With the size of a family tied to social status and growing infertility - not to mention politicians keen to win support by offering couples what they most desire - IVF has become big business in the Gaza Strip.
The hangar is filled to the brim and the agitation is palpable. More than 6,000 couples from every corner of the Gaza Strip joined the contest. Only a hundred will be chosen. On one side, men smoke and laugh, their gaze fixed on the organisers. Across from them are women covered in long cloaks, enjoying trays full of sweet and savory snacks with hesitance. Someone makes a call for silence and a young man walks up the stage and starts picking little notes from a bowl. And the announcement "the next beneficiaries of the free In Vitro Fertilization (IVF) will be..." follows.
“When I heard our names, I couldn't believe it,” says 34-year-old Omar a year later, as he lightly touches his wife's leg. “It may sound like a hazard to have children in these poor conditions,” he continues, giving us enough time to notice that he lives in a dark and bare space along with his 30-year-old wife Warda and another 27 family members. “But life without kids is meaningless and Allah will help us.”
His wife smiles, betraying a hint of exhaustion. “If you only knew what we went through,” she adds with a heavy heart. In 2004, Omar, a former militant in the Palestinian resistance, lost his right eye due to an Israeli missile. Since then he has been receiving 170 euros per month from the state and it is thanks to that payment that he and Warda can just about survive.
Two years ago, the UN declared that Gaza would be unlivable by 2020, and since then the situation has worsened. Due to both the economic blockade imposed by Israel and the inner political confrontations between Hamas and Fatah, electricity doesn't last more than five hours per day, and it seldom goes beyond three. Out of Gaza's two million inhabitants, 1.3 depend entirely on humanitarian aid, which last year President Donald Trump decided to thoughtlessly halve.
The water is contaminated and the fuel is expensive and funnelled intermittently, whilst the healthcare is in pieces and unemployment has reached appalling levels. Despite all this, the UN reports that the fertility rate in Gaza is still one of the highest in the Middle East with an average of 4.5 children per couple. “As a direct consequence of the current economic crisis, the number of IVF procedures dropped to one hundred per month,” says Salah al Rintissi, the Director of Khan Younis Hospital and spokesperson of the Ministry of Health. “But only four months ago it was four times higher.” As it is, this year at least 1,200 treatments will be performed.
It was 1996, when Doctor Baha al Ghalayini – the Director of the Gaza Strip’s most famous al Basma IVF clinic – returned home after four years in the UK, where he met Patrick Steptoe, the founding father of the first ‘test-tube babies’, and started dedicating himself to that remarkable invention. It took him 10 years to convince the religious authorities, concerned that Muslim women's eggs may get mixed with sperm different from their husbands', of the benefits of IVF. It took a few more to make it as common to bump into a couple who have tried IVF as it is to know a family with either a martyr or a detainee.
Today everybody in Gaza speaks about IVF. Using this assisted reproductive technology is natural for people who are eager, often to the point of obsession, to enlarge their families and enhance their social status within society. Infertility causes both isolation and social stigma, which end up wearing out, and even tearing apart, many couples. Omar and Warda got married 11 years ago thanks to a match combined with Warda's sister, who had previously married Omar's brother. At first, Omar was a hot head but the newlyweds managed to find their harmony at the end. After a few months, though, this balance was broken, because Warda couldn't get pregnant.
“Our brothers and sisters kept having babies, whilst Omar's parents thought I was good for nothing and Omar and I argued all the time,” Warda explains. “Then, five years ago, Omar asked me for a divorce and said he would marry another woman...”
Many years have passed by but Warda still struggles to recall those memories. It is Omar to take the floor. “Her first reaction was to rip apart the pictures of our wedding and then she tried to throw herself from the window,” he says, with the head bowed between his legs. “Finally, I left the house and we didn't see each other for six months.” When Warda decided to marry another man, Omar begged her to forgive him.
It's not at all clear whether Omar already knew the truth back then, because he doesn't want to talk about it. But three years later when he collected 2,200 euros ($2,450) from relatives and friends for the in vitro fertilisation, which eventually failed, the medical exams couldn't be clearer: it was him who was infertile.
“I felt the earth falling under my feet,” he now admits. If Warda doesn't want to rub salt into Omar's wounds, then other women, who have passed through a similar experience, speak on her behalf.
“There's something deeply unjust and sick about our society,” says 47-year-old Sabat el-Sa, a mother of twins born through the IVF procedure after 30 years of marriage. “When the couples can't have children, it is always the woman to be blamed. Usually, men don't even do medical checks, while the whole family supports them and even insists they would get a second or third wife. In my case, my husband remarried to then find out that it was him, who couldn't have kids!”
In contrast to female infertility, male infertility is a taboo, especially in patriarchal societies like Gaza.
While it's true that the birth rate is still high, in the Strip there's been a significant increase in the number of infertility cases amongst men.
“In 90 percent of cases men suffer from either few or slow spermatozoa,” states Doctor Tharwat al Helou, for who a famous Gaza City clinic was named. “Moreover, today most of the patients live in border areas, which are exposed to the military attacks, thus I believe there is a link between infertility and the advent of the three wars. Surely, to the traumas caused by the bombings, we must add the exposition to chemical agents, pesticides, and white phosphorus...”
Due to the lack of research centres, there are no precise estimates, but all local doctors we talked to confirmed this theory. Doctor Ghalayini agrees with it too but is adamant to remark:,
“In Gaza the infertility threshold is lower than in Europe both in terms of time, because couples don't want to wait longer than six months after the wedding to conceive a child, and number, which means that the higher the number of kids they have, the better.”
It is inside al Basma clinic that we meet Fadi and Loreen Bahr, residents of Shaja'ya, one of the eastern neighbourhoods at higher risk. After having followed the prescribed treatment for two and a half months, the time has come for Loreen to receive the embryo transfer and the couple is very nervous. It is the second time they have tried IVF, after the first one failed, but theirs is quite a peculiar case. “We have two beautiful daughters but I wanted to have a son that could follow in my footsteps,” Fadi says, ruefully. “Sadly, with the passing of time I got less fertile, hence... here we are again.” Sex selection, which is forbidden in most Western countries, is instead very popular in some Islamic ones – like in Egypt, Jordan and the UAE - and hugely widespread in Gaza. By adding 700 euros to the basic treatment, success is almost guaranteed.
Besides medical and cultural reasons, behind IVF's popularity there are political interests, too. “Until 2004, the year of his death, [late leader Yasser] Arafat funded many IVF treatments without but favouring a clinic over another,” explains Doctor al Helou regretfully. “People believed he paid from his own pockets.”
Between 2006 and 2013, Hamas' government, which back then could rely on a much more solid financial bases than the current one, used to grant disadvantaged families between 440 and 880 euros ($490 and $980) to cover part of their IVF treatment. “After I insisted for a while, they allocated us a dozen cases but the largest share was handed over to clinics that had a good relationship with them, like al Basma,” says al Helou. Today Hamas supports its state employees who suffer from infertility and whose salary has been halved for more than a year, detracting the money they owe them from the overall IVF costs.
When the first operation failed, Omar sought some new solutions, until he came across an advert that promoted the free IVF treatments offered by the Palestinian Centre for the Human Perseverance (Fata). “I knew who was behind Fata, but I was assured it only had humanitarian purposes,” claims Omar, referring to the rumours that surround the foundation of Jalila Dahlan, the wife of ex-Fatah leader Mohammed Dahlan, who was expelled from his own party due to rivalries with Abu Mazen, and now head up the Reformist Democratic Current party. While Fata can't operate in the West Bank, it has invested a billion dollars in charitable services in Gaza.
“Since 2015 the IVF has absorbed roughly 40 percent of our total funds,” Fata's CEO Wissan Jebroun says. “Behind all the incentives to have more children, there is always a political agenda,” argues the spokesperson of the Ministry of Health al Rintissi. “Political parties want popular consent and the only way they can get it is by giving people what they desire the most.” In short, it's an opportunity to have more and more children.