The Sound of Silence

"I am here today in the United States to testify about the impact of theglobal gag rule," declared Susana Galdos Silva, the co-founder of MovimientoManuela Ramos, a women's health organization in Peru that receivesfamily-planning funds from the U.S. Agency for International Development (USAID).This was last July. She was speaking, with full awareness of the irony, beforethe Senate Foreign Relations Committee. Only months earlier, Congress had votedto uphold the Bush administration rule that prevents Galdos from testifying athome.

Peru, where abortion is illegal, has the second-highest maternal mortalityrate in South America, Galdos told the senators, and unsafe abortions account fornearly one-quarter of it. "It is estimated that 60 percent of all pregnancies inPeru are unwanted," she said. "And 30 percent of all pregnancies end in abortiondespite Peru's restrictive law... . Every year, 65,000 Peruvian women are harmedto the point of needing hospitalization due to complications of unsafe abortion."

These are numbers Galdos would like to put before her own legislators--or atleast 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 isdevastating, says Susan Cohen, deputy director of governmental affairs at thepro-choice Alan Guttmacher Institute. Under the gag rule, they must "either giveup the [USAID] funding needed for services essential to women's health care orgive up the right to lobby and advocate for changes in the reproductive-rightslaws of their own country." Yet, as in Peru, reform of abortion laws may be justas essential to women's health.

The Center for Reproductive Law and Policy (CRLP) in New York is suing theBush administration, calling the gag rule an unconstitutional violation of thefree-speech rights of Americans involved in women's health work internationally,as well as a violation of international human-rights laws and the sovereignty offoreign governments. CRLP attorney Julia Ernst describes the difficulty of gettingGaldos or anyone else even to discuss the problem: "When CRLP asked her to speakout about the impact of the regulations on her work, she told us, 'I'd love totalk to you.' But then she held her scarf up over her mouth as though she weregagged. Even privately, with us, she was afraid." Galdos requested and receivedexplicit authorization from a U.S. court before she would testify on CapitolHill. And there she pointedly reminded the senators: "When I return to my countrytomorrow, I will again be silenced."

On his first official day as president--the 28th anniversary of the Roev. 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 receiveU.S. family-planning assistance, an organization must pledge that it won't useeven its own, non-U.S. funds to "actively engage in or promote abortion" or toengage in "activities or efforts to alter the laws or governmental policies ofany foreign country" concerning abortion.

Though the rule may appear to concern abortions exclusively, its impact isactually much broader. Indeed, the gag rule's long-tentacled reach extends intowomen's health and gender-equity movements throughout the developing world.Groups that depend on USAID funding have been scared out of providing evennonrestricted health services, such as treatment of septic abortions. And many ofthe world's most important advocates for women have been frightened away from thediscussions that advocacy requires.

Take the following interview with a clinic worker in Bangladesh. It waspublished in 1988 by the Population Crisis Committee, a multinational advocacygroup (now called Population Action International), as an example of the chillingeffect that the original Reagan gag rule had on local health organizations.

Q. Do you provide treatment to women who may be sufferingthe 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 hersomeplace?
A. No, we can't do anything. We can't tell her anything. She just has to goaway.

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 leta woman die?
A. I guess because if she gets taken care of, other women might follow herexample and do more abortions.

The Population Crisis Committee reported that in Bangladesh, as in manycountries where abortion was legal, shifting post-abortion care from U.S.-fundedorganizations to other clinics had diminished medical care and "reduced thequality of post-abortion contraceptive counseling and services."

What's more, the gag rule keeps U.S.-funded health care groups fromcollaborating with others concerned about reproductive-health issues in theircountry. "Imagine the United States government saying you can't talk to peopleabout your research exposing the causes of a disease in your country," CRLP'sErnst says indignantly. "The U.S. government is telling their partners overseashow to talk, or not talk, about their abortion policies. This undermines ... thedemocracy-building efforts the U.S. touts rhetorically."

No doubt some USAID recipients are overinterpreting the restrictions. But thefine print of the global gag rule is complicated and difficult to translate intoeven the first language of many countries, much less the third, fourth, and fifthlanguages spoken by indigenous health workers in remote rural areas. And theconsequences of a translation mistake are terrible. According to AdrienneGermain, president of the International Women's Health Coalition, family planningin Bangladesh is 80 percent to 90 percent dependent on USAID funding. Elsewhere,too, "there would be nobody to replace the funding" if American aid werewithdrawn. Worldwide, Population Action International calculates, the UnitedStates, despite cutbacks in recent years, is still the largest single donor offamily-planning funds to developing countries. Its $450 million infamily-planning aid this year amounted to more than one-third of grantsworldwide.

Gag and Spin

The Bush administration has tried to portray its reimposition of the gagrule as a necessary safeguard against federal funds being used for overseasabortions. But this is false spin. In fact, it has been illegal to financeabortions abroad with U.S. aid since 1973, when Congress first passed SenatorJesse Helms's amendment forbidding the practice--and no violation of thatprohibition 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'scomprehensive study of the first global gag rule. Its conclusion was plain: "Thereis no evidence that the curtailment of services by aid-supported clinics reducedthe number of abortions."

It's far more likely, in fact, that the gag rule, by reducing theeffectiveness of those programs best equipped to prevent unwanted pregnancies,will hurt the effort to lower abortion rates. Because the cultural and legalsituation in each country is unique, it is difficult to generalize, but theexperiences of individual countries can be eye-opening. In Turkey, for instance,where abortion is legal, programs launched in the early 1990s by the Ministry ofHealth lowered high abortion rates by coordinating abortion and family-planningservices. According to Susan Cohen at the Guttmacher Institute, offeringpost-abortion counseling and contraceptive distribution at the same sites whereabortions were performed resulted in a significant increase in contraceptive use.At one hospital, the proportion of clients using contraception after theirabortions jumped from 65 percent to 97 percent in only one year. "At the sametime," Cohen reported earlier this year, "the number of abortions performed atthat hospital dropped markedly, from 4,100 in 1992 to 1,709 in 1998."

Health experts say the success of this Turkish program could be replicatedeasily in the many other countries where abortion is legal and access tocontraception still limited. But not, of course, if the foreign-fundednongovernment organizations, which in many developing countries offer the onlyhigh-quality health-and-family-planning services available to most of thepopulation, are prohibited from coordinating services. In the meantime, the gagrule seems far more likely to undermine contraception programs in these countriesthan to reduce abortion rates--which is why many of its opponents wonder if thatisn't one of the Bush administration's purposes.

"Hospitals or clinics that provide legal abortions in India...are stilleligible...to receive U.S. funds for HIV/AIDS prevention or child-survivalactivities," Cohen pointed out. "That only family-planning dollars are deemed'fungible' and tantamount to indirect support for abortion...strongly suggeststhat the target is as much family planning itself as it is abortion."

"Make no mistake," said Senator Barbara Boxer, the California Democrat, at theSenate hearing. "The Mexico City gag rule is restricting family planning, notabortions."

The United States first added a family-planning component to itsforeign-assistance package in the 1960s, and ever since, it's been a bone ofcontention between battling domestic camps. Presidents, who have the leeway tointerpret the terms and conditions of foreign assistance, have weighed inaccording to their party's position on abortion, with Ronald Reagan, George Bushthe 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 hoursof the 1999 legislative session, Clinton was forced to accept a limited versionof the gag rule in order to get a Republican Congress to pay back-dues the UnitedStates owed the United Nations. However, he instructed USAID officials tointerpret the policy "in such a way as to minimize to the extent possible theimpact on international family-planning efforts and to respect the rights ofcitizens to speak freely on issues of importance to their countries.")

While American politics swings back and forth, international health officialshave followed a different trajectory. Their goal at first was to address what wasseen as a dangerous global-population explosion. The success of the USAID programwas to be measured in the declining fertility rates of developing countries. Andby this standard, the program was successful. Fertility rates in the 28most-populous countries receiving USAID funds have been reduced over the yearsfrom an average of more than six children per family to an average of just overfour. Up until 1994, that seemed good enough.

But when representatives of 179 nations gathered in Cairo that year to assessthe state of global-population programs, it became apparent that the focus onfertility rates was too narrow. In fact, research collected mostly by USAIDrecipient groups all over the world showed that many demographic accomplishmentshad been achieved by constraining rather than educating women--by abettinggender discrimination and ignoring women's health, so long as contraceptive usewent forward. This approach, health officials increasingly believed, was not onlyunjust; it was shortsighted.

One of the population-control programs scrutinized at the Cairo conference wasBangladesh's famous turnaround story. Dan Pellegrom, the president of PathfinderInternational, an intermediary group that advises recipients of USAID fundingabroad, says that Bangladesh, with a population of 125 million, is a specialcase. It has been one of the top recipients of USAID funding for decades, and ithas experienced what may be the most dramatic reduction in population-growthrates in the world, from 3.1 percent in 1975 to 1.8 percent last year. But otherssay that, before the Cairo conference, this was achieved at considerable cost toBangladeshi women.

Anthropologists Sid Schuler and Lisa Bates, who study family-planning programsin Bangladesh, say that before the Cairo conference health workers would go doorto door in poor communities offering or imposing whatever birth-control methodsthe health workers thought their neighbors should have: You've already had enoughchildren; take these pills. You're too ignorant for pills; we'll give you an IUD.The "clients" were rarely provided counseling, information, or even healthservices or facilities--just contraceptives. If something got confusing or wentwrong, these women were resourceless. Under the circumstances, it's notsurprising that maternal-mortality rates in Bangladesh continued to be among thehighest in the region.

The Cairo conference produced an international consensus that favoreddramatically shifting the focus of population-control efforts. Health officialsworldwide came to understand that the most enlightened--and in the long run, themost successful--family-planning programs would combine contraceptivedistribution with counseling, education, and political and social lobbying forwomen's reproductive and human rights. According to an analysis prepared by theUnited Nations Population Fund (the largest multilaterally funded source offamily-planning assistance worldwide), the "cornerstones" of population anddevelopment policies, after Cairo, were "advancing gender equality, eliminatingviolence against women, and ensuring women's ability to control their ownfertility."

Neither developing countries nor donor nations met the funding targets for theyear 2000 that they all had agreed to in Cairo. But programs around the world didchange. Many organizations in Bangladesh, for example, have begun promotingwomen's active involvement in making decisions about their health. And UNdocuments show that at least 76 countries since 1994 have reported liberalizingtheir laws and policies concerning women.

The progress is undeniable, but ironically, the changes brought on by theCairo conference mean that the global gag rule will have even graver consequencestoday than it did under Reagan or the elder Bush. Family-planning groups thatreceive USAID funds are now among the most influential players in nationalmovements advocating women's rights and reproductive health. The gag rule'schilling 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 itsability to run a training program for foreign journalists on reproductive-healthissues. No session dealing specifically with abortion could be scheduled. SaidErnst, who led one workshop: "The participants were aware of the fact that thetraining was sponsored by [a USAID-funded organization]. A USAID official was inattendance. Because of this, a pall was present during the meeting, with mostpeople--including the journalists--reluctant to speak about abortion even thoughI brought it up as part of my discussion."

One bright spot: Efforts by the pro-choice community are graduallymoving opinion in Congress. The Senate Foreign Relations Committee recently voted12-7 (with the support of several Republicans) to overturn the gag rule. In theHouse, sentiment has been shifting against it. On the most recent floor vote,last May, opponents came within eight votes of striking it. Thirty-threeRepublicans braved White House arm-twisting to vote against the gag rule. As thebrutal costs of Bush's policy become better understood, the gag rule is morelikely to be remembered as an embarrassment than as a moral triumph.