On Thursday, Joe Biden is expected to participate in what’s become a regular post-inauguration ritual for U.S. presidents by signing an executive order repealing the Mexico City Policy, known by its opponents as the global gag rule, which prohibits U.S. funding to foreign nongovernmental organizations that provide abortion counseling or referrals. The policy is a textbook case of how the lives of people thousands of miles away can be directly affected by America’s culture wars. And while Biden’s move will be applauded by reproductive rights advocates and family planning service providers around the world, the uncertainty and instability the rule introduced will be hard to erase.
The rule was first announced by Ronald Reagan at a conference in Mexico City in 1984. It builds on the Helms Amendment, a law passed by Congress following Roe v. Wade that prohibits U.S. funds from being used to actually carry out abortions. As an executive action, the Mexico City Policy flips back and forth like clockwork every time a new party takes the White House. Bill Clinton repealed it, George W. Bush reintroduced it, Barack Obama repealed it, then Donald Trump brought it back with a vengeance. The rule initially applied only to family planning funds, but the Trump administration’s version of it, officially known as Protecting Life in Global Health Assistance, applied to all U.S. health aid. Secretary of State Mike Pompeo announced a further expansion of the rule in 2019, withholding money to foreign NGOs that give money to other groups that provide abortions, which Pompeo called “backdoor funding schemes.”
A recent Government Accountability Office report found that from the beginning of the Trump administration through fiscal year 2018, the policy had been applied to 1,300 global health awards totaling $12 billion in funding—the vast majority of it from the U.S. Agency for International Development and the Centers for Disease Control and Prevention. The report identified 54 awards and subawards (those passed through other NGOs) for which the recipients had not received funding because of refusal to agree to the terms of the PLGHA. Rather than reducing abortions, the effect of the policy has been to reduce family planning services overall. A study by Stanford researchers in 2019 found that abortion rates actually rose in countries that were highly exposed to the policy during the years that it was in effect.
“You cannot overestate the impact. The loss of U.S. government funding meant closure of services,” says Carole Sekimpi, a medical doctor and Uganda country director for MSI Reproductive Choices.
MSI, a U.K.-based global NGO that provides family health services and contraception, maternal health care, HIV/AIDS care, and abortion services around the world, is one of the largest recipients of U.S. aid that declined to accept the terms of the rule, resulting in the loss of more than $24 million in funding, according to the GAO report. Sekimpi says the effect has been felt acutely in Uganda, where MSI provides about 60 percent of family planning services. Because of the Trump-era cuts, MSI cut its number of mobile health teams, which travel to provide services in rural areas, to five from 35.
“We have had to adapt over the years to the constant back and forth between the Republican and Democratic administrations. We’re trying to adopt a system that provides some stability for women and girls across the world,” says Sekimpi. Doing that has meant diversifying funding sources. But worse than the direct effect of the gag rule, Sekimpi says, may be its chilling effect on other organizations.
The provisions of the gag rule—which services and what sort of cooperation between organizations it applies to—can be difficult to parse, particularly given how often they change, and many organizations adopt a better-safe-that-sorry attitude and simply shun cooperation with noncompliant organizations. “We have to constantly work with them to explain the extent and the do’s and don’ts of the global gag rule,” says Sekimpi. “There’s lots of misapplication, lots of fear, and as a result, a significant loss of partnerships.” NGOs say these disruptions have hindered efforts to combat diseases including HIV/AIDS and Zika, and are particularly damaging at a time when the pandemic has imperiled family planning programs in many poor countries.
This chilling effect doesn’t necessarily dissipate when a Democrat takes office. A 2018 report by the Center for Health and Gender Equity cites a Kenyan NGO as saying local organizations “may not have been aware that the policy was lifted by Obama, because they saw women whose lives were at risk be refused health care by organizations that were continuing to apply the policy in error.” It also quotes a former U.S. government employee recounting that after the Obama administration took power, USAID missions continued to be cautious about working with organizations that had been denied funding under the Bush administration, saying, “What’s in it for us? Because we get four or eight years, and then it’s back to where we were.”
This suggests that simply repealing the policy isn’t enough. Even if agencies are remarkably clear and reassuring about the types of partnerships and communication that are now allowed, organizations may still overapply the gag rule out of fear that it could be back in a few years.
Fixing that uncertainty will, unfortunately, require Congress to get involved. There have been some attempts to do so. In 2019, Sen. Jeanne Shaheen and then-Rep. Nita Lowey introduced legislation to permanently repeal the Mexico City Policy by guaranteeing that NGOs that receive U.S. funding could continue to provide abortion counseling using non-U.S. funds. Last year, Rep. Jan Schakowsky introduced a bill to repeal the Helms Amendment, which blocks aid for abortion services.
The Mexico City Policy is a priority issue for religious conservatives in the U.S., and these measures are probably long shots in a divided Congress, although GOP Sens. Susan Collins and Lisa Murkowski backed the Shaheen-Lowey bill, known as the Global HER Act. [Update, Jan. 28, 2021: Shaheen announced on Thursday that she is reintroducing the Global HER act, saying, “Rescinding this rule is the start but it is not enough—there needs to be a permanent fix.”]
With Congress more and more deadlocked, more and more foreign policy initiatives, ranging from climate change agreements to Mideast policy, are likely to, in time, resemble the gag rule, carried out through executive action and subject to complete reversal by a successor looking to please domestic constituencies. That’s likely to lead to dwindling global influence for a country whose commitments abroad are only good for four years.