Marcia Inhorn is the William K. Lanman Jr. Professor of Anthropology and International Affairs and Chair of the Council on Middle East Studies (CMES) in the MacMillan Center for International and Area Studies at Yale University. She is the author of three books on infertility and assisted reproductive technologies in the Middle East: Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt (Routledge, 2003); Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt (U Pennsylvania Press, 1996); and Quest for Conception: Gender, Infertility, and Egyptian Medical Traditions (U Pennsylvania Press, 1994). She is also a past president of the Society for Medical Anthropology. Last November, when she came to give a talk at McGill, Marcia agreed to sit down with me for an interview about her research, the state of medical anthropology and the recent SMA conference she organized at Yale.
Eugene Raikhel (ER): To begin I wanted to ask about how you got started working on fertility in Egypt? What were the motivations for you?
Marcia Inhorn (MI): When I went to graduate school at Berkeley, the motivating questions were stigma and suffering. This is a funny story, but on the first day – I wasn't necessarily planning to work on the Middle East. I had been to the Middle East, I had travelled there with friends, but I thought maybe I was going to work in the States. When I got to the first day of the Anthro Seminar 203, and we had to introduce ourselves, every single person had some interesting field site – Albania, Rajasthan. So I said, OK, I'm going to make my commitment to the Middle East. I had been there, and I was interested in stigma and suffering, and it was just one of these fortuitous things.
There was a project at UCSF on blinding eye disease, trachoma. They had epidemiologists and doctors, but they had not been able to reduce the level of this problem. They realized that they needed some qualitative or anthropological research, and they invited a more advanced student from the UCSF-Berkeley program, and I was also invited. It was a multidisciplinary project, which was sort of the beginning of my multidisciplinary work. There were opthamologists, epidemiologists, and we lived in this very poor little community, with almost no resources. I realized – I had very little Arabic at that point – that when I asked women how many children they had, that there was a sort of silence when they didn't have kids, and that it was very sensitive for women. I thought, that's really interesting, infertility might be something really stigmatizing. So I went back, and I took a graduate seminar with Suad Joseph on women in the Middle East, I did a literature review, and there was nothing that had been published by anthropologists on infertility in the Middle East. But all the anecdotal evidence suggested it was a horrible thing for a woman, so that lit review led me to think that I should go back to Egypt and work on infertility. Then they actually opened a public infertility clinic in this poor public maternity hospital.
To be frank, there was no anthropological literature on infertility at that time.
ER: Was that because most of the focus had been on overpopulation?
MI: Yes, discourses of the third world being overpopulated, so all the attention was on contraception. But now, years later, we talk about the paradox of barrenness amidst plenty and we realize that you have the highest rates of infertility in high fertility areas. Because people get exposed to pregnancy but they end up having miscarriages, and so on. The WHO, to its credit, has always been a monitor of infertility rates and technologies, and has shown that sub-Saharan Africa has the highest rate of infertility in the world and that infection is the cause – they have been writing about that since the 1980s. So in the public health world there was a discourse around the idea that we should do something about that. Infertility has been a neglected issue, but in some sense now there are many of us. There are about 50 anthropologists working on infertility and assisted reproductive technologies around the world. We have a rich body of literature. It has been an incredibly productive area, moving into reproductive technologies. I have never left it. I still feel passionate about it because it continues to change in interesting ways.
ER: What are you working on at the moment?
MI: I have three projects, two of them are really in the middle, and one is a future project. I am trying to finish up a book called Re-conceiving Middle Eastern Manhood: Islam, Assisted Reproduction, and Emergent Masculinities. This came out of Egypt, working on IVF clinics in the late 1990s. I had always focused on women and infertility, and their gendered suffering. But once you get in these high-tech clinics, you immediately realize that the majority of cases are male-factor infertility. And though I wasn't intending to interview men, I ended up talking to all of these men about infertility, and their own perceptions of it, and how they felt about it. So I decided I could interview men. So I switched countries and went to Lebanon, for interesting reasons, and did a large project on male-factor infertility, lasting from 2003-2005. I interviewed Lebanese, Syrian, Palestinian, and Yemeni men, and then I came back to Michigan, America's largest Arabic population, and I interviewed Lebanese, Palestinian, and Iraqi men. So I had a huge sample of more than 250 men that I had interviewed about their experiences. I'm writing that up now, focusing on three issues: Trying to re-conceive manhood, the stereotypes of masculinity in the Middle East, in response to some of the popular discourses, feminist discourses, reframing the notion of hegemonic masculinity. And I'm looking at Islamic bioethics around assisted reproductive technologies, which don't allow sperm donation, and thus really biologize the solutions. You have to use your own sperm, no adoption. And then I'm looking at the medicalization that goes on as a consequence. So that's project one.
ER: If I recall, the background to that was a new technology for male infertility?
MI: Yes, everyone has an idea about IVF, but there's a variant to it that was developed in Belgium in the 1990s, called Intracytoplasmic Sperm Injection or ICSI. Not to glorify the technology, but it revolutionized the overcoming of male infertility, because it forces fertilization for men whose sperm are just not viable otherwise. And nobody knows about it. It's never discussed. So I want this book to deal with the emergence of ICSI and what it's done for manhood in the Middle East. So I have this book on male reproductive health that I want to finish up. We don't have enough people working on men's lives. Men are dealing with stresses and health problems. I give a huge amount of credit to all the women anthropologists who have worked on women's lives, but we have really missed out on men's lives in some ways.
The next project that I've been doing since 2007 is on reproductive tourism, which is the term for travel, the transnational quests for reproduction. I sited my project in the Arab Gulf, which is the hub of that kind of travel. I've got a project looking at why people move, their motivations, the flows in and out. What happens to Muslims when they are not allowed, for the most part, to use donor gametes, and what are the moral decisions they make?
And then I have sort of a biocultural project. The world's most common reproductive endocrine disorder is called PCOS, Polycystic Ovary Syndrome. We have high rates of female infertility because of the global epidemic of overweight, diabetes and insulin resistance. In societies where women basically succumb to these problems, there is disruption to the ovaries, which is very difficult to fix, and is tied to these new problems of sedentary lifestyle. You see it in all over the Middle East—the Gulf has the second highest rate of diabetes in the world—and South Asians coming to the Gulf definitely have problems. So I want to look at women's feelings about their bodies when they are told they are infertile because they need to lose weight. So that's another project. But I'm going to stay with this problem of infertility, because it's just kept me going, and the technologies themselves are rapidly changing.
ER: What was the story behind your switch of fieldsites, from Egypt to Lebanon?
MI: I had been working in Egypt from 1985 to 1996. I had always had Fulbrights, and you have to apply through the Fulbright Commission in Egypt to work there. And Egypt unfortunately has become extremely sensitive to human subject research fieldwork. They're still allowing archival research, but they have become sensitive to people talking about topics that they don't necessarily want to have revealed. So my project was called "Middle Eastern masculinities in the age of new reproductive technologies", and I tried to get it through the Fulbright Commission. Little did I know that they not only have academics but also the Mukhabarat, who are like the secret police, on the board. And while the academics all accepted the project, the Mukhabarat did not, and it was turned back about four times, each time saying something like 'nothing on men, masculinity, reproduction', and the next time, 'nothing on manhood, fertility, infertility'. The Fulbright Commission was trying to work with me, the project was increasingly shifting away from what I wanted it to be, and then my husband said, 'Don't you see the writing on the wall? They do not want your project.' They were not going to let it go.
Meanwhile the Fulbright program in Lebanon had been closed down because of the civil war, but they had just reopened it to faculty, and they were very keen on the project. So I went. And then the war in Iraq started in 2003, and every single Fulbright program in the Middle East shut down except for the one in Lebanon. I was very lucky. I was going to do work in Syria as well, but its program was shut down, Jordan's was shut down. These are the politics of trying to work in the Middle East right now. There are huge parts of the region about which we know next to nothing, because you can't get in. Egypt used to be extremely open to Western research, but it has become increasingly restricted.
ER: I really enjoyed your article in Social Science and Medicine a couple of years ago about privacy and fieldwork. Can you speak a bit about the challenges of conducting fieldwork in IVF clinics on these locally contentious issues?
MI: I think about this a lot, because to get into very high-tech medicine, you have to enter these clinics, and do clinic-based ethnography, which takes us into this intersection of STS and medical anthropology. Increasingly my research has become very clinic-based. But to get into these clinics, you have to have permission. Now even in the Middle East they have opened up an IRB process, so you have to go through those channels. Putting it into Middle Eastern cultural terms, you have to have patronage: intermediaries who are willing to help you get sited. It's always a challenge finding people willing to help you, but I have always found at least one person who was really keen on my project and I have made some very interesting alliances along the way. In Egypt, I had very close collegial relations with two physicians, I had published about one, and am publishing with another. Three Egyptian physicians decided I could work in their clinical sites, but one of them really acted as the powerful patron, and if I hadn't had him to make those introductions, I don't think I could have done the kind of study that I did in Egypt. It was the same situation in Lebanon: I found two physicians who were keen on me working in their clinics, and in the UAE I found a couple, though I ended up working mostly with one. These people have their own reasons, they have their own publishing agendas. In some cases they say, "We want to find out what we're doing right and wrong," –they want some feedback. So I have always ended up writing reports for the physician-directors. People have found that useful in some cases. They have ended up being really good colleagues. That said, I call it patronage – it is patronage. If you don't make these alliances it is almost impossible to work in these settings.
The other problem in the world of IVF, especially ten years ago, but less so today, is that it's very stigmatizing, (a) to be infertile, and (b) to be using these technologies, especially when there's a moral taint, because people are very concerned that there's mixing of gametes, and thus something immoral going on. People really did not want to give their names, they didn't want to be known as having been in these places. Although lots of anthropologists reject the IRB process and informed consent as problematic, I ended up using IRB forms in clinical settings, translated into Arabic, to say that I would tell them about the project, and to ensure that it would be private and anonymous. People read these—these people are generally middle class to elite, so they can read—and I never had a woman not agree to be in a project. I did have men saying they wanted nothing to do with it. Though I still had 300 men agree, as long as I wasn't tape-recording. It was a catharsis. A lot of men told me intimate things about their lives and sexuality. So I argued in that piece that we can use the whole IRB process to our advantage, if it makes people feel more comfortable. And in the Middle East people are increasingly familiar with signing off on things, it's becoming an increasingly common process.
ER: Could you speak a little bit about what, for you, have been significant ways of engaging with public health and with clinical medicine?
MI: I am one of those anthropologists of the generation who witnessed the shift from international health to global health. I think I was really fortunate to be a member of the UCSF program, and to have some mentors who were engaged in the world of the WHO and international health. Fred Dunn was especially significant as a mentor in that regard. I was interested in getting some training in Public Health and I took a year's leave of absence from my anthropology program and received an MPH in Epidemiology the UC-Berkeley School of Public Health. I've always found this epidemiological training to be very useful, and I still believe in things like detailed reproductive histories, and even asking people questions about things in their lives that might be risk factors for infertility. I still do that sort of work, and so I have increasingly become involved in the world of global health. Also, my first job was at the University of Arizona where Mark Nichter works, and he has been very much working at the intersection of public health and anthropology. So I have had some very good mentors who made me realize that this is a very important intersection where we should be working: global public health and anthropology.
Robert Hahn is another close colleague from my Emory days. He and I have just come out with a second edition of his book. He originally called it Anthropology In Public Health, this time we renamed it Anthropology and Public Health. The structure of the book looks at four ways anthropology intersects with the public health world. The first is just really good ethnographic understandings of public health issues, from alcoholism to my chapter on infertility, looking at doing what we do as ethnographers, understanding why things happen when and where they do. We have wonderful ethnographic work on HIV/AIDS that looks at the suffering that goes along with that. The second section of the book is on anthropological intervention, those medical anthropologists who are doing nuanced interventions based on ethnography, working on very good culturally tailored interventions. In that book I refer particularly to the work of Jeannine Coreil and Gladys Mayard in Haiti, who just did a wonderful intervention for women with lymphatic filariasis (Elephantiasis). They gave them a little bit of money to create social support groups – and these women just ran with it, they created these groups. They called it the indigenization of the social support group. The third section of the book is on evaluation. Anthropologists with our training have been very good at evaluating, and saying what worked and what didn't. So we have a wonderful section with articles on things like PMTCT, preventing mother to child transmission: why the recommendations on a local level won't work. The final section of the book is on critiques of global health policy. Anthropology brings the critical ethnographic lens, which is really important. I think anthropology has a role to play in all four of these domains, and different people will take on different roles.
I myself never do interventions, but I always produce policy recommendations. On topics like: Why don't we promote family fostering as a solution to childlessness in Egyptian families? Shouldn't we be focusing on reproductive tract infection as the leading cause of preventable infertility in women? I also try to publish, from time to time, in places where people in the medical world will read my work. They're not going to read my ethnographies, but if I publish in public health journals, and in Fertility and Sterility—the leading journal in the area I work in—doctors do read my work and they write to me. So that's the way I see this intersection, it's very powerful I think.
ER: Could you say a little bit about being a US scholar working on the Middle East at this critical time when issues surrounding this part of the world are so contentious—and particularly about the role that anthropology has to play here?
MI: I have ended up, again not exactly by plan, devoting the last decade of my career to developing contemporary Middle East Studies at two major US universities, the University of Michigan and Yale, where we have national resource centers, supported by the US Department of Education Title VI program. It's interesting because when they get to be senior, many anthropologists end up running these Title VI programs, on South Asia, Southeast Asia, China, and Eastern Europe. I end up thinking that the anthropological intervention could really help in terms of providing the kinds of courses that students really need in such a fraught world. We can really teach some local cultural sensitivity, that is different from political science and religious studies discourses. Also, I was convinced that we anthropologists have a very important role to play in helping to educate the next generation of Americans—who are going to come out with more understanding than the last generation. So I have ended up teaching these foundation courses called "Culture and Politics in the Middle East", where graduate students read ethnographies of the region of the world that I work in. I love these courses. I have taught them in almost every university I have been in, to undergrads and graduate students. So in some ways I have become more of an advocate of the importance of area studies in our world today, than I ever imagined I would be. Nonetheless there are ways to critique area studies. Unfortunately a lot of the area studies programs got their footing during the Cold War, and the impetus really was to understand particular parts of the world in that geopolitical context. And now, similarly, they have been throwing money into area studies for what are, in some senses, the wrong reasons: you need to know about the terrorist threat. This is depressing to me as well. I just came from the Middle East Studies Association where there were very few anthropologists because that meeting always overlaps very closely with our AAA meeting. So a lot of anthropologists don't show up at our area studies meeting, and the few of us in anthropology were talking about the depressing lack of good ethnography in the book exhibits. The books were all about Al-Qaeda, Hizbollah, Hamas, Islamism, and terrorism. Every other book seems to be on those subjects, often written by people who aren't specialists on the region--pundits. Middle East Studies has the potential to be taken over by pundits, and that's dangerous. So that's why I do feel a certain responsibility to training young anthropologists to be really embedded in languages and places, so that they can reject some of this.
ER: It seems that there is sometimes a tension between the kind of close study of regional dynamics and local milieu fostered by area studies and an emphasis on globalization--or at least the somewhat superficial way of conceptualizing globalization that is prevalent in popular discussion.
MI: And that is the danger, especially the rhetoric that everything is global. If there is one thing the early anthropologists of globalization emphasized, it was that globalization does not homogenize the world, globalization ends up with a diverse set of responses on the local level. Someone still needs to be committed to the local, and I think that's really the contribution of anthropology – the wonderful nuanced understandings we bring to local places. So that should be our role, in the midst of all this meta-discourse about globalization and terrorism and all of these issues.
ER: I wanted to shift gears a bit and just talk to you a little bit about the recent SMA conference, and medical anthropology generally. The conference seems to have been a great success. What are your general thoughts?
MI: Thank you. I have spent several weeks just floating on a cloud, because it had been such a long planning process. The discussion started probably in 2005, and had gone through several SMA boards: a long process. Moving to Yale was extremely fortuitous because as part of moving there, I said we really want to do this SMA Conference and we need resources. And Yale was in a position at the time to say, 'This is great, and how can we help?' And also they encouraged me to look for grant money, so I went to the NSF which came through with a big grant, then Yale was able to back that up. The funny thing about it was that at the first SMA Board meeting where we discussed the meeting, we had talked about how many medical anthropologists would show up to a conference. And the guesses ranged from 200 to a maximum of 500. We had done a survey and it seemed there was a lot of interest. And then lo and behold, the day before the abstracts were due, on April 15, about 150 people had registered, and we thought, maybe it'll be 300. And then on April 15, the morning they were due, abstracts started flooding in, and we were up to 1000 when Yale Conference services said, 'You have got to shut it down, we can't accommodate, we've got one room on campus that accommodates more than 1000 people'. Had we been able to keep it open, another thousand might have come. So I felt sad for those who couldn't come, but so happy to know we have this huge global discipline, and that half the people who did register were from outside North America. The European medical anthropologists: whole departments of medical anthropologists came over from Edinburgh, Amsterdam, Norway. People came from Europe and Latin America, and some from Asia.
It was interesting because you could see all the patterns of research. I think having the interdisciplinary thematics really helped because people got kind of inspired to show off their interdisciplinary work that they were doing. We had about 20 panels that had something to do with global health, numerous on genomics, STS panels on all those areas of intersection. Occupational science: every afternoon they had a whole session devoted to that. There are areas that are really coming up in medical anthropology that came up in the conference. I felt like it was this youth, energy, international colleagues brought together, that we should really try to do it again. And I actually think it should probably be held outside of North America if it is done again. And we're going to publish the plenary papers in an edited volume that will hopefully be out in 2011.
ER: Several years ago as part of your presidential address to the SMA, you gave a survey of medical anthropology that looked at intersections with various disciplines. That clearly formed the basis of the organization for the 2009 conference, but I'm curious about what you saw in terms of the papers actually presented: do you see any new emerging areas among younger scholars, or areas that are particularly strong?
MI: I do. It was very interesting to me, the whole area of what used to be called psychiatric anthropology, mental health, ethnopsychiatry. That's not my area so I hadn't been following it. But we had Arthur Kleinman do the plenary and there were at least 20 sessions on some aspect of neuro-, psychological, psychiatric, including this entry into neuroscience, addiction – there were several panels on addiction. That shows us that the area is heading in new directions.
Something I think is definitely new is the anthropology of war, trauma, humanitarianism. I had given my presidential address a few years ago on medical anthropology against war, arguing that there had been little anthropology on the wars in the Middle East. That was two years ago, and now I can tell you all the work that is going into Iraqi refugees, trauma after the Lebanese war. All of a sudden there seems to be group of people working on refugees, forced migration, sexual violence, and I think this is in part because of Didier Fassin's work. I think this is an area new to the last two to five years that you could see at the conference. I think that was really great.
The work on genetics and genomics is really going to boom as an STS topic I think – we've had some really great work which now I think is really coming into its own. Also the areas of disability and occupational science, able-bodiedness. That was interesting, focusing on disability rights in unlikely places.
Also medical anthropology and environmental issues, we don't really have it yet, but I think that is going to be really important. We have a bit, Petryna's work on Chernobyl, that seminal work on a major environmental disaster. You don't yet really have that work, but I think it's going to happen.
And the anthropology of reproductive health and women's health is strong. There was a panel on men's health and men's lives. So I think there are some really interesting areas that have emerged. And STS is important. We had two plenary addresses, one on STS, and one on feminist technoscience. Because that, along with global health, is another very important intersection, researchers looking at high tech science, around the world.
Thanks to Tobias Rees for inviting Marcia Inhorn to speak at McGill and for arranging this interview, and thanks to Rachel Sandwell for transcribing the recording.