“When are you coming back? Why have you left? Why aren’t you coming to our community?” These are the questions that women and girls in Mozambique, Zimbabwe, and other developing countries ask in desperate phone calls to their health-care providers after a local health clinic shuts down. The women are at a loss to understand why these clinics, often the only facility accessible to them in small towns and remote rural villages, have suddenly stopped providing much-needed services.
The reason for these life-endangering cutbacks? President Trump’s resurrection of the global gag rule. The expanded rule has been in effect for a little over a year, and several international health organizations have detailed how the anti-abortion policy, originally dreamed up by the Reagan administration in 1984, has led to major losses in health services, especially for hard-to-reach and vulnerable populations across the globe.
The Reagan-era version prohibited international non-governmental organizations (NGOs) that receive certain kinds of U.S. foreign assistance funds from providing, counseling, or making referrals for abortion services. But Trump’s “Protecting Life in Global Health Assistance” (PLGHA) memorandum went further, targeting all global health assistance funds that an organization controls. An international NGO is prohibited from even using its own funds to “perform or actively promote abortion as a method of family planning” if it wants to continue to receive U.S. aid.
The Trump policy affects all global health assistance, including services related to family planning and reproductive health, maternal and child health, water, sanitation and hygiene, nutrition, HIV and AIDS prevention, and infectious diseases. Exceptions to the gag rule can only be applied in instances of rape, incest, or pregnancies that endanger the life of the woman.
And, last year, Trump cut all U.S. funding to the United Nations Population Fund (UNPF), claiming that it “supports, or participates in the management of, a program of coercive abortion or involuntary sterilization.” According to its website, UNPF has never promoted abortion as a form of family planning; however, it is the world’s largest provider of contraceptives.
The Trump administration has forced international health organizations to make a choice: Either they accept U.S. aid and limit their services, or they refuse to comply and likely have to cut back on programs or find alternative sources of funding. Some international NGOs have chosen the latter option, including the International Planned Parenthood Foundation (IPPF) and Marie Stopes International (MSI), which will lead to funding gaps of $100 million and $80 million, respectively. For providers deciding to forgo U.S. aid, this means being forced to shut down their clinics’ doors.
As many organizations grapple with funding cuts and lost services, others are actively tracking and documenting the impacts of the policy for health-care providers and their recipients. They intend to demonstrate how the global gag rule exacerbates global poverty and reverses progress toward combating maternal mortality, sexually transmitted diseases, unsafe abortions, and numerous other inequalities. Their goal is to illuminate the extensive damage that this shortsighted, ideologically driven policy will have on women and girls in the developing world.
The United States is the largest global health donor in the world, with a budget of about $8.8 billion in foreign assistance. The expanded gag rule is projected to impact about $2.2 billion of that funding. Supporters of the gag rule believe that the United States should not furnish assistance to organizations that provide abortion services. However, the global gag rule has historically been associated with an increase in abortion rates, and many of those procedures are in unsafe conditions because safe services have halted.
In February, the State Department released a six-month review of the gag rule, stating that NGO compliance with the policy was running smoothly. The report stated that of its 733 funding awards, only four “prime partners” (organizations that receive aid directly from the U.S. government) and 12 “sub-prime” partners (groups that receive U.S. funding from their prime partner) lost funding.
Only a single group, the U.S. Conference of Catholic Bishops, praised the policy. The group lauded it as “one of the most significant policy initiatives on abortion ever taken by the United States in an area of foreign assistance.” However, the report also determined that “six months is insufficient time to gauge the impacts of the [Protecting Life in Global Health Assistance] policy,” and that another follow-up review would be produced in December 2018.
Numerous organizations immediately criticized the review, saying it was misleading, incomplete, and failed to include pertinent funding information. IPPF claimed that the review did not quantify the long-term effects of the gag rule, and that IPPF member organizations had already been forced to shut down clinics, reduce staff, and cut back on critical supplies.
Serra Sippel, president of the Center for Health and Gender Equity (CHANGE), noted that bishops do not tend to be global health experts.
The only group mentioned in State Dpt review of the #GlobalGagRule is the US Catholic Bishops praising the administration's expansion of the policy across all global health. Since when are the bishops #globalhealth experts? https://t.co/ODoSCxL4gy #TrumpGlobalGag
— Serra Sippel (@SerraSippel) February 8, 2018
Bergen Cooper, Director of Policy Research at CHANGE, notes that one of the most critical issues for people on the ground is the loss of health-care services, particularly for women and girls. For the Mozambican Association for Family Development (known by its Portuguese acronym, AMODEFA), inability to comply with the gag rule meant that the group had to end many of its services, including HIV consultations for girls and young women. The national health organization, which works on HIV, tuberculosis, and malaria prevention and other health problems, stands to lose 60 percent of its budget because of Trump’s gag rule.
“When they got U.S. government funding, they were able to provide 6,800 HIV consultations to girls and young women during a three-month period,” Cooper says. “Once they lost U.S. funding … they were only able to reach 833. That’s a drastic difference.” According to UN AIDS data, Mozambique saw 83,000 new HIV infections in 2016 and 1.8 million citizens living with HIV. In 2017, approximately 2.1 million Mozambicans live with HIV.
The policy has also already had a chilling effect on providers on the ground, creating confusion about which programs are, in fact, affected by the gag rule. “Prime partners” must inform their “sub-prime partners,” who have no direct contact with U.S. officials, about the gag rule and any changes to the policy. But often, the intricacies of the policy get lost along the way.
“I sometimes describe the policy as a terrible game of telephone that comes from the U.S. government to the prime partner, to the sub-prime partner, and then of course to the folks implementing programs,” Cooper says.
Cooper adds that the Trump administration policy has also jeopardized the trust that health-care providers have built up with members of the communities they serve, including vulnerable groups like LGBTQ communities, sex workers, and people living with disabilities.
“Some of the organizations that have been working with sex workers and LGBT populations are the ones that have been there for so many years who have built the trust with the community,” Cooper says. “And another organization can’t suddenly come in and take over the program immediately.”
Other reproductive-rights organizations, such as Population Action International (PAI), MSI, and the International Women’s Health Coalition (IWHC), have released separate reports echoing one another’s findings: The global gag rule has led to major losses in services and diminished resources; it has created a chilling effect and confusion among providers; it has diminished resources even for NGOs complying with the policy; and it has long-lasting effects on societies, particularly for women and girls.
A May IWHC report also revealed another serious problem: the anger the policy has sparked among local health workers toward the United States. The gag rule is at odds with local laws in numerous countries where abortions are permitted. Health workers, particularly in African countries, found the policy to be an “imposition of U.S. political ideology, and a form of neoliberalism.” They also called it “racist,” “unfair,” and a “bullying tactic,” adding that their positive impressions of the United States would suffer, since the policy will lead to an increase in maternal mortality. An advocate from a sexual and reproductive health and rights organization in Nigeria told the IWHC, “It is not American women dying, it is Nigerian women that are dying.”
Many Americans do not support the global gag rule either. A recent bipartisan poll conducted by CHANGE and PAI, an advocacy group that works to improve global access to family planning and reproductive health services, found that 59 percent of likely American voters “oppose banning U.S. global health assistance to health care organizations in other countries that provide abortions or referrals to women even if they use their own funding.”
The poll also found that 77 percent of respondents agree that the United States has a moral obligation when it comes to the health of girls and women, and 66 percent strongly agree a view that transcends party identification, race, and abortion stance. A majority of respondents also see lack of access to medical care for women and girls globally as a serious problem.
Indeed, according to the Guttmacher Institute, investing in global health assistance, particularly family planning, “generates substantial health, economic and societal benefits for individuals, families and nations.” When women and girls have access to contraceptives, their capacity to make other choices—like pursuing higher education (which increases earning potential and savings), taking care of children, and participating in civic life—improves.
Despite Americans’ lack of support for the gag rule, proponents of the policy say they aim to prevent the use of taxpayers’ money for abortions. But a 1973 U.S. law known as the Helms Amendment already prevents supplying U.S. foreign assistance for abortion services. The Helms Amendment, which Congress passed in the wake of the Supreme Court’s landmark decision in Roe v. Wade legalizing abortion, is not unlike the gag rule, but there are some key differences. The gag rule hinges on eligibility and places the burden on clinics in developing countries to comply with American regulations in order to receive aid. The Helms Amendment is a funding prohibition for abortion-related services and casts a wider net of affected institutions, including U.S. NGOs, non-U.S. NGOs, multilateral organizations, and recipient country governments.
As previously reported in The American Prospect, Trump has also considered implementing a domestic version of the global gag rule that would prevent reproductive health organizations from discussing abortion as a family-planning option. This proposal would likely apply to providers that receive Title X funding, which helps low-income people access family-planning services like contraceptives and testing for sexually transmitted infections.
Less than 24 hours after Trump reinstated and expanded the gag rule, reproductive health advocacy groups and members of Congress came together to assemble a bill that would forever end the policy. “We knew it was coming,” says Jonathan Rucks, senior advocacy director of PAI, of the global gag rule. The proposed Global Health, Empowerment, and Rights (HER) Act would remove eligibility restrictions placed on international recipients of U.S. foreign assistance and give power back to health organizations to use their own funds to provide safe abortion.
Though the pending bill has bipartisan support, the final passage of the measure would rely on a titanic shift on Capitol Hill—Democratic majorities in both houses.
Despite the bill’s slowed momentum, Rucks cautions that there is still important work to be done now. “The more and more that we can work to elevate that number [of supporters] and have those Americans speak out will help underscore the need to permanently do away with this policy,” he says.
For decades, the United States has stood tall as a leader in providing global health assistance by promoting values of human rights through development. USAID’s stated mission is to “reduce poverty, strengthen democratic governance, and help people emerge from humanitarian crises and progress beyond assistance.” But as long as its funding is at the mercy of ideologically driven policies over evidence-based research, the United States will continue to fail in its commitment to combating global poverty and force millions of women and girls to face new perils.