Pink Permits and Reproductive Products: Transnational Fertility Migrants and the Invisible Impacts of COVID-19

A few years ago, I found myself accompanying a fertility migrant through the Tlokweng border between Botswana to South Africa. A Tswana woman called Sethunya was going to meet a woman she met on Twitter to barter over some sperm and eggs. Sethunya and her boyfriend had been trying to conceive for some time and had been told both by an OB/Gyn and by a traditional healer in Sethunya’s home village that there seemed to be some problems with them “falling pregnant.” Botswana is a stable, democratic, and wealthy nation, and while there are excellent health care systems and access throughout the country, assisted reproductive technologies (ARTs) and services remain largely non-existent.

Whereas reproductive options such as in vitro fertilization, intracytoplasmic sperm injection, gamete intrafallopian transfer, intrauterine insemination, egg donation, mail order sperm and snowflake babies are ubiquitous in contemporary North American and European reproductive life (for those who can afford it, of course), the same is not true for women like Sethunya.  Caught between cultural imperatives of reproduction (for both men and women) and more contemporary access to ARTs, many Tswana women have become fertility migrants, and hashtags such as #madiamasweu#foryou,  #madimae and #Polokwane#pulaonly#donoreggs (hashtags that translate as “sperm for you”, “cash for eggs”, and a border village where donor eggs can be purchased for pula, the local currency) are the most visible online markers of an often private struggle.  

Botswana and southern Africa account for over 75% of all tweets across the continent. Tracking Twitter transactions concerned with ARTs is illuminating and represents a new way to think about how migration and fertility intersect. In Botswana, fertility migrants increasingly rely on Twitter for informal connections and information about ARTs and access to actual resources that are either limited or nonexistent.  This reliance on social media forces a new kind of transnational migration in search of full personhood, citizenship (which allows access to health care resources, for example, all BaTswana have access to free HIV/AIDS anti-viral medications) and gendered identity. While @EggDonor and @Fertile_med are as resonant along the transnational borders in southern Africa as they are in Western contexts, the tweets in SeTswana indicate larger structural inequities in access, gendered obligations, and the agency that social media can provide to those whose reproductive abilities are challenged and who risk being rendered invisible by infertility. It is clear that Ong’s concept of “flexible citizenship” remains salient. People are more than mere products, or the sperm or eggs they seek. And as Rockefeller more recently states, digital diasporas and transnational fertility migrants help complicate the idea of “culture carriers and products” by interlacing (not replacing) technologies such as Twitter and ARTs with migration and gender expectations. It is not simply that people travel to get sperm, eggs or embryos. These movements are about defining identity, gender and personhood. Yet movement and migrations in the era of COVID-19 are also complex and fraught.

In late 2015, building on my own prior research on infertility and HIV/AIDS in the region, I connected with a group of transnational fertility migrants who use low-tech online tools and entrepreneurial energies to acquire and share fertility products not available to them in Botswana, in part this is due to costs of treatments but arguably also a result of assumptions that only women are infertile. Bodily products, too, are always subject to potential witchcraft. In fact, the University of Botswana medical school encountered problems when trying to teach Gross Anatomy. Few Tswana felt comfortable with organ or cadaver donation, and thus the school had no “human” resources to teach with.  Legally, there are also some challenges to the use of fertility technologies. The Public Health Act, re-envisioned as I was starting this work, addresses the use of gametes and tissues of the living for use by another. Nevertheless, outside the public debates and facilitated through apps such as MedAfrica and Twitter hashtags, women avail themselves of biomedical interventions to address infertility by traveling daily across the border to South Africa.

With the advent of COVID-19, these migrations and women’s informal and mostly invisible strategies for achieving reproductive health and successful fertility outcomes have come to a screeching and much-surveilled halt. Control over female bodies has become all the more heightened as border crossings, once relatively unchallenged from Botswana to South Africa, are now limited to “essential” travel only.  

Botswana has been on nationwide lockdown since March. Commercial flights were suspended; permits (known as “pink permits”) became required for travel to and from work, shops, and essential business countrywide, and people have complied. A country of approximately two million people, Botswana has had just one coronavirus related fatality. Prevention was key from the outset, and while those in more rural areas feared the worst should the virus take hold, there were lessons to draw upon as people considered what the greatest risks to the public’s health might be. As one of my colleagues in my main field site of Maun pointed out, “We learned this lesson with AIDS, you remember, people knew what was happening but we could not stop it, viruses are social…if the virus comes to the village…it will not leave.”

As in many parts of the world, the pandemic’s rapidly shifting dynamics have given rise to numerous public health messages. Recently, the messages have become more contradictory. When a truck driver tested positive for COVID-19 after entering Botswana through the Tlokweng border near the city of Gaborone (the same one that Sethunya and I cross), government officials declared it a “high-risk area,” and all the “pink permits” were revoked in the capital zone. Dr. Kereseng Masupu, the coordinator of the COVID-19 task force in Botswana gave a press conference on BTV (Botswana television) on May 24th of 2020 and reported that an additional five individuals who were transiting through the country had tested positive. While Dr. Masupu reported on the upcoming phased reopening of the country, social media comments made it clear that the public was more concerned about individuals who were “moving” about and could cause potential harm. As Sethunya said as we watched the update together virtually, “We [fertility migrants] are going to be criminals, people are sympathetic when you are childless but there have always been strategies [for successful outcomes], now we are trapped, we will be criminals because of culture and infertility must stay invisible.” And none of this is possible now during COVID-19 and the revocation of pink permits, never mind the promise of elusive reproductive commodities. Women for whom reproduction is essential, and who have been planning in order to achieve successful reproductive outcomes, are now caught between competing cultural messages about what is “healthy” – bearing children or protecting the public’s health.

Given that to be considered a reproductive, productive, or “full” person in Botswana one must be seen as a fertile person, the emergence of a new digitally-driven diaspora and transnational migration by women is hardly surprising. The surveillance of bodies and reproductive products creates an interesting hierarchy and raises important questions. Who is willing to go to what lengths to achieve fertility? How? What sacrifices are women willing to make to be viewed as valuable? How are these sacrifices reconfiguring the meaning of migration and the availability of technology? Moreover, there are profound losses to contend with, given the pandemic’s uncertain trajectory, with fertility treatments and plans having been put on hold around the globe. Sethunya and others remain hopeful that “pink permits” will soon be extended to include travel for reproductive reasons, yet they remain anxious, wondering when access to fertility markets and resources will open, placing them literally and figuratively in liminal spaces. 

Surveillance over one’s health and bodies continues in new and powerful ways as a result of the COVID-19 pandemic. In Botswana, alcohol and cigarette sales remain prohibited. As Sethunya told me on our last WhatsApp conversation, “It’s not the same but motherhood also feels that way, prohibited, out of reach.” As I write elsewhere, Tswana women have long been subject to scrutiny of their fertility status. Today, would-be fertility migrants are now caught between competing contemporary cultural narratives over what it means to be “healthy”, as their fertility strategies fall outside of official health systems and they must remain inside COVID-19 mandated borders. 

Rebecca L. Upton is Professor of Sociology & Anthropology at DePauw University, and co-Founder/co-Director of the Global Health program. She received her Ph.D. in medical anthropology from Brown University and her M.P.H. degree from the Rollins School of Public Health at Emory University, where she is an affiliated faculty member. She researches the intersections between reproductive health, gender, migration, and HIV/AIDS in southern Africa.