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Women’s Health Isn’t a Geopolitical Game


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On Thursday, President Biden lifted theMexico City Policy, known more commonly to critics as the global gag rule, which denies U.S. aid to nongovernmental organizations if they advocate for, suggest or even mention the word abortion.

Mr. Biden’s move was not a surprise. Since the rule was established under Ronald Reagan in 1984, Republican presidents have sustained the policy, and their Democratic counterparts have repealed it. The gag rule does not simply project America’s culture battles onto the lives of women and families in far-flung communities across the world — though it very much does that — but also creates what Simon Cooke, the C.E.O. of the U.K.-based women’s health organization MSI Reproductive Choices, calls a “yo-yo” effect which badly strains global health care distribution.

To cut the yo-yo’s strings, Congress should take up legislation first introduced in 2017 by now-retired Representative Nita Lowey, Democrat of New York, and Senator Jeanne Shaheen, Democrat of New Hampshire. It’s called the Global Health, Empowerment and Rights Act (“HER,” in case you missed it). Senator Shaheen reintroduced it on Thursday. “The life and health of a mother on the other side of the world shouldn’t be at the whim of a President’s partisan politics,” she told me by email. Representatives Barbara Lee and Ami Bera, Democrats of California, and Jan Schakowsky, an Illinois Democrat, introduced the same bill in the House.

Women who want abortions, as NGO leaders I spoke to underscored, do not eschew them simply because they find them harder to reach — they go to providers who are unsafe, or underground. And, as Mr. Cooke emphasized, the gag rule also undermines the post-abortion care that can mean the difference for a woman dying of a back alley abortion and surviving one. Further, while disrupting abortion is its goal, the gag rule has had the effect of upending all health and family planning services.

The HER Act would codify the right before U.S. law of NGOs abroad to use their own funds to recommend and support abortion and post-abortion services. It also stymies future administrations who would condition U.S. aid on silence.

Meanwhile, the reprieve offered by Mr. Biden might last only one presidential term.

“That is the concern, as we approach the resumption of the relationship with USAID now,” Mr. Cooke said, “what happens in four years time, and to what extent do we embed ourselves in that again, because it is difficult for an organization like us to scale up and scale down so quickly.” Partisan application of health funding undermines credibility and breaks down local relationships that will take years to rebuild, Jonathan Rucks, senior director of policy and advocacy at PAI, the global health and reproductive rights organization told me. Regaining trust will take time, particularly after this latest version of the rule.

Donald Trump broadened the policy when he came into office in January 2017, relabeling it with the Atwoodian phrase “Protecting Life in Global Health Assistance.” While under the previous Republican administrations the policy was applied only to family and reproductive aid organizations, about $600 million in annual U.S. funding, Trump attempted to silence all health care organizations that received or hope to receive American aid — including those who working on everything from tuberculosis to HIV/AIDs — some $9 billion to $12 billion in annual U.S. funding. (Secretary of State Mike Pompeo announced yet another expansion of the policy in 2019.)

In January 2019, amfAR, the Foundation for AIDS Research, published a paper outlining how the expanded policy had, as a result, disrupted global H.I.V. prevention and management.

Under President Barack Obama, USAID money and American funding supported a move toward integrated health care. Integration meant women in rural areas and low-income communities could say, vaccinate their toddlers and newborns, learn about long-term contraception and be checked out for cervical and breast cancer all in one visit. This strategy makes intuitive sense both in reaching those for whom clinics are far, or those who can’t take time away from work; it allows for more comprehensive and holistic health care since it stretches dollars. But integration also made all those services far more vulnerable to disruption by the newly expanded policy. Mr. Trump’s rule created mass confusion among providers, required endless red tape and rewriting of materials, and sowed enormous fear of running afoul of rules regarding U.S. aid. It also simply shut down services.

Satyajit Pradhan, who has spent the last six years working for MSI in Nepal as its “Evidence to Action director,” spoke to me from Kathmandu. “Our inability to secure any USAID funding meant we were cut off from being able to provide essential health care, as we call it, for women across Nepal,” he said. “The chilling effect resulted in partners failing to refer women to MSI for abortion care, even in the case of rape or incest or if the life of the woman was at risk.” Further, he added, “No one wanted essentially anything to do with us. We were secluded … it was pretty hard.” MSI, he said, had to shutter nine clinics in Nepal alone.

Analyzing data collected by the International Women’s Health Coalition, two years into Trump’s gag rule, editorialists in The Lancet, the British medical journal wrote, “118 interviews with health service providers, civil society organisations, government agencies, and anti-abortion groups in Kenya, Nepal, Nigeria, and South Africa revealed that access to services for abortion and post-abortion care has been reduced, along with contraceptive services, antenatal care, H.I.V. testing and treatment, and screening for cervical, breast, and prostate cancer.”

In 2019, a retrospective analysis by researchers for the The Lancet Global Health journal looked at data collected from sub-Saharan African countries during the Clinton, Bush and Obama administrations. Years with the gag rule in place saw a 40 percent increase in abortion in the countries analyzed, a decrease in contraceptive use and a rise in pregnancies. In other words: the policy worked directly counter to its purported anti-abortion goals.

The irony of the gag rule is that no U.S. funding has supported abortion overseas since the passage of the 1973 Helms Amendment. The gag rule really is about speech.

President Biden’s reversal of the global gag rule is, in a way, “a short-term fix,” Nina Besser Doorley, associate director of Advocacy and Policy at the International Women’s Health Coalition, told me earlier this week ahead of the White House announcement. “What we have seen about this policy is that its impacts aren’t going to go away just because the policy is revoked. The threat of it being reimposed in a few years if the political winds in Washington change will continue to have impact.

“What we are looking for is a permanent legislative fix to this problem. And congressional legislation to prevent a future president from unilaterally reinstating the policy.”

In other words, repeal of the gag rule is only part of the answer. The best option is a law that puts the global gag rule out of reach of the capricious presidential pen.

Sarah Wildman is a staff editor in Opinion. She is the author of “Paper Love: Searching for the Girl My Grandfather Left Behind.”

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