In a continuous effort to misrepresent the impact of a disastrous policy, the Trump administration recently issued its premature 6-month review of the Global Gag Rule. The policy forbids any nongovernmental organization receiving US global health funds from providing legal abortion services, information, or referrals, even with their own, non-US funding.
The Trump administration used its review to suggest that the Gag Rule is having only minimal impacts and not causing a disruption of health services. Evidence gathered by the International Women’s Health Coalition (IWHC) over several months with local partners in Kenya, Nigeria, and South Africa, suggests otherwise.
In addition to the funding restrictions, Trump’s Global Gag also bans nongovernmental organizations (NGOs) from engaging in advocacy to expand abortion access within their own country. While similar policies have been put in place by every Republican president since Ronald Reagan, Trump’s extended version affects almost $9 billion in funding covering a vast array of programs, including HIV/AIDS, malaria, tuberculosis, water, sanitation, and maternal and child health, in addition to family planning and reproductive health.
Signing the Global Gag Rule was one of Trump’s very first actions in January 2017, and affected agencies began rolling out implementation of the deadly policy in mid-May 2017. Despite its purported goal of curbing abortion, the Gag Rule has historically resulted in an increase in unintended pregnancies, abortions, and maternal deaths in sub-Saharan African countries.
The 6-month review by the US Department of State presents findings through the end of September 2017, less than 6 months after the huge expansion of this policy. While the review acknowledges that the full effects of this policy may not yet be visible, its narrow scope fails to capture some of the harmful early effects that IWHC and our partners have documented.
IWHC’s findings, grounded in our partners’ local context and knowledge, notably differ from those presented by the State Department. The evidence presented here comes primarily from interviews conducted with civil society organizations, health service providers, and government agencies in the three project countries.
Misinformation and Confusion
The State Department review highlights “extensive outreach to and training for” staff at the US Agency for International Development (USAID) and presents numbers of people trained at affected agencies, including international and local NGOs. However, it fails to disclose what these numbers represent as a proportion of all who should be trained, or how successful the trainings have been at educating people about the policy.
Interviews conducted by IWHC and our partners have found that knowledge about Trump’s Global Gag Rule has yet to reach many organizations that will be newly affected due to the expansion. In South Africa, IWHC interviewed a director at an organization with several projects exposed to the Gag Rule, who was surprised to learn that the policy extends to HIV/AIDS funding. She said simply, “I’m a person who should know, [and] I don’t know.”
Misunderstanding is not isolated to NGOs. In fact, an IWHC grantee partner (not involved in this documentation project) received incorrect information directly from their USAID country office, stating that “the provision prohibits any institution receiving funds from the US government from providing or promoting methods of family planning.” Beyond these examples, we have documented instances of misunderstanding and fear that the State Department review does not capture.
A Chilling Effect on Civil Society
Our research consistently found that the harmful effects of the Global Gag Rule persist beyond its implementation period. In Nigeria, Kenya, and South Africa, some interviewees thought the Gag Rule was a permanent US policy with varying degrees of emphasis and enforcement. Others described how the back-and-forth nature of the policy leads to over-implementation, both knowingly and unknowingly. They gave several reasons why organizations act as if the policy were always in place.
Firstly, due to a lack of knowledge, organizations may think they must adhere to the policy, regardless of its implementation status. Secondly, some organizations will not engage in abortion-related activities—even when the policy is not in place—out of fear that doing so would jeopardize their ability to receive US funding once the policy is inevitably reinstated. Lastly, the constant changing programmatic activities with each reinstatement of the Gag Rule can prove burdensome, and some organizations will operate as if it is always in place so as not to waste time and money adapting to US political fluctuations.
Interviewees provided other examples of organizations over-interpreting the scope of the Gag Rule by discontinuing services permitted under the policy, such as family planning and referrals for abortion services in cases of rape, incest, or a life-endangering pregnancy. Other organizations preemptively stopped abortion-related activities as soon as Trump was elected.
Threatening Access to Health Care
The State Department review foresees minimal disruptions in services, arguing that only 4 out of 733 prime partners declined to sign the Gag Rule agreement. The review omits any information about the volume of funding, or the services and countries affected. The report also mentions that USAID is minimizing service disruption and working to transition the activities of organizations that declined to sign the Global Gag Rule to other groups. It does not discuss whether organizations equipped to meet this service gap actually exist.
The small, grassroots, and community-led organizations often best placed to address local health needs are likely to be sub-recipients of US government funding and will be more deeply affected than larger organizations. The State Department review fails to address ways the policy affects these organizations, which are end providers of service, mostly in direly underserved communities.
Across all three countries, interviewees emphasized the threat to the health of women and girls, especially marginalized populations, as organizations are forced to cut outreach programs and subsidized services. The policy forces organizations to choose between offering their patients information, referrals, or care for abortion—an essential reproductive health service—or losing funding for other essential services.
One Kenyan organization told IWHC that the Global Gag Rule “is limiting provision of services for family planning and HIV clients. It has impacted how we service the community, so currently we are not doing outreach; our clients have to come in physically at a cost to themselves.” In South Africa, interviewees emphasized that already marginalized populations (including people who are poor, black, living with HIV, in rural areas, or sex workers) would be most affected by the increasing barriers to services caused by this policy.
IWHC uncovered other ways that the policy could reduce access to services. In South Africa, where advertisements for unsafe clandestine abortion services remain prevalent, interviewees fear that the Gag Rule will reduce or eliminate information, counseling, and referrals relating to safe abortion, resulting in an increase in unsafe abortion levels. Voicing similar concerns, a service provider from Nigeria commented that the Gag Rule “does directly the opposite of what it is intended to do. It denies lifesaving services to a lot of women. It ends up being really anti-life.” Findings from studies documenting the negative health implications of previous versions of the policy substantiate these concerns.
Now that the Trump administration has expanded the Global Gag Rule to include HIV/AIDS, maternal and child health, and other global health funding, the scope of the harm will be even larger. In South Africa in particular, our research highlighted fears that this policy will set back recent progress toward integration of HIV services with other healthcare, undoing years of investment and undermining the efficiency of the health system.
Anger and Pushback
The review presents the policy as having wide acceptance based on the number of times that prime partners declined to sign agreements that included the Global Gag Rule language. This claim is disingenuous.
IWHC and our partners have documented outrage about what some called a “barbaric” and “neocolonial” policy. In South Africa, they reminded us that their national sovereignty includes the “right to have access to health care services, including reproductive care” in their constitution. In Nigeria, the injustice of a US policy that denies services to women in other countries was emphasized by a family planning advocate who said, “It is not American women dying, it is Nigerian women that are dying.”
The 6-month review was not only premature, it also failed to make any meaningful attempt to capture the full implications of the policy. While IWHC welcomes the Trump administration’s announcement of an additional review by December 2018, future reviews should address shortcomings of the report, namely the lack of meaningful stakeholder engagement, minimal opportunities for feedback from civil society, and lack of consultation with directly affected populations in the Global South.
Meanwhile, in 2018, IWHC will continue to work with our partners to contribute to the growing body of knowledge documenting the effects of this policy, and highlight the voices and lived experiences of those who are most affected, without which any assessment falls short.