Sunday, January 11, 2009

Mr. Bush’s Legacy: The Global Gag Rule

The New York Times, Jan 3, 2009, has an editorial entitled “Mr. Bush’s Health Care Legacy.” Acknowledging that “This page has criticized the Bush administration’s weak performance on many important health care matters: its failure to address the problem of millions of uninsured Americans or stem the rising costs of health care, its refusal to expand eligibility for the State Children’s Health Insurance Program, its devious maneuvers to cut Medicaid spending, its support of unjustified subsidies for private health plans, to name a few,” the editorial goes on to laud his “achievements in health care”. The editorial names his work on proposing funds (increased by Congress to $50 billion over 5 years) to fight AIDS, tuberculosis and malaria worldwide and his pushing the Medicare drug-benefit program, Medicare Part “D”, despite their disagreement with “many features of the program – the refusal to allow the government to negotiate with manufacturers for lower prices, shortfalls in providing subsidies to low-income Americans, a failure to protect many patients from high out-of-pocket costs.”

I am willing to credit anyone, even George W. Bush, for anything that they do that is good, and I am willing to acknowledge that funding for fighting these terrible diseases and to help older Americans obtain prescription drugs are important. I will not add to the Times’ list of flaws in Medicare Part “D”, though they are very serious and could be expanded upon. I will point out that the current funding for fighting AIDS, TB, and malaria comes with strings attached, but it is also a very good thing. I do, however, want to focus on a particularly vile part of Bush administration policy that has had very destructive effects worldwide, the Global Gag Rule (“Mexico City Policy”) preventing any agency using any of its funds from any source to do – or counsel about – abortion from getting any family planning funds from the US Agency for International Development (USAID).

You may remember an effort by the Bush administration to impose such a "gag rule” domestically, that was thankfully unsuccessful. However, this policy has been in placed for international aid through all Republican presidencies since it was announced at the Mexico City Conference of the United Nations International Conference on Population by Alan Keyes of the Reagan administration in 1984. It was repealed by executive order by President Clinton in 1993, and reinstated by President Bush in 2001. Its effect has been devastating in the developing world, particularly in Africa and Asia, where local organizations have had to decide between losing significant portions of their funding (the International Planned Parenthood Foundation lost 20% of its funding) or not performing critically important family planning services to their clients. The impact of this rule are detailed at the website “The Global Gag Rule Impact Project is a collaborative research effort led by Population Action International in partnership with Ipas and Planned Parenthood Federation of America and with assistance in gathering the evidence of impact in the field from EngenderHealth and Pathfinder International. The Project’s objective is to document the consequences of the Global Gag Rule. The Project was initiated soon after the policy was reinstated by President George W. Bush in January 2001. While the missions of the collaborating organizations are diverse, we are united in our belief that policies governing U.S. assistance should be evidence-based and reflect proven public health practices.” Since much of the concern about AIDS revolves around sex, this restriction impacts much of the vaunted AIDS funding also.

Since there are many who support this rule because they are opposed to abortion, it is critical that the data supplied by those at and others, such as that of physician Isaiah Ndong, on the blog RH Reality Check ( are so important. These rules restrict information, about sex, safe sex, contraception, and, yes abortion. The result of the restriction of such information is that there is just as much (perhaps more) sex, more unsafe sex, less contraception – and no less, perhaps more, abortion. But the abortions are more unsafe, especially in countries in which, often influenced by the US, it is illegal. This is true not only in the Third World, but in the US and Europe – restricting access to abortion, and making it illegal does not make women have fewer abortions, it makes them have less safe abortions, and makes more of them die. This may not be what abortion opponents want to happen, but it is what does happen. And when funds are stripped for educational programs, again in the US as well as in the Third World, young people do not have less sex, but they have less-safe sex, and are more likely to contract and transmit STIs, including HIV. And they have more abortions.

The USAID funds available for HIV/AIDS, lauded by the Times, are also tied to “abstinence only” educational programs, similar to those supported domestically by the Bush administration. These programs, which hope to decrease STIs including HIV, and unwanted pregnancy (and thus, presumably, abortion) by teaching ONLY abstinence, are abysmal failures in every venue. Teaching abstinence as one, perhaps the best, method of not getting pregnant or sick, is a good idea; teaching only abstinence is cynical and disastrous. Other wishful-thinking-with-terrible-results ideas include “virginity pledges”; another study was just published describing its failure (from the abstract, bold mine): “Five years after the pledge, 82% of pledgers denied having ever pledged. Pledgers and matched nonpledgers did not differ in premarital sex, sexually transmitted diseases, and anal and oral sex variables. Pledgers had 0.1 fewer past-year partners but did not differ in lifetime sexual partners and age of first sex. Fewer pledgers than matched nonpledgers used birth control and condoms in the past year and birth control at last sex.” [i] A recent publication in the US demonstrates that People – including young people – will have sex, and will get pregnant, and will often seek abortions. There are only two things that have ever helped to decrease this are 1) comprehensive and accurate sex education, which at best empowers young people to only have sex when they want to and are ready, or at least provides them with the information to protect themselves, and 2) freely available safe abortion, so women do not die of septic abortion.

Finally, the ultimate irony. The factor most associated with economic and social development in a country is the educational level of its women. In many third-world countries women struggle against enormous barriers to achieve education. Unfortunately, it is often costly and often the only avenue open to earning money is prostitution. So our policies, rather than encouraging and supporting education of girls and women, make it likely that, should they get pregnant, they will either have to end their education, or risk their life having an unsafe abortion, or get HIV. Or all of them.

We can do better. We must do better.
[i] Rosenbaum JE, “Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers”, Pediatrics. 2009 Jan;123(1):e110-20.

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