Trump's “global gag rule”: implications for human rights and global health

The USA has engaged in international health activities for more than a century. With a budget request proposal of US$10·3 billion in 2017 in specified funding for global health, the USA is the world's largest source of global health financing and implementer of global health programmes.1IHMEFinancing Global Health 2015: Development assistance steady on the path to new Global Goals. Institute for Health Metrics and Evaluation, Seattle, WA2016http://www.healthdata.org/sites/default/files/files/policy_report/2016/IHME_PolicyReport_FGH_2015.pdfGoogle Scholar, 2Viergever RF Hendriks TCC The 10 largest public and philanthropic funders of health research in the world: what they fund and how they distribute their funds.Health Res Policy Syst. 2016; 14: 12Crossref PubMed Scopus (81) Google Scholar Under President George W Bush, the US government's funding for global health increased markedly, spawning major US funding initiatives, such as the President's Emergency Plan for AIDS Relief (PEPFAR) and the President's Malaria Initiative (PMI),3Kaiser Family FoundationDonor funding for health in low- & middle-income countries, 2002–2013. The Henry J Kaiser Family Foundation, Menlo Park2015http://kff.org/global-health-policy/report/donor-funding-for-health-in-low-middle-income-countries-2002-2013/Google Scholar, 4Kaiser Family FoundationThe US Government engagement in global health: a primer. The Henry J Kaiser Family Foundation, Menlo Park2017http://files.kff.org/attachment/report-the-u-s-government-engagement-in-global-health-a-primerGoogle Scholar as well as support for the multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria, which receives its largest proportion of funding from the US government. Under the Obama administration, support for these initiatives increased,5United States Congressional Research ServiceMajor foreign aid initiatives under the Obama Administration: a wrap-up.https://www.everycrsreport.com/files/20170104_R44727_951ba5c847a4dc7970b42300e24d4caa19a71f9c.pdfDate: Jan 4, 2017Google Scholar and the government also focused attention and funding on other global health programmes, including maternal and child health, neglected tropical diseases, and family planning and reproductive health. In 2015 alone, the USA provided more than 36% of all global development assistance for health.1IHMEFinancing Global Health 2015: Development assistance steady on the path to new Global Goals. Institute for Health Metrics and Evaluation, Seattle, WA2016http://www.healthdata.org/sites/default/files/files/policy_report/2016/IHME_PolicyReport_FGH_2015.pdfGoogle Scholar Such outreach has transformed the lives of millions of people around the globe and generated incalculable goodwill towards the USA and its people. Given this proud history, it is deeply concerning that newly elected President Donald J Trump, has, through an executive order in his fourth day in office, reinstated a Reagan-era prohibition on the disbursement of federal funding to non-governmental organisations (NGOs) and agencies that provide, promote, or make referrals to abortion services, or give information about abortions.6Trump DJ Presidential Memorandum Regarding the Mexico City Policy. The White House, Office of the Press Secretary.https://www.whitehouse.gov/the-press-office/2017/01/23/presidential-memorandum-regarding-mexico-city-policyDate: Jan 23, 2017Google Scholar Introduced by President Ronald Reagan in August, 1984, at the International Conference on Population, in Mexico City, the “Mexico City Policy” or “global gag rule”, as it has become popularly known, was rescinded by President Bill Clinton in 1993, resurrected by President George W Bush in 2002, and rescinded by President Barack Obama in 2009.7Blanchfield L Abortion and family planning-related provisions in US foreign assistance law and policy. Congressional Research Service.https://fas.org/sgp/crs/row/R41360.pdfDate: Jan 24, 2017Google Scholar The enforcement of the policy has affected major international agencies such as the United Nations Population Fund (UNFPA), which lost over $244 million in US federal funding during the George W Bush era.8UNFPAUNFPA welcomes restoration of US Funding. United Nations Population Fund, New York, USAJan 23, 2009http://www.unfpa.org/press/unfpa-welcomes-restoration-us-fundingGoogle Scholar The USA has had a standing policy since 1973 under the Foreign Assistance Act, as amended, which prohibits foreign assistance funds to be used for the performance of abortion as a method of family planning or to motivate or coerce any person to practise abortions.9Section 104(f)(1) of the Foreign Assistance Act of 1961 (P.L. 87-195; 22 U.S.C. 2151b(f)(1)), as amended by the Foreign Assistance Act of 1973 (P.L. 93-189), approved Dec 17, 1973.Google Scholar The Mexico City Policy extends this policy so that organisations that wish to use their own, or non-US, funds to undertake abortion-related services, but US federal funds to support programmes that are unrelated to abortions, are barred from receiving US federal funding. In effect, the Policy seeks to restrict activities that are deemed lawful in the USA (according to the Roe v Wade ruling) and many recipient countries, on partisan ideological grounds, even when US funds are not being used for those activities. Further, the version of this policy that President Trump reinstated will apply not only to recipients of family planning funding, but also to recipients of all global health assistance furnished by all US government departments or agencies. The implications are profound. US federal-funded NGOs and agencies focusing on diseases such as Zika virus, Ebola virus, tuberculosis, and AIDS but also providing family-planning-related services that even so much as mention abortion, could now be barred from receiving US federal funds. This executive order could have great human rights and ethics implications. South Africa is an example of a country that stands to be adversely affected. The country bears the world's largest burden of HIV and is a major recipient of US federal funding.10Foreignassistance.gov. 2017 Planned Funding in South Africa—Health. http://beta.foreignassistance.gov/explore/country/South-Africa (accessed Jan 28, 2017).Google Scholar The country's constitution enshrines the right to reproductive decision-making and the right to health,11Section 12 and section 27, Constitution of the Republic of South Africa.http://www.gov.za/sites/www.gov.za/files/images/a108-96.pdfGoogle Scholar while its laws on termination of pregnancy places a legal obligation on health-care providers to provide or refer abortion-seekers to relevant facilities, when qualifying criteria are met.12Choice on Termination of Pregnancy Act, Act 92 of 1996.http://www.gov.za/sites/www.gov.za/files/Act92of1996.pdfGoogle Scholar Compliance with Trump's order will potentially require clinicians in NGOs and international agencies that operate in South Africa and receive US federal funding to violate their professional codes of ethics,13Health Professions Council of South AfricaGuidelines for good practice in the health care professions. General ethical guidelines for reproductive health. Health Professions Council of South Africa, PretoriaMay 2008http://ipasa.co.za/Downloads/Ethics%20and%20Professional%20Practice/Health%20Professions%20Council/booklet_13_reproductive_health.pdfGoogle Scholar the country's abortion laws, and the country's bill of rights. For example, a pregnant woman attending the Centre for the AIDS Programme of Research in South Africa (CAPRISA)'s rural AIDS clinic, who happens to request information on termination of her pregnancy, could put the organisation's funds from the National Institutes of Health for HIV vaccine research at risk should they attempt to address her query, as required by abortion laws in South Africa. Similarly, clinical staff at the University of the Witwatersrand (one of many recipients of PEPFAR funding in South Africa14University of WitwatersrandSouth African organisations selected to address HIV/AIDS globally.https://www.wits.ac.za/news/latest-news/general-news/2015/2015-12/south-african-organisations-selected-to-address-hivaids-globally.htmlDate: Dec 21, 2015Google Scholar) who work at Chris Hani Baragwanath Academic Hospital, which offers abortion services, among a range of other services, will find themselves having to choose between breaking the law or violating the terms of their institution's funding, should they face abortion requests or queries. Such so-called remote control interference with a clinician's human rights and professional obligations is morally untenable. The Mexico City Policy is also flawed on evidentiary and public health grounds. A 2011 study15Bendavid E Avila P Miller G United States aid policy and induced abortion in sub-Saharan Africa.Bull World Health Organ. 2011; 89 (80C): 873Crossref PubMed Scopus (49) Google Scholar found that enforcement of the Mexico City Policy by the George W Bush administration led to an increase in abortion rates in sub-Saharan Africa, probably because of decreased contraception access and increased unwanted pregnancies. The resurrection of the Mexico City Policy by the Donald J Trump administration looks set to yield similar or worse outcomes in the years ahead, in settings served by NGOs and agencies that rely on US federal funding. For example, Marie Stopes International (MSI), a family planning NGO, currently receives USAID funding exclusively for voluntary contraception services. The conditions of the Mexico City Policy would restrict MSI from providing abortion services using other funding, in countries where abortion is permitted. If MSI were to continue providing abortion services anywhere, the organisation would have to forfeit USAID funding for contraception services. This could have major implications in setting such as Bolivia, which is experiencing a Zika virus epidemic.16PAHO / WHOZika epidemiological report: Bolivia (Plurinational State of). Pan American Health Organization, Washington, DC2016http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=35135&Itemid=270Google Scholar In light of South American governments issuing unprecedented warnings urging women to avoid pregnancy,17Aiken ARA Scott JG Gomperts R Trussell J Worrell M Aiken CE Requests for abortion in Latin America related to concern about Zika virus exposure.N Engl J Med. 2016; 375: 396-398Crossref PubMed Scopus (1) Google Scholar Bolivian women are likely to seek contraception services. In 2015 alone, 98 000 Bolivian women accessed contraception services offered by MSI, resulting in 33 000 unwanted pregnancies being averted. MSI has disavowed Trump's Mexico City Policy and stands to lose its USAID support. Seen in this light and the scale of US federal funding for global health initiatives, the Trump administration's expanded ambit of the Mexico City Policy is a direct threat to global health. Recipients of US federal funding are now forced to make a stark choice: to accept US federal funding and deny women services and information about abortions, even in countries where this is their right by law and when such services are funded by other sources, or to reject US federal funding and give women information about their reproductive health rights and options, thereby forfeiting US federal funding for crucial non-abortion related health initiatives, such as tuberculosis, HIV, and Zika virus control. Neither option is compatible with human rights, ethics, or global health. The authors are affiliated to the Centre for the AIDS Programme of Research in South Africa (CAPRISA), an Non-Governmental Organisation that receives US federal funds for AIDS and tuberculosis research in South Africa. No specific funding was received for this Comment. The views of the authors do not necessarily reflect the views of their funders.

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