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FEATURE | summer 2003

Global Gag Rules
The Bush administration's global gag rule on reproductive health is costing women's lives all over the globe.

they say the aim is to prevent abortions worldwide. But the impact of U.S. policy has produced something quite different in reality. Opportunistic, ideological and driven with a ferocity that is the hallmark of political extremism, a group of U.S. politicians are imposing health care standards on millions of women, rules that defy both common sense and fundamental notions of freedom. By silencing international family-planning providers, cutting off U.S. funds for the United Nations Fund for Population Activities (UNFPA) and hiring anti-choice ideologues to make women’s health decisions, these politicians have put lives at risk. The case is clear: Women have died as a result.

Dr. Solomon Orero winces at the thought.

That’s why he risks his distinguished career—and subjects himself to a possible 14-year prison term—in order to provide safe abortions in Kenya, where abortion is illegal. “When I was in medical school,” says the obgyn, “I saw so many women dying [from botched, unsafe abortions]. Some were my relatives, some were students, women in the prime of their lives. Occasionally they just died in my hands. I promised myself I would try to turn the tables.”

Dr. Orero, a man who radiates compassion, is a hero to many women in his country. Although women with means can obtain illegal hygienic abortions in this African nation, poor women rely on crude methods: They ingest dubious concoctions or allow anything from bicycle spokes to sticks to be inserted in their uterus. Orero has had to retrieve such things from his patients’ bodies. He’s had to reconstruct a woman’s abdomen, severely damaged by a botched abortion. And he’s had to create a permanent colostomy for an 18-year-old after her untrained abortionist mistook her anus for her vagina.

“When a woman has an unwanted pregnancy, she’ll go to any lengths [to end it],” he explains, with a mixture of anger and sadness. In Kenya, most women seeking abortions have already given birth to several children and simply can’t afford another. In fact, too many pregnancies too closely spaced threaten the health and survival of both mothers and children. Also, for unwed women, pregnancy is stigmatized— they get thrown out of school, thrown out of their homes. Not surprisingly, for women as well as men in the developing world and Eastern Europe, birth control is either unaffordable or in short supply. One can’t simply walk into a 7-11 and buy condoms. In addition, women don’t often have a voice in sexual matters.

“Women are dying because we don’t care enough for their lives,” insists Orero. Furthermore, when a poor woman dies in a country such as Kenya, the children she leaves behind without her care and financial support may die as well. Considering that the average birthrate in Kenya is nearly five children per woman, one mother’s death looms as a disproportionately large loss. Orero is particularly concerned these days because of the Bush administration’s escalating global war against reproductive rights. In his second day in office, the president fired the first salvo by reinstating the Mexico City Policy, more commonly known as the global gag rule.

Established during the Reagan administration, it prohibits non-governmental organizations (NGOs) that receive U.S. Agency for International Development (USAID) monies to even mention abortion to clients (with some exceptions)— even if the NGOs aren’t using U.S. funds for abortion services or advocacy. That’s one step beyond the 1973 Helms Amendment, which outlawed U.S. funding for abortions overseas. The gag rule prevents family-planning clinics from steering clients toward safe abortion providers. But not only that, it stifles advocacy of abortion law reform in countries where the procedure remains illegal. In other words, while the United States loudly celebrates “democratic ideals,” the First Amendment can’t get a passport to travel.

USAID has been the key supporter of foreign family-planning clinics for the past half-century, currently supplying $446 million annually. So most insidiously, the gag rule on USAID has a chilling effect not on just overseas abortion rights but on all women’s reproductive-health services. Sign the gag, lose your ability to provide integrated health care. Don’t sign the gag, lose your financial ability to do so. Besides, as the American College of Obstetricians and Gynecologists puts it, the restrictions “violate basic medical ethics by jeopardizing a health care provider’s ability to recommend appropriate medical care.”

making women suffer

During the Reagan and first Bush administrations, international family-planning providers learned creative ways around the gag rule. Among other strategies, doctors waited “downstream” for women to induce abortions, then would treat them. When Bill Clinton took office he immediately removed the gag, providing a more “comfortable” environment for women’s health services, according to Orero. “But now the rule is back with specific clauses,” he says. “It’s tougher.” Clinics that don’t sign the gag rule often have to cut staff severely or close their doors. After they refused to be gagged, the Family Planning Association of Kenya cut its outreach program in half, shut three clinics and raised fees at other clinics. Marie Stopes International (MSI), a British NGO that offers reproductive health services in 38 countries, had to cut 80 jobs in Kenya, close two clinics and scale back its rural outreach program.

“The gag rule has let Kenya down,” MSI’s Kenya Program Director Cyprian Awiti told the Fredericksburg, Va., Free Lance-Star: “The gag rule has made women suffer. The gag rule has made more women die, because they can’t access safe family planning.”

Of course, U.S. policies aren’t affecting just Kenya and sub-Saharan Africa. In Nepal, for example, several family planning clinics funded by UNFPA have closed, and the country’s Family Planning Association has laid off more than 80 staff members. Yet the renewal of the gag rule comes at a time when the country has liberalized its very restrictive abortion laws. Now if a pregnant woman’s life is at stake—a decision made by her doctor—she can legally get an abortion. That’s a far cry from the early 1990s when dozens of Nepalese women were imprisoned after having had abortions. In one case, a 14-year-old girl was given a 14-year jail term for abortion and infanticide after undergoing an abortion procedure at seven months and then delivering a stillborn. The reason for her desperate abortion attempt: She’d been raped by her stepbrother.

“The closure of these family-planning clinics means that more women’s lives are at risk,” says Nepalese-born Pradeepta Upadhyay, an activist for South Asian women’s health who championed the 14-year-old’s case (she served four years). “Even though the [legalization] bill has been passed, the same affordable health care won’t be there.”

And she emphasizes, “Any policy made in America has a huge effect on the lives of women and men in developing countries.”

“What makes this so tragic is that in our country, where we talk about getting contraceptives, condoms and abortion information as rights, it’s impossible to understand a woman who has no access to services,” says Amy Coen, president of Population Action International (PAI) in Washington, D.C. “Pregnancy [elsewhere] can mean life or death, or can have severe physical complications.”

In Latin America, despite being illegal, abortions tend to be safer than in sub-Saharan Africa. Still, the gag rule will force clinic closures simply because providers find it unconscionable to comply, causing them to lose U.S. funding for other services. The irony is hard to miss: The Bush administration ostensibly wants to stop abortions, yet its policies limit contraception—which could lower the number of abortions. A misguided political policy, in other words, is in fact producing more abortions. It’s not surprising that the U.S. government’s new advisors on international family planning include people who, like former Vatican envoy John Klink, consider many contraceptive devices and medications to be “abortifacients.”

stifling the u.n.

In its zeal to limit a woman’s right to the full range of reproductive choices, the Bush administration hasn’t stopped with a global gag.

In July 2002, Bush used the Kemp-Kasten Amendment— which prohibits U.S. funds from supporting organizations engaged in coercive reproductive-health practices—to withhold $34 million in already appropriated funds for UNFPA. The rationale? Despite findings to the contrary from three international monitoring teams, including a State Department group, the president agreed with allegations that UNFPA supports coercive abortions in China. That country’s population-limiting policies have been used since the mid-1980s as a red herring to hamstring international aid for contraception.

This time, Bush pointed as evidence to a report from a small right-wing group called Population Research International (PRI), a spin-off of the anti-family-planning Huunfpaman Life International. PRI, directed by Steven Mosher, has been championed by such vehemently anti-choice Republican members of Congress as Henry Hyde of Illinois and Chris Smith of New Jersey.

In fact, UNFPA funds neither voluntary nor coerced abortions. Its mission, in more than 140 countries, is to work with governments and NGOs to provide contraceptives, HIV/AIDS prevention, pregnancy care and education to combat violence against women. It supports such “controversial” health care as Pap smears, mammograms, prenatal checkups, Apgar health tests for newborns, vasectomies and aspirin for 13-year-old girls suffering from cramps. According to UNFPA, the monies the United States has withheld— 12.5 percent of its annual budget—would have helped prevent 800,000 abortions, along with 2 million unwanted pregnancies, 60,000 cases of serious maternal injury and illness and, most ominously, 4,700 maternal and 77,000 infant deaths.

The UNFPA defunding so angered a retired French teacher in California and an attorney in New Mexico that they came up with the idea of raising the money themselves—by creating the remarkable 34 Million Friends campaign.

sidetracking cairo, gagging aids?

In 1994, the U.N. Population and Development Conference in Cairo produced a landmark consensus linking family planning and economic development to reproductive rights and women’s empowerment. Its recommended actions sound like a feminist blueprint: yes to gender equity, education and family planning; no to female genital mutilation and other violence against women. Conferees also set a goal that by the year 2015 there would be universal access to reproductive-health services. Now as the 10th anniversary of Cairo approaches (and in characteristic rebuke of the international community), Bush wants to undermine that plan of international action.

After making noise that the United States might withdraw from the Cairo agreement, the Bush administration sent an anti-abortion and anti-family planning delegation to the Fifth Asian and Pacific Population Conference in Bangkok last December. Instead of focusing on how to further implement Cairo’s recommendations, the U.S. delegates nitpicked over terms in the agreement. Reproductive health and reproductive rights were seen as code for abortion, and consistent condom use (suggested as a strategy for adolescent HIV/AIDS prevention) was deemed unacceptable since the mere mention of condoms might invite promiscuity. Forcing a vote on its objections, the United States lost 32–1 and 31–1,finding itself in the position of isolated minority rather than world leader.

The U.S. delegation’s bias against nearly all forms of contraception led to at least one jaw-dropping moment in Bangkok. U.S. advisor Elaine Jones of the State Department lectured international experts on the efficacy of “natural” family planning, enthusing about the method she used: cervical- mucus monitoring.

International health providers now worry that the Bush administration has other gags waiting in the wings. A key concern is the promised $15 billion in U.S. aid for HIV/AIDS care in the 12 African and two Caribbean countries hardest hit by the disease. Although the administration has said it will distribute these funds to groups that also provide abortion services, it insists that those services be physically and financially separated—which is often un-realistic in places where health care is already so limited. For all intents and purposes, such a policy is a gag rule, which had previously not applied to AIDS funding.

today the world, tomorrow the usa?

If the Bush administration can get away with gag rules overseas, what will stop them from trying it here? Bangkok notwithstanding, the administration has been almost unimpeded in its drive to weaken support for abortion and family planning internationally.

“It appears that this administration tests things abroad first, and that’s what we’re worried about,” says Amy Coen of PAI. “It’s very, very hard for women in the United States to feel the lack of rights so many women in the world live with: They don’t get educated. They sometimes don’t get as much food as the boys do. They have no property rights. They can’t choose when to use contraceptives. The decisions the U.S. government makes are not widely reported, and they’re in areas that are very technical and complicated, so programs are being defunded and services for women eliminated and no one knows about this.”

Consider what the federal, state and local governments have been up to lately:

• The Northern Kentucky public health board only narrowly defeated (by one vote) a proposal to decline $170,000 in annual Title X money for family-planning services on the grounds that birth control pills and IUDS cause abortions.

• Bush has been nominating and renominating anti-choice judges to key federal posts, such as Priscilla Owen, 5thU.S. Circuit Court of Appeals.

• The federal government signed on to the antiabortion scare tactic of linking breast cancer to abortions by removing from the National Center Institute website a strongly worded fact sheet showing “no association” between the two and replacing it with a more ambivalent declaration.

• State legislatures have been flooded with anti-choice measures—in 2001 there were 398 in 49 states and the District of Columbia, according to the Ms. Foundation for Women. They include bills banning all or most abortions: setting burdensome “TRAP” (Targeted Regulations Against Abortion Providers) requirements on abortion providers; classifying fetuses as unborn children; creating state “Choose Life” or “Respect Life” license plates (with fees earmarked for “crisis pregnancy centers” that steer women away from legal abortions); setting up mandatory waiting periods for abortions (“come back in 24 hours”) and parental notification/consent requirements for minors. “It’s a chipping away, because we’re not paying attention,” says Coen.

• Gag rules may be harder to institute in the United States because of constitutional questions, but that doesn’t mean the anti-choice forces won’t be trying.

fighting back

Despite the pressure from the Bush administration and Bush-emboldened antichoice activists, equally impassioned pro-choice activists and legislators continue their efforts.

In March, Congressional Democrats Carolyn Maloney and Joseph Crowley of New York and Barbara Lee of California introduced the United Nations Population Fund Funding Act of 2003. HR 1196 would authorize the United States to appropriate $50 million for UNFPA in 2004 and $84 million in 2005—thus making up for the money withheld in 2003. To avoid a repeat of the China gambit, the law would withhold only “country specific ” funds if China failed to certify that it wasn’t using coercive family-planning measures. In other words, the Bush administration would have to come up with a brand new excuse to hold back all the UNFPA money next year.

In addition to the expected Democratic support, the House bill found its First co-sponsor in Iowa Republican Jim Leach. Also, James Greenwood (R-Pa.) has strongly criticized the global gag rule, and went to Kenya last year to see its ill effects firsthand.

“Unfortunately, our party has been co opted by so-called religious or neoconservatives,” Greenwood told a reporter. “They have persuaded themselves that if they cut funding to agencies that provide or counsel on abortions, somehow that will actually reduce abortions.”

Before the Reagan administration, family planning was a popular Republican cause as well as a familiar Democratic one. George W. Bush’s grandfather, Prescott Bush, was a staunch supporter of Planned Parenthood. George H.W. Bush supported a woman’s right to choose—until Ronald Reagan asked him to change his position in order to become his vice-presidential running mate.

getting around the gag

On the ground, foreign practitioners keep looking for creative ways to bypass the gag rule and the funding cuts. Dr. Solomon Orero travels around Kenya as part of the Kisumu Medical and Educational Trust, teaching health-care workers how to clean up botched abortions. He performs abortions himself, too, because he’s figured out a way around Kenya’s anti-abortion law: He insists that abortions are aimed “at the preservation of the woman’s life,” which the law does allow.

The irony is that Kenya has been moving toward legalizing abortion, with Health Minister Charity Ngilu calling for the country to provide women with reproductive choice. But Orero points out that legal abortion is only a starting point if a nation lacks funding to supply and staff clinics. When Zambia liberalized its abortion law, for example, women in the country still had very limited access to services. Says Orero, “We want to put services in place now for when the law is eventually liberalized.”

As the Cairo plan pointed out, reproductive rights are key to women’s well-being. Says PAI’s Coen, “The number of children you have profoundly affects the quality of your life. You can support and have a good life with three children but not with 10. And when you have hope in your own life, you can provide hope to your children.”

Perhaps that is the most bitter aspect to this particular Bush administration polemic, its cynical strategy, so hostile to hope, so seemingly determined to put a domestic electoral agenda ahead of fundamental health issues.