Thursday, September 13, 2018

Trump's expansion of Global Gag Rule sows chaos in global health

One of Donald Trump’s first acts as U.S. president was the re-imposition of the Global Gag Rule (GGR), also called the Mexico City Policy, a policy that denies healthy options to women and girls, not just safe abortion and contraception but potentially all areas of global health. 

Trump changed its name to “Protecting Life in Global Health Assistance,” but most global health advocates call it the Global Gag Rule because it silences health providers from providing comprehensive reproductive health options to women and girls.

The global gag rule is a failed, outdated and deadly policy,” writes Serra Sippel, the president of the Center for Health and Gender Equity (CHANGE), in the comprehensive new report Prescribing Chaos in Global Health: The Global Gag Rule from 1984 to 2018.

“Throughout this report, CHANGE seeks to document the breadth of the GGR’s impacts on civil society and health systems. For example, CHANGE provides evidence that the GGR under President George W. Bush had consequences outside family planning programs, and that it adversely impacted a wider range of health services provided by foreign NGOs. Some of these impacts were mitigated when President Barack Obama rescinded the policy, but the harmful effects have been shown to linger, particularly as each iteration has become more oppressive, culminating now with the Trump GGR.” 

The policy is having exactly the effect the Trump Administration intended it to have – women are losing health services, programs are being down-sized or closed and advocacy work disrupted. Because of poor communication and miscommunication coming from the U.S. government and prime partners, the CHANGE report says, many organizations are over-interpreting the policy, and going further than they really need to go, out of fear of losing funding and alienating an important donor (the U.S. government).

The GGR requires that foreign NGOs (including both foreign nonprofit and for-profit organizations) cannot receive U.S. foreign assistance for family planning if they perform or actively promote abortion as a method of family planning, even if they pay for such activities with their own, non-U.S. funds.

Abortion rates are similar in countries where it is mostly legal and where it is highly restrictive – 37 abortions take place for every 1,000 women in the most restrictive countries and 34 where it is least restrictive, according to a report by the Guttmacher Institute. The report says: “Highly restrictive laws do not eliminate the practice of abortion, but make those that do occur more likely to be unsafe.”

Since its advent in 1984, GGR has applied only to international family planning assistance – until Donald Trump became president. On May 15, 2017, the policy was expanded to include virtually all global health areas, including global health security, health system strengthening, HIV/AIDS, malaria, non-communicable disease, nutrition, tuberculosis and water, sanitation and hygiene. The expanded GGR applies to $8.8 billion in global health funding, according to the CHANGE report.

The report gives examples of the impact of Trump’s GGR. One of them is from Zimbabwe where the DREAMS Partnership has reduced new HIV infections in young women by 25-40 percent in 41 districts in 10 African countries since 2015.

Southern African HIV and AIDS Information Dissemination Service (SAfAIDS) is a regional NGO that promotes effective responses to reproductive health, tuberculosis and HIV. Before Trump reinstated the GGR, nearly half of SAfAIDS’ budget was from USAID and most of that went to support DREAMS. 

One of SAfAIDS’ sub-grantees —Roots (Real Open Opportunities for Transformation Support) — had a five-year agreement with SAfAIDS that made up 60 percent of their budget. Both SAfAIDS and Roots decided they could not comply with the Trump GGR. Roots’ funding was being used for interventions that were focused on keeping girls in school or getting them back in school, in rural, agricultural, mining towns, where adolescent girls and young women are particularly vulnerable to HIV infection. 

The initiative included education and providing safe spaces, as well as training in income-generating activities such as manufacturing detergent and floor polish. They anticipated undertaking some agricultural projects. These activities stopped in October 2017 because of the GGR. 
One DREAMS beneficiary supported by Roots said:

“Roots used to come to our rural communities and give us information … Some of us were sex workers only because we come from poverty – we had no money … when DREAMS came, it [helped] us do projects so that we could become empowered. Now all of that has stopped. Girls were benefitting from savings club, but now that has stopped – they don’t have money anymore. We were anticipating starting agricultural projects but DREAMS stopped, so that isn’t going to happen.”

Another DREAMS beneficiary said that without these savings clubs, they face barriers to earning money. “You hear a young girl saying, ‘For me to buy one [menstrual] pad, I need to sleep with two men.’” 

The Trump GGR does have some exceptions in the case of rape, incest and if the woman’s life is in danger. It also has some other exceptions that are not well known. 

One of them is referred to as “passive referrals” for abortion in countries where abortion is legal for reasons broader than rape, incest and life endangerment. If these four criteria are met, a health provider may tell a woman where she can get an abortion: 1) The woman is pregnant; 2) she must state that she has already decided to have a legal abortion; 3) she must ask where a safe and legal abortion can be obtained; and 4) the provider must believe that the ethics of the medical profession require this information to be disclosed.

CHANGE makes several recommendations to the Trump Administration for improving the current abysmal communication on the GGR. But its main recommendation is to Congress: Use legislative action to end “the most extreme and sweeping iteration of a policy that has fomented confusion, fear and harm for NGOs and health care providers around the world since 1984 and over six U.S. presidential administrations.

The U.S. State Department did conduct a six-month review of the Protecting Life in Global Health Assistance but found that, with less than six months of implementation, it was “too early to assess the full range of benefits and challenges” of the policy. It called for a further review of the policy by December 15, 2018, “when more extensive experience will enable a more thorough examination of the benefits and challenges.”

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