The Sound of Silence

"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

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 30 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 USAID 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

A. No, we can't do anything. We can't tell her anything. She just has to go

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 post-abortion care from U.S.-funded
organizations to other clinics had diminished medical care and "reduced the
quality of post-abortion 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 90 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 $450 million in
family-planning aid this year amounted to more than one-third of grants

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 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

The United States first added a family-planning component to its
foreign-assistance package in the 1960s, 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

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 USAID-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.

How Pro-Lifers Promote Death

When her husband ran off with another woman, Goma Bogati was left
destitute with three young children. Speaking to an interviewer from her prison
cell in September 1997, the 34-year-old Nepali described the events leading to
her arrest: After a few years with no sign of her husband, she began a romantic
relationship with a man living in her remote village. He promised her that he had
undergone a vasectomy. Some months later, Goma realized she was pregnant.

Nepal, which received about $8.5 million in family-planning funds from
USAID this year, maintains one of the most punitive abortion laws in the
world. Induced abortion is treated as a criminal act equal to infanticide, with
no exceptions--even in cases of rape, incest, or threat to a woman's life.
Researchers in Nepal say that 20 percent of women prisoners there are serving
time for abortion or infanticide. Nonetheless, Goma Bogati felt that she had to
terminate her pregnancy. She drank a full bottle of a medication meant for
animals that she bought without suspicion at a veterinary shop. When the medicine
induced no abortion, Goma's boyfriend pressed a heavy stone on her belly,
focusing on areas where he could see or feel movement. Yet this, too, seemed to

Desperate, Goma decided to buy more animal medicine, but as she walked to the
store she began hemorrhaging. She expelled her fetus in the middle of the road. A
passerby who saw Goma lying on the ground unconscious reported her condition to
the police.

Drastic and barbaric measures to induce abortion--swallowing hazardous
compounds, breathing in poisonous gases, inserting sharp sticks pasted with cow
dung or glass powder or toothpaste into the vagina, and even getting oneself
beaten with stones like Goma Bogati--are common in Nepal, where on average six
women die every day from unsafe abortions. Abortions, according to Nepali
statistics, accounted for fully half the country's extremely high rate of
maternal mortality (in total, more than 540 deaths per 100,000 women each year,
compared with eight deaths per 100,000 in the United States).

At the time she was interviewed, Goma had already served 15 months in an
overcrowded, unheated prison and did not know how much longer she would be
incarcerated. As is the case with many women inmates in Nepal, Goma's three
children, ages 10, eight, and five at the time of the interview, were in prison
with her. At this writing, there is no word of what has happened to them.

Goma Bogati's story was among the 80 collected by interviewers that have
helped convince the Nepali Ministry of Health to bring together health
organizations, human-rights advocates, journalists, and women's rights leaders to
collaborate on reforming the country's abortion laws. The Family Planning
Association of Nepal (FPAN)--the country's oldest and largest
reproductive-health NGO, which sponsors up to 30 percent of the nation's
family-planning programs--is spearheading this lifesaving effort.

But as FPAN's director, Dr. Nirmal K. Bista, told a U.S. Senate committee
this summer, FPAN had to give up its USAID family-planning funds in order
to do so. "This was by no means an easy decision," he testified. "It will have a
major impact on our ability to continue to operate reproductive health care
clinics in Nepal's three most densely populated areas." But under the Bush
administration's global gag rule, he explained, "we cannot engage in any advocacy
effort to legalize abortion--even if it is with our non-U.S. money and at the
behest of our own government."