Gagged and bound: Abortion, the Mexico City policy and the cost of silence

Exemplary sleight of hand. A dramatic move to the left of the stage, while the action takes place on the right.

This is, in essence, the concern of local advocacy groups in light of the ongoing confusion over the reinstated “gag rule” that would cut US aid funding to organisations that performed, advocated or even presented abortions as an option.

Late in January, US President Donald Trump announced – to widespread horror but little surprise – that he would be continuing the presidential policy-go-round that dated back to 1984, reinstating the Mexico City policy, commonly known as the “gag rule”. What was different: he not only reinstated it, he significantly expanded it. The initial reinstatement was shrouded in confusion. The media were left somewhat in the dark. It was only when an advocacy group tweeted a screenshot of some drastic amendments that media began to pick up on the expansion.

Weeks later, the finer points of the policy are as vague as ever, with even Republicans demanding an update. Trump has made at least one announcement domestically, but, says South African activist Marion Stevens, the details “remain unclear”.

“It is very worrying,” she says.

Stevens, ?co-ordinator of WISH (Women in Sexual and Reproductive Rights and Health) Associates, chair of the Sexual and Reproductive Justice Coalition, and Research Associate at UCT’s African Gender Institute, told Daily Maverick the continued lack of clarity was concerning not only because it would have devastating effects on healthcare outside the US (women’s and other), but because in a global storm of outrage and confusion, other critical issues were obfuscated.

“There’s truth and there’s truth,” she says. “The relationships between researchers and funders form a large, industrial complex. There’s interesting research on a range of things, but it’s also very clear what many research bodies will not do. Many will not touch the controversial matters. Once again, we are facing the control of women’s fertility. It’s not even a debate, because people have decided for women already that it’s more of a concern that they must have a baby than whether they are at risk for HIV.”

Stevens is referring here to the World Health Organisation (WHO)’s release of new data and the announcement that Pfizer-manufactured contraceptive Depo-Provera was moving from a category 1 to category 2 risk due to the likelihood of HIV transmission. Depo-Provera, due to funding from inter alia the Bill and Melinda Gates Foundation and the UN Population Fund, is the most commonly used contraceptive in sub-Saharan Africa. According to the new research, it increases the risk of contracting HIV by up to 50%.

It’s worth pausing here to question the relationship between Trump and Big Pharma, which also remains ambiguous. Trump’s promise to lower drug prices kept sceptics busy earlier in 2017. Eyebrows were raised when Trump turned to pharmaceuticals veteran Rich Bagger for assistance on his transition team, but he’s also made promises that can make him enemies in the medical industry, so it’s unclear where the chips will fall. Against the backdrop of Trump promising to “invest in women’s health”, the relationship between Trump and pharmaceutical manufacturers – as well as how accessibility is affected – will be crucial to watch.

For Stevens, the relationship between US funding and reproductive healthcare abroad isn’t a zero-sum game. It’s not only about organisations directly gaining or losing funding, or the exact number of abortions that will or won’t be performed – although this data, too, is significant. Healthcare is broadly affected, she argues. There’s a delicate relationship between the research organisations that can, for instance, provide alternative means of family planning, subsidised reproductive healthcare, or educate women about the risks and benefits of each available method. It’s also about increasing options, she believes. And most important, placing the health of women ahead of political tactics.

Although some South African media have reported that the effect of the gag rule on South Africa will probably be limited, Stevens believes this is to grossly underestimate the implications.

“The gag rule really affected us when Bush came in, and then we saw the interpretation of the rule was around abortion, sex work, MSM – any advocacy around that was affected,” she explains. “Groups that were mainstream, just as (HIV/Aids) treatment was getting under way… we saw a very clear direction with the treatment movement. Groups that did what we now call intersectional work on social justice and women’s health just did not survive. Around abortion, our work and our engagement died and has not really recovered.”

Stevens is at pains to emphasise that “this is not just happening now, in 2017. It’s historical.”

That’s where the “gag” comes in. Dr Tlaleng Mofokeng, Deputy Chairperson of the Sexual Health & Reproductive Justice Coalition (SRJC) and resident doctor at Kaya FM, echoes Stevens’ explanation. Mofokeng chaired a Médecins Sans Frontières-hosted panel discussion on the matter on March 7 and told Daily Maverick that many women’s health, advocacy and research bodies – led by the national department of health or independently, by NGOs – have ties to “some form of US funding or support”.

“The extent to which the government of South Africa has allowed and embraced these fundamentally flawed conditions to foreign aid speaks to our ability to self-gag, so much so that when Obama rescinded the gag rule we continued on this conservative path that is really leading to many preventable deaths,” she says.

Marie Stopes International, which has vowed not to comply with the gag rule internationally, suffered in South Africa under Bush. The organisation, which offers free abortions in several countries as well as post-abortion care, lost a great deal of funding locally.

Today, there’s an additional lack of clarity regarding the future of Pepfar, which former US President Bush specifically exempted from the gag rule due to the inroads made in HIV/Aids prevention, among other things. But with the Trump expansion, the fate of Pepfar hangs in the balance. Trump’s attitude towards Pepfar has not been tremendously supportive, although analysts have expressed tentative optimism due to the initial decision to retain Obama appointee Dr Deborah Birx. The difficulty, however, according to The Atlantic: “Keeping Birx… seems to demonstrate that the [Trump] administration values Pepfar, [but] they may also have endangered its ability to function… It’s unclear how the new global gag rule will be implemented, and how Pepfar’s support of other organisations will be affected.”

Or, as Stevens puts it: “There seems to be huge institutional memory and I can’t imagine that such huge funding and multimillions of dollars of research are going to be lost. But I’m not holding my breath. I don’t think that Trump and his advisers really know what’s going on.”

This is where it gets interesting for South Africa, depending on how you spin the numbers. (A breakdown of several useful healthcare statistics can be viewed here.) Just 16% of South Africans have private medical aid – the rest are dependent on subsidised care. South Africa spends around 9% of GDP on healthcare, which is supplemented by foreign aid. Between 2005 and 2013 alone, HIV spending increased by 262%. A WHO diagram from 2015 puts Pepfar’s contribution to South Africa’s HIV/Aids expenditure at 20%, with a further 3% coming from the Global Fund and the remainder funded by the SA government. Viewed from another angle, the overwhelming majority of the foreign aid South Africa receives is spent on healthcare.

The trouble, says Mofokeng, is that although there are global statistics and global estimates of the possible damage caused by Trump’s escalated gag rule, there’s precious little information that will allow South Africa to quantify it and take well-planned corrective measures. “The area of abortion research is poorly done,” she says. “The government does not collect statistics specific to abortion service, be it deaths from illegal and or unsafe procedures, co-morbidities as a result of sepsis, and/or hysterectomy done as a life-saving surgery from severe pelvic sepsis.

“So the next question related to statistics is: how is government planning and directing resources to a life-threatening issue if they cannot quantify it? The statistics should be asked and sought from the national department, because private providers and researchers can only do so much within a system that does not prioritise abortion.”

But this is tricky, says Stevens, because the gag rule forces organisations and healthcare providers to “fudge” post-abortive care and other forms of care where possible. “People get around the hypocrisy,” she says.

Mofokeng says there is little available data for South Africa on the healthcare impact of safe and varied family planning options. “What you will find are government stats around how many people are on family planning. You will not find stats which tell you how many of those experienced contraceptive failure and what were the issues,” she says.

“Abortion is a part of family planning and for as long as it is treated as if it is a procedure reserved for those ‘deserving’ – usually women who have been raped or undergone some other form of trauma – it means we are further stigmatising people. Contraceptive roll-out is great, but you also have to respect people’s autonomy and choice with the contraceptives available. Quality options are important to ensure adherence, but also a better side-effect profile. The burden of family planning often falls on women, yet when things go wrong men suddenly want to have a say on what happens to women’s bodies. The need for abortion will never go away, even with the best contraceptive roll-out. The issue is: how do we make it safe and accessible for all?”

Currently, Mofokeng’s goal seems distant. It’s been estimated that the gag rule will cause a loss of around $600-million in funding, although She Decides has managed to drum up $190-million in alternative support. Meanwhile, Marie Stopes International has predicted – based on empirical research by Stanford University following the Bush regime – that the gag rule will drive more unwanted pregnancies, more unsafe abortions, and more deaths of women and girls. The Stanford study, in fact, found that abortion rates went up by 40% the last time the gag rule was in place. MSI, for its part, has estimated there will be an additional 2.2-million abortions each year worldwide, 2.1-million of which will be unsafe.

The trouble, says Stevens, is that aid-dependent countries “know where their bread is buttered”, which is why, even if we can’t accurately count the cost yet, we can take an educated guess. “You’re not going to get the people like the main social justice and treatment bodies in South Africa making too much noise, because they know where their bread is buttered,” she says.

“We’ve got to fight the big fight. There’s an agenda. And too often, women are not on the agenda.” DM

Photo: Vice President Mike Pence (L) and Speaker of the House Paul Ryan (R) applaud as US President Donald J. Trump (C) delivers his first address to a joint session of Congress from the floor of the House of Representatives in Washington, DC, USA, 28 February 2017. EPA/JIM LO SCALZO / POOL

Read more:

• How the Global Gag Rule undermines US foreign policy and harms women’s health


• The impact of the Global Gag Rule on Ghana


• MSF deeply concerned about dire implications of the US Global Gag Rule