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Haunting Images

A Cultural Account of Selective Reproduction in Vietnam

Tine M. Gammeltoft (Author)

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Unjacketed Hardcover, 336 pages
ISBN: 9780520278424
February 2014
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Based on years of careful ethnographic fieldwork in Hanoi, Haunting Images offers a frank and compassionate account of the moral quandaries that accompany innovations in biomedical technology. At the center of the book are case studies of thirty pregnant women whose fetuses were labeled “abnormal” after an ultrasound examination. By following these women and their relatives through painful processes of reproductive decision making, Tine M. Gammeltoft offers intimate ethnographic insights into everyday life in contemporary Vietnam and a sophisticated theoretical exploration of how subjectivities are forged in the face of moral assessments and demands.

Across the globe, ultrasonography and other technologies for prenatal screening offer prospective parents new information and present them with agonizing decisions never faced in the past. For anthropologists, this diagnostic capability raises important questions about individuality and collectivity, responsibility and choice. Arguing for more sustained anthropological attention to human quests for belonging, Haunting Images addresses existential questions of love and loss that concern us all.
List of Illustrations
Acknowledgments

Prologue: Haunting Decisions
Introduction: Choice as Belonging

1. Sonographic Imaging and Selective Reproduction in Hanoi
2. A Collectivizing Biopolitics
3. Precarious Maternal Belonging
4. “Like a Loving Mother”: Moral Engagements in Medical Worlds
5. “How Have We Lived?” Accounting for Reproductive Misfortune
6. Beyond Knowledge: Everyday Encounters with Disability
7. Questions of Conscience

Conclusion: Toward an Anthropology of Belonging
Appendix: Core Cases
Notes
Bibliography
Index
Tine M. Gammeltoft is Professor of Anthropology, University of Copenhagen. She is on the Editorial Advisory Board for the journal Reproductive Health Matters.
"This deft and often moving volume makes a signature contribution to the growing anthropological literature on Vietnam ... Keenly observed and compellingly written."—Martha Lincoln Medicine Anthropology Theory
"Beautifully written . . . of interest to scholar's in Asian, women's, and gender studies and anthropology, reproductive health, and disability studies."—CHOICE
"This is a powerful, haunting cultural account of selective reproduction in Vietnam. I encourage each reader to think through what this means and what this tells us about pregnancy management throughout the world."—Barbara Katz Rothman Sociology of Health & Illness
"This is a moving ethnography that ‘haunts’ the reader long thereafter. . . . Daring and promising."—Catalina Tesar Social Anthropology
"Powerful, heart-wrenching, and beautifully written . . . As anthropology, the book is also a fine example of the ethnographer's craft. . . . Highly recommended."—Erik Harms Journal of Southeast Asian Studies
"Fascinating and powerful . . . Haunting Images is an outstanding piece of scholarship that brings new dimensions to thinking about key themes in social theory."—Tsipy Ivry Medical Antrhopology Quarterly
"Beautifully written . . . a must read."—Ann Marie Leshkowich American Ethnologist
"This deeply moving and path-breaking ethnography takes us to the social crossroads of global medicine in post-war Vietnam. Here struggles over belonging and value are part and parcel of haunting histories of loss and become the very fabric of visceral conceptual work.” —João Biehl, author of Vita: Life in a Zone of Social Abandonment

"In this beautifully crafted ethnography of intense pregnancy sonograms, Tine Gammeltoft reveals screen fetuses that stand at complex historical and cultural intersections. At once biological and cosmological, their haunting images are constructed where public health commitments, gendered and kinship decision-making, religious traditions, and the half-life of Agent Orange all meet. This is the first full-length study of sonography in a developing-nation context and a must-read for anyone who wants to know what lies beyond individual 'choice' in the use of a selective reproductive technology." —Rayna Rapp, Professor of Anthropology, New York University

"This is a luminous, compassionate book about complex moral dilemmas facing Vietnamese women and families who receive a diagnosis of fetal abnormality late in pregnancy. Reading this book was a powerful, humbling experience. Gammeltoft courageously shows us that there are other perspectives that must be considered, reminding us in this age of neoliberal subject-making that parents-to-be are also charged with fulfilling genealogical, spiritual, and national responsibilities. Belonging and longing are linked in this narrative, as people yearn for futures (and pasts) other than those they receive."—Lynn M. Morgan, Mount Holyoke College, author of Icons of Life: A Cultural History of Human Embryos (University of California Press, 2009).

"Haunting Images focuses on difficult moral decisions, on questions of belonging and on what constitutes a human being. Gammeltoft brings us a nuanced understanding of the lived texture of life in Vietnam today. This ethnography is delicate, sensitive, loving, and complex, faithful to the tone of the people and the place and to the ambiguities of life. The issues raised in Vietnam confront us all."—Diane Fox, Senior Lecturer of Anthropology and Vietnamese Studies, College of the Holy Cross

2015 Eileen Basker Memorial Prize, Eileen Basker Memorial Prize

AES Senior Book Prize, Senior Book Prize

Chapter 1

Sonographic Imaging and Selective Reproduction in Hanoi

Hanoi's Obstetrics and Gynecology Hospital, November 3, 2003

"Beautiful, right!" Dr. Tuấn exclaimed, pointing to the 3D image of a fetus on the monitor in front of him. Despite the routine character of his work-as the hospital's most senior sonographer, he performed hundreds of scans every week-Dr. Tuấn seemed equally fascinated by every single scan he did. He praised each fetus for its beauty, its agile movements, its fine facial features, the perfect roundness of its head, and the balanced dimensions of its limbs. His wonder at the capacities of the machine he operated, and the pregnant woman's visible relief and delight when the scan went well, turned each of these medical encounters into emotionally powerful events.

This was my first day of fieldwork in the 3D scanning room at Hanoi's Obstetrics and Gynecology Hospital. The waiting rooms and corridors were busy, crowded with women at all stages of pregnancy and health staff in white uniforms striding from one room to another. Although it was relatively small, approximately three by five meters, the 3D scanning room served as a clinic and a waiting room at the same time: the scanning machine and examination bed were placed at one end, and at the other were seven blue plastic chairs along the walls. Each ultrasound scan was, in other words, a public performance involving not only the pregnant woman, the sonographer, and the nurse but also the women who were waiting for their own turn.1 At the end of the day, Dr. Tuấn told me that he appreciated our research: the hospital had only recently invested in this 3D scanning machine, and he and his colleagues expected a lot from it. 3D scans, according to Dr. Tuấn, have strong popular appeal: "2D pictures are not very clear; only professionals like me can interpret them. But everyone can see a 3D image. People like you can see it too. You see, pregnant women like to see if their child is beautiful or ugly, and they want to see if it has any problems. 3D images give a clear and true picture. Ultrasound scanning is very useful, it is highly necessary in antenatal care."

In this chapter I introduce the reader to Vietnam's capital, Hanoi, and offer a brief description of the political context in which obstetrical ultrasound scanning has come to be considered a practically mandatory part of pregnancy care. I place obstetrical ultrasonography within four terrains of Vietnamese politics: the politics of health, abortion, disability, and population. At the beginning of the twenty-first century, I argue, the problem complex named Agent Orange affected these political terrains in profound ways. For ten years during the Second Indochina War-from 1961 to 1971-U.S. troops sprayed massive amounts of herbicides over Vietnam in order to defoliate jungles and rural lands, thereby depriving Việt Cộng guerillas of cover. Containing dioxin, one of the most toxic chemicals known to science, the herbicides-nicknamed Agent Orange-caused wide-ranging environmental damage. At the time of our fieldwork, this herbicide dioxin played a significant role in the politics of reproductive health in the country. In this chapter I therefore also present a brief account of the assumed public health consequences of wartime herbicide spraying and discuss the role played by Agent Orange in the uptake of prenatal screening. To begin with, I shall briefly introduce the setting of the research: the city of Hanoi.

Hanoi: Public-Private Spaces

Vietnam's capital Hanoi traces its foundation to the eleventh century: according to historians, King Lý Thái Tổ of the Lý dynasty established Hanoi in the year 1010. Its name, Hà Nội, "the inside of the river," refers to its location on the right bank of the Red River, a calm reddish-brown river that sometimes swells into violent floods during the rainy season. In 1873, French forces occupied Hanoi, and in 1887 it became the capital of French Indochina. During the August Revolution of 1945, Việt Minh forces took control of the city, and on September 2, Ba Đình square became the scene of one of the most momentous events in the history of socialist Vietnam: in the presence of a large gathering of people and in an exuberant atmosphere, Hồ Chí Minh read the Declaration of Independence of the Democratic Republic of Vietnam (cf. chapter 2).2 In 1946, however, the French returned, and in 1954, after nine years of anticolonial resistance, Hanoi became the capital of an independent North Vietnam, the Democratic Republic of Vietnam. During the Second Indochina War (1964-1975), the city was the target of numerous attacks by U.S. air forces; Mễ Trì, the commune in which part of this research was conducted, was particularly heavily bombed due to its proximity to a radio transmitter. When the last U.S. troops left Vietnam on April 30, 1975, national victory and reunification were celebrated in the streets of Hanoi. Yet, according to today's Hanoians, postwar existence did not match the dreams and expectations that had animated the fight for independence. In his autobiographical novel, The Sorrow of War, Bao Ninh (1994:138) describes the collision between a guerilla fighter's wartime imaginings and 1975 realities: "Post-war Hanoi, in reality, was not like his jungle dreams. The streets revealed an unbroken, monotonous sorrow and suffering. There were joys, but those images blinked on and off, like cheap flashing lights in a shop window. There was a shared loneliness in poverty, and in his everyday walks he felt this mood in the stream of people he walked with."

In 1986, after a decade of persistent poverty and failed development efforts, the socialist planned economy was officially abolished and Vietnam embarked on the economic reforms known as đổi mới (renovation). With đổi mới, a partial marketization has taken place, but politically Vietnam remains a one-party socialist state ruled by the Communist Party.3 The country's integration into the global capitalist economy accelerated in 1994, when the U.S.-led trade embargo was lifted, and achieved further momentum in 2007, when Vietnam became a member of the World Trade Organization (WTO). As an element in its economic reforms, the Vietnamese state has withdrawn much of its support for health care, education, and social protection, and considerable economic disparities now exist between subgroups of the population. At the same time, however, economic growth rates have been high since the reforms began: the general poverty rate fell from 58 percent in the early 1990s to 14.5 percent by 2008, and today the country's economy is four times larger than in the early 1990s (World Bank 2012). In 2010, Vietnam escaped the low-income country category and was defined as a lower-middle-income country.4

Over the years that I have lived in Hanoi, these economic changes have left their mark on the city. In the early 1990s, Hanoi was a dense assemblage of villages; a city of bicycles, cyclos, and tree-lined avenues, of men dressed in green army clothes, women in dark trousers and conical hats, and children in school uniforms with red scarves around their necks. In the makeshift markets scattered across the town, vendors sold locally produced goods: green bean candy; jasmine soap; fish from local rivers and ponds; beef, pork, poultry; and a variety of rice, flowers, and fruit. In winter, there were miniature green apples, bananas, and guavas dipped in salt and chili pepper; in summer, mango, longan, durian, and lychee. On cool winter days in drizzling rain, or on summer days under a torrid sun, the city seemed calm, quiet, and self-contained. Today's Hanoi is different. A city of around three million people in the early 1990s, Vietnam's capital now numbers over six million inhabitants. In 2008, large parts of the surrounding provinces of Hà Tây, Vĩnh Phúc, and Hòa Bình were incorporated into the city of Hanoi, and rapidly expanding new urban zones now cover the suburban areas where rice fields used to stretch. The streets of today's Hanoi are packed with motorbikes and cars, shop windows display fashion clothes, and commercial advertisements for beauty products compete with official party-state posters and banners for the public's attention. Economic growth and the increasing integration into the global economy have expanded consumer options dramatically: whereas before the đổi mới period it was a luxury for people in Hanoi to own a Chinese bicycle or a bar of perfumed soap, today's middle-class citizens find it hard to imagine an existence without smartphones, motorbikes, and cars. Consumer goods that were unavailable as recently as the 1990s now fill stores, streets, and middle-class homes, and an expanding market for products associated with pregnancy and child care has emerged. Items for sale include toys, strollers, disposable diapers, formula milk, pregnancy manuals, and child care literature. Glossy magazines celebrate the joys of family life and motherhood, accentuating, implicitly as well as explicitly, parental-especially maternal-responsibility for child health and well-being. Within this consumer economy, children have become objects of investment in historically unprecedented ways, and middle-class parents have unprecedented amounts of money to spend on their care and upbringing.

Yet despite the city's growth and internationalization, in some ways Hanoi seems to have retained its villagelike character. At the time of our fieldwork, the city was divided into fourteen districts, of which nine were defined as inner-city (nội thành) and five as outer-city (ngọai thành) areas. Each urban district consisted of several smaller villages (làng or thôn) with their own communal houses, temples, and guardian spirits. Often, the inhabitants of these urban villages would express pride in the fact that local histories stretched centuries back in time. Village identities and close neighborhood relations, in other words, tend to persist in Hanoi today, defying conventional distinctions between urban and rural forms of sociality. As houses in Hanoi are often cramped, many day-to-day activities are undertaken outside: people washing their hair, brushing their teeth, feeding their children, drinking tea, quarrelling, and engaging in love affairs in the public spaces of streets, alleys, and parks. Silence is rare, the normal backdrop to life being the roar of traffic, tapestries of human voices, dogs barking, roosters crowing, and the sounds of radios, televisions, and CD players. In many respects, then, lines between public and private tend to be blurred in Hanoi, as intimate life spills into public spaces and public stirrings reach into private homes. The areas around the city's two large maternity hospitals-the National Obstetrics Hospital and Hanoi's Obstetrics and Gynecology Hospital-are among the sites where this merging of the intimate and the public happens in particularly graphic ways: around these hospitals, numerous private ob-gyn clinics advertise their services through the display of large images of fetuses, cervixes, and semen. Here, women's wombs are turned inside out, their contents rendered visible and public. If fetuses have, as Michaels and Morgan (1999:2) note, "become a regular, almost unremarkable feature of the public landscape" in the United States, this seems to be the case in Hanoi too.

Hanoi's Obstetrics and Gynecology Hospital is located in Ba Đình district, between inner- and outer-city areas. The hospital was established in 1979, funded, its director told me, by an international women's organization as a gesture of solidarity with the women of Vietnam. At the time of our fieldwork, the hospital had three floors, its several buildings surrounded by a spacious yard in which tall eucalyptus trees offered shade to motorbikes and cars. In and around the hospital, Vietnam's increasing social differentiation was highly apparent: there were dramatic differences, for instance, between the economic means of patients coming from outlying rural areas on rented motorcycle taxis (xe ôm) and those of senior doctors who would arrive in shining cars with tinted windows. In the 3D scanning room, some women wore jeans and expensive leather jackets, while others had bare feet in rubber sandals. During the first months of fieldwork, I was struck by the intensive social exchanges that unfolded in this medical site. While waiting for examinations, women would often confide in each other, sharing intimate stories of reproductive difficulties and of family pressures and expectations. The hospital staff, too, engaged in constant and lively exchanges: while performing ultrasound scans, the sonographer in the 3D scanning room would often chat and joke with doctors in the adjacent 2D scanning room; as the walls did not reach all the way to the ceiling, people could hear each other across separate physical spaces, and news and rumors spread quickly within the hospital.5 "Hospitals," note Sjaak van der Geest and Kaja Finkler (2004:1995), "both reflect and reinforce dominant social and cultural processes of their societies." Daily life in this Hanoian maternity hospital-the walls that did not really separate people, the lively exchanges of sentiments and stories, the constant presence of other people, talking, looking, touching, asking, acting-seemed to index the socially dense and communal character of everyday lives in Vietnam. In this medical facility as in day-to-day lives, there were always others around. In birth and death, in crises and routines, each individual would find herself accompanied by others; by people who would have an opinion, people who might help her or undo her, people on whom her existence would depend.

The Commercialization of Ultrasonography in Đổi Mới Vietnam

In the course of one or two decades, practices of pregnancy care have changed dramatically in Hanoi. In 1993-1994, when I did my first fieldwork, antenatal care services consisted of basic physical examinations, while ultrasonography was used only under special circumstances. In 2004, a questionnaire study that my colleagues and I conducted among four hundred newly delivered women at the maternity department of Hanoi's Obstetrics and Gynecology Hospital showed that each woman had obtained an average of 6.6 ultrasound scans in her most recent pregnancy. A fifth of the women had had 10 scans or more; and we encountered some who had had 30 scans in one pregnancy. Ultrasonography had, it seemed, become a routine and unquestioned part of antenatal care. As one woman remarked: "You cannot go to an ob-gyn clinic and say, 'I don't need an ultrasound scan.' When you come in, the doctor tells you to lie on the bed and he will combine the antenatal examination and the ultrasound scan into one." Although some women expressed uncertainties about its safety, the vast majority seemed to take the use of this technology for granted.6 The question was not whether or not to obtain ultrasounds, but how many, of what kind, and from which health care provider. How, then, did this rapid transition in pregnancy care practices come about?

To find answers to this question, I consulted half a dozen senior obstetricians identified by doctors at Hanoi's Obstetrics and Gynecology Hospital as pioneers in the introduction of obstetrical ultrasonography in Vietnam. According to these physicians, the first ultrasound scanning machines arrived in northern Vietnam in the early 1970s as donations from other countries, international organizations, or manufacturing companies.7 In the beginning, ultrasonography was used only in highly specialized medical facilities and, in pregnancy, only when there were complications. The trend toward more widespread use of this technology began in the late 1980s when health sector reforms were initiated, and accelerated in the mid-1990s when the international trade embargo against Vietnam was lifted. By the late 1990s, ultrasonography was offered by all public hospitals and by a host of private ob-gyn clinics across Hanoi while also being available in provincial and district health facilities in rural areas. The routinization of obstetrical ultrasound scanning in urban northern Vietnam has, in other words, occurred at the same time as market economic reforms have taken hold in the country. As an element in Vietnam's economic transition, comprehensive health sector reforms have been undertaken: in 1989, user fees for health care services were introduced, and private medical practice legalized. In the years that followed, public spending on health dropped significantly, reaching its lowest level in 2006. At present, the share of out-of-pocket payments for health care remains high, accounting for around 55 percent of total health expenditure (Trần Văn Tiến et al. 2011). Furthermore, wages in the health sector are low and corruption rampant.8 The consequence is inequity. For those who can afford it, access to high-tech health care has improved significantly over the past few decades, but for the country's poor, disease and disability can have catastrophic economic consequences.9 For health care providers, the underfunding of the health sector creates strong incentives to gain additional income through the supply of revenue-generating services; and ultrasonography is, as Dr. Tuấn pointed out, among the services that have particularly strong consumer appeal.10 Prenatal ultrasounds are offered by private ob-gyn clinics as well as by public health institutions; in the rapidly expanding health care market that had emerged in Hanoi by the time of our fieldwork, not only 2D but also 3D and 4D scans were offered. The price for a 2D scan was equivalent to US$1.30-2.00; for a 3D scan US$5-6; and for a 4D scan US$13-20. These prices were affordable for most women living in urban areas, but for rural women they were often prohibitive.

In short, the proliferation of ultrasonography in Hanoi must be seen in the context of health care sector liberalization; in Vietnam as in many other countries with privatized health systems, overuse of medical technology makes economic sense for health care providers and institutions. Yet while acknowledging the importance of revenue motives, the obstetricians I met also insisted that the adoption of this technology had been fueled by a profound professional fascination. Ultrasonography, they maintained, has brought remarkable benefits for antenatal care, allowing women in Vietnam to receive pregnancy care of a quality that matches that offered in more affluent countries. Dr. Tuấn, for instance, told us that he had worked with ultrasonography since 1988, when he attended a training course at Hanoi Medical University. "When you first encountered this technology," my colleague Hằng asked him, "what was your impression?" Dr. Tuấn responded promptly:

My first thought was that ultrasound brought a revolution to antenatal care. It was as if a great dream of mine came true. Before we had ultrasound, it was very difficult to diagnose in antenatal care. So this was something we had hoped for. I immediately said, "Now, this is something that is endlessly good for women and for our patients." Today, I still think so. I think this is something great. It is very good. We can offer better examinations and the technology is entirely safe. I have been captivated since I first encountered this technology. I am completely bewitched (mê mẩn) by it. I like it very much.

Like Dr. Tuấn, practically all health care providers framed ultrasonography as a benevolent intervention that helps women to go safely through pregnancy and to experience the joy of seeing their child-to-be develop month by month. In a conversation we had in June 2004, Dr. Lương, an obstetrician-gynecologist, expressed his position on this technology in terms that reflected what we had heard from many other health providers:

Dr. L.: I think ultrasound is very good. It is very useful. It enables people to see the child. Seeing the child and knowing that it is developing without problems makes both doctors and parents feel happy. This is endlessly beneficial. I don't think there is anything harmful about it. I simply think that this is something we need. In my opinion, we must extend the awareness of ultrasound even wider, to reach more doctors.

TG: Many women have an ultrasound scan each month. What do you think of that?

Dr. L.: I think it is normal. It is not too much. This must be up to the individual. Some think it is too much, but I think it is normal. The parents have a need to see how their child is developing and growing. Since we know that ultrasonography is absolutely safe, I don't see why we should not do that for people if they ask for it.

Like Dr. Tuấn and Dr. Lương, Hanoian physicians generally embraced this new technology with enthusiasm, praising the numerous advantages that it brought to antenatal care. A female ob-gyn, Dr. Hương, summed up its benefits: "In the first trimester, we can see if the fetus is properly placed in the uterus and if it is developing well. In the second trimester, we can detect if there are any malformations and check the fetus's position and development. In the third trimester, we can see the development of the fetus, its weight and position, the amount of amniotic fluid, the placenta."

In the United States and Europe, the use of ultrasonography for obstetrical purposes is usually considered uncontroversial, whereas its use for reproductive selectionraises ethical problems. In Vietnam, in contrast, ultrasonography was considered beneficial because it enabled health care providers to detect and act on fetal anomalies; it was the capacity for selection that physicians and pregnant women alike defined as the main advantage of this technology. In the words of Oanh, a thirty-two-year-old mother of two: "Today, if there is a problem, people will terminate the pregnancy. In the past people did not know anything. When a child was born disabled, they were astonished. But now, with modern science, people go for examinations and if there is a problem, they will give up the pregnancy." Selective reproduction was, in other words, generally embraced by people, framed as an element in an enlightened and modern way of life that reaps the benefits of scientific progress. The use of ultrasonography, then, rested on a key premise: if a severe fetal anomaly was found, the woman was expected to consider a termination of her pregnancy. This assumption is, of course, not unique to Vietnam. As Rapp (1999:129) points out in a U.S. context, induced abortion is "the barely hidden interlocutor of all prenatal testing." But two other characteristics are specific to Vietnam. First, no attempts are made to conceal this clinical-political agenda of reproductive selection; and second, national abortion laws are, seen in a global perspective, unusually liberal. While prenatal screening is relatively new in Vietnam, induced abortion is a well-established reproductive health intervention.

Pregnancy Terminations in Vietnam

Limited information is available on the legal status of induced abortion in Vietnam in early postcolonial times, but some sources suggest that abortion was legalized in the Democratic Republic of Vietnam already in 1945.11 From the early 1960s, family planning became a political priority, and contraception and abortion became increasingly available in public health services. In the 1960s and 1970s, birth control was officially represented as an element in efforts to create a modern socialist society, free from the entrenched gender inequalities, kinship hierarchies, and economic underdevelopment that had characterized the pre-socialist era (see chapter 4). In 1988, seeking to bring population growth rates under control, the government launched a one-to-two-child family planning policy. The new policy was modeled on China's one-child policy but implemented through less draconian means: through moral persuasion, cash incentives for sterilization, and economic sanctions, citizens were urged to limit the size of their families by stopping at two children. With the launch of this policy, fertility control was more vigorously promoted, and pregnancy terminations became routine medical procedures, performed in hospitals and clinics in urban areas and by mobile teams in rural districts.12

By the mid-1990s, global estimates found Vietnam to have one of the world's highest abortion rates. In the public sector alone, each woman in the country obtained an average of 2.5 abortions in her reproductive lifetime. Since the number of abortions performed in the private sector was estimated to equal that of public sector abortions, this added up to a considerable number (cf. Henshaw et al. 1999). According to official reports, abortion rates have declined significantly since the 1990s, from 86 abortions per 1,000 women in 1996 to 26 in 2003 (Sedgh et al. 2007). It is, however, practically impossible to assess abortion trends in Vietnam, since private sector abortions are not registered. In the public sector, most pregnancy terminations are performed in the first trimester. In 2005, 77 percent of all recorded abortions were done prior to 8 weeks' gestation. The remaining were performed after week 9, but official data do not distinguish between later first- and second-trimester abortions (Bélanger and Oanh 2009). An increasing number of second-trimester abortions are performed on female fetuses; although sex-selective abortion has been illegal since 2003, growing numbers of women resort to this procedure in the hope of having a son in their next pregnancy.13

At the time of this fieldwork, the legal limit for abortion in Vietnam was 22 weeks' gestation. First-trimester abortions were affordable and easily accessible, offered by both public and private service providers, while second-trimester abortions were performed only at provincial and central hospitals. Abortions prior to 18 weeks' gestation were usually performed surgically: in the first trimester through manual vacuum aspiration (MVA) (hút thai) or dilatation and curettage (D&ampC) (nạo thai), and from week 13 to 18 through dilatation and evacuation (D&ampE). Abortions after the end of 18 weeks' gestation (phá thai to) were performed either through a modified Kovac's method or through medical abortion.14 These abortions were more costly-hospitals charged around 1.5 million Vietnamese đồng (US$100) per procedure-and more administratively cumbersome, requiring the presentation of identification documents. If a fetus was found to be anomalous, there was no legal upper limit for abortion, but the termination had to be approved by a professional board at the hospital where it was performed. At Hanoi's Obstetrics and Gynecology Hospital, abortions after week 18 were induced through use of the drug Cytotec (known generically as misoprostol). After the medication had been administered to the woman, the delivery would usually take place within twenty-four hours. Neither feticide nor fetal autopsies were performed.15

Existing research has shown that many people in Vietnam consider pregnancy terminations to be morally problematic interventions (see chapters 3 and 7). During the years when family planning was a key political priority, such concerns were articulated mainly in private and were shrouded in silence in the public sphere.16 At the time of this fieldwork, however, moral skepticism toward abortion began to be articulated more openly. Under the headline "Abortion-Belated Tears," for instance, an article published in the official journal Family and Children asserted: "Abortions generate not only physical pain but also spiritual trauma for pregnant women" (Thùy Hương 2009:20-21). Defining induced abortion as an extremely dangerous procedure, the article told heart-wrenching stories of women who had suffered profoundly when having their pregnancies terminated. One story portrayed a couple that decided to opt for a sex-selective abortion in the wife's 18th week of pregnancy. On this occasion, the husband cried for the first time in his adult life. The journalist commented: "Thinking of the bloody scene and the innocent little creature who had not had the chance to live, all he could do was to cry."

In public discourse, however, abortions for fetal malformation were represented as categorically different from other kinds of pregnancy termination. The pain of this particular kind of abortion, official accounts suggested, is modest in comparison with the suffering that the birth of a severely disabled child would have caused; unlike abortions that aim to select for sex, selection against disability was represented as entirely morally appropriate. At the time of this fieldwork, newspaper stories, government reports, and population policy documents all depicted the prospect of childhood disability as a serious threat to individuals, family, and society. As one government report warned: "Congenital defects still severely threaten the lives of the next generation" (National Committee for Population and Family Planning 2001:9). To contextualize such statements, I now briefly consider the social and political connotations of the notion of disability in present-day Vietnam.

"The whole leaf shall support the damaged one": Disability in Vietnam

The government of Vietnam prides itself on a long tradition of compassion and support for people with disabilities. Socialist Vietnam's first Constitution, issued in 1946, stated that "old and handicapped persons (người tàn tật), incapable of working, shall receive assistance." All subsequent constitutions (1959, 1980, 1992) have explicitly guaranteed social protection of the nation's disabled people. In official discourse, measures to protect the disabled are often represented with reference to a long-standing cultural tradition in Vietnam of mutual care and protection, as captured in sayings such as "The whole leaf shall support the damaged one" (Lá lành đùm lá rách) or exhortations to "love others like yourself" (thương người như thể thương thân). Despite this, there is no national disability registration system in Vietnam, and estimates of disability rates vary. In an effort to enhance evidence-based policy making, questions on disability were included in two national surveys: the 2006 Vietnam Household Living Standards Survey and the 2009 Vietnam Population and Housing Census. The 2009 census found that among Vietnam's 78.5 million persons aged five years or older, almost 6.1 million, or 7.8 percent, lived with one or more disabilities in seeing, hearing, walking, or cognition. Of this population, 385,000 were categorized as persons with severe disabilities (UNFPA 2011a). In 2005, the Vietnamese Ministry of Labor, Invalids, and Social Affairs (MOLISA) estimated that around 3 percent of all children were born with congenital disabilities (Government of Vietnam 2006:13). According to MOLISA statistics, in 2007, the number of people with disabilities who received regular support from the state was 487,384 individuals (UNFPA 2011a). The remaining individuals either supported themselves or were supported by relatives.

Initially, in Vietnam as in many other countries, disability policies aimed primarily at the provision of support for war veterans. In the words of a 1994 government ordinance: "The Fatherland and its people will be forever indebted to those who have made sacrifices to the revolutionary cause for national liberation and the defense of the Fatherland. Caring for the material and spiritual life of these people and their families is the responsibility of the State and the entire society" (Maarse 2000:33). In the 1990s, however, under the influence of international organizations, disability policies began to include a broader group of people, targeting disabled children (trẻ khuyết tật) in particular. The 1992 Constitution states that "the State and society shall create the necessary conditions for disabled children to acquire general knowledge and appropriate training"; and the 1998 Ordinance on Disabled Persons expressed extensive state commitment to the enhancement of the political, economic, cultural, and social rights of people with disabilities. In the wake of this ordinance, several laws concerning education and employment have included protections for people with disabilities, and a variety of projects and programs have been launched to enhance educational and employment opportunities for the disabled, thereby increasing their inclusion in community and society (hòa nhập với cộng đồng, xã hội). The effectiveness of these measures is, however, not clearly documented. Findings from existing research indicate that social protection of the disabled remains limited; that disability and poverty are closely linked; and that Vietnam's disabled people continue to face enormous problems in accessing education, health care, and employment.17

At the time of our fieldwork, disability statistics and stories figured prominently in the mass media. On a daily basis, the citizens of Hanoi were confronted with television programs and newspaper accounts that offered personal stories of disabled individuals and their families, portraying the plights of mothers who must leave their severely disabled children unattended for hours while they went to work; of fathers who engaged in desperate searches for medication, spending fortunes on futile therapeutic journeys; and of unhappy children who spent their days lying in one place. These mass-mediated stories were always told with great pathos, detailing the pain (nỗi đau), suffering (nỗi khổ), and unhappiness (bất hạnh) of disabled individuals and their families. Newspaper articles were often accompanied by heart-wrenching photographs of crying children, of young adults who spent their days on a straw mat on their parents' living room floor, of worn-out parents and grandparents. Many stories ended with appeals to their readers to offer financial contributions that could help the disabled to achieve a life like everyone else's. The special moral obligation of the national mass media was explicitly set forth in an editorial in the Ministry of Health's journal Health and Life on the occasion of the International Day of Persons with Disabilities in 2004:

Newspapers and mass media have an important role as bridges in this area. In the past years, many newspapers have organized help and support directly. The voices of newspapers and journals, of public opinion, are extremely important means of calling on conscience and responsibility. And next, together, schools, families, and mass organizations are places where charity and charitable deeds can be cultivated. Our country is still poor, but in Vietnam we have a one thousand-year-old history of human compassion (lòng nhân ái)! Together, let us offer people with disabilities more attention. (Sức Khỏe và Đời Sống [Health and Life] 2004)

In official discourse, it seemed to be taken for granted that disability equals suffering (see chapter 6). State messages suggested, moreover, that while treatment, rehabilitation, and social support are important for averting such suffering, the prevention of disability is a societal obligation too. In Europe and the United States, the use of prenatal screening to prevent the birth of children with disabilities has met strong criticism from disability rights advocates who claim that such measures cannot but convey the idea that people with disabilities are of less value than others. Saxton (2006:108), for instance, writes that selective abortion must be resisted because "contributions of human beings cannot be judged by how we fit into the mold of normalcy, productivity, or cost-benefit. People who are different from us (whether in color, ability, age, or ethnic origin) have much to share about what it means to be human. We must not deny ourselves the opportunity for connection to basic humanness by dismissing the existence of people labeled 'severely disabled.'"

During fieldwork in Hanoi, I very rarely heard anyone express opinions of this kind.18 The disability movement in Vietnam is still nascent, and there is no national organization that advocates for disabled people. Over the past decade, an array of local self-help disability groups has emerged, including groups for parents, students, women, and groups of people with specific impairments.19 To date, however, none of these groups have expressed criticism of the use of prenatal screening and selective abortion; rather, there seems to be nearly complete social consensus that these are useful and beneficial medical interventions. When I talked to activists in local disability groups, I found to my surprise that nearly everyone condoned prenatal screening. Rather than seeing this medical intervention as an indication of discrimination, they depicted it as a privilege, their main concern being whether women with disabilities could get as easy access to screening as others. On February 22, 2006, for instance, my colleague Toàn and I met with forty-nine-year-old Phương, who was mobility impaired and an active disability support group member. We visited Phương in her home in a spacious house near the Red River where she lived with her husband and twenty-year-old son. Her tricycle was parked inside the gate, covered with a plastic sheet to protect it against the winter rain, and the yard was full of luxuriously green potted flowers. Inviting us in, Phương opened the conversation by telling us about her own childbearing experiences. "Before I had my son," she said, "nobody had imagined that I was able to have a child. At that time, people thought that a disabled person would never get married, have children, or take a job." When I asked Phương what she thought of the new technologies for prenatal screening that are now available in Vietnam, she replied: "I think this is something very humane. To have a child like that means suffering. The child will suffer, the family will suffer, even society will suffer. Of course, it is very difficult (ái ngại) for the parents to find out that something is wrong with their child and to undergo an abortion. But in my opinion, if one finds out that the fetus is not normal, it is best to have an abortion. It is better to feel pain for a short while than for an entire life."

These relatively homogeneous views of disability and prenatal screening must, I contend, be seen in the context of the social problems associated with the herbicide dioxin known as Agent Orange. Given that physicians and pregnant women found prenatal screening so necessary, that policy makers emphasized the need for systematic interventions to prevent disability, and that disability was equaled with suffering even by disability movement members, this must all be seen in the context of the agony associated with Agent Orange. At the time of our fieldwork, the nation's Agent Orange victims (nạn nhân chất độc da cam) were the objects of intense mass media attention. The editorial in Health and Life mentioned above concluded with these words: "The war in our country ended thirty years ago, but many of the nation's beloved children, and their children, grandchildren, and families, must still bear the bitter consequences of war; the consequences of Agent Orange, of infirmity and disease. . . . They sacrificed their blood and bones in order to win back independence, freedom, and peace for our country."

"Agent of Agony": Human Consequences of Wartime Herbicide Spraying

Between 1961 and 1971, U.S. airplanes sprayed 11 to 12 million gallons of herbicides over Vietnam in order to defoliate forests and mangroves presumably used by the Việt Cộng for cover. The spraying caused massive environmental destruction, devastating large areas of land, and affected between 2.1 and 4.8 million Vietnamese people directly (Stellman et al. 2003).20 The herbicide mixture most often used has become known as Agent Orange, named for the orange stripes on the barrels in which it was shipped. Agent Orange contained dioxin, a highly toxic chemical that is very persistent in the environment and in human tissue. "Dioxins are of concern," notes a WHO fact sheet, "because of their highly toxic potential. . . . Once dioxins have entered the body, they endure a long time because of their chemical stability and their ability to be absorbed by fat tissue, where they are then stored in the body" (WHO 2010).

During the years of our fieldwork, there was mounting concern in Vietnam about the long-term health effects of herbicide spraying. The Vietnamese Association of Victims of Agent Orange (VAVA) has estimated that more than 3 million citizens of Vietnam suffer from serious health problems caused by dioxin exposure (Martin 2009). The chemical has, advocacy groups claim, harmed the health of Vietnam's people in several ways. First, those who were directly exposed to Agent Orange during the war, or who live in areas with residual dioxin in soil and water, experience a much higher rate of certain diseases than other members of the population. Second, the children and grandchildren of individuals exposed to herbicide spraying are born with unusually high rates of congenital malformations or diseases, or both. According to Nguyễn Trọng Nhân, vice president of VAVA, the rate of severe congenital anomalies in herbicide-exposed populations in Vietnam is 2.95 percent, compared to 0.74 percent in non-exposed populations (Stone 2007:178). Like the WHO, Vietnamese researchers point to the uncanny persistence of dioxins in the human body and in the environment, arguing that dioxins not only may be transmitted from the exposed generation to the next, but may also skip a generation and manifest again in the grandchildren of those directly exposed (Hoàng Bá Thịnh 2006).21 Internationally, questions of how dioxin exposure affects human health are steeped in uncertainty, as the impact of toxic chemicals on human beings cannot be easily gauged. The possible health consequences include increased risk for cancers, adverse reproductive and developmental effects, immune deficiency, endocrine disruption, and neurological damage including cognitive and behavioral damage from in utero exposure (Schechter et al. 1995:520). There is firm evidence of association between exposure to dioxin and five illnesses: soft-tissue sarcoma, non-Hodgkin's lymphoma, chronic lymphocytic leukemia, Hodgkin's lymphoma, and chloracne. There is limited or suggestive evidence of association between dioxin exposure and a range of other ailments, including prostate and respiratory cancers, Parkinson's disease, Ischemic heart disease, Type 2 diabetes, and spina bifida in offspring of exposed individuals (Institute of Medicine 2009). To date, the actual consequences of dioxin exposure for the health of Vietnamese citizens remain a topic of intense scientific and political controversy (see D. Fox 2007). The impact on reproductive health is perhaps the most unsettling and contentious issue.

In Vietnam, concerns that dioxin exposure may cause birth defects were first raised in newspaper articles in Saigon in the 1960s. Since the 1970s, epidemiological studies conducted by Vietnamese researchers have found elevated rates of congenital malformations in children of men and women who have been exposed to the chemical.22 In 1980, the Vietnamese government set up the 10-80 Committee (named for the month and year of its establishment) as the official body for Agent Orange research, and the consequences of herbicide spraying for human health and the environment were discussed at international scientific conferences held in Ho Chi Minh City and Hanoi in 1983 and 1993. Epidemiological research on herbicide spraying conducted by Vietnamese researchers has, however, rarely been published in international peer-reviewed scientific journals. The validity of this research has therefore been questioned, some scholars claiming that with the exception of spina bifida and anencephaly, the peer-reviewed literature does not offer convincing indications of connections between herbicide exposure and congenital malformations (Schechter and Constable 2006). The official U.S. standpoint is that there is no conclusive evidence that herbicide spraying has caused health problems among exposed Vietnamese individuals and their children.23 In 2007, then-U.S. ambassador to Vietnam Michael W. Marine declared: "But honestly, I cannot say whether or not I have myself seen a victim of Agent Orange. The reason for that is that we still lack good scientific definitions of the causes of disabilities . . . that have occurred in Vietnam. . . . We just don't have the scientific evidence to make that statement with certainty" (Martin 2009:7). Despite this purported lack of evidence, five countries involved in the war-the United States, Vietnam, Australia, South Korea, and New Zealand-now offer their veterans compensations for diseases and congenital birth defects related to Agent Orange (Fox 2007:3). Meanwhile, victims in Vietnam have received no compensation from the U.S. government or the companies that produced the chemicals.24

"Justice has no borders": Contested Responsibilities for Health Damage

In May 2005, I talked informally to a senior official employed at the U.S. embassy in Hanoi. When I mentioned that I found it noteworthy that U.S. veterans are offered compensations for health problems associated with Agent Orange while Vietnamese citizens are not, he responded: "Actually, you know, no one really believes that Agent Orange causes health damage. In the U.S., there were huge pressures for compensation from veterans' organizations, and it was felt that we had to give them something. But we never really believed that these things are linked." As represented by this official, in other words, the granting of compensation to U.S. veterans was a moral gesture made in recognition of the pain they had suffered; it was not, he claimed, an evidence-based acknowledgement of causality. His opinion echoed that expressed by Agent Orange manufacturers who continue to insist that the chemical does not cause health problems. On its homepage, for instance, Dow Chemical Company (2013) states that the "very substantial body of human evidence on Agent Orange establishes that veterans' illnesses are not caused by Agent Orange." The U.S. decision to grant veterans compensations for health problems in spite of these controversies regarding the evidence must be seen against the background of a historic toxic tort lawsuit.

In 1984, a group of U.S. veterans filed a class action lawsuit against Agent Orange manufacturers. While denying any link between the chemical and veterans' health problems, seven companies settled the lawsuit out of court, agreeing to pay a compensation of $180 million. Seven years later, in 1991, the U.S. Congress passed the Agent Orange Act, making veterans who served in Vietnam eligible to receive treatment and compensation for certain conditions. It is likely, observers have noted, that the court case and its settlement contributed to the passage of this act (Martin 2009:24). No legal liability has, however, been admitted. In 1984, Judge Jack B. Weinstein, who presided over the court case, emphasized that given the scientific uncertainties at issue, there was no proof that Agent Orange had harmed veterans' health (Schuck 1986:185). Despite this denial of responsibility and despite the fact that the compensation that veterans received was financially modest, the 1984 settlement did constitute an important symbolic gesture. As Veena Das (1995:141-142) observes: "Courts became sites on which the Vietnam war and its hardships were symbolically re-enacted. The same law suit could also be seen as a cathartic drama in which war veterans gave public expression to annoyance at their dismal treatment at the hands of their society: the court case became an occasion to comment upon the moral problems of contemporary society." U.S. veterans have, in other words, been relatively successful in contesting companies' definitions of harm and in gaining moral recognition of their suffering. In this regard, Vietnamese victims have had less success.

In Vietnam, Agent Orange has only recently become a matter of public concern. Although the possible problems caused by Agent Orange were afforded some scientific attention in the decades immediately following the war, from 1975 to around 2000 there was a marked reluctance in both Hanoi and Washington to discuss the Vietnamese Agent Orange case in public. On Vietnam's part, this silence was due to intertwined economic and diplomatic concerns: officials feared that publicity around the Agent Orange issue could damage Vietnam's image internationally, making it harder to market agricultural and aquacultural products, while also hindering the normalization of diplomatic relations with the United States. It was not until the mid-1990s, therefore, that the fate of Agent Orange victims was brought to mainstream public attention. Vietnamese writers and artists played a key role in this process: in 1996, Trần Văn Thủy's film A Story from a Corner of the Park depicted a Hanoi family affected by Agent Orange, and in the nation's newspapers, writers and journalists began to tell victims' stories. In 1998, the Vietnamese Red Cross established an Agent Orange Victims' Fund; in 2000, the Vietnamese government set up its Agent Orange Central Payments Program, providing financial assistance to victims; and in 2001 the Vietnamese government launched a campaign for "poor disabled people, including those thought to be affected by Agent Orange."

In Hanoi, public attention to Agent Orange heightened in 2005 when three Vietnamese citizens filed a class action lawsuit in U.S. District Court in New York against Agent Orange manufacturers, demanding compensation for the injuries inflicted on them. Their claims were dismissed. The court ruled that since the herbicides were not intended to poison humans, their use was not a violation of international law; this could not be considered chemical warfare. Judge Weinstein-the same judge who presided in the 1984 court case filed by U.S. veterans-concluded: "The fact that diseases were experienced by some people after spraying does not suffice to prove general or specific causation. Proof of causal connection depends primarily upon substantial epidemiological and other scientific data" (Stone 2007:179).25 The attempts made by Vietnamese victims to draw U.S. public attention to their grievances have, in other words, had limited effect; their lawsuit failed to achieve the moral and financial results gained by U.S. veterans. As observed in a petition issued by the Association of Agent Orange/Dioxin Victims of Ho Chi Minh City in July 2012: "The greatest injustice is that of all the victims of this monstrous chemical, only the American veterans have been compensated since 1985 whilst the Vietnamese victims have been discriminated [against] and ignored" (Gender and Society Research Center 2012).

At the time of our fieldwork, public demands for justice and U.S. acknowledgment of its responsibility were intensifying in Vietnam. In the months preceding the New York court case, the mass media unleashed a torrent of unsettling stories of Agent Orange victims, defining the lawsuit-a "suit for conscience and justice" (vụ kiện vì lương tri và công lý)-as a necessary response to this human suffering. When the victims' case was dismissed, the ruling was characterized as unjust, inhuman, and irresponsible-"a verdict that challenges the world's conscience," as one newspaper put it. Given the deep and perhaps permanent damage that has been done to the health of Vietnamese citizens, mass media reports asserted, U.S. manufacturers and authorities must be held accountable. Under the headline "The U.S. Must Take Responsibility," for instance, the daily newspaper Hà Nội Mới commented, "This pain will haunt (ám ảnh) the people of Vietnam from this generation to the next. The U.S., a country that always preaches loudly about human rights, must assume responsibility for Agent Orange victims in Vietnam" (Bích Thuận 2005).

In today's Vietnam, such demands for responsibility are articulated most vocally by nongovernmental organizations. The above petition, for instance, declares:

The war has been over for 37 years but for the victims of Dioxin/Agent Orange the war has not ended. Every day of their lives, they endure physical pain and severe mental wounds. The consequences of Agent Orange are long term and [a] heavy burden on society. The pharmaceutical companies (Dow Chemical and Monsanto), the producers of the toxic chemical and the decision-makers who are responsible for the use of dioxin during the war in Vietnam remain unperturbed and avoid their responsibility for their own acts. . . . The reality is that more than 3 million AO Vietnamese victims are confronted with a daily struggle for life and enduring physical pain from the fatal diseases. Many died very young. Others, and in particular their children born after the war, are malformed and unable to care for themselves. Nor should we forget all the dead fetuses that did not see life. . . . We believe that it is high time for all of us to demonstrate our clear and simple message and demand that the U.S. pharmaceutical companies and the U.S. government take responsibility for their actions and alleviate the severe effects of the Dioxin Agent Orange in Vietnam. . . . Everyone in this world should be treated equally; justice has no borders. Agent Orange victims wherever they reside should be treated fairly. . . . The suffering of the victims is the common pain of all Vietnamese and, it can be even said, the pain of humanity. (Gender and Society Research Center 2012)

The demands set forth in such public calls for responsibility drew moral and emotional force from the harrowing stories of the plight of Agent Orange victims that have proliferated in the mass media since the beginning of this millennium. Depicting the day-to-day lives of families in which several generations suffered from devastating dioxin-related diseases and disabilities, these narratives paid particular heed to tragedies of a reproductive nature. One typical story, told in Family and Society under the headline "A Pain Bearing the Name Orange," introduced readers to a man named Phạm Hùng who lived in Phú Yên province. During his military service, Hùng worked in heavily sprayed areas. Since his return, he had suffered from frequent health problems, and three of his four children, Hường, Hoài, and Hoa, had been "crazy" (điên) from birth. None of them could talk, yet their shrieks could be heard far away. Hùng and his wife made their living from a small plot of land, and one of them always had to stay at home to watch their children; in a moment's lapse of parental attention any one of them could run out of the house and injure him- or herself. Meeting this family, the journalist wrote, she could not hold back her tears. Hùng too shed tears as he said: "We don't know what to do. We have given birth to them, so no matter what they are like, these are our children. We do our best. Even though we have only vegetables and rice gruel to eat, we get by day by day" (Nguyễn Xuân Hoài 2005).

Often, stories of Agent Orange victims' plights portrayed parents who had had one severely disabled child after the other, yet kept clinging to a desperate hope of having at least one healthy child. Reporting on her interactions with victims, for instance, the social researcher Phạm Kim Ngọc, from the nongovernmental Research Center for Gender, Family, and Environment in Development (CGFED), writes:

We have heard heart-breaking stories of the destruction of health, particularly reproductive health. There were women who suffered unspeakably (chết đi sống lại), because each time they gave birth, the child was deformed. There were fathers who had to bury the bloody lumps of meat [when their children were born] inhumanly deformed. There were parents who had to swallow their own tears to look after children who had been born without intelligence and awareness, who could do nothing for themselves, who did not have the ability to learn, to think or to work. There were parents who thought they were living in happiness when suddenly their children got ill and nothing could be done to help them. . . . All those fathers and mothers, husbands and wives, always nourish a deep desire, although they know that it can never be fulfilled: giving birth to a healthy and normal child. (Phạm Kim Ngọc 2006:33-34)26

Through stories conveyed in the mass media, Vietnamese citizens have become intimately familiar with images of children without arms or legs, with weirdly deformed limbs, or without eyes; children with enormous heads; children whose skin flakes off or whose bodies are covered with black hair or dark spots; children who are partly or completely paralyzed and spend their days on beds or in cagelike enclosures.27 These images, I suggest, formed a vital substratum for people engaged in selective reproduction with the fervor I observed; at this moment in time, all citizens of Hanoi were keenly aware of the fact that human reproduction can go terribly awry. Partly in response to the agony associated with Agent Orange and partly in an effort to accelerate the country's economic development, Vietnamese policy makers have recently turned problems associated with the "quality" (chất lượng) of the nation's population into a central political issue. In this policy realm, emotional mobilization around the Agent Orange issue forms an important basis for political strategies and interventions.

Enhancing Population Quality: Ultrasonography as a Political Device

As I approached Hanoi's Obstetrics and Gynecology Hospital on a bright day in September 2009, I noticed that one of the private clinics outside its gates advertised its services in a new terminology. On the glass doors that separated the clinic from the street outside, large red letters now announced: "Prenatal screening. Screening for the factors that determine human quality (chất lượng con người). A chance to give birth to healthy children for every family." Next to the clinic entrance, a huge photograph, approximately two meters high, showed a child lying curled up inside the palm of a hand. This image, presented in an effort to attract customers, attested not only to the commercialization of reproductive health care in Vietnam, but also to the increasing political attention that this area of human life attracts. While human reproduction has long been an important terrain for the exercise of state power in Vietnam, at present the quality of future citizens is problematized in novel ways.

At the beginning of the twenty-first century, the Vietnamese government's efforts to control population growth seemed to have largely achieved their objectives: national fertility rates had dropped from an average of 5.7 births per woman in 1979 to 3.8 in 1989 and 2.1 in 2005 (Teerawichitchainan and Amin 2009). Political attention therefore began to turn toward questions pertaining to the quality of the country's population. The first official document that placed population quality on the political agenda was the national Population Strategy for the years 2001 to 2010, issued in 2001. In the years that followed, questions about what population quality means and how it can be measured were intensely debated in government policy papers and state-run journals. Often, officials would refer to UNDP's Human Development Index(HDI, which combines measures of life expectancy, literacy, educational attainment, and GDP per capita), regretting Vietnam's low ranking as compared with other Southeast Asian countries. But while making frequent reference to the HDI, government documents also defined this as a relatively simple index that "does not include the full complexity and multifaceted character of human development . . . and does not highlight all the challenges that a developing country must give priority to solving" (Ủy Ban Dân Số, Gia Đình và Trẻ Em2003:135). One key dimension of human development that the HDI ignores, officials claimed, is the physical quality of the population.

At the time of this research, policy papers and the public press expressed intense concern regarding the physical deficiencies of Vietnam's citizens: young people, citizens were told, are too short in stature compared to their peers in the region; too many children are born at a low birth weight; the nutritional status of children under five is too poor; and the proportion of disabled people in the population is too large. These deficiencies, officials maintained, hamper the competitiveness of the national workforce; if Vietnam is to compete with other nations in the global capitalist arena, the physical quality of the country's citizens must be enhanced. In a special issue of the state-run journal Family and Children, for instance, a high-ranking population official wrote:

The low population quality hinders the development of our country and places us at risk of falling even further behind. We cannot yet meet the requirements for a high quality work force that can serve the industrialization and modernization of the nation. . . . It is necessary to extend preliminary models for technological intervention in the areas of prenatal and neonatal screening in order to detect and treat congenital diseases, neonatal disability, and genetic disabilities, and it is necessary to perform premarital health examinations and counseling. Step by step, through research and experimentation, we must develop models of intervention that can contribute to reducing the factors that weaken our stock (giống nòi), models for building cultured families,28 safety, and social dynamics that suit a developing society, particularly as Vietnam joins the World Trade Organization. (Nguyễn Bá Thủy 2007:7)

If Vietnam is to benefit from the development opportunities arising from gaining membership in the World Trade Organization in 2007, officials argued, the physical quality of the population must be enhanced; to attain this goal, the number of children born with diseases and disabilities must be reduced. It is in this context of heightened biopolitical attention to the bodily quality of Vietnam's present and future citizenry that obstetrical ultrasonography has achieved its significance as a political device.

At the time of this fieldwork, prenatal genetic tests such as amniocentesis were used only at Hanoi Medical University and at the city's largest maternity hospital, the National Obstetrics Hospital, and in both sites only on an experimental basis. According to the policy makers I talked to, general coverage of genetic examinations in pregnancy was not considered immediately realistic.29 Due to its limited cost, in contrast, ultrasonography was seen as having the potential for more widespread use. The expectations that officials and physicians invested in this new technology were set forth with particular clarity in a talk that Dr. Lan, a senior ob-gyn, gave at a scientific conference on prenatal screening held at Hanoi's Obstetrics and Gynecology Hospital on March 31, 2006. Dr. Lan said:

Abnormal fetuses pose large problems for our entire society. Across the world, numerous different methods have been used to detect abnormal fetuses, such as X-rays, amniocentesis, chorionic villus sampling, fetal tissue sampling, umbilical blood sampling, maternal serum screening. These methods are very precise, but they intervene in the body and require time, equipment, and medical specialization. Therefore, they cannot always be used. Thanks to the rapid progress of science and technology, ultrasound scanning is now widely used.

At birth, children have the right to health, the right to play and to learn. The birth of sick and disabled children not only increases the risk of tragedies in terms of health, which make both the family and the disabled child itself tense and tired. Such children are also an economic burden for both family and society. The use of ultrasound scanning for early detection of fetal malformations is a simple and affordable method that can easily be used everywhere, at any time, even at basic health care service delivery points. Therefore, we need more research on this issue in order to eliminate fetuses with severe disabilities at an early stage.

Since the turn of the millennium, official appeals to the nation's citizens to make use of selective reproductive technologies have been made with increasing intensity. An article in Family and Society, for instance, told its readers that "methods for genetic screening and diagnosis bring benefits for women, families, and the community, improving the chances of having healthy children and reducing worries about having disabled children. At the same time, they reduce costs for families and society and contribute to improving population quality. . . . According to experts, if pregnant women undergo prenatal and neonatal screening, it is possible to eliminate up to 95% of all abnormal cases and ensure that healthy children come into being" (Hà Thư 2010c:6). Newspaper reports often expressed regret that rates of prenatal screening are too low in Vietnam. In Singapore, one article stated, 99 percent of all children are screened before birth; in Thailand this figure is 80 percent and in Australia 100 percent. In Vietnam, in contrast, only 1 percent of children were reportedly examined before birth (Hà Thư 2010d:6).

On December 3, 2004, I asked Đặng Văn Phòng, a senior official with Vietnam's Commission for Population, Family, and Children, how the concept of population quality had been introduced in Vietnam. Sitting at his desk, surrounded by stacks of research reports, policy papers, and other documents, he told me that examples set by other countries in the region had compelled Vietnamese policy makers to place questions of quality at the center of national development efforts:

We noticed that several other countries in Asia placed population quality high on the agenda. Asian countries are often poor and underdeveloped, and many people have weak physiques and are very small. . . . So for these reasons, we had to take up the problem of population quality in order to participate together with other countries in processes of modernization and industrialization. We also studied documents from other Asian countries, for instance from Japan, where they addressed the issue of population quality already around 1945, after the Second World War.30 I read documents that stated that after losing in the war, Japan was a very poor country that encountered many difficulties. Therefore, Japan had to strive hard to reach the development level of other countries. Genetics programs were implemented, and policies were launched that encouraged scientists to have many children and allowed people to marry foreigners. . . . In Japan they thought that this could enhance the quality of Japanese people. They wanted to change the stock (giống nòi) of the Japanese in order to be able to engage with other countries.

If a country such as Japan had attained economic development by enhancing the fitness of the national labor force, Phòng and other officials reasoned, then Vietnam must leap out of its poverty and postwar deprivation in a similar manner. But, Phòng suggested, at the time that population quality became an object of political attention in Vietnam, more country-specific anxieties were at issue as well. In the 1990s, a national-level research project had been conducted on different aspects of population quality, and among a range of topics under consideration, the involved officials had decided to give priority to genetics. The government's interest in genetics, Phòng said, was directly associated with concerns about the long-term consequences of wartime herbicide spraying. As a part of efforts to enhance population quality, recommendations were made to extend the availability of genetic health care services, particularly to citizens exposed to Agent Orange. In Phòng's words:

We must explain clearly to such people that this may affect their childbearing. If their parents lived in areas exposed to Agent Orange, this will be carried in their genes. Research conducted by Professor Cầu found that the chemical affected five generations, but in irregular ways: perhaps the children were not affected, but the next generation was. So it is very complicated, and we must tell these people the truth and encourage them to be careful in their reproductive practices. I have visited local areas together with the Ministry of Labor, Invalids, and Social Affairs and met people who do not know [about their genetic status], so they keep hoping that they can have a normal child. Therefore in some families they have three, four, or five children who are all disabled. It was so painful to witness this. It was like a disability camp (cái trại bị dị tật)-all the children were disabled. The entire family lived in misery. The kin group suffered too, because other family members such as aunts and uncles had to help. The village also had to help, so this became a very heavy burden for the entire society. Therefore, this problem is very complicated in Vietnam and we have not been able to solve it yet.

When Phòng contributed to the drafting of national population policies, he saw before him the suffering child victims he had encountered during field trips. Such suffering can, he told me, be prevented: "I am not saying that Agent Orange victims should not have children," he emphasized, hinting at a conversation we had recently had about twentieth-century European eugenics. "What I say is that these people need help from the health care system. If they lived in your country, they would have access to genetic health care services. So why should we not be able to offer Vietnamese people this kind of assistance?"

Numerous official documents, including the government's 2001 Population Strategy and the 2003 Population Ordinance, make direct reference to the population's exposure to toxic chemicals, linking the need for expanded prenatal screening to this unsettling national history. Reading these policy documents, I was often struck by the emotion and empathy that animated them. Policy making in the realm of selective reproduction seemed inflected with heartfelt distress, anxiety, and compassion.

When calling for more extensive use of prenatal screening, policy makers would often, like Phòng, refer explicitly to the devastating consequences of dioxin contamination for human health and lives. In official discourse, the suffering of Agent Orange victims was represented as iconic of the suffering that all severe disability induces; the horrors associated with Agent Orange seemed to spill over into the realm of disability in general. The following excerpt from an official document accompanying the government's 2003 Population Ordinance illustrates how observations that alluded specifically to Agent Orange could slip into more general statements about disability:

At present, considerable numbers of children are born with congenital disabilities. Due to a lack of knowledge about reproduction, many families with disabled children still hope that their second, third, or . . . [later-sequenced] child will not suffer such consequences. This has led to a situation in which many families have three or four disabled children, causing suffering and difficulties for family and society. Congenital disabilities are very difficult to treat, the death rate is high, and the disabilities usually remain for the entire life of the disabled person. The life situation of people with congenital disabilities is very painful, and the lives of family members are very difficult and full of suffering. This places burdens on society too. (Ủy Ban Dân Số, Gia Đình và Trẻ Em2003:140)

Existing analyses of East Asian population policies have often framed state policies as rational and instrumental technologies of power that are driven by faceless bureaucratic machineries (e.g., Sigley 2009). During fieldwork in Hanoi, however, I came to see Vietnamese state efforts to enhance population quality as a politics of proximity; that is, as a way in which intuitive reactions to the suffering of other persons were turned into a basis for policy measures and political claims (cf. Levinas 1998a [1985]:165). When policy makers in Hanoi strove to avert the suffering associated with severe disability, they seemed motivated not only by economic goals or national development ambitions but also by a sense of responsibility and solidarity, by feelings of compassion with fellow citizens whose family lives had been thrown off track by a war that ended decades ago. The words of policy makers such as Phòng draw our attention to these affective aspects of state policies, to the human anxieties and desires that animate biopolitical strategies.31 Ignoring these dimensions of governance may, I contend, lead us to portray the actors who devise and implement state policies as less than human and to overlook the emotional forces that lie behind citizens' compliance-or complicity-with state demands.32

In today's Vietnam, as this chapter shows, state and citizen anxieties tend to merge in the realm of reproductive politics. The policy makers, pregnant women, and health care providers I met all expressed fears and concerns about the long-term consequences of herbicide spraying for human reproduction and an acute awareness of the risks that childbearing entails. During a conversation we had about selective reproduction, for instance, Dr. Tuấn said: "Vietnam is a country that has been through many wars. Many weapons have been used, including chemical ones. Their environmental effects are very long term and they affect the people of Vietnam. . . . But in the health care system there are things we can do. We can encourage women to get enough folic acid, and we can conduct prenatal screening. We can categorize the children in a scientific and effective way, to ensure that those that are born have good physiological indicators and are perfect (hoàn thiện)." When a disability movement activist such as Phương defined prenatal screening as a necessary and humane intervention, she too was associating disability with the deformation of human bodies caused by herbicide exposure. During our conversation, it soon became clear that when Phương talked about the disasters involved in having "a child like that," it was images of Agent Orange victims that were on her mind. When we asked her about the differences between severe and mild disabilities, she answered by pointing to the problems associated with Agent Orange: "Some Agent Orange families have four children and they are all disabled. This shows that there is a need for better communication. It is important to make such people understand that even if they have ten children, they will never have a complete (lành lặn) child. Sooner or later, the child will become sick. Such families suffer, and indirectly society suffers too. They keep hoping, but their hope is groundless. So there is a need for better counseling, to make these people understand."33

In sum, the human damage done by the spraying of toxic herbicides over Vietnam during the Second Indochina War is figured in public discourse in ways that render close surveillance of the pregnancies of the nation's women a social, political, and humanitarian necessity: official responses to the toxic aftermaths of war include biopolitical attempts to ensure the integrity of the national body through active promotion of selective reproduction. Yet present-day Vietnamese biopolitics differs, I contend, in significant respects from the forms of governance that unfold in advanced liberal societies where moral and political primacy is placed on individual decision making and choice. This is what I discuss in the following chapter.

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