Foreign aid, abortion, and a new reminder of the Trump administration’s cruelty

It was one of the first things Donald Trump did when he got into power. Within days of entering office in January 2017, the US President reinstated the “global gag rule,” stripping US government funding from foreign NGOs involved in any aspect of abortion work worldwide.

Two and a half years on, new research has confirmed just how harmful this rule really is. As the evidence continues to mount, so does the damage inflicted on vulnerable groups.

Also known as the Mexico City Policy, the global gag rule has been repeatedly repealed and reinstated by a cycle of Democratic and Republican presidents since 1984. It does not apply to US-based organisations, whose free speech is protected by the US constitution. But foreign NGOs are not afforded the same rights.

Trump embarked on an unprecedented expansion of the policy to see it cover more than $8bn worth of US global health assistance—a move far more dramatic than any of his Republican predecessors, who had limited it to affecting some hundreds of millions of dollars’ worth of foreign aid. He renamed it the “Protecting Life in Global Health Assistance” policy.

The gag rule is not about foreign aid directly funding abortions—that has been prohibited since 1973. What the rule means is that foreign NGOs receiving US funding for other health care services cannot also fund abortion work using other means—for example, money raised from public donations or from other governments. It also prevents NGOs from offering information or legal advice about abortion to patients, even if it is legal in the country where they work.

That might sound complicated. But in summary, it has come to be known as the gag rule among opponents because it prohibits foreign NGOs, their health professionals and outreach workers from so much as mentioning abortion as an option. In January 2017, those NGOs receiving US funding faced a choice: comply with the rule by refraining from the offending activities, or forfeit the money.

As the world's largest economy, the US is also by far the biggest provider of global health assistance, working with NGOs, governments and multilateral institutions around the world to help control threats such as HIV, malaria and maternal mortality. As a result, the impact of such a restrictive policy on NGOs and the health systems that rely on them has been severe.

Sexual health services and clinics have been shut down, as well as health services more broadly. Because many of the NGOs affected work across a range of issues, it has limited access not only to abortion care but also to contraceptive, maternal health, HIV/AIDS, cancer and gender-based violence services. Advocates estimate it will lead to tens of thousands of unnecessary deaths over the course of Trump's presidency.

Governments that themselves allow abortion have lost the partners they contracted to provide those services, as a US policy has dictated what they can and can't do with their own money. It increases the risk of women seeking out unsafe, backroom abortions as they lose access to medically-supervised ones.

But not only does the global gag rule damage health services in lower-income countries—if its goal is to reduce the number of abortions worldwide, it is also counterproductive. Last month, a study by Stanford University researchers published in the Lancet found that the policy was associated with a significant increase in abortions in the countries most affected by it. The authors said they believe that is because it limits access to contraception and related family planning services.

And it's no surprise. Earlier research published by the World Health Organisation back in 2011, as well as a 2011 study in Ghana, and more research published in a book on the policy in January, all reached the same conclusion. A 2017 op-ed in the New England Journal of Medicine described it as “a stark example of 'evidence-free' policymaking that ignores the best scientific data.” Which raises the question of whether the goal is really to prevent abortions at all, or simply to appeal to a conservative voter base.

The existing studies have only been able to examine the impact of earlier iterations of the gag rule—data that would allow a full analysis of the current version is not yet available. Two and a half years on, the full impacts of the policy are still revealing themselves, as contracts expire without being renewed, surveys are conducted and figures gathered. But as a far more exhaustive take on its predecessors, there can be little doubt the numbers of abortions, and deaths, associated with the policy will be higher, too.