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" concerning abortion.

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 abortion.

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 women.

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 being constructed.

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 my discussion."

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.

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