America’s Arab Refugees
Vulnerability and Health on the Margins
Marcia C. Inhorn

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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 things are getting better in Iraq with the government’s help. But my dad and mom were in Iraq this year, trying to get his retirement. He hired an attorney, and for three months he stayed there, but nothing’s happened. He owns a little business here, but he doesn’t make much money. He needs his retirement [from Iraq], and he can’t get it.

SADIQ: We have not been back since we left in 1991. We’ve not been back there. If you want to go back home, and you see your country and feel bad all of the time, then you go there and get depressed. People say it got worse and worse. I don’t think it’s a good time to go to see the country. You’ll look and see where your country is, and you’ll just want to stay away until it gets better.

FATIMA: I would like to go and visit someday. I would love to go to the Middle East. But definitely not now.

I told Fatima and Sadiq that few Americans probably realized that Iraq had once been a country known for its higher education, including an excellent health care system and many talented Iraqi physicians.2 This caused Fatima to reflect on American attitudes toward Iraqis and Arabs more generally:

FATIMA: From my experience, when I was at school and at work—and I went to school here, not back home [in Iraq]—I noticed people always look at you. They don’t look at you as an Iraqi or Yemeni. You’re all mixed up in their minds. You’re an “Arab.” They don’t know the differences between the Lebanese, Iraqis, Yemenis. I think, unfortunately, I would have to say that the majority of people here are not educated about anything having to do with different cultures and religions. Back home, we focused on history, language, and culture. But here, even college students don’t know anything about other cultures. I have friends who took four years of high school Spanish, and now they can barely communicate. So what they know about the world is because of their families, their environment. We thought about moving, maybe to a different state. Now there are Iraqi communities in New Mexico, New York, Philly, California, Florida, and Texas. But our families are here, both sides, and at least there are other Arab people who can understand you.

Due to increasing Islamophobia and anti-Arab sentiment, Fatima and Sadiq felt a measure of safety living in a mostly Arab ethnic enclave, even if it rendered them “stuck” in Michigan for the foreseeable future. Moreover, because of their IVF cycle, Fatima and Sadiq had twenty unused embryos waiting for them in cold storage in the Arab-serving IVF clinic. When I asked them what they planned to do with their frozen embryos, they had this to say:

SADIQ: I have no idea. I thought about it, but I don’t know. I guess they can keep them there.

MARCIA: Would you consider donating some of them to other couples?

FATIMA: No! I don’t want to do that. We don’t want our kids with someone else.

SADIQ: I like to keep them to myself.

MARCIA: So you’re opposed to donation?

FATIMA: I wouldn’t say I’m against what they do, especially if people want to do this to save their marriage. But for me, I wouldn’t want to do it.

SADIQ: To me, it seems like . . . I can’t really imagine giving my kid to someone else and to see it grow up. “This is my kid, and I donated it.” Even if it’s okay to do, it doesn’t seem right to me. Donating the baby to someone else, I don’t see that it’s a good idea.

MARCIA: Do you know if donation is approved by the religion?

SADIQ: He doesn’t approve, Sayyid Sistani [that is, Iraq’s major Shia religious authority]. He’s the main person we follow.3

MARCIA: So, if you have extra embryos, what will you do?

FATIMA: Can you get rid of them?

SADIQ: Yes.

FATIMA: I think we will have to ask our religious person.

SADIQ: You can get rid of them.

FATIMA: But we’ll have to ask, just to be safe.

Like many pious Muslim couples, Fatima and Sadiq were concerned about the moral acceptability of IVF, relying on the opinions of highly respected Islamic religious authorities. But their most immediate concern was the unexpected news they had received that very afternoon—namely, Fatima was pregnant, even though none of her IVF embryos had been transferred to her womb in the midst of her life-threatening OHSS emergency.

Although I was happy for this young Arab refugee couple—who had faced a perilous journey and so many subsequent difficulties—I was confused about Fatima’s “mystery” pregnancy. Fatima explained to me that the doctor had told them to refrain from sex during the IVF cycle. But, once again, they had thrown caution to the wind. One episode of unprotected intercourse had resulted in an unplanned pregnancy—a “natural” pregnancy that had withstood the rigors of IVF hormonal stimulation and a severe case of OHSS.

As the clinic was about to shut its doors for the weekend, I asked Fatima how she was feeling about the pregnancy. “I didn’t know I was pregnant,” she explained. “It was a surprise, an unexpected surprise!” Sadiq added, “Oh yeah, it was the lucky nine, the lucky shot!”

Fatima was still feeling sick and distended from the OHSS. Sadiq was still unemployed with no idea where he would find another job. The couple’s unpaid mortgage and hospital bills were piling up. But that summer afternoon, Fatima and Sadiq were beaming. They had each other. They had a miraculous pregnancy. And they now had hopes and dreams of a future baby—an American baby, born to Arab refugee parents, on the margins of Detroit.

Notes

1. Walbridge and Aziz (2000) describe the horrific conditions and violence experienced by the Iraqi refugee population before and after they gained entrance to Saudi Arabia.

2. Dewachi 2017.

3. Ali Al-Sistani of Najaf, Iraq, is one of the world’s leading Shia Muslim clerics. His fatwas, or written religious rulings, are followed by millions of Shia Muslims.