Nelly Munyasia breathed a huge sigh of relief when Joe Biden won the US election in November.
“I am excited and I am hopeful that things are going to be better. We are going to access funding and we are going to save the lives of women and girls,” she says, before explaining how tough the past four years has been.
Munyasia is executive director of Reproductive Health Network Kenya (RHNK), which promotes health services, including offering information about abortion. This put the network in the sights of Donald Trump’s administration. In 2017, the US president used an executive order to reinstate the Mexico City policy (also known as the “global gag rule”), which prohibits overseas organisations that receive US funding from using money from another source to do abortion-related work.
The policy – usually rescinded by the Democrats and reintroduced by Republicans – has affected global family planning since it was introduced in 1984. Under Trump, the policy was expanded to cover almost all US bilateral aid for global health, affecting as much as $12bn (£8.9m) in funding.
The policy had an immediate and devastating impact on Munyasia’s organisation. All of its funding came from the US, via Planned Parenthood Global (PPG), which had refused to sign the global gag order. RHNK lost as much as $1m a year. Munyasia had to stop outreach programmes to marginalised communities and halt the training of more than 500 health workers. Thousands of women couldn’t get contraceptives, HIV tests or cancer screening. Teenage pregnancies increased, and women resorted to unsafe abortions. Foetuses were found on riverbanks, Munyasia says.
The organisation went from seeing 300,000 women and girls a year to just 150,000 over two years – thanks only to money secured through the SheDecides movement.
“We lost 100% of our funding. It was devastating. We were in the process of renewing our contracts … when we were told by PPG that they were not able to give us funding.”
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In January 2017, the Trump administration reintroduced the Mexico City policy – known as the “global gag rule”.
The policy prohibits overseas NGOs that receive US funding from using money sourced elsewhere to undertake any work related to abortion. The policy – which is traditionally rescinded by Democrats and reintroduced by Republicans – usually targets family planning programmes funded by the US Agency for International Development (USAid).
But under Donald Trump it was expanded to cover all bilateral health funding, administered by all departments or agencies. This included HIV, malaria, water and sanitation, and nutrition programmes. It also prevents NGOs from supporting other groups that provide abortion services.
The Protecting Life in Global Health Assistance policy has affected up to $12bn in health funding.
The full impact of the vastly expanded policy may not be known for some time. But researchers who studied 26 countries in sub-Saharan Africa during the administrations of Bill Clinton, George W Bush and Barack Obama found that when the gag rule was imposed abortion rates increased by about 40%, contraception use fell by 14% and pregnancies rose by 12%.
Health advocates say the policy does not reduce abortion. Even without the gag rule, an estimated 7 million women in low-income countries are admitted to hospital as a result of unsafe abortions each year. Over the past four years, there have been reports of women drinking battery acid or using sticks or wire clothes hangers to abort.
Organisations receiving PEPFAR (President’s emergency plan for aids relief) money for HIV work in South Africa, Eswatini, Kenya and Mozambique have reported changes to and the closure of some programmes.
The US government believes there has been no significant disruption to services.
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Munyasia is counting the days until Biden is sworn in. “We’re ready to go, things are in place. I’m sure we can quickly open up avenues to access funding.”
But the process may not be smooth and won’t be quick. “It’s not like flipping a light switch,” says Jonathan Rucks, senior director at reproductive rights organisation PAI. “We’re likely to be undoing this well into 2022. It will take a lot to undo and really help partners to be comfortable again to understand what they can and can’t do with their own funding.
“When family planning funding was limited it did incredible damage, but to 24 or 25 countries. The expanded policy [affects] well over 60 countries. That’s providers in 60 countries around the world now thinking do I work with the US government again, knowing that support could be cut off at the whim of politicians?”
Moses Mulumba, executive director of Uganda’s Center for Health, Human Rights and Development (CEHURD), says the administration needs to ensure all US country offices are clear about policy changes.
Global gag restrictions came as a huge shock, he says. A four-year grant ended after one. Contacts and collaborations that had taken time to build were lost.
Reproductive health NGOs pin hopes on Biden reversing ‘global gag rule’
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“We were creating relationships with MPs and health workers, creating relationships with districts on accountability, advocacy, and we lost it,” he says.
Beirne Roose-Snyder, director of public policy at the Center for Health and Gender Equality in Washington, says civil society is better prepared to go back to business than it was in 2009 when Barack Obama became president after eight years under George W Bush.
“We’re better coordinated and in contact with each other. The technology is quite different, we’re all on Zoom,” she says. But undoing the damage will still require an “enormous amount of work from all of us”.
The disruption to services has been so broad “we are going to need much clearer leadership in this, particularly the Biden government to acknowledge and understand all the harm”.
The new administration will need to go much further than just rescind the gag, say rights groups. It needs to throw its weight behind the Global Health, Empowerment and Rights Act, introduced last year to repeal the policy permanently. The legislation, which has been referred to committees in the House and Senate, is cosponsored by vice-president elect Kamala Harris and there are high hopes it will pass into law.
Biden must also remove, or at least publicly clarify, the Helms amendment, which prohibits US funds being used for abortion overseas, except in cases of rape, incest or when a woman’s life is in danger. The amendment has been widely interpreted as a total ban on US-funded abortion care. A bill to repeal it was introduced in July.
But more than that, on day one, activists want the new administration to publicly commit to sexual and reproductive rights. It needs to rejoin the World Health Organization and the UN human rights council and start refunding the UN population fund (UNFPA).
Over the past four years, the Trump administration has sought to rewrite internationally agreed human rights policies and create an alternative agenda. It has raised objections and amendments to resolutions and UN declarations. In October, the US persuaded more than 30 countries to sign an anti-abortion policy, the “Geneva consensus declaration”.
“The Geneva consensus declaration, which was neither signed in Geneva nor is a consensus, and the Commission on Unalienable Rights have been hugely destructive,” says Roose-Snyder. “We are going to need something more public [from the Biden administration], to be a clear signal to other governments that this is not the thinking we are going to support or pursue.”
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