As the coronavirus spreads, governments and professionals are forced to ask a more fundamental question: “Is assisted reproduction an essential service?”
COMMENT
A recent New York Times article heightened the sense of dystopia of the world that we seem to be currently inhabiting. According to the article, thousands of babies born to surrogate mothers will be left “stranded” in Ukraine because coronavirus pandemic-related travel bans prevent their parents — from all over the world — from fetching them.
Foreign embassies would have automatically given the babies the citizenship of their biological parents, but for now these babies are “surrogacy orphans”.
In the United States, a surrogate mother is similarly “stranded” with the baby she birthed for a gay couple from China. Although she promises to give the baby to the legal parents whenever they can travel, she confesses to having strong feelings of attachment with the baby who currently lives with her and snuggles with her all night.
In another city, a gay couple from Israel remain stuck in a hotel with their newborn twins — born by egg donation and surrogacy — petrified as the virus spreads, knowing that none of them have any health insurance in the US.
The world of assisted reproductive technology (ART), a multibillion-dollar global industry including services like in vitro fertilisation (IVF), surrogacy, egg and sperm donation, among others, has been a hotbed of similar scenarios, scandals and contradictions long before the current pandemic. I have discussed the paradoxes of ART, in general, in my book Wombs in Labor, and the specific context of South Africa in my earlier works.
As the coronavirus spreads, governments and professionals are forced to ask a more fundamental question: “Is assisted reproduction an essential service?”
In March, the world’s leading bodies in the field of reproductive medicine — the American Society for Reproductive Medicine (ASRM) and ESHRE, its European counterpart — recommended stopping all new fertility treatment.
This did not go unchallenged by either investors or clients of such services. A public petition with thousands of signatories asked the ASRM to reconsider its recommendations, and the New York department of health issued a guidance to explicitly include these treatments as essential.
South Africa witnessed a similar trajectory. In March, the professional body in South Africa, the Southern African Society of Reproductive Medicine and Gynaecological Endoscopy (Sasreg), issued a guideline suspending all non-urgent fertility treatments but a few weeks later published a legal opinion allowing new fertility treatments for almost all categories of patients, in essence classifying fertility treatment as an essential service.
Apart from the very pragmatic question as to whether one should pursue any kind of treatment that is not life threatening when there is a deadly virus making its rounds, there are other ethical dilemmas. For instance, should we be diverting resources towards fertility treatments during a pandemic that threatens to be debilitating for health infrastructures in all parts of the world? One can argue that fertility treatment, especially in the Global South and countries such as South Africa, falls primarily under private healthcare, with minimal investments by the government, and hence anxieties around diverted public resources are unfounded.
But any argument built on the public-private binary underplays the overlaps between the two, and the ways in which private health care is subsidised by the government. Such treatments are taking away critical and scarce resources, which include personal protective equipment; hospital beds; and operating rooms, apart from the time and effort of physicians and support staff which could be meaningfully diverted towards emergency care.
These dilemmas go beyond the pandemic context, especially in countries with limited resources and many competing reproductive health priorities. For instance, what are the social consequences of classifying infertility as a disease? On the one hand, in South Africa, where the burden of “failed fertility” falls almost exclusively on women and causes extreme socio-psychological and even physical harm, recognising infertility as a treatable problem may reduce the gendered stigma.
But, on the other hand, does the prevailing setting of offering high-cost and high-tech technological fixes, primarily via private healthcare, even meet this “essential” need? The causes of infertility (especially among poor and black women), such as sexually transmitted infections, poor medical treatment during an earlier birth or abortion, workplace and environmental toxins, require relatively affordable preventable measures rather than the ex-post facto technological interventions that such patients cannot afford.
In South Africa, reproductive health services, much like the rest of the health system, are riddled by debilitating inequities based on race and class. The total health care expenditure in South Africa in 2017 was about 8.8% of GDP, but of the amount allocated towards healthcare, nearly 60% goes directly towards the private sector, which only services 16% of the population.
One of the consequences is that public sector services and our essential workers, including doctors, nurses and hospitals midwives are under-resourced, stressed and overworked, leading to “compassion fatigue” and even abuse of patients in such settings.
Women giving birth, or requiring reproductive health care often face a host of dehumanising psychological, verbal and physically violent acts from the overworked care providers (for instance, there are reports of nurses and doctors slapping women in labour, non-consensual contracepting, and unnecessary medical interventions). Since the public healthcare system is mostly used by the poor, this violence is yet another instance of the embedded inequities in reproductive experiences.
What the pandemic is forcing us to ask is this: can we continue to legitimise the investments in cutting-edge technology, and five-star luxury fertility clinics, when our reproductive health sector is riddled with systemic inequalities? Can we justify assisted reproductive technologies as essential, if it continues to serve just a privileged few? Can we continue to look for individual based biomedical solutions to these “diseases”, when our health system is in a permanent state of crisis?
This is the perfect storm to challenge the neoliberal approach to reproductive healthcare, where individually accessed technological solutions have effectively depoliticised structural inequalities.
The pandemic provides us the prism to reflect on what and who is deemed “essential”, and at what cost.
Amrita Pande is associate professor in the sociology department at the University of Cape Town