Every month, Marta Royo visits health care clinics and mobile health brigades across Colombia. There, Profamilia, a nonprofit Royo runs, provides checkups, vaccinations, contraceptives, and family planning services, including abortion, to some of the country’s poorest residents.
In May, Royo helped a mobile brigade in a community on Colombia’s northern coast where people live in tin houses without running water. Royo met undernourished children with measles and other ailments, people suffering from lung disease, and mothers of three to four children who were in need of contraception.
“It is heartbreaking,” Royo said. But she also feels “rage,” she said—at a U.S. policy that forced Profamilia to shut down four clinics providing health care to 60,000 people.
Profamilia lost U.S. funds it used to run its clinics after the Trump administration brought back and expanded a Ronald Reagan-era policy—formally known as the Mexico City policy, but often called the “global gag rule” by critics—that prohibits U.S. health-related aid to foreign non-governmental organizations that perform or promote abortion. The rule has such far-reaching impacts that, beyond limiting abortion access, it has also decreased access to contraception and treatment for illnesses such as HIV and tuberculosis, as organizations that have lost funding roll back or close services.
Scrambling, Profamilia tried to replace the closed clinics with mobile teams—called mobile health brigades—that set up pop-up clinics in communities for two to three days at a time for “the most basic, basic needs,” explained Royo. But it was a poor substitute: The clinics had offered extensive services, including free counseling for adolescents, and educational workshops about sexual health and reproductive rights. Teens in these communities, where teen pregnancy rates are as high as 49 percent, desperately need this information, Royo said. Otherwise, unintended pregnancies and unsafe abortions could rise.
Globally, the Trump administration’s policy is contributing to a backlash against women’s and girl’s rights, according to women’s rights advocates, including Royo, and political leaders from around the world who attended Women Deliver, the world’s largest conference on gender equality, in Vancouver in early June.
“We’re seeing a pushback against women’s rights, whether it is attacks on a woman’s fundamental right to choose or violence against indigenous women and girls,” said Canadian Prime Minister Justin Trudeau at a press conference at Women Deliver, where he pledged $525 million annually for global sexual and reproductive health rights, including abortion.
George Ingram, a senior fellow at the Brookings Institution in Washington, D.C., and a former U.S. Agency for International Development official, called the Trump policy “absolutely counterproductive.” “It is preventing the U.S. from working with very important organizations and providing them support,” he said.
Beyond that, the policy is killing women, according to the “Crisis in Care” report released on June 5 by the International Women’s Health Coalition (IWHC), which conducted more than 170 interviews with people affected by the policy in Kenya, Nepal, South Africa, and Nigeria. The report concluded that the gag rule has led to a rise in unwanted pregnancies and unsafe abortions by cutting funding to organizations that provide sexual health services, including contraception and sexual education, and reducing access to safe abortions. Instead, women and girls risk serious injury and death by seeking “back alley” abortions from “quacks.”
In addition, there is so much confusion and fear around the policy that, even if it permits abortion in cases of rape, incest or when a woman’s life is at risk, many organizations “over-implement” and fail to provide abortion referrals at all, including to victims of sexual violence, the report said. The rule also has a “chilling effect” on advocacy for reproductive rights and damages partnerships in the health care sector because “gagged” organizations fear losing funding if they are linked to ones that don’t conform to the policy, the report said.
One example: In Kenya, an organization that provides HIV services to more than 10,000 sex workers and young women took U.S. funding so it wouldn’t have to shut down. Now, it has stopped providing information about or referrals for abortion, according to the report. Consequently, two clients died trying to “self-procure an abortion,” the organization’s director told IWHC. One used a knitting needle.
Such unsafe abortions are widespread in Kenya, where they kill seven women every day and account for 25 percent of maternal deaths, according to the African Population and Health Research Center. But the policy has worsened the situation, said Jedidah Maina, the executive director of the Trust for Indigenous Culture and Health, an NGO that helped IWHC document the impact of the rule in Kenya.
The Trust for Indigenous Culture and Health runs a toll-free hotline that provides Kenyan women and girls with counseling for sexual and reproductive health. They aim to refer poor women from rural areas and slums to free or subsidized health services. But some of their partners have lost U.S. funding and no longer provide free services. Others shut clinics, leaving entire districts without reproductive health services, Maina said.
Now, some women must choose between putting food on the table and getting a safe abortion, which costs 15 to 20 percent of a typical poor family’s monthly income, Maina said. Many turn to back-alley providers who provoke miscarriage by inserting plastic tubes like drinking straws into the uterus to perforate the amniotic sack. When such abortions go badly, women risk sepsis and death, Maina explained.
A spokesperson for USAID said in an email that the majority of its partners continue to work with the U.S. government in spite of the rule. “As the world’s largest bilateral donor to global health programs, the United States remains committed to helping women and their children thrive,” the email said.
Trump’s anti-abortion policy hails back to 1984, when the Reagan administration prohibited foreign non-governmental organizations from using U.S. family planning aid to perform or promote abortion. Democratic presidents since then have repealed the rule, while Republican presidents have reinstated it.
Trump reinstated the rule within days of taking office in January 2017, but with a critical difference: In May 2017, his administration expanded the policy to apply to global health aid to foreign NGOs (the policy doesn’t apply to American organizations because it would violate their First Amendment rights).
So Trump’s policy—formally called “Protecting Life in Global Health Assistance”—applies to an estimated $8.8 billion in U.S. global health assistance, rather than the roughly $600 million annually earmarked for family planning. Then, in March 2019, the Trump administration announced US health aid recipients cannot give money for any purpose to foreign NGOs that promotes abortion, even if the funds are from a different donor and designated for something other than health.
Organizations that have lost U.S. funding have also been forced to reduce or shutter services providing contraception and information about sexual and reproductive health. For example, Kenya’s Reproductive Health Network, a group of health care providers committed to sexual and reproductive health rights, lost all its funding when it refused to comply with the rule. The organization scraped together alternate funding but now reaches 15,000 fewer people with its services, said executive director Nelly Munyasia.
“At times, I’m unable to sleep,” says Munyasia, who is also a nurse. She is particularly worried about adolescent pregnancies in rural Kenya, where girls as young as 9 have babies. At a community forum in rural Kenya two months ago, Munyasia met a pregnant 11-year-old who already had one child. Such girls become pregnant because of a combination of misinformation (or lack of information) about sex, a lack of access to contraception, and crushing poverty, Munyasia explained. For example, girls who are desperate for sanitary pads, but who lack money to buy them, may resort to having sex in exchange for money.
In other cases, the rule has made health care less accessible by cutting assistance to organizations that provide a range of services, including HIV/AIDS testing and treatment, cancer screenings, and treatment for malaria, according to the IWHC report. Such negative impacts even extend to countries with unrestrictive abortion laws, such as Nepal, which was forced to close clinics in 11 remote distracts. The report also said that a national sexuality education curriculum under development in South Africa won’t include any references to abortion because of the gag rule, even though abortion is legal there. The gag rule doesn’t apply to foreign governments, but NGOs helping develop the curriculum receive US aid.
Back in Colombia, demand for Profamilia’s services has intensified as millions of Venezuelan migrants have streamed across the border with Colombia. In addition to providing them with basic health care, Profamilia is responding to rising sexual violence linked to sex trafficking around the border. Last year, it provided more than 272 abortions to Venezuelan women, the majority of whom had been raped or experienced sexual violence.
“Despite Trump, despite bureaucracy, despite so many crazy things that happen all around us, it’s my motivation to be there,” Royo said. “I always tell my team: ‘You feel overwhelmed because there are so many needs and so many people, but the one life that you help, that already means the world to that person.’”
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