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.
Haunting Images A Cultural Account of Selective Reproduction in Vietnam
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 t