The Sound of Silence
by Alyssa Rayman-Read
The American Prospect magazine
Special Supplement - Body Politics, Fall 2001
I am here today in the United States to testify about the
impact of the global gag rule," declared Susana Galdos Silva,
the co-founder of Movimiento Manuela Ramos, a women's health organization
in Peru that receives family-planning funds from the U.S. Agency
for International Development (USAID). This was last July. She
was speaking, with full awareness of the irony, before the Senate
Foreign Relations Committee. Only months earlier, Congress had
voted to uphold the Bush administration rule that prevents Galdos
from testifying at home.
Peru, where abortion is illegal, has the second-highest maternal
mortality rate in South America, Galdos told the senators, and
unsafe abortions account for nearly one-quarter of it.
"It is estimated that 60 percent of all pregnancies in
Peru are unwanted," she said. "And 3o percent of all
pregnancies end in abortion despite Peru's restrictive law....
Every year, 65,000 Peruvian women are harmed to the point of needing
hospitalization due to complications of unsafe abortion."
These are numbers Galdos would like to put before her own
legislators-or at least be able to give them when they ask. "But
because of the global gag rule," she said, "this work
is forbidden to us."
The dilemma faced by health organizations like Movimiento
Manuela Ramos is devastating, says Susan Cohen, deputy director
of governmental affairs at the pro-choice Alan Guttmacher Institute.
Under the gag rule, they must "either give up the [USAID]
funding needed for services essential to women's health care or
give up the right to lobby and advocate for changes in the reproductive-rights
laws of their own country." Yet, as in Peru, reform of abortion
laws may be just as essential to women's health.
The Center for Reproductive Law and Policy (CRLP) in New York
is suing the Bush administration, calling the gag rule an unconstitutional
violation of the free-speech rights of Americans involved in women's
health work internationally, as well as a violation of international
human-rights laws and the sovereignty of foreign governments.
CRLP attorney Julia Ernst describes the difficulty of getting
Galdos or anyone else even to discuss the problem: "When
CRLP asked her to speak out about the impact of the regulations
on her work, she told us, 'I'd love to talk to you.' But then
she held her scarf up over her mouth as though she were gagged.
Even privately, with us, she was afraid." Galdos requested
and received explicit authorization from a U.S. court before she
would testify on Capitol Hill. And there she pointedly reminded
the senators: "When I return to my country tomorrow, I will
again be silenced."
On his first official day as president-the 28th anniversary
of the Roe v. Wade decision-George W. Bush relaunched the Reagan-era
"Mexico City Policy," known by opponents as the global
gag rule. The policy stipulates that to receive U.S. family-planning
assistance, an organization must pledge that it won't use even
its own, non-U.S. funds to "actively engage in or promote
abortion" or to engage in "activities or efforts to
alter the laws or governmental policies of any foreign country"
Though the rule may appear to concern abortions exclusively,
its impact is actually much broader. Indeed, the gag rule's long-tentacled
reach extends into women's health and gender-equity movements
throughout the developing world. Groups that depend on US AID
funding have been scared out of providing even nonrestricted health
services, such as treatment of septic abortions. And many of the
world's most important advocates for women have been frightened
away from the discussions that advocacy requires.
Take the following interview with a clinic worker in Bangladesh.
It was published in 1988 by the Population Crisis Committee, a
multinational advocacy group (now called Population Action International),
as an example of the chilling effect that the original Reagan
gag rule had on local health organizations.
Q. Do you provide treatment to women who may be suffering
the ill effects of a self induced abortion or an infected abortion?
A. No, we can't do anything like that anymore. We can't touch
Q. Well, what do you do if a woman in that condition comes
into the clinic, someone who might die if she doesn't get medical
treatment? Can you refer her someplace?
A. No, we can't do anything. We can't tell her anything. She
just has to go away.
Q. Why? That's not doing or promoting abortion.
A. That's what the government wants.
Q. Do you mean the U.S. government? AID? Why would they want
you to let a woman die?
A. I guess because if she gets taken care of, other women
might follow her example and do more abortions.
The Population Crisis Committee reported that in Bangladesh,
as in many countries where abortion was legal, shifting postabortion
care from U.S.-funded organizations to other clinics had diminished
medical care and "reduced the quality of postabortion contraceptive
counseling and services."
What's more, the gag rule keeps U.S.-funded health care groups
from collaborating with others concerned about reproductive-health
issues in their country. "Imagine the United States government
saying you can't talk to people about your research exposing the
causes of a disease in your country," CRLP's Ernst says indignantly.
"The U.S. government is telling their partners overseas how
to talk, or not talk, about their abortion policies. This undermines
. . . the democracy-building efforts the U.S. touts rhetorically."
No doubt some USAID recipients are overinterpreting the restrictions.
But the fine print of the global gag rule is complicated and difficult
to translate into even the first language of many countries, much
less the third, fourth, and fifth languages spoken by indigenous
health workers in remote rural areas. And the consequences of
a translation mistake are terrible. According to Adrienne Germain,
president of the International Women's Health Coalition, family
planning in Bangladesh is 80 percent to go percent dependent on
USAID funding. Elsewhere, too, "there would be nobody to
replace the funding" if American aid were withdrawn. Worldwide,
Population Action International calculates, the United States,
despite cutbacks in recent years, is still the largest single
donor of family-planning funds to developing countries. Its s450
million in family-planning aid this year amounted to more than
one-third of grants worldwide.
GAG AND SPIN
The Bush administration has tried to portray its reimposition
of the gag rule as a necessary safeguard against federal funds
being used for overseas abortions. But this is false spin. In
fact, it has been illegal to finance abortions abroad with U.S.
aid since 1973, when Congress first passed Senator Jesse Helms's
amendment forbidding the practice-and no violation of that prohibition
has ever been documented.
Moreover, the administration's claim that reinstating USAID
restrictions will "make abortion more rare" is contradicted
by the Population Crisis Committee's comprehensive study of the
first global gag rule. Its conclusion was plain: "There is
no evidence that the curtailment of services by AID-supported
clinics reduced the number of abortions."
It's far more likely, in fact, that the gag rule, by reducing
the effectiveness of those programs best equipped to prevent
unwanted pregnancies, will hurt the effort to lower abortion
rates. Because the cultural and legal situation in each country
is unique, it is difficult to generalize, but the experiences
of individual countries can be eye-opening. In Turkey, for instance,
where abortion is legal, programs launched in the early 1990s
by the Ministry of Health lowered high abortion rates by coordinating
abortion and family-planning services. According to Susan Cohen
at the Guttmacher Institute, offering post-abortion counseling
and contraceptive distribution at the same sites where abortions
were performed resulted in a significant increase in contraceptive
use. At one hospital, the proportion of clients using contraception
after their abortions jumped from 65 percent to 97 percent in
only one year. "At the same time," Cohen reported earlier
this year, "the number of abortions performed at that hospital
dropped markedly, from 4,100 in 1992 to 1,709 in 1998."
Health experts say the success of this Turkish program could
be replicated easily in the many other countries where abortion
is legal and access to contraception still limited. But not, of
course, if the foreign-funded nongovernment organizations, which
in many developing countries offer the only high-quality health-and-family-planning
services available to most of the population, are prohibited from
coordinating services. In the meantime, the gag rule seems far
more likely to undermine contraception programs in these countries
than to reduce abortion rates-which is why many of its opponents
wonder if that isn't one of the Bush administration's purposes.
"Hospitals or clinics that provide legal abortions in
India...are still eligible...to receive U.S. funds for HIV/AIDS
prevention or child-survival activities," Cohen pointed out.
"That only family-planning dollars are deemed 'fungible'
and tantamount to indirect support for abortion...strongly suggests
that the target is as much family planning itself as it is abortion."
"Make no mistake," said Senator Barbara Boxer, the
California Democrat, at the Senate hearing. "The Mexico City
gag rule is restricting family planning, not abortions."
The United States first added a family-planning component
to its foreign-assistance package in the 19605, and ever since,
it's been a bone of contention between battling domestic camps.
Presidents, who have the leeway to interpret the terms and conditions
of foreign assistance, have weighed in according to their party's
position on abortion, with Ronald Reagan, George Bush the elder,
and now George Bush the younger all adopting the Mexico City Policy,
and Bill Clinton, in his first presidential act, rescinding it.
(In the final hours of the 1999 legislative session, Clinton was
forced to accept a limited version of the gag rule in order to
get a Republican Congress to pay back-dues the United States owed
the United Nations. However, he instructed USAID officials to
interpret the policy "in such a way as to minimize to the
extent possible the impact on international family-planning efforts
and to respect the rights of citizens to speak freely on issues
of importance to their countries.")
While American politics swings back and forth, international
health officials have followed a different trajectory. Their goal
at first was to address what was seen as a dangerous global-population
explosion. The success of the USAID program was to be measured
in the declining fertility rates of developing countries. And
by this standard, the program was successful. Fertility rates
in the 28 most-populous countries receiving USAID funds have been
reduced over the years from an average of more than six children
per family to an average of just over four. Up until 1994, that
seemed good enough.
But when representatives of 179 nations gathered in Cairo
that year to assess the state of global-population programs, it
became apparent that the focus on fertility rates was too narrow.
In fact, research collected mostly by USAID recipient groups all
over the world showed that many demographic accomplishments had
been achieved by constraining rather than educating women -by
abetting gender discrimination and ignoring women's health, so
long as contraceptive use went forward. This approach, health
officials increasingly believed, was not only unjust; it was shortsighted.
One of the population-control programs scrutinized at the
Cairo conference was Bangladesh's famous turnaround story. Dan
Pellegrom, the president of Pathfinder International, an intermediary
group that advises recipients of USAID funding abroad, says that
Bangladesh, with a population of 125 million, is a special case.
It has been one of the top recipients of USAID funding for decades,
and it has experienced what may be the most dramatic reduction
in population-growth rates in the world, from 3.1 percent in 1975
to 1.8 percent last year. But others say that, before the Cairo
conference, this was achieved at considerable cost to Bangladeshi
Anthropologists Sid Schuler and Lisa Bates, who study family-planning
programs in Bangladesh, say that before the Cairo conference health
workers would go door to door in poor communities offering or
imposing whatever birth-control methods the health workers thought
their neighbors should have: You've already had enough children;
take these pills. You're too ignorant for pills; we'll give you
an IUD. The "clients" were rarely provided counseling,
information, or even health services or facilities-just contraceptives.
If something got confusing or went wrong, these women were resourceless.
Under the circumstances, it's not surprising that maternal-mortality
rates in Bangladesh continued to be among the highest in the region.
The Cairo conference produced an international consensus that
favored dramatically shifting the focus of population control
efforts. Health officials worldwide came to understand that the
most enlightened-and in the long run, the most successful-family-planning
programs would combine contraceptive distribution with counseling,
education, and political and social lobbying for women's reproductive
and human rights. According to an analysis prepared by the United
Nations Population Fund (the largest multilaterally funded source
of family-planning assistance worldwide), the "cornerstones"
of population and development policies, after Cairo, were "advancing
gender equality, eliminating violence against women, and ensuring
women's ability to control their own fertility."
Neither developing countries nor donor nations met the funding
targets for the year 2000 that they all had agreed to in Cairo.
But programs around the world did change. Many organizations in
Bangladesh, for example, have begun promoting women's active involvement
in making decisions about their health. And UN documents show
that at least 76 countries since 1994 have reported liberalizing
their laws and policies concerning women.
The progress is undeniable, but ironically, the changes brought
on by the Cairo conference mean that the global gag rule will
have even graver consequences today than it did under Reagan or
the elder Bush. Family-planning groups that receive USAID funds
are now among the most influential players in national movements
advocating women's rights and reproductive health. The gag rule's
chilling effect on them will be felt wherever democracies are
It is also felt right here at home, as Julia Ernst described
in an affidavit, where one U.S.-based organization that receives
USAID funding was crippled in its ability to run a training program
for foreign journalists on reproductive-health issues. No session
dealing specifically with abortion could be scheduled. Said Ernst,
who led one workshop: "The participants were aware of the
fact that the training was sponsored by [a US AID-funded organization].
A USAID official was in attendance. Because of this, a pall was
present during the meeting, with most people- including the journalists-reluctant
to speak about abortion even though I brought it up as part of
One bright spot: Efforts by the pro-choice community are gradually
moving opinion in Congress. The Senate Foreign Relations Committee
recently voted 12-7 (with the support of several Republicans)
to overturn the gag rule. In the House, sentiment has been shifting
against it. On the most recent floor vote, last May, opponents
came within eight votes of striking it. Thirty-three Republicans
braved White House arm-twisting to vote against the gag rule.
As the brutal costs of Bush's policy become better understood,
the gag rule is more likely to be remembered as an embarrassment
than as a moral triumph.
ALYSSA RAYMAN-READ is an American Prospect writing fellow.