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In Ethiopia, adolescent health clinics that were once supported by US foreign aid have closed. In Kenya, a decades-long effort to integrate HIV testing and family planning was undone. And in Nepal, intrepid government workers who once traversed the Himalayas to disseminate reproductive health information were arrested.
Around the world, countries that depend on U.S. foreign aid have scrapped or scaled back ambitious public health projects, reshaping their health systems over the past four years to comply with President Donald Trump’s sweeping anti-abortion restrictions that they went further than any Republican president before him. .
The effects have been profound: As groups scrambled to abide by the strict ideologically driven rules of the administration, they cut ties with healthcare providers discussing abortion in any way, removing references to abortion on the sites web and in sex education curricula, and stopped discussing modern contraception fear of losing American life support.
President-elect Joe Biden has vowed to reverse the policy when he takes office, and campaigned on a promise to enshrine the right to abortion in federal law. But for many foreign aid groups, the changes can be permanent.
“The United States has lost its position as a leader and its credibility,” said Terry McGovern of the Mailman School of Public Health at Columbia University, who has overseen research on Trump’s policy in several countries.
Since Ronald Reagan, Republican Presidents have banned foreign aid organizations from using America’s global health funds to counsel women about abortion or refer them to a safe abortion provider. But the Trump administration vastly expanded those anti-abortion restrictions, known as “the global gag rule” by opponents. Under Trump, the rule applies to about $ 9 billion of aid that touches almost every facet of global health financing, including groups working on HIV, malaria, tuberculosis, and water sanitation. Under President George W. Bush, the policy applied to a fraction of that, $ 600 million in foreign aid.
The Trump administration proudly touted these efforts to protect “the foreign-born,” but the rules have left international aid groups deeply skeptical of America’s promises and deepened the nation’s gap with countries. Europeans who have long viewed access to abortion as vital to women’s health and safety.
Some major organizations chose not to receive funding from the US instead of complying with the new restrictions, including Marie Stopes International and the International Planned Parenthood Federation, among the largest providers of reproductive health care in the developing world. Untold numbers of front-line healthcare workers, both in big cities and remote villages, have been confused by what appear to be sudden changes in American politics.
And that unease may not dissipate quickly even with a Democrat in the White House.
“Biden and Trump can seem radically different to Americans,” said Jennifer Sherwood, policy manager for Amfar, the Foundation for AIDS Research. “But if you are a small organization in sub-Saharan Africa, you may not understand what is new. [Biden] means of administration and whether the United States can be trusted. “
The restrictions intentionally restrict the activities of foreign aid groups, many of which have worked closely with their US counterparts for decades. The rules also have a ripple effect on their funding: US funding to foreign groups depends on them not accepting money from other countries, or even from private foundations, to fund abortion-related services. They are not allowed to outsource to other organizations running separate abortion-related projects.
Trump telegraphed global advances against abortion in appeals to evangelical Christians. In early October, Secretary of State Mike Pompeo touted the policy during a speech to the Florida Family Policy Council, a conservative anti-abortion group, calling it an “unprecedented defense of the unborn abroad.”
“Our administration has been based on our first principles to defend life in our foreign policy like no administration in all of history,” said Pompeo, who is an evangelical Christian.
The far-right policies of the Trump administration stand in stark contrast to the continued liberalization of abortion laws in countries around the world over the past two decades. Since 2000, more than two dozen countries have relaxed abortion laws, including Ireland, South Korea, the Democratic Republic of the Congo and Ethiopia.
Even in countries where abortion is prohibited, the rules have an impact on reproductive health care. In Madagascar, where abortion is illegal without exception, the largest contraceptive provider, Marie Stopes, turned down American money, jeopardizing its ability to provide unrestricted health care to women, ending support for nearly 200 public facilities and private.
Mamy Jean Jacques Razafimahatratra, a researcher at the Institut National de Santé Publique et Communautaire in Antananarivo, found that this led to a shortage of contraceptives in a poor country where travel to nearby cities is difficult.
“The women asked us, ‘What is the cause of this breakup?'” Razafimahatratra said. “We try to explain why and [they say], ‘But that regulation is for abortion, so we don’t understand why they sanction us too?’ “
Researchers from Amfar and Johns Hopkins, in a study published in Health Affairs, found that anti-abortion policies could have deadly consequences, specifically in preventing the spread of HIV / AIDS. Sherwood said young African women face the highest risk of contracting HIV and many clinics have combined HIV testing and treatment with family planning services.
But, fearing conflict with Trump’s policy and thus losing funds, clinics have restricted family planning for patients, reducing the number of women seeking care in African countries.
“Many times, they want contraception,” Sherwood said. “That’s what they have in mind, and HIV is secondary, something we can address to meet their needs at once.”
Jennifer Kates, director of global health and HIV policy at KFF said: “I have no doubt that some groups are going to say, ‘We’re not going to play there anymore'” (KHN is an editorially independent program from KFF).
The practical challenges of restarting these programs are great: rehiring, reopening clinics, retraining employees, rewriting curricula.
“You can imagine being a healthcare worker who was under threat of losing his funds to counsel a patient about abortion,” Sherwood said. “For us, it’s like a light switch that can be turned on and off, but for them, this is a very opaque and confusing process. This is not how healthcare systems work. You cannot change the way they work from the overnight. “
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