Susan Kihika’s phone was ringing off the hook last month. “I was getting calls from Nigeria, from South Africa, from the UK and the US, every hour on the hour, night and day,” she told me recently. “I was bullied. I was getting death threats. And what they were saying is: ‘You must drop the bill.’”
Kihika is a senator in Kenya, where she is trying to pass her country’s first comprehensive reproductive health law. That law would bridge gaps in sexual and reproductive health care, including abortion services for women whose life or health is endangered by pregnancy — a right guaranteed by Kenya’s constitution but nearly impossible to access in practice. Kihika is working to fix that the old-fashioned democratic way, listening to interest groups, meeting with her opponents, and shoring up support from lawmakers for the long fight ahead.
But even if she wins in her country’s Parliament, Kihika is going to lose somewhere equally influential: in Washington. The Kenyan government spends only $33 per person annually on health care. Roughly 20 percent of Kenya’s health spending comes from donor countries, and many of the health services those donors support have their hands tied, or are about to, by American religious opposition to abortion.
Using foreign funding as leverage to restrict abortion in other countries is not new for the United States, the biggest health donor in the world. Ever since Ronald Reagan added anti-abortion restrictions to family planning funding in 1984, the “Global Gag Rule,” as it has come to be known, has changed with the man in the White House. Democratic presidents have rescinded it, and Republican presidents have restored it. But until President Trump took office, the policy had always looked the same: It prevents doctors or other health providers supported by American money from discussing abortion with women, even if the procedure is legal in their country.
On his third day in office, Trump added something new: He expanded the rule, so that instead of applying to roughly $575 million in family planning funds, it covered all global health funding. Any foreign organization accepting American global health aid must agree not to provide abortion, referrals for abortion, or any information related to abortion — even if it uses non-US funding to do that.
It took nearly two years, and diligent work by the nonpartisan Government Accountability Office, to get even a partial picture of the financial impact of the rule. In its first 18 months, the rule was applied to at least $12 billion in global health funding; more than $8 billion of that supports HIV/AIDS prevention and response, and mostly in Africa. Though there are exceptions for multi-lateral groups like the World Health Organization, the restricted funds run the gamut of global health. Preventing and treating malaria, improving child nutrition, even detecting new, deadly diseases — accepting US grant funds for any of these efforts requires signing an anti-abortion pledge. And once the procedural details are in place, the rule could restrict up to two-thirds of the $11.2 billion allotted for global health this year.
Undoubtedly, the impact will be felt most fiercely by women. Marie Stopes International, one of the biggest global health providers, with a presence in 37 countries, lost $44 million when the policy went into effect. MSI estimates the policy has resulted in 5.2 million women losing health services, leading to 3.4 million additional unsafe abortions and 16,000 additional maternal deaths since Trump took office.
Trump’s expanded policy targets services — and an entire model of health care delivery — far beyond reproductive health. Over the last decade or so, global health specialists have worked to bundle health services, making it easier for patients to accomplish as much as possible in a single visit to a clinic. But if one service provider refuses to comply with the expanded gag rule, the loss in funding could close down the whole service hub. “So what happens to those people? Where are they going to go when the place they trust is no longer available?” asked Loyce Pace, president of the Global Health Council, headquartered in Washington, D.C. “This affects not only their quality of life, or their ability to live with HIV, but now they’re also at risk for something like COVID-19.”
Last year, Secretary of State Mike Pompeo expanded the gag rule even further, by targeting organizations that don’t take US funding but might work with organizations that do. Concerned that groups complying with US rules might somehow “support” groups that don’t, Pompeo refashioned the rule so that it works like a virus: Once a foreign organization touches US global health funding, the gag rule attaches itself to all the other funding that runs through that organization, infecting every other program and budget.
It doesn’t take much to feel Pompeo’s squeeze. Needed aid work gets done on the ground thanks, in part, to layers of subcontracting as complicated as a Biblical genealogy. If there’s US global health money anywhere in the family tree of funding, everything else on the family tree is gagged, too. Pompeo’s rule effectively gags the aid of other sovereign countries, private foundations, and even the multi-lateral organizations that are supposed to be exempt from the rule.
It’s too soon to know what the effects of this expansion may be. But last year, Pompeo fired a warning shot, cutting funding to the Organization of American States, an important regional governance body in Latin America, after alleging its leader had “lobbied” for abortion. The move, global health advocates say, had a clear chilling effect.
The stakes of this American ideological crusade couldn’t be higher — and yet there is no evidence US anti-abortion efforts actually reduce abortion. In fact, the data show the opposite. Under an earlier, narrower version of the gag rule, abortions actually increased by 40 percent, and a woman’s odds of receiving an unsafe abortion nearly tripled.
In Kenya, unsafe abortion is responsible for 17 percent of maternal deaths each year — and that’s just the best estimate. “Measuring the incidence and magnitude of abortion is quite complex, given the secrecy around abortion in this part of the world, and it’s probably – no, not even probably, it’s definitely worse than that,” said Anthony Ajayi, a postdoctoral research scientist at the African Population and Health Research Center in Nairobi.
Meanwhile, Susan Kihika is still trying to get reproductive health legislation through Kenya’s parliament. It’s a difficult battle, and she said her globally organized opponents have shifted from targeting her bill to targeting her seat in the Senate. But she insists she’ll persist. The alternative, she says, is clear: “Things go to hell, and women die.”
Jina Moore, a journalist based in East Africa, has written about health, human rights, and politics from more than 30 countries.