam, Chair, MES Distinguished Scholar Award Committee