Cosmopolitan Conceptions? Biopolitics and Emiratisation in Dubai’s IVF “Reprohub”

By Marcia C. Inhorn

Despite the political tumult in the Arab world, Dubai continues to draw medical tourists from around the globe, including infertile “reprotravellers” who are seeking IVF services. However, Emirati state attempts to manage, legislate, and “emiratise” IVF services threaten to dismantle Dubai’s reputation as a global “reprohub.”

Introduction

Since the beginning of the new millennium, the Arab world has experienced unprecedented levels of political violence and disruption. However, against this bloody backdrop, a high-tech reproductive revolution has quietly unfolded. Namely, by the mid-2000s, the Arab world had developed one of the most robust in vitro fertilisation, or IVF, sectors in the world. To be more specific, among the 48 countries performing the most assisted reproductive technology cycles per million inhabitants, eight Arab nations – including Lebanon, Jordan, Tunisia, Bahrain, Saudi Arabia, Egypt, Libya, and the United Arab Emirates (UAE) – could be counted.1

The UAE was an early entrant into this burgeoning field of IVF globalisation. The UAE opened its first IVF clinic in a government hospital in 1991, only five years after Saudi Arabia introduced IVF to the Arab Gulf. By 2005, the UAE hosted seven IVF clinics, five of them private facilities. By 2012, that number had doubled to fourteen, twelve of these privately owned.

As an emerging global “reprohub”, Dubai now sits squarely in the centre of a “reproscape” – a world of assisted reproduction in motion – characterised by new global “reproflows” of actors, technologies, and body parts.  

Today, thousands of infertile couples are traveling to Dubai from Africa, Asia, Australia, Europe, the United States, and other parts of the Middle East in desperate quests for conception. These “reprotravelers”2 are often fleeing home countries where IVF services are either absent, inaccessible, ineffective, illegal, or even harmful. Thus, as an emerging global “reprohub”, Dubai now sits squarely in the center of a “reproscape” – a world of assisted reproduction in motion – characterised by new global “reproflows” of actors, technologies, and body parts.  

Because of Dubai’s status as a global city and a booming international tourism hub, IVF in Dubai is decidedly cosmopolitan, with clinicians from various countries delivering IVF care across national, ethnic, linguistic, religious, and cultural boundaries. Yet, cosmopolitanism in Dubai exists in tension with a state-sponsored project called emiratisation. Emiratisation is an attempt by the UAE government to prioritise the needs of Emiratis, particularly through a formal government mandate intended to increase the participation of Emiratis in key positions in the UAE private-sector workforce.3 On a broader societal level, however, emiratisation is about putting Emiratis first – prioritising the needs of the muwatinun, or “nationals”, over foreigners. This is partly because Emiratis now constitute a tiny fraction of the overall populace in their own country – less than one million out of a total of nine million, approximately eight million of whom are foreign workers.4

Since the mid-2000s, the Emirati state has made two major efforts to emiratise IVF services in the country. The first involves the Emirati government’s brief experiment with IVF public financing, which started off as a globally inclusive program, but ended up solidifying preferential treatment for local Emiratis. The second is the 2010 passage of UAE Federal Law No. 11, which now stands as one of the world’s most restrictive pieces of ART legislation.

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The Birth of Emirati IVF and the Public Financing Experiment

Before the UAE’s first IVF clinic opened in 1991, infertile Emiratis were medical travellers, leaving the country, primarily to London, to undertake IVF under UAE state largesse. However, sending all infertile Emirati couples to London was difficult for the UAE Ministry of Health to sustain financially over time. Thus, around 1990, the Dubai Health Authority decided to start its own IVF unit in a local government hospital. Given the UAE’s former status as a British protectorate, the Dubai Health Authority turned to Great Britain for expertise in setting up the nation’s first IVF clinic. British-trained gynecologists began traveling to Dubai as “IVF troubadours”5 – taking the art of assisted conception with them from its birthplace in England.

With an effective monopoly on IVF in the UAE, the new Dubai IVF clinic was able to charge high prices for its services, between $5,000-$6,000 per IVF cycle, equivalent to the most expensive private IVF clinics on London’s Harley Street. The stature of both Dubai and Abu Dhabi as growing cosmopolitan cities, with many Western expatriate foreign workers, seemed to sustain these high fees, outstripping even petro-rich Saudi Arabia, where a single ivf cycle could be obtained for less than $5,000.

Interestingly, Emiratis themselves were not exempt from these high fees. Like the foreigners flocking to Dubai’s IVF clinic, Emiratis were expected to pay full fare. Furthermore, due to demand pressure on the nation’s sole clinic, both Emirati and foreign couples began to experience long waiting lists. Increasingly disgruntled, infertile Emirati couples put pressure on the government, resulting in two decisive actions. First, the UAE Ministry of Health allowed private IVF clinics to open outside of Dubai, primarily in the neighbouring emirates of Abu Dhabi and Sharjah. Such private clinics – run by non-Emirati IVF clinicians for both Emirati and foreign couples – were allowed to operate as long as they were “sponsored” by a kafil, or a local Emirati “silent partner”, who would invest in a clinic’s infrastructure, but would also reap at least 51% of the ongoing profits. As a result, several wealthy Emirati businessmen became both benefactors – and beneficiaries – of the resulting privatisation of IVF services in the Emirates.

In addition, the UAE Ministry of Health decided to relieve demand pressure by opening a second government IVF clinic. Rather than placing it in glitzy Dubai, the MOH underwrote clinic construction in a government teaching hospital in Al Ain, Abu Dhabi. In a sweeping gesture of state largesse, IVF cycles were offered free of charge to both Emiratis and non-Emiratis alike. This marked the beginning of the UAE’s brief experiment in IVF public financing. Public financing is the term used by health economists to describe the funding of assisted reproduction either through direct payment by the state to IVF clinics, or through state-funded health insurance schemes that offer reimbursement for IVF to infertile couples.6  In the Emirates, the new government IVF clinic adopted the second system, offering reimbursable IVF cycles to both Emirati and foreign couples through the state’s national health insurance system.

However, what the UAE government did not realise is that it had opened a veritable floodgate of infertility in the country. Foreign workers – from the most elite European expatriates to the poorest South Asian construction workers – began clamoring to the new government IVF clinic. Soon, long waiting lists formed, and because local Emiratis received scheduling priority, foreign couples living in the country had to wait months, even years, to be granted an appointment. Such foreign flooding of the solo “free” government IVF clinic quickly became unsustainable. By the mid-2000s, less than five years after the clinic’s opening, this brief experimental moment of “IVF for all” had ended. The state returned to reimbursing IVF cycles only for local Emiratis, providing them with everything – from the costly IVF medications to the expenses involved in the IVF procedures themselves – so long as they were willing to travel to Al Ain to access this state-subsidised care.

The UAE would become the only Arab country to fully subsidise IVF for its citizens – but not foreign residents of the country, who are rarely naturalised as citizens.

In retrospect, this brief experiment in Emirati public financing of IVF was an early manifestation of emiratisation. The UAE would become the only Arab country to fully subsidise IVF for its citizens – but not foreign residents of the country, who are rarely naturalised as citizens. Foreigners could still access IVF at government clinics, but they were required to pay full fare. In other words, the fiscal emiratisation of state IVF became a citizenship right in a country where only Emiratis themselves are citizens.

 

The Legal Emiratisation of IVF

The second aspect of IVF emiratisation involves religion and law. The UAE follows the dominant Sunni branch of Islam. In Sunni Islam, IVF is allowed only if it occurs between a husband and wife, using their own eggs and sperm.8 “Mixing” of eggs, sperm, or embryos – either intentionally or by mistake – is explicitly prohibited and carefully spelled out in numerous Sunni Muslim fatwas, or religious decrees on IVF, issued since 1980. Since then, this anti-donation religious stance has been upheld repeatedly, effectively instantiating a powerful Islamic bioethical ban on third-party reproductive donation across the Sunni Islamic world, from Morocco to Malaysia. As a result, the vast majority of  Sunni Muslims – who account for approximately 80 to 90 percent of the world’s 1.6 billion Muslims – will never consider undertaking such third-party reproductive donation, because they regard these practices as haram, or deeply immoral.9

Having said this, a little-known fact about the UAE is that it is the only Sunni Muslim country in the Arab world to have once allowed both egg and sperm donation. Furthermore, and quite ironically, third-party donation of both egg and sperm was offered from the very beginning in the UAE’s own government IVF clinic! At the outset, no one seemed to question what was going on in the Dubai government IVF clinic, which was run by mostly British staff members. British staff were quite comfortable offering third-party donation to the many infertile couples from Europe, America, Australia, and many parts of South and Southeast Asia. However, by the end of the 1990s, increasing disquiet among the local Muslim population began to take hold. Many Emiratis, as well as other Arab patients coming to the clinic, began to question the third-party donation services on offer at the clinic. By 1998, the Dubai Health Authority effectively suspended third-party donation, insisting that the clinic’s bank of donor sperm and embryos be destroyed.

This marked the end of Dubai’s seven-year “permissive” period. From that point on, IVF in the Emirates would be conducted according to Sunni Islamic guidelines. These guidelines would be enforced through a new phase of legal Emiratisation. Namely, by January 2007, the Abu Dhabi-based Ministry of Health ratcheted into high gear. A national committee was formed to develop federal guidelines. Over a three-year period, from 2007 to 2009, the Ministry of Health worked out its comprehensive IVF legislation. Federal Law No. 11 regulating IVF clinics in the UAE was officially passed into law in early 2010,  and was signed by all seven standing emirs, or rulers of the confederation.

Quite significantly, the UAE’s Federal Law No. 11 can be described as one of the most comprehensive – but also one of the most draconian – assisted reproduction laws in the world.

The outlawing of the vast majority of possible IVF practices can only be described as a kind of legal emiratisation – the UAE’s own biopolitical attempt to prevent any form of third-party “mixing” from occurring on Emirati soil.

Of the 22 potential assisted reproduction procedures, only seven, or approximately one-third, are now allowed in the Emirates. Fifteen others are prohibited, including, most notably, cryopreservation, or freezing of embryos; third-party donation of eggs, sperm, and embryos; gestational surrogacy; or any kind of assisted reproduction outside of heterosexual marriage. The outlawing of the vast majority of possible IVF practices can only be described as a kind of legal emiratisation – the UAE’s own biopolitical attempt to prevent any form of third-party “mixing” from occurring on Emirati soil.

 

Conclusion

In short, IVF practices in the UAE have been increasingly emiratised over the past 25 years in response to government fiscal pressures and the cultural and religious sensibilities of the local Emirati population. An IVF sector that began entirely as a British import – transplanted directly into the womb of the UAE’s main government hospital – has gradually become indigenised in response to perceived local needs. This process of IVF emiratisation can be understood as a variant of the more formal government-mandated program of emiratisation, which is designed to increase Emirati representation in the private labour force in the country. In the IVF sector, clinics have also come under increasing government pressure to cater to the needs of Emiratis over foreigners.

An IVF sector that began entirely as a British import – transplanted directly into the womb of the UAE’s main government hospital – has gradually become indigenised in response to perceived local needs.

As a result of this emiratisation process, IVF services that were once openly practiced and deeply desired by a globally diverse group of infertile couples have gradually disappeared over time. Emiratisation – in its moral, medical, fiscal, and legal forms – has proven extremely difficult for the millions of non-Muslim IVF patients living in, or traveling to, the Emirates in the hope of accessing high-quality, medically cosmopolitan IVF care. Once they arrive, they are often shocked to discover a contemporary moral-legal environment in which many potential assisted reproductive technologies are entirely unavailable. For many of these reprotravellers, this conservative biopolitical regime is oddly out of sync with Dubai’s progressive image as a globally sophisticated, culturally cosmopolitan reprohub. A beacon of high-tech modernity on the one hand, and a bastion of Emirati privilege and local morality on the other, the UAE is trying to have it both ways – leading to significant paradoxes and complexities, as well as new forms of reproductive privilege and discrimination.

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Marcia C. Inhorn is the William K. Lanman Professor of Anthropology and International Affairs at Yale University. A medical anthropologist focusing on infertility and IVF in the Middle East, Inhorn is the author of five books on the subject, including Cosmopolitan Conceptions: IVF Sojourns in Global Dubai (Duke UP, 2015).

References

1. Adamson, G. David (2009) “Global Cultural and Socioeconomic Factors that Influence Access to Assisted Reproductive Technologies.” Women’s Health 5:351-353.
2. For a fuller explanation of this “reprolexicon” of terms, see Inhorn, Marcia C. (2015) Cosmopolitan Conceptions: IVF Sojourns in Global Dubai. Durham, NC: Duke University Press
3. Toledo, Hugo (2013). “The Political Economy of Emiratization in the UAE.” Journal of Economic Studies 40:39-53.
4. Vora, Neha (2013) Impossible Citizens: Dubai’s Indian Diaspora. Durham, NC: Duke University Press.
5. Simpson, Bob (2016) “IVF in Sri Lanka: A Concise History of Regulatory Impasse.” Reproductive BioMedicine and Society 2:8-15.
6. Brigham, K.B., Cadier, B., and K. Chevreul (2013) “The Diversity of Regulationi and Public Financing of IVF in Europe and Its Impact on Utilization.” Human Reproduction 28:666-675
7. Jones, Howard W., Ed. 2010. International Federation of Fertility Societies: Surveillance 2010. https://www.researchgate.net/publication/46123849_International_Federation_of_Fertility_Societies_Surveillance_2010_Preface
8. Inhorn, Marcia C., and Soraya Tremayne, Eds. (2012) Islam and Assisted Reproductive Technologies: Sunni and Shia Perspectives. New York: Berghahn.
9. Inhorn, Marcia C. (2003) Local Babies, Global Science: Gender, Religion and In Vitro Fertilization in Egypt. New York: Routledge.

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