How Egyptian family planning policies navigate between the Westernized state and traditional Islamic groups.
Series: No. 21Sales restrictions: Not for sale in Egypt or the Middle East
In this ethnographic study, the author examines the policies and practices of family planning programs in Egypt to see how an elitist, Western-informed state attempts to create obliging citizens. The state sees voluntary compliance with the law for the common good as the cornerstone of modernity. Family planning programs are a training ground for the construction of self-disciplined individuals, and thus a rewarding area of study for the fate of social programs in developing countries.
Through a careful examination of state-endorsed family planning practices in urban and rural contexts, the author shows us the pervasive, high-pressure persuasion of women, who are encouraged to think as individual decision makers of their immediate families and their national interests. But what of the other forces at work in these women’s lives, binding them to their extended families and to their religious identities? And what of the laws that allow for polygamy and discriminate against women in marriage, inheritance, and as part of the workforce?
These forces operate against the received wisdom of the state. Is the Muslim community thought to end at the borders of Egypt? What about local constructions of masculinity when the state appeals to wives to decide for themselves? How does widespread labor migration to foreign countries affect attitudes toward family planning? How is female contraception viewed by the Islamic Brotherhood and other modern Muslim groups?
This book questions much that we have taken for granted and gives us grounds for reexamining our assumptions about family planning and the individual and state in developing countries such as Egypt.
- Part 1
- History of Family Planning
- Changing Behavior
- Part 2
- Spatial Context
- Women's Bodies
- Women's Choices
- Men and Family Planning
- Part 3
- Constructing New Selves
- Islamist Futures
I say this frankly. It is very difficult business. You should know that we have increased in only five years by six million people, about as much as [the total population of] one or two countries around us. You see we have increased in six, five years [by] a country or two.
—Hosni Mubarak, president of Egypt, Al-Ahram, 1 May 1987
This text discusses how development initiatives in general and family planning in particular help train and produce new bodies and selves in the wider context of capital expansion and accumulation as we enter the twenty-first century. I argue that family planning programs do not just reduce the number of children and regulate reproduction. Rather, they also introduce or foster notions of individual choice and responsibility, risk aversion, and personal independence. In short, they help to construct a new kind of individuality, guided by legal constructs of citizenship rather than by communitarian and familial control.
Taking the Egyptian family planning program as a case study, I also demonstrate how the Egyptian poor, the intended targets of the fertility control program, make fertility decisions informed by their own notions of sexuality, fertility, the body, and the self. My study integrates their responses to the family planning program and to the global and local social processes that shape their lives.
The Egyptian state has, in the last fifteen years, collaborated with international donor agencies on an ambitious population control program. The program operates on the assumption that rapid population growth is a prime obstacle to the realization of development goals set by the Egyptian state. During the period of my stay in Egypt (1992-1994), the Egyptian state argued that the high population growth rate (2.6% annual growth) was the cause of the economic and social crises confronting the country. Governmental agencies and the media maintained that the poor, who have larger families, were responsible for their own plight as well as for the general economic crisis. The obvious solution, they claimed, was to reduce the population to a level that would permit continued economic development.
The arguments surrounding the active population planning program in Egypt echo larger international debates on population control. Ecological degradation, hunger, poverty, and political instability are buzzwords that are used in studies to define the present world population problem (Hartmann 1995). According to demographic estimates, the world's population exceeds 6 billion people, with the greatest population growth occurring in the lesser developed countries. Concurrently, experts predict that an increase in the density of the human population will lead to further erosion of agricultural lands and subsequent decreases in food production worldwide. It also is believed that, despite technological innovations in agriculture and other development projects, the increased population will not be adequately sustained.
Industrialized countries in Europe and North America cite the rise in emigration of people from the southern to the northern hemisphere as a key factor in the "world population problem," while third-world countries identify rural-urban migration as contributing to the creation of economic crises (Sen 1994:62). Analysts contend that millions of inhabitants in most third-world megacities need to adjust to a life with fewer state-sponsored infrastructural resources. Such arguments proclaim that one of the main reasons that most non-Western states are unable to provide adequate investments in housing, education, and other social services is because of their large populations. Keeping these arguments in view, the internationally sponsored development effort in Egypt, exemplified by the population control program, combines the arguments about scarcity of resources, cultivable land, and adequate employment.
It is necessary to look at recent Egyptian economic history in order to situate these arguments. One narrative on this topic is as follows. In the late 1980s, after a decade of growth and rising income, the Egyptian economy started to stagnate under increased international debts, high unemployment rates, and growing budget deficits. The Egyptian government's investment priorities, international borrowing, and accounting policies led to an accumulation of internal and external account imbalances. Egypt became caught in an economic recession because of reduced remittances and an international debt of almost $50 billion, exacerbated by a decline in migration to the Gulf states and a drop, during the mid-1980s, in the price of petroleum on the international market.
As a result of the recession, Egypt was unable to service its debt and paid only half of its $6 billion obligation for the year 1989-1990. The Gulf War also contributed to the severe economic crisis, leading as it did to a sudden return of many migrants and a reduction in tourism earnings. The year 1990-1991, therefore, saw Egypt with reduced creditworthiness, decreased revenues, double-digit inflation (20%), and 12-14 percent unemployment rates. In response to these factors, in May and November of 1991 the International Monetary Fund (IMF) and the World Bank negotiated a Standby Agreement and a Structural Adjustment Loan with the government of Egypt. This provided the basis for the Economic Reform and Structural Adjustment Program (ERSAP).
Immediately after signing the agreement and because of its role in the Gulf War, Egypt was granted debt reduction by the Paris Club and, independently, by the United States, which cancelled $6.7 billion in U.S. military debt. In July 1991, other creditor nations reduced the net value of Egypt's debt by 15 percent. Additional relief of between 15 and 20 percent was promised upon completion of goals required by the IMF (U.S. Embassy Cairo 1993; Abdel-Khalek 1993). These reductions helped fiscal reformers establish control over national accounts, reduce the deficit (from 17% of GDP in 1990-1991 to 1% in 1997-1998), improve the balance of payments, and increase domestic savings. Whether the impact of the reductions on poverty levels, inflation, and employment was as positive is, however, less clear.
What the narrative given above ignores is that in the 1990s, unemployment levels remained high; notably, university and technical institute graduates constituted 65-75 percent of the openly unemployed.10 Although official figures reported unemployment at 8-10 percent in the early 1990s, other estimates ranged from 15 to 20 percent of an Egyptian workforce of almost 18 million people (U.S. Embassy Cairo 1993; Pfeifer 1999). Unemployment could rise further with privatization of state-owned enterprises and workforce reductions. Linked to unemployment figures is the rate of inflation, which was officially stated to be under 5 percent in 1996 (Pfeifer 1999) unofficial estimates, though, considered it to be in the double digits, between 12 and 14 percent. The rise in inflation was primarily a result of increases in the cost of food, energy, and transportation (U.S. Embassy Cairo 1993; Korayem 1993).
The 1991 adjustment package has substantially raised the poverty levels in Egypt, at least in the short term. The per head GDP decreased from $640 in the late 1980s to $610 in mid-1995. Poverty is defined by international standards as a total income of $35 per month; by that definition the percentage of Egypt's population living in poverty increased from 20-25 percent in 1990 to almost 33 percent in 1995, and to more than 45 percent by 1997 (EIU 1995; Mitchell 1999). Economists estimate that since 1991 there has been a 680 percent increase in key food and energy prices, items that acutely affect poor families. Such families spend 60 to 75 percent of their monthly budget on food and another third on energy bills (U.S. Embassy Cairo 1992; EIU 1995).
The population program in Egypt needs to be understood in relation to the above-mentioned changes in the Egyptian economy. A USAID report in 1989 recounted how urbanization had caused loss of agricultural land, how the universities could not absorb more students, how the government's capacity to employ graduates had diminished, and how gross domestic savings had declined (Gillespie et al. 1989:3-4). The report argued that a reduction in population size might translate into reduced development expenditures for the state and less pressure to provide for education, health care, and jobs in the future. Social expenditures for Egypt's people remained secondary in this process to the transfer of resources to international financiers of the modern-day economy.
International development agencies have compelled the Egyptian state to rationalize its economy, privatize its assets, and remove social subsidies. These same donor agencies provide the largest subsidies for population control. They argue that a reduction in state support for children would increase the cost of having children and thus persuade families to adopt planning as their own "voluntary and non-coercive" choice. The IMF-sponsored structural adjustment policy is supposed to cut excess in the economy. The family planning program should, presumably, guarantee a correspondingly lean family. Playing on the imagery of surplus and waste, both the structural adjustment program and the population program in Egypt can be viewed as ways to streamline the social and economic corpus of Egypt.
A key feature of present-day economic globalization is the flexibility of capital. Due to its flexible nature, capital no longer depends on the availability of labor at a fixed site. The world labor market is differentiated according to skills and pricing, which creates competition among developing economies for foreign investment by guaranteeing a disciplined nonunion labor force (Trouillot 2001; Miyoshi 1996).
Along with new labor practices globalization also entails active participation in what has been referred to as the "ideology of consumption" (Jameson 1998:69). The aim is to create wants, desires, and demands that are linked to new notions of individuality and selves, in order to increase consumption among the diverse populations of the world. Consumption by the upper classes is believed essential to the growth and accumulation of capital. In this context, recent global economic restructuring as promulgated by the World Trade Organization (WTO) has provided arguments for free trade and open foreign markets and has acclaimed the emergence of difference, plurality, and tolerant coexistence. Yet the forced integration of national markets into the world system, the disappearance of national subsistence, and the new forms of division of labor present a different aspect to this reality (Jameson 1998:57).
The poor in first- and third-world countries suffer the effects of resource management and the removal of social subsidies (Harvey 1996:143-144) that the process of economic globalization forces upon individual states. As development initiatives in the service of global capital help curtail social expenditure, they also work to create a more compliant and disciplined citizenry.
To enable this process, I argue, the family planning program in Egypt, through its pedagogical efforts, not only seeks to reduce population size but also introduces notions of individual choice and self-regulation. The target of the family planning program in Egypt, as elsewhere, is primarily the female body, though the male body is not ignored. Egyptian women are invited to participate in family planning through their own conviction and not through coercion. They must be persuaded, which entails the production of desires that help women make the choice of contraception for themselves and, by extension, the good of the nation. Through such means, the family planning program introduces Egyptian women to new ideas and values about home, child welfare, motherhood, and, consequently, the meaning of family, community, and nation.
In this text I will present Egyptian voices that oppose or accept such impositions, but I will also go beyond such an exclusive presentation. I will illustrate how Egypt, as a modernizing state, uses the family planning program as a pedagogical project to manage its population. To understand how people in Egypt enter into modern projects that transform them into self-regulating individuals, it is imperative that we simultaneously understand how new categories of individuals are produced and strategically deployed (Trouillot 1991).
In the following chapters I seek also to account for the tensions and contradictions that exist within the state system while presenting the complex set of factors that impact on population control in Egypt. Therefore, as much as this narrative discusses the Egyptian state's imposition of new categories of self and personhood on its population, I am sensitive to the negotiations, ambiguities, and contradictions that are inherent in these undertakings. I examine, in the following sections of this introductory chapter, two interrelated phenomena: first, the efforts to produce self-regulating, new, and modern individuals of which the family planning program in Egypt is one component; and second, responses and reactions to such interventions.
Evaluating the Question
The historian Nikki Keddie suggested in a review article about gender and women in the Middle East, "Problems in the Study of Middle Eastern Women" (1979), that a future research agenda for the Middle East should include the study of sexual habits of the people. She argued that methodological problems posed by such studies should be overcome in order to gain a better understanding of gender relations in the Middle East (Keddie 1979:239). An elucidation of sexual relations would, according to Keddie, aid our comprehension of people's attitudes toward childbirth and their use of contraception. She claimed that researchers would be able to gauge the success of the fertility control policy only after knowing the intimate details of domestic life in the Middle East. Keddie's desire to learn about the private lives of the Arab family may be embedded in the liberal feminist political concerns of the 1970s. But her position may also be linked to a developmentalist agenda that seeks to change the private behavior of couples so that they can successfully use modern contraceptive methods. This concern with the private and sexual lives of the people persists, in many forms, in contemporary debates on health and reproduction in the Middle East.
These debates continue to generate arguments on how new methodological perspectives can be applied to acquire information about people's intimate lives. I became aware of this during my fieldwork months in Cairo (1992-1994), but a more recent example helps to further clarify this point. In early 1998 I attended a seminar in Alexandria, Egypt, sponsored by the Population Council and USAID, on male involvement in reproductive health in Egypt. At this seminar I witnessed a distinct shift in methodological preference for research on reproductive health issues. Demographers and statisticians repeatedly emphasized qualitative methods that had helped them to improve questionnaires or had provided them with better data on household practices as related to family planning. It was clear that qualitative methods for these researchers primarily meant focus groups. At this seminar, though, a consensus evolved that, without long-term ethnographic work within communities, intrahousehold dynamics and methods of communication between husbands and wives could not be ascertained. Focus group techniques, despite their value as research tools, were deemed incapable of uncovering the complexity of familial situations.
This seminar reflected potential changes within the larger field of population studies. Anthropological theory has repeatedly criticized the economistic reasoning inherent in demographic quantitative literature that guides the creation of knowledge about populations and their relationship to resources. Anthropological knowledge has, on the contrary, focused on the multiple ways in which people create meaning and construct symbols to explain their actions in different cultures. Further, ethnographic studies profoundly deepen our understanding of people's lives by being flexible and able to probe sensitive matters in their social, cultural, and economic contexts.
Similarly, anthropologists who work in the field of development research argue that health interventions into communities are bound to fail if they continue to rely on technical solutions and fail to pay attention to the social and cultural characteristics of the target populations. Many anthropologists who work with international health agencies enumerate the ideas and practices of peoples so as to assist health planners in formulating programs. A certain form of medical anthropological input, therefore, provides a local perspective to health policy managers. This knowledge is crucial to the design of international health programs because it assures that the "cultural facet" of the community or target group is considered (Pigg 1997).
This call for understanding the people's perspective also has an antecedent in the history of colonialism. In the early part of the twentieth century, colonial discourse on health in, for example, India and Africa used a specific notion of "culture" that ascribed groups with defined and fixed traits and habits. Megan Vaughan (1991), in her historical work on colonial health intervention in Africa, argues that colonial public health officials attributed ill health among Africans to their traditional culture. Culture, in some cases, was condemned as hindering the progress of scientific modes of treatment. This static and objectified notion of culture was used, at other times, as a pragmatic vehicle to introduce Western ideas into people's lives (Pigg 1997). In the past several decades, international health campaigns have identified this notion of culture, with slight shifts, as one of several factors that influence the health of a given community.
Theoretical changes in the discipline of demography now emphasize the micropractices of individuals as prime determinants of fertility change. Embedded in this new approach, demographic research works with a concept of culture that links an ideational change model to the acceptability of modern birth control (see Handwerker 1986; Caldwell et al. 1987). This argument again consists of a narrowly construed formulation of culture as communication within a household with minimal reference to the social, political, and economic forces of the larger society (Greenhalgh 1995:7). It also encompasses the idea that people in traditional cultures are more fatalistic about their fertility outcomes and are willing to leave reproduction to the will of God (Schneider and Schneider 1995:181). This understanding of culture effectively places households/families and their behavior patterns on a traditional to modern continuum.
As a general critique of demographic literature, social researchers such as Agnes Riedman (1993) describe demographic surveys and research as an extension of colonial penetration and bureaucratic surveillance of people's lives in postcolonial independent societies. Riedman asserts that these surveys seek to modernize third-world populations by shifting them toward individualistic values and nucleation of households (Riedman 1993:3). The international researchers who conduct these surveys are censured for their disregard of indigenous cultural norms such as family size, sense of privacy, and territorial integrity. Riedman would like the interventionist demographic agenda to shift toward anthropological research that acknowledges the historical, cultural, and social causes of population growth.
Though I am sympathetic to Riedman's criticism of demographic methodology, I believe that more culturally sensitive research can also present the possibility of intervention. The crucial issue in my perspective is not a comparison between good social science versus bad social science, or anthropological analysis in contrast to demographic research; rather, it is that both these methodologies are embedded in historical forms of social inquiry that create facts and represent reality.
I would advocate caution with regard to the use of anthropology in the service of larger developmental goals. This caution is necessary because the liberal stance within the field of anthropology, linked as it is to the notion of progress (Ferguson 1999:33), continues to play a major role in developmentalist discourse. Anthropologists may need to question the liberal, humanistic, and reformist assumptions of anthropology before embarking on a progressive crusade to change the world. These assumptions have their own historical baggage, which, in the name of understanding diversity, might in fact seek to homogenize the world (Pool 1994:16). There is always the danger that the use of anthropology to understand native categories and to bridge the gap between differing knowledge forms may in fact serve to reduce all forms of knowledge as a variation of a universal (read Western) theme (Pool 1994).
My intent in writing this text is not, therefore, to provide an ethnographic model that overcomes the shortcomings of demographic surveys; neither is it to specifically gauge the success or failure of a particular development project. Nor am I interested in supplying evidence about women's motivations for accepting or rejecting contraceptives. These issues are discussed in the body of the text but do not necessarily form the core of my argument. Rather, the development debate and the family planning program as they are manifested in Egypt provide an opportunity to investigate how these processes aid in the construction of new bodies, new selves, and new notions of individuality.
This approach helps me distance myself from development-oriented remedies and enables me to move away from certain tropes of representation prevalent in the field of Middle Eastern anthropology. More than a decade ago, the anthropologist Lila Abu-Lughod (1989) argued that there are three central zones of theorizing within Middle Eastern anthropology: segmentation, harem, and Islam. By focusing on the construction of new subjects, I would like to push the boundaries of these theoretical zones and seek to place the production of knowledge on the Middle East at the juncture of a more dynamic and interactive globalizing moment.
The Construction of the Modern Subject
Enumeration and classification historically are products of improvement in statistical sciences in nineteenth-century Europe. Methods of counting population were generally used for the purposes of taxation and army recruitment before the nineteenth century. Statistics became linked in the nineteenth century to emergent social laws designed to regulate populations and create the notion of the "normal." For example, regularities in social life were vigorously studied in Victorian England so as to understand the social deviancies of suicide, crime, prostitution, vagrancy, and madness. Survey methods used currently in demographic research are related to this ongoing history of normalization and progress that is linked to data collection and enumeration of deviances (Hacking 1990).
Statistical language is one of the "strong languages" that is also one of the "discursive interventions by means of which the modes of life of non-European peoples have come to be radically changed by Western power"(Asad 1994a:78). Cast as vital to the concept of progress in developing countries, statistical methods are presumed to represent and to construct people's lived experiences. Techniques used by governments are linked to this language about the control and discipline of the body. A socially pathogenic value, for example, may be attributed to high birth rates. Discourses on personal responsibility and the sacrifice of personal pleasure are then related to procreation. This may motivate a couple toward having fewer children and, therefore, toward a larger social good.
The liberal notion of the self-regulating individual is paramount for these disciplinary techniques. The history of liberal political thought prepares us for the pedagogical exercises of constructing such a self-regulating individual. Harnessing the absence of self-control and the excess of passion is crucial to the construction of the Lockean concept of the self-understanding individual. As the political theorist Uday Mehta (1992) argues, for this to happen individuals need to be embedded in social institutions, especially the institution of education. Education, Mehta stresses, reins in the natural untutored imagination so that it submits to conventional authority and social norms. Liberalism, from this perspective, does not consider individuality to be a foundational given that can be regulated by political institutions; rather, it is a process of coming-to-be, a constructive agenda through which the individual is fashioned. A picture of liberalism that incorporates the ethical individual with collective rights and governmental restraint may be proper, but we need also to pay attention to liberalism's underlying fear of libertine excesses and human passions. The control of desires, self-denial, responsibility, and reason are taught and learned so as to curb natural instincts and to become self-disciplined and disciplining individuals (Mehta 1992).
Nineteenth-century debates on poverty and its reform in Britain give us empirical evidence of the processes that created self-governing individuals. By midcentury, social knowledge produced by scientifically gathered empirical facts on people's lives created opportunities in urban centers for public health campaigns, poor laws, sanitary reports, and scientific studies of social evils like prostitution to contribute to development of a normalized individual self. Mary Poovey (1995) shows how the charisma of the early-nineteenth-century social reformers and the social investigative and reformative laws passed by government bureaucrats should be seen as two faces of modern administration. Both these methods were used to organize the poor in England. They combined tutelage/education of the poor by the reformers with production of rationalized knowledge and information about the lower classes by the government bureaucrats. These interventions were intended to produce disciplined individualism, which would help people express their freedom through voluntary compliance with the law (Poovey 1995).
The task of reconstructing practices of body and health was not limited to Europe. The colonial enterprise, linked as it was to the extraction of surplus and the exploitation of resources and labor, also was involved in reshaping and redefining indigenous beliefs and practices. The history of colonization might be understood, in part, as the institutionalization of new practices to rationalize and control colonized populations. As David Scott (1995) shows, colonial reforms in nineteenth-century Ceylon sought to create desires in which individual agency and free will took precedence over the natural rights of the sovereign or the landlord. The reorganization of market and labor was planned in such a way as to covertly lead individuals to regulate themselves into responding to the pressures of want and self-interest. The market was meant to inculcate a "desire for industry, regularity and individual accomplishment" (Scott 1995:211). The political problem was not to contain resistance or accommodate local grievances; rather, it was to assure that these could be defined only in modern political and social categories (Scott 1995:214).
Historians of the postcolonial era have argued that in the last two hundred years "Europe" has remained a silent referent to all histories including those that are non-Western. The subjects of these Eurocentric histories, the colonized societies, are never credited with reaching their objective and, as a consequence, are characterized by a lack. Dipesh Chakrabarty (1992) argues that British rule in India was about creating subjects that were always caught between the categories of traditional/modern, feudal/capitalist, and despotic/constitutional. The colonial "subject," Chakrabarty stresses, had not yet evolved enough to be the rational civilized person with industrial habits, a sense of responsibility, and the strength of character to become a citizen for the British imperialist liberal theory. The colonized nationalist elite in India resisted this imposition of inadequacy and engaged in political struggle for a nation-state and citizenship (Chakrabarty 1992; Chatterjee 1993:6).
The changing nature of Egyptian society in the late-nineteenth century, after a period of colonialism and almost a century of continuous European presence, was made manifest through the introduction of ideas of equality and justice and regulations that reordered Egyptian society. This was backed by the political ideology of European liberalism. Timothy Mitchell (1988) systematically shows how European influence and colonialism in Egypt ordered and disciplined the body and minds of the Egyptian people by introducing modern education and modern methods of policing through the discourse of law and order, periodic census, registration of births and deaths, and new ideas about health and hygiene.
In a manner similar to that of Indian nationalists during the colonial period, the emerging Egyptian nationalists politically challenged the British, not so much as a mechanism for change, but to determine who would be responsible for these changes and forge the people into an unitary nation. Colonial Egypt too lacked capital development and the presence of an independent bourgeoisie, as well as the modern notion of the "private" and "public" spheres that are regulated through laws embodied in the structure of the state. The privilege of citizenship was not available to the Egyptian elite until much later in this historical narrative of progress and nation building. Hence histories, whether nationalist or colonial, were written as one of arrival and becoming. Though the modern indigenous elite may have "arrived" and become part of a universalizing history, millions of poor, the disenfranchised and, in the case of Egypt, the peasantry were still placed outside this narrative. Similar to what Deniz Kandiyoti described in the case of Turkish modernity, the rural hinterland became the repository of immobility, tradition, and backwardness (Kandiyoti 1997:117). The postindependence nation-state, much like that of the colonial regime, has attempted to incorporate the populace into this civilizing project through violence, pedagogy, consciousness raising, or the market.
In this text I argue that the educated and the elite Egyptians who represent the Egyptian state today possess the particular subjectivity for them to play the roles of protector, educator, and the champion of justice for others and consequently to act as gatekeepers to modernity (Colla 1994). Late-nineteenth-century Egyptian reformers primarily concentrated on the improvement of their own class yet saw themselves as representing the future of the entire Egyptian nation. Today, as non-Western states like Egypt aspire to integrate into the global market, they increasingly regulate the lives of their populations with the help of modernizing developmental agendas prescribed by Western donor agencies. The modern Egyptian state, in alliance with international capital, seeks to admit others into the realm of citizenship through the process of public health campaigns and rural uplift programs or through the rhetoric of equality and justice.
Development in the postcolonial era is linked to a teleological narrative modeled on histories that have already been experienced in the West. It becomes the self-representation of modernity for third-world states that aspire to bring the fruits of progress and innovation into the lives of their citizens (Gupta 1997). National governments in Egypt or in India, armed with an anticolonial rhetoric, did seek to create a debate on a path of development that was critical of Western impositions. Yet increasingly in the late twentieth century, development initiatives linked to economic globalization led to the rationalizing and naturalizing of capitalism's power in progressivist terms "as the engine that brings those on the bottom 'up' toward those who are already there" (Cooper and Packard 1997).
In this scenario, modern states become guarantors of progress; they function as referees that mediate individual obligations to moderate the burden of risk that a person imposes on society. A language of individual choice and freedom is propagated by the state seeking to displace the traditional forms of control on the individual (in the case of women, the family patriarch). At the same time, this freedom of choice is socialized as the state decides the parameters in which these choices may be made. The problems of the state are, further, rebounded on the people so that society itself is implicated in the task of resolving them. Health, for example, becomes an issue of civic responsibility. As a list of unhealthy behaviors that adversely affect the economy is prepared, public health campaigns seek to target irresponsible social groups that are "defined in terms of greater pathological risks they present to and the cost they impose on the collectivity" (Donzelot 1991b:273).
These regulatory powers have already been established in Western industrial societies; thus, countries like Egypt emulate their example by constructing the legal and social institutions that are a necessary prerequisite for exercise of these powers (Asad 1992a:336). I argue that international development programs, such as the family planning program in Egypt, are precisely meant to advance the construction of modern subjectivities linked to the process of creating more socially controlling institutions similar to those that are present in industrialized democracies.
Modernizing developmental states also employ these governmental technologies to deliver social goods to their populace at a low cost. The task before such states is not merely one of constructing rights for their citizens but also of managing the population. Partha Chatterjee (1998) argues that the emergence of the modern state in the West in the twentieth century is marked by the distinction between the domain of theory linked to citizenship and the domain of policy inhabited by populations. Following Michel Foucault's now familiar argument on governmentality, Chatterjee asserts that populations are identifiable, describable, and classifiable through statistical techniques. The concept of population, unlike citizenship, which carries an "ethical connotation of participation in the sovereignty of the state" (Chatterjee 1998:279), allows governments to intervene politically and administratively in the lives of the populace who become the targets of its policies (279). Governments such as that of Egypt may seek legitimacy not only by encouraging liberal notions of participatory democracy but by "claiming to provide for the well-being of the population" as well (279).
Playing on similar themes of social costs and well-being, the Egyptian family planning program seeks to persuade women to shed their ideas of their bodies and selves and convert to scientific ideas of fertility management. This process emphasizes the construction of a modern individual associated with notions of rights, rationality, responsibility, and sexuality, embedded in a new order of morality and law. Through the systematic deployment of different apparatuses of institutional discipline and control, it also creates arenas to change and govern bodies, and manage mannerisms and behaviors (Lukes 1985).
Such interventions, however, do not remain uncontested. For example, there are other factors besides that of the family planning program's language and policy that shape the responses of the people to contraceptive methods and to other developmental strategies. Religious groups, political parties, feminists, and popular media help condition attitudes toward fertility issues. Further, unstable socioeconomic conditions, increased rural-urban migration as a result of diminished opportunities to own arable land coupled with an increasingly wage-based rural economy, high levels of urban unemployment, housing shortages, and a lack of modern educational opportunities influence decisions about household size. The increased disparity of income levels, which is independent of family size, also allows for a critique of the state's emphasis on family planning over issues of equity of distribution and social justice.
The process of managing populations, hence, is invariably connected to and influenced by the responses of people themselves. The Egyptian state's desire to change and modernize its masses inadvertently confronts inherent gaps and contradictions. This text attempts to portray the relationship between impositions of the state and the way people respond to the development agenda. As the state, linked to international capital, seeks to change the behavior and practice of its populace to produce self-regulating and modern desiring subjects, it faces a population that conceives and constitutes its selves, bodies, and communities in different and diverse forms.
I emphasize that people, through their practices, transform the meaning and intention of developmental impositions and give us a sense of leading modern lives that do not completely comply with the homogenous and teleological model posited by the history of the West. These "resistances" and transformations are conducted in a terrain constituted by the modern state. It is in the modern state that we find struggles over issues of individual rights, gender politics, procreation, or sexuality. Those who do not conform to the new social categories, those who adhere to other notions of the individual, the community, or the nation are particularly sought out by the state to be educated out of their beliefs so that they can also participate in the predetermined history of progress, freedom, and modernity, linked as it is to the forward march of capital (Chatterjee 1993).
This being so, it is important to investigate the differences that hinder this forward march. The task before me is to represent bodies and selves that continuously disrupt modern government's desire to subjugate and to civilize; lives that from within the narrative of capital and coexistent with it remind us of different ways of being human (Chakrabarty 2000:94). This investigative emphasis compels us to "take the vernacular voices of the popular and their modes of self fashioning seriously" (Scott 1999:215). This is not to simply resurrect the figure of the subaltern as a subject of modern democracies linked to a desire to make society more representative as a whole (Chakrabarty 2000:94), which is a laudable goal in itself and is often championed by progressivist historical narratives. Yet what gets elided in these emancipatory narratives, Dipesh Chakrabarty reminds us (2000), is how the secular-modern middle classes, the authors of these narratives in their liberal or socialist versions, have historically excluded the popular. Following David Scott (1999) I argue that to take the vernacular voices and practices seriously is to recognize their popular refusal to integrate into the available forms of middle-class identifications and moral truths provided by the postcolonial state (Scott 1999:215).
I conducted my fieldwork in multiple sites rather than doing intensive research at one field site as is still customary in anthropology. The questions that I sought to investigate partly determined my choice of this methodology. Following the development population agenda as it was manifest in Egypt meant not only a multisited ethnography but also one that was analytically multileveled. I had initially planned to spend an extended period (eight to twelve months) in one village (preferably in the south of the country) to acquire a situated knowledge of a given community's response to the fertility control program. This was not to be, however. I did get access to a Delta village and even poor urban neighborhoods, but only after much apprehension and creative maneuvering as a result of problems with Egyptian security services.
My credentials as a medical doctor, an anthropology graduate student from Johns Hopkins University with a fellowship from the Population Council, and my local affiliation with the American University in Cairo did not change the fact that I was a Pakistani national. Whatever that may mean in other parts of the world, for the Egyptian state intelligence services in 1992-1994 it meant that I was a man who could be in league with the Islamists. Mine was a case in which national identities became enmeshed in political struggles and social constructions.
The years 1992-1994, during which I did my fieldwork, were the worst in the violent conflict between the state authorities and the Egyptian Islamist political groups. Pakistan, my native country, was one of the frontline states used by the United States against the Soviet invasion of Afghanistan. It was primarily in Pakistan that U.S.-sponsored experts gave training and resources to Muslim "freedom fighters" to fight the "Red Devil." They trained an international group of religiously motivated young men to resist the invading Soviet army. The Egyptian state apparatus now feared that Egyptian nationals returning from that jihad had entered another one against the secular authorities at home. I may have been viewed as suspicious because of these complicated circumstances.
I was regularly asked by police and military officials, with whom I needed to meet periodically for security clearance prior to the start of my research, why I, as a Pakistani, was not conducting research in my own country. They would say that they could comprehend Euro-Americans, Egyptians, and other Arab Middle Easterners conducting research in Egypt, but a Pakistani? This in itself was suspicious. The understanding of the paths by which middle-class and privileged third-world nationals acquire access to first-world education and sources of funding, allowing them to be competitive in the same spheres as their first-world colleagues, was still alien to these officials. These encounters also raised questions of how research in this globalizing world is contingent on an individual's passport and the sense of security, power, and prestige it provides. As a result, I could not obtain the necessary permission to do fieldwork in the village of my choice. Thus, the change of locales was also partly imposed.
A multi-sited ethnographic fieldwork, however, offered a broad understanding of social phenomena from different and varied perspectives. These perspectives helped me to link macrolevel arguments on population control and middle-level implementation by state bureaucracies to the effect of these policies on the people on the ground. I also used a variety of sources: archives, literary works, official reports, my interviews, and observations and questionnaires. In addition my ethnographic encounters included interviews with bureaucrats who worked in international agencies and the health ministry in Cairo, with doctors and nurses involved in family planning clinics, and with the women and men in the rural and urban localities in which I did my community fieldwork.
I asked government bureaucrats at the Ministry of Health (MOH) and the National Population Council (NPC) questions about the family planning program, the problems they faced in its implementation, their successes, and their vision of the future. I visited the offices of USAID, the World Bank, the Ford Foundation, the Population Council, the United Nations Development Programme (UNDP), and other nongovernmental organizations (NGOs) (e.g., the Egyptian Family Planning Association) in Cairo. I attended seminars offered by these institutions on population issues and interviewed those responsible in their offices for the health and population sector. I asked them general questions on their short- and long-term priorities with regard to the population program in Egypt and visited specific projects that they conducted. I also systematically visited family planning clinics in Cairo and, when possible, in villages in the Delta and in southern Egypt. There I spoke to the doctors, nurses, and patients about various aspects of the program. For example, I was interested in popular forms of contraceptives prescribed in the clinic and also why a specific method was so widely used. I periodically asked patients about the benefits of contraceptive use and about the side effects and problems of these methods. In the communities where I lived and worked, I was interested not only in the specific responses on family planning methods but also in how people lived, what they earned, and how they related to each other. In addition, through discussions with the people in those communities, I sought to learn how they conceived of their own bodies and what their ideas were about health, procreation, and sexuality.
I was introduced to a Delta village community through doctors who ran a clinic there for a major medical university in Cairo. As I spent time within the village, which I call Qaramoos, I put myself in a configuration of power where others also had control over my life. This is pertinent because, as alluded to earlier, the Egyptian state's security apparatus can make extensive fieldwork virtually impossible without the protection and support of the local population itself.
As I started visiting Qaramoos I became acquainted with people from many households. I initially hesitated to ask women questions that I thought were too intrusive. As a non-Egyptian yet Muslim male, albeit with a medical degree, I was unsure as to how women would react to my questions about personal relations, birthing, menstruation, and sexual practices. The issue was partially resolved as women started sharing with me some of their ideas about self, body, and health.
During the course of my stay, my host family's relatives and friends sought advice from me on minor ailments. While I remained sensitive to local notions of respectability and gender relations, I used these exchanges to converse with women visitors about issues that pertained to my research, but my queries were not always welcome and were, at times, ignored. I spent considerable time with men; however, during the midday or evening meals I had opportunities to speak with the older women. They were interested in my personal life (how people lived in rural Pakistan or the United States), and I would attempt to speak to them about their lives. I also talked with traditional midwives (dayas) whom I had met earlier in focus group sessions. These women were extremely important because they helped me to understand how women thought of their bodies and health. The dayas were comfortable speaking with me on topics that would be considered impolite among other women because they were much older in age and thought of themselves as professional healers.
I would stay in Qaramoos for two or three nights and then return to Cairo due to security reasons. In Cairo, I worked in the northern urban neighborhood of Behteem. Cairene friends who knew male industrial workers in the area facilitated my introduction into Behteem. I would spend most of the weekends speaking to men and visiting various households accompanied by my fellow female researcher, who would speak to women about our research issues. Over time, we became a common fixture in the area, and we were invited to gatherings and celebrations. The women of the area, especially from the homes of men who had now become my friends, would now speak to me directly about their ailments and about the problems they had with their contraceptives. These encounters, in the framework of the larger realities of their social experiences, helped me to understand priorities in the women's lives and put into perspective their ambivalent relationship with the state and its family planning agenda.
Finally, my fieldwork experiences need to be looked at as a reminder of how the "field" is a place where the authority to define, to report on, and to assemble facts on one's informants is continuously challenged. In the narrative that follows this introductory chapter, I hope the reader, like my friends in the village and other locations in Egypt, will critically engage with the text and continually questions its assumptions and representations. The important issue is not only the presentation of "data" but also the production of a narrative that is situated in a field of power relations and in the subject positions that the ethnographer inhabits.
Outline of Chapters
Moving through different levels of society exposed me to the underlying social and economic changes in people's lives that, to some extent, determined their acceptance and use of family planning methods. The organization of chapters conceptually represents this movement through societal levels. The text is divided into three parts: Part 1 has two chapters that describe and analyze the various facets of the family planning program in Egypt. Chapter 1 gives a detailed history of the population issue in Egypt. It recalls early-twentieth-century debates on population pressures and presents the changing nature of the impact of international demographic theories on family planning policy in Egypt. It also gives an account of the various actors and agencies that participate in the family planning program in Egypt.
Recent emphasis in family planning circles in Egypt is on the quality of care and treating the client with respect, as the overall approach toward family planning service delivery is being reoriented toward "client satisfaction." The client needs are posited as primary, and the provider plays the role of a helper who guides the client toward solving her problem and choosing the most appropriate contraceptive. This engagement leads to the construction of consent and individual choice. To emphasize this encounter, in the second chapter, through ethnographic examples, I briefly evaluate a public health campaign that was created to motivate contraceptive use among rural Egyptians. I demonstrate how the need for individual counseling leads to training sessions for doctors. Finally, I describe counseling and service delivery in an urban family health clinic.
Part 2 of the book is based on ethnography from the rural and urban communities in which I worked. Chapter 3 presents data on social life within those communities. It spatially and socially situates the ethnography presented in the remainder of the text. Chapter 4 examines how the family planning program in Egypt may falter in its attempt to convince women of its goals and benefits. I focus, in this chapter, on how rural and urban poor women construct their own notions of birthing and fertility. This suggests an implicit critique of the family planning program's model of the individualized self by highlighting the experiences of women themselves. Based on my ethnographic findings I demonstrate how some women continuously experience their bodies as linked and situated in a larger social world. Continuing on the theme of the fourth chapter, chapter 5 guides us toward a greater understanding of the many ways women reach their contraceptive decisions. Chapter 6 is a larger discussion of how the family planning program cannot be understood solely through the construction of individual choice for women. I introduce, as an example, the emphasis by international family planning programs on the male point of view. This chapter discusses how men are implicated in the population discourse, illustrating male notions of health, fertility, infertility, potency, and virility.
Part 3 has two chapters that illustrate the expanded discursive and political context within which people make decisions on fertility control in Egypt. In chapter 7 I present the argument on reproductive rights and give some examples of secular women's groups that criticize the state for not fulfilling its social role as a provider of safe and affordable health services for women. The last chapter discusses how Islamists challenge the morality of the Egyptian state in propagating family planning and how, in the process, they present an alternative view of domestic life and the larger nation.
“Kamran Ali, a Pakistani physician and anthropologist, takes an original and multifaceted approach to understanding the practicalities of family planning in Egypt.”
Nancy Gallagher, author of Egypt’s Other Wars: Epidemics and the Politics of Public Health