America’s Arab Refugees: Vulnerability and Health on the Margins

Stanford University Press

Stanford, California

©2018 by the Board of Trustees of the Leland Stanford Junior University.

All rights reserved.

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Printed in the United States of America on acid-free, archival-quality paper

Library of Congress Cataloging-in-Publication Data

Names: Inhorn, Marcia C., 1957– author.

Title: America’s Arab refugees : vulnerability and health on the margins / Marcia C. Inhorn.

Description: Stanford, California : Stanford University Press, 2018. | Includes bibliographical references and index.

Identifiers: LCCN 2017017086 (print) | LCCN 2017019970 (ebook) | ISBN 9781503604384 (e-book) | ISBN 9780804786393 (cloth : alk. paper) | ISBN 9781503603875 (pbk. : alk. paper)

Subjects: LCSH: Refugees, Arab—Medical care—Michigan—Detroit. | Refugees, Arab—Health and hygiene—Michigan—Detroit. | Refugees, Arab—Michigan—Detroit—Social conditions.

Classification: LCC RA448.5.A73 (ebook) | LCC RA448.5.A73 I54 2018 (print) | DDC 362.108992/753077434—dc23

LC record available at https://lccn.loc.gov/2017017086

Typeset by Thompson Type in 10/14 Minion

AMERICA’S ARAB REFUGEES

Vulnerability and Health on the Margins

Marcia C. Inhorn

Stanford University Press

Stanford, California

For Arab refugees everywhere

Contents

List of Acronyms

War in Lebanon: A Timeline

War in Iraq: A Timeline

Preface

Prologue: Fatima and Sadiq: From Iraq to Michigan

Introduction: When Arabs Fled: A Legacy of Conflict

1. Why They Fled: War and the Health Costs of Conflict

2. Where They Resettled: Poverty on the Margins of Detroit

3. How They Struggle: Health Disparities and Unequal Treatment

4. What They Feel: Reproductive Exile between Moral Worlds

Conclusion: Why America Must Care: The Lives of Arab Refugees

Acknowledgments

Notes

References

Index

List of Acronyms

AAA (American Anthropological Association)

ACC (Arab American and Chaldean Council)

ACCESS (Arab Community Center for Economic and Social Services)

ALICE (asset limited, income constrained, employed)

ASRM (American Society for Reproductive Medicine)

CDC (Centers for Disease Control and Prevention)

CFR (Council on Foreign Relations)

CMES (Council on Middle East Studies)

DAAS (Detroit Arab American Survey)

DU (depleted uranium)

ESHRE (European Society for Human Reproduction and Embryology)

ESL (English as a Second Language)

EU (European Union)

FCSRCA (Fertility Clinic Success Rate and Certification Act)

FLCIVF (Friends of Low-cost IVF)

GCC (Gulf Cooperation Council)

GM (General Motors)

GWS (Gulf War syndrome)

HOMP (High-order multiple pregnancy)

IBC (Iraq Body Count)

ICSI (intracytoplasmic sperm injection)

IDP (internally displaced person)

IED (improvised explosive device)

IFHS (Iraq Family Health Survey)

IMHS (Iraq Mental Health Survey)

IOM (Institute of Medicine)

IRAP (Iraqi Refugee Assistance Project, renamed International Refugee Assistance Project)

IRIS (Integrated Refugee and Immigrant Services)

ISIL (Islamic State of Iraq and the Levant)

ISIS (Islamic State of Iraq and Syria)

IT (information technology)

IVF (in vitro fertilization)

KS (Klinefelter syndrome)

LCIVF (low-cost in vitro fertilization)

MAIC (Medical Aid for Iraqi Children)

MSF (Médecins Sans Frontières, or Doctors Without Borders)

NATO (North Atlantic Treaty Organization)

NGO (nongovernmental organization)

NIH (National Institutes of Health)

OCHA (Office for the Coordination of Humanitarian Affairs)

OEF (Operation Enduring Freedom, Afghanistan)

OIF (Operation Iraqi Freedom)

OHSS (ovarian hyperstimulation syndrome)

PCOS (polycystic ovary syndrome)

PLO (Palestine Liberation Organization)

PTSD (posttraumatic stress disorder)

RMA (Refugee Medical Assistance)

SLA (South Lebanon Army)

SMA (Society for Medical Anthropology)

SOHR (Syrian Observatory for Human Rights)

SSI (Supplemental Security Income)

TANF (Temporary Assistance to Needy Families)

TESA (testicular epididymal sperm aspiration)

UAE (United Arab Emirates)

UN (United Nations)

UNFIL (United Nations Interim Force in Lebanon)

UNHCR (United Nations High Commissioner for Refugees)

UNICEF (United Nations Children’s Fund)

UNRWA (United Nations Relief and Works Agency)

USCIS (United States Citizenship and Immigration Services)

USCRI (United States Committee for Refugees and Immigrants)

USRAP (United States Refugee Admissions Program)

UXO (unexploded ordnance)

VolAg (voluntary agency)

WHO (World Health Organization)

WMD (weapon of mass destruction)

WMH (World Mental Health)

War in Lebanon: A Timeline

War in Iraq: A Timeline

Preface

THIS BOOK IS ABOUT A POPULATION OF POOR ARAB IMMIGRANTS and refugees, mostly from the countries of Iraq and Lebanon, who have fled from Middle Eastern war zones and who have subsequently struggled to make a life for themselves in America. I extend my deepest sense of gratitude to those individuals and couples whose stories of exile and hope are captured in the chapters that follow. Without their willingness to share their lives with me, I would not have been able to write this book.

As a scholar and a feminist, I have been deeply moved and inspired by two strands of theory and activism, which have helped me to frame the discussion of Arab refugee lives in America. The first is the Black Lives Matter movement, a movement that was started online by young black activists in the wake of multiple incidents of racial profiling and police brutality, particularly toward young black men. However, since its beginning in the summer of 2015, the Black Lives Matter movement has diversified, raising awareness about perceived injustices in a variety of social systems and among a variety of people of color and genders in this country. I am both impressed by, and grateful for, the Black Lives Matter movement and its agenda to achieve greater social justice in America. My gratitude is both personal and professional. On the personal level, my husband Kirk Hooks is black, and my children Carl and Justine Hooks are biracial. Thus, I hope that my children grow up in a fairer, less racist America. As a scholar, the Black Lives Matter movement has also motivated me to think about the profound struggles of another very oppressed minority group in America, namely, Arab Muslims, many of whom have come to this country as war refugees.

This book highlights the profiling of both black and Arab populations in this country and the widespread vilification of both black and Arab men as inherently violent and untrustworthy. Furthermore, the location of this ethnographic study in Detroit, Michigan—a predominantly black city, incorporating a substantial Arab ethnic enclave, and manifesting poverty so deep and pernicious that the collapsing urban infrastructure is reminiscent of a Middle Eastern war zone—facilitates this comparison of black and Arab lives.

America’s Arab Refugees also draws conceptual inspiration from intersectionality theory, as defined by black feminist scholars,¹ and taken up by both black medical anthropologists and public health scholars.² Intersectionality theory elucidates the relationships among multiple forms of oppression based on gender, race, and class but also sexual orientation, age, ability, religion, and national origin. Rather than acting independently, systematic forms of oppression are interrelated and multiplicative in their effects, leading in many cases to poor health outcomes and premature mortality. Intersectionality theory has been applied primarily to the lives of black women and less so to those of Latinas in the United States. However, this framework has great utility in understanding intersecting oppressions facing other minority populations. In the case of Arab Muslim refugees, intersecting oppressions include, but are not limited to, discrimination based on ethnicity, religion, social class, race, gender, and appearance (for example, veiling). This book thus applies intersectionality theory to the study of Arab Muslims’ lives in the United States, showing the utility of this theoretical approach in interrogating axes of oppression beyond the theoretical triumvirate of gender, race, and class.

For many years now, at both the University of Michigan and Yale, I have taught a feminist anthropology course on Intersectionality and Women’s Health: Ethnographic Approaches to Race, Class, Gender and ‘Difference.’ I see myself as a committed feminist scholar, and I teach this course to make my generally privileged college students much more aware of the intersection of race, class, and gender oppression in the lives of poor urban and rural women in America.

Beyond all this, I have worked as a scholar for more than thirty years in the Arab world. This is a world about which I feel great passion—but also at this moment great heartache. The Arab world is currently imploding, causing massive human suffering in its wake. As I write this book in the midst of the worst refugee crisis since World War II, I hope to convince readers that the lives of Arab refugees matter and that America must care. That is the main message of this book.

Marcia C. Inhorn

Yale University

Prologue: Fatima and Sadiq

From Iraq to Michigan

ON A SWELTERING FRIDAY AFTERNOON IN AUGUST, I DROVE my minivan from Ann Arbor, Michigan, to Dearborn, the Arab ethnic enclave located about forty minutes to the east on the outskirts of Detroit. I made this trip to Dearborn on most Friday afternoons, passing the polluting smokestacks of the massive Ford Rouge auto factory. My destination in Dearborn was a nondescript two-story brick medical office building, located on a treeless cement-gray commercial boulevard.

Once inside the building’s front door, however, I was transported into another world—the Arab world. Iraqi women dressed in black abayas (traditional long cloaks) and Yemeni women wearing black niqabs (facial veils) pushed their sick children in strollers into the first-floor pediatrics clinic. Across the open foyer, older Arab gentlemen with white skullcaps visited the Lebanese-run pharmacy, usually after visits to Arab doctors’ offices on the second floor. I would make my way upstairs to one of those offices, the satellite clinic of southeastern Michigan’s largest infertility and in vitro fertilization (IVF) treatment center.

It was there on that late Friday afternoon in August that I met Fatima and Sadiq, an Iraqi-born couple who were struggling to overcome their infertility problem and many additional hardships. Fatima wore a hijab (Islamic headscarf), which framed her pretty face. Her husband Sadiq was also good looking, his full head of hair evenly shaved almost to the scalp. In excellent English, Fatima and Sadiq poured out their story to me. I spent the rest of the afternoon listening to them, the three of us leaving the office as it was closing for the weekend.

I learned that both Fatima and Sadiq had grown up in Basra, a Shia Muslim–dominated city in southern Iraq. When Saddam Hussein invaded Kuwait in 1990, and President George H. W. Bush responded with Operation Desert Storm in early 1991, the population of southern Iraq was caught in the middle. Shia men had been encouraged by the US-led coalition to take up arms against Saddam Hussein after US forces withdrew in February 1991. However, this intifada (uprising) failed, leaving many Shia male fighters in the grips of Saddam’s revenge. Those who were not disappeared or killed—often after periods of brutal imprisonment and torture—fled to neighboring countries. Families fled, too, given that Iraq’s southern Shia Muslims were viewed as potential enemies of Saddam.

Although Sunni Muslim–dominated Saudi Arabia was reluctant to take in nearly 40,000 fleeing Iraqi Shia refugees, the United States and United Nations put pressure on Saudi Arabia to open its borders. A desolate refugee tent camp was set up near Rafha, a Saudi town in the remote northern desert region. Conditions were harsh. Food was scarce and the water salty. Scorching heat and gusts of sand made skin and eyes burn, and high desert winds made the flimsy tents collapse. The Saudi camp guards were also reluctant hosts, sometimes committing acts of violence against this vulnerable refugee population.¹

Among these refugees were Fatima, age eight, and Sadiq, age eleven. Fatima’s father had stayed behind to fight while his wife and their six young children fled to Saudi Arabia with his younger brother. Sadiq’s father was not a fighter, but he feared for the lives of his wife and ten children, fleeing with them to Saudi Arabia.

It was in these unfortunate circumstances that Fatima and Sadiq spent their formative preteen years. They never knew each other in the Saudi refugee camp, nor did their families meet when both eventually were granted asylum in the unlikely American city of Lincoln, Nebraska. When I asked Fatima and Sadiq why they were resettled in America’s heartland, Sadiq replied, I don’t know why. Why there? They just picked Lincoln, Nebraska, I guess. Fatima added, Now Nebraska is supposed to be a good place for Iraqis. But when we were there, back in the early ’90s, there were very little, not too many Arabs. For that reason, Fatima’s family left Lincoln for Philadelphia within a year but decided to move permanently to Dearborn, with its growing Iraqi refugee population.

Sadiq’s family stayed in Lincoln for several years, and Sadiq was somewhat nostalgic about his early days in Nebraska. Although he had neither been able to go to high school nor to learn English fluently, Sadiq was nonetheless able to obtain meaningful employment in Lincoln’s Kawasaki factory, which manufactured all-terrain vehicles. Sadiq exclaimed, I never looked for a job. The job looked for me! But he then added, quietly, Now I look for it, but I can’t find it.

As I soon discovered, Sadiq was currently unemployed. When he had moved with his family to Dearborn seven years earlier, he had begun working as a busboy in a Lebanese restaurant, before landing a factory job in a company making plastic parts for the local automotive industry. As good factory jobs with accompanying benefits were hard to find in Michigan’s depressed economy, Sadiq had been lucky to secure this kind of stable employment. He used his job to save money for his marriage. He also took a second night job in a Lebanese-owned Mobil gas station.

Through connections in the local Iraqi community, Sadiq met Fatima and married her on a cold winter day in January, shortly before he turned thirty. Sadiq was attracted to Fatima not only for her beauty but also because she was smart and was one of the few Iraqi refugee women attending the local branch of the University of Michigan. Fatima applied herself to her studies and was well on her way to obtaining a bachelor’s degree in information technology (IT) management. In addition, Fatima had obtained a coveted government position at the state’s unemployment agency. Being fully bilingual, Fatima was able to help local Arab refugees and immigrants fill out their unemployment forms. Fatima’s position provided her with health insurance benefits and also allowed her to pay her own way through college, as her father could ill afford the tuition bills.

Fatima and Sadiq began their marriage with the highest hopes and aspirations. They both had good jobs with benefits. Fatima was on track to graduate from college. And in a depressed housing market with low interest rates, the couple was able to buy a small home on a tree-lined street in a mostly Lebanese Shia neighborhood. Living apart from their large families for the first time in their lives, Fatima and Sadiq also had some measure of marital privacy. Like most Arab newlyweds, they started trying to make a family from the first night of marriage.

But a year and a half later, the couple’s plans had gone terribly awry. Metro Detroit was in an economic free fall. Sadiq’s factory job, reliant on the local General Motors (GM) and Ford factories, swiftly disappeared due to downsizing. But Sadiq was most disturbed by the fact that he had not been able to impregnate Fatima, who was coming under community scrutiny for her inability to prove her fertility. Although Sadiq’s wages as a gas station attendant were meager, he encouraged Fatima to make an appointment for both of them at the local infertility clinic.

When I asked Sadiq and Fatima how they had come to find this clinic, Fatima explained, I heard about it from the community. It is ‘known’ in the Arab community as the only clinic for these kinds of things. So we came here, and they couldn’t find anything [wrong]. When they started doing X-rays and check-ups, everything was perfect, except that I have an enlarged [fallopian] tube. That is the only problem. There were no sperm problems.

Fatima was suffering from tubal-factor infertility, the very condition for which IVF was initially developed. Although the Lebanese-American IVF physician explained to Fatima and Sadiq that they might eventually become pregnant without the help of IVF, the couple was quite eager to start a family. Throwing caution to the wind, they decided to put all of their remaining savings—$10,000, to be exact—into the purchase of a single IVF cycle, an elective procedure that was not covered by Fatima’s health insurance plan. Furthermore, Fatima lost that plan when she decided to cut back to half-time employment. With the daily blood tests, ultrasound scans, and hormone injections, fitting her medical appointments into a full-time work schedule was too difficult. To add insult to injury, Sadiq lost his gas station job soon after Fatima began the IVF cycle. But because they were already committed—and had paid fully for the IVF cycle—they decided to press forward.

The IVF cycle itself seemed to be going well. Because Fatima was still young, in her late twenties, she produced twenty-six healthy eggs, a considerable number, which were retrieved from her ovaries in an outpatient procedure that was performed under general anesthesia. However, two days later, when Fatima was scheduled for the transfer of the embryos back into her uterus, she began to feel unwell. Her abdomen became extremely bloated, and she found herself gasping for breath. In addition, severe pain and cramping in her lower abdomen and legs meant that she could not walk or even stand on her own. Realizing that something was terribly wrong, Sadiq rushed Fatima to the emergency room of the local hospital, where she was admitted for ovarian hyperstimulation syndrome (OHSS). OHSS is a rare but potentially fatal complication resulting from some forms of fertility medication. Although most cases of OHSS are mild, involving abdominal bloating, nausea, and slight weight gain, Fatima’s case was severe. She experienced marked abdominal bloating above the waist and shortness of breath due to pleural effusion, or the buildup of excess fluid in her lungs. The couple described the medical emergency—and the unpaid hospital bill totaling thousands—to me in this way:

FATIMA: I got sick, with fluid in the lungs. It was hyperstimulation. It was bad, and I was in the hospital for a whole week. I had pleural effusion.

SADIQ: Yeah, they had to put a tube in her. It drained all the fluid from her lungs. It was bad hyperstimulation, and she had to stay in the hospital until she got better.

FATIMA: I still have a lot of pain in my lower belly and back. My ovaries are big. They said they will get better after I have a period. But now, it’s going to take three to four weeks before they will decrease in size.

SADIQ: But at least now she’s feeling good. She can walk on her own and can breathe better.

FATIMA: This is the worst time ever in both of our lives. I never got that much sick before. This was the most toughest time I’ve ever had. And I had spent a lot of time coming for ultrasounds and blood work. It was costly, painful, and also time consuming. Every other day, I was doing treatment. But no one knew, not even the family. It was too personal, and I wanted to keep this to ourselves. Also, I had been working full-time for the state. But because we wanted to start a family, I cut to part-time and lost my state benefits. We started treatment from our own pockets. But when we left the hospital, the hospital bill was still unpaid. We’re going to have to ask a charity to help pay for our hospital bills. It’s a charity in the hospital. They will pay for the stay, but you have to prove that you’re low income or not working. I wasn’t expecting that I’m going to get sick when I saved just enough money for the in vitro. The IVF was maybe $10,000, all totaled with the medicine. At least that is paid for. But now we’re so broke that I can’t go back to school in the fall. I would register as a senior in the fall, but I don’t think I can go back to school. The tuition is going up. Right now, to register for four classes, three to four months ago would have been $4,000. But there was a 7 percent [tuition] increase. So now it’s $5,200 for one semester, for four classes, just for the tuition. I was planning to graduate on time, but this is never going to happen.

Because Fatima had revealed their financial woes to me, I asked the couple if their families could help provide them with any form of financial support. Sadiq was the first to respond, explaining how the Michigan economy was sinking:

SADIQ: Businesses around here keep laying people off. So there are not that many people who can help us in our families. If we have no choice, then I’ve got to go to my family. But first, I must try my best. We just bought a house, but now she’s sick, and I never thought this would happen.

FATIMA: My dad worked for the largest oil company in Iraq as a supervisor for twenty years. They say in the news that