Global Gag Rule

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Next week marks the one year anniversary of the reinstatement of one of the most pressing reproductive health issues today, the inhumane policy known as the Global Gag Rule, which undermines family planning efforts and threatens the health and lives of individuals and families abroad. Beirne Roose-Snyder, Public Policy Director for Center for Health and Gender Equity (CHANGE), talks to us about the dangerous impact of the rule.

Originating as the Mexico City Policy under the Reagan administration in 1984, the Global Gag Rule began as an anti-choice presidential memorandum that restricts who can receive U.S. global health assistance. The Global Gag Rule prevented foreign NGOs from receiving U.S. family planning assistance if they performed or promoted abortion, or advocated, counseled, or referred patients for abortion. Cutting off organizations from U.S. family planning meant clinics had to cut back on services, hours or even close all together.

Since the beginning, the Global Gag Rule has been consistently implemented and removed by various conservative and liberal presidents. On January 23, 2017, Donald Trump issued a presidential memorandum that not only immediately reinstated the Global Gag Rule, but vastly expanded it to include all of global U.S. health assistance rather than just family planning- meaning, instead of $600 million being impacted, $9 billion would be subject to the new Global Gag Rule.

The Global Gag Rule puts family planning and reproductive health groups like Marie Stopes International (MSI) and International Planned Parenthood Federation (IPPF), among many others, in an impossible situation of choosing between the comprehensive care they believe women deserve versus adequate funding to serve more people. 

*Please note: since recording this podcast episode, Marie Stopes International has since updated their projections. Here are the new statistics:

By 2020, more than 2 million women will go without access to MSI services. This will result in:

• 2.5 million unintended pregnancies

• 870,000 unsafe abortions

• 6,900 avoidable maternal deaths

Links from this episode

Center for Health and Gender Equity on Facebook
Center for Health and Gender Equity on Twitter
Information on H.R. 671
Information on S.210
Marie Stopes International
International Planned Parenthood Federation

 Transcript

Jennie: Welcome to rePROs Fight Back a podcast on all things repro. I'm your host Jennie Wetter. In each episode, I'll be taking you to the front lines of the escalating fight over our sexual and reproductive health and rights at home and abroad. Each episode, I will be speaking with leaders who are fighting to protect our reproductive health and rights to ensure that no one's reproductive health depends on where they live. It's time for repros to fight back.

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Jennie: Today on rePROs Fight Back, we're going to do a deep dive into the global gag rule. For that I'm going to be talking with Beirne Roose-Snyder, the Director of Public Policy at the Center for Health and Gender Equity Change. And I'm so excited that Beirne is here. So thanks for joining me.

Beirne: Thanks for having me.

Jennie: So let's start like at the beginning. So what is the global gag rule and where did it come from?

Beirne: Well, the global gag rule comes from 1984 and from President Ronald Reagan who announced this new policy in Mexico City at the Conference on Population and Development there, it's also called the Mexico City policy, uh, and has been historically. Advocates call it the global gag rule. And in the Trump administration, as they've expanded it, we've, they've rebranded at the Protecting Life in Global Health Assistance for sort of ease of all, all of us. And we're advocates, we'll call it the global gag role, but it started in '84 and it's gone on and off with each Republican and Democratic president since then.

Jennie: The global gag rule. Its kind of is an example of what the policy does. So let's kind of talk about why advocates call it that.

Beirne: Well, so the global gag rule is a presidential memorandum. It's not a law. It's not, it's, it's something that comes straight out of the White House, uh, which is why it's identified with presidents rather than congresses. And it's a policy that restricts who can receive US money. It's not about what can be done with US money. We have a lot of different laws and regulations and policies that go into that. But this is about who can get US global health assistance. And historically it's attached to international family planning funds. So that sort of 4-500 million dollar investment in helping women and girls around the world control their fertility and have the families they want to have. Um, it's, you know, it's one of our great, uh, global health programs and it has in Republican administrations had this policy attached. And the policy says if you receive international family planning money, historically, you cannot provide, promote counsel, refer, or advocate around abortion as a method of family planning. And unlike other places in US law, we define abortion as a method of family planning in the global gag rule. And it's defined as for the purposes of spacing births, and it only excludes abortion in the cases of rape, incest and life endangerment. So any organization receiving international family planning funds cannot anywhere in their portfolios be providing counseling, referring or advocating around changes in abortion laws as a method of family planning. The giant caveat is that this only applies to foreign organizations. Because it is a gag, it is about what organizations can say and do with anyone's money anywhere in their organization. It is a, it would be unconstitutional as applied to US-based NGOs. So you and I as US-based NGOs can go, we could take US money, we won't, but we could take US money and go and with other people's funds, be promoting abortion, advocating, doing whatever with other people's money because we're US-based NGOs. It explicitly targets local foreign, national, non US NGOs with this policy restriction.

Jennie: That's also a really important thing that you mentioned there, that it's what you can do with other people's money. That there are already restrictions on what you can do with US money, but that this goes beyond and it attacks what you can do with money that other donors are giving you to do things that are priorities for them.

Beirne: I mean, so imagine your goal as an organization is to reduce maternal mortality in Uganda. You know, that uh, between six and like 13% of maternal deaths in Uganda are caused by unsafe abortion. You're trying to address this. Um, it's a high policy priority for you as an organization. You have money from other donors, private donors that you've worked with on, on grants over many years to sort of get that, get that funding to support your mission. Um, you're maybe working with another, a foreign government, someone who has this a priority. Maybe the Dutch government is supporting a program, um, or some advocacy. You also get US money for for health systems advocacy or providing contraception at 20 clinics or doing a couple of mobile units to with HIV testing and contraception to get too far off, uh, rural areas. You're getting US global health money there. If you continue to take the US money, you can no longer do all the other things you are granted to do if they involve advocacy around liberalizing abortion laws, if they involve counseling and referrals. So it's a real attack on other donors, on individual groups, autonomy and also sovereignty. Um, in a lot of countries this is a really important health issue. Um, all countries, that's an important health issue, but it's a priority in many countries. And, and this is really the US government saying, we don't care what your situation, your laws or your policies are. This is. This is what we want to buy you off from being able to do.

Jennie: It makes a huge difference because historically the US has been the largest donor for family planning assistance. So a lot of these organizations have to make a really tough choice to take a lot of US money, but refuse to provide services they think are important. I mean this is a really hard trade off for a lot of places.

Beirne: Yeah, certainly a lot of organizations, um, are put in in a pretty untenable situation of losing, losing important programming, losing their mission or losing US funds. And to be honest, I mean this is, this is what the White House wants. I mean it wants to put them in this position of needing to, to stop doing things that are important to them because of the, the value of us money. I think it's sort of important to note again that in the Reagan administration, the first Bush administration, the second Bush administration, this attached international family planning money, uh, it was incredibly destructive. But I think it, for certain people conceptually they could understand. We don't want to give to family planning groups that also provide abortion as a method of family planning. It's not really how health systems work and it's not how human rights work. But that at least is the sort of the tether that I think made it an easy political decision for politicians that identify as pro-life. What we know from the previous iterations of the global gag rule, there is data that we've been able to go back and sort of look at and health data and data on abortion is really hard to gather. So there's limitations and we also have not as a global community gotten a lot of support or funding to really measure the impact. But, uh, the impact we do know, um, just from the last iteration in the Bush administration is incredibly alarming, both for health systems and organizations, but also obviously on an individual, woman level of sort of ability to access family planning, ability to access HIV testing, ability to access a antenatal care. We know sort of in the last Bush administration, it prevented women and girls from accessing contraception as well as safe abortion that may have been consistent with the laws of their country, but they, they were still not able to access it. It has hampered HIV prevention efforts. It contributed to the closing of a lot of health clinics and in particular obstructing rural communities access to care. And I can sort of unpack that too.

Beirne: And I think most sort of gallingly because of the, the way that people frame the issue is it a, was associated with pretty significant increase in abortion rates. Which for people who understand what lack of access to contraception means, that's not a surprise. But I think intuitively for people who blindly support the policy because it's supposed to be pro-life, um, the idea that it would increase abortion and, and increase unintended pregnancy and the abortion, that it's increasing is unsafe abortion. And so that also means it's contributing to maternal death. And again, this is what we saw in the Bush administration. There's a couple sort of clear examples that sort of tell us how, how health systems work and how interconnected they are. And this, this notion that frankly we're seeing domestically now to the like, well, if we take money from this group, if we take money from Planned Parenthood, someone else will just provide those services. Like, no big deal. We're, we'll just give them money to the good people that we, that we like. The problem is that doesn't work in the United States and it really doesn't work in rural areas that are, that are highly underserved for health. So we saw in Ghana during the Bush administration, you know, the Ghana Planned Parenthood is a member of the International Planned Parenthood Federation, IPPF. IPPF had a massive cut about almost a 50% cut in their funding during the Mexico City policy and the Bush administration that gets passed down to to national level. The Ghanaian Planned Parenthood saw um, about a 54% cut in their funding. They had to close a huge number of clinics, mostly in rural areas where there are, because they're expensive to run, they're expensive to get to, they're expensive to get supplies to. And so what you really saw is women in rural areas losing all access to health services. And not just like the place they go to get family planning, but that may also be the place where vaccines are administered and may be the only opportunity to get condoms. It may be their only opportunity to get HIV testing, which again, I hate to draw the parallels but you know, is similar to what we saw in southern Indiana with, um, then Governor Pence's attack on Planned Parenthood. You saw a real health services desert that supported a really huge outbreak of HIV because there was no place to get tested, no place to get condoms, no place to get counseling and services. So we saw that in Ghana with a Ghana Planned Parenthood. We also saw, you know, this has huge implications for HIV even when it was attached to just international family planning funds. Um, in Lesotho the last year of the Clinton administration, Lesotho was receiving about just over 400,000 condoms from USAID as well as some depoprovera and IUDs. And the Lesotho Planned Parenthood Federation again is the only one with the sort of the a network, uh, be able to receive and distribute that number of condoms. Lesotho is not a large country. Um, it's kind of the size of Washington, DC. Like it's not, it's not big enough to have other organizations. And because the Lesotho Planned Parenthood was no longer able to receive them, shipments were just suspended. Um, so, so we went from 400,000 condoms to zero in the first, uh, year of the Bush administration. And at that time, one in four women in Lesotho were HIV positive.

Jennie: These clinics are in places that it's not easy to step in and fill that role. So you often hear advocates of the gag rule say, well, we'll just find other organizations, but you can't replace relationships with the community that these clinics have developed. Or in a lot of areas that are remote, you've seen a lot of groups developing really innovative things to reach people that are, you know, really far from the clinic, whether that's, you know, mobile service delivery or any number of things that just are not easily replaceable. So you're going to create this big gap in women's ability to access services.

Beirne: And on an individual woman level, the, you know, a break in care is, is potentially catastrophic. Whether it's there aren't condoms that week, let alone that year, or missing your, your depo shot. Uh, missing your other contraceptive moments. That can be the difference between a healthy pregnancy and not, a wanted pregnancy and not.

Jennie: So we've gone through eight years of no gag. What has changed in that time? I know the Obama administration had a real commitment to investing in family planning and some other things. So you know, going from gag to no gag. What have we seen in that time?

Beirne: That's such a good question Jennie, because that's sort of one of the under discussed catastrophes here is that the last eight years in the Obama administration were spent with a new vision on global health. The administration did something called the, it had sort of a commitment to, to global health integration and that included integration of health services, particularly HIV and family planning, but also maternal health nutrition. How can we be providing people with what they need at single sites or single moments? How can we be not siloing the health services that people need? Some of the other sort of, there was a something called USAID Forward, which was a new way, um, that does have flaws obviously, but a way of really pushing a, a slightly different view on how we do development. And part of that was several requirements about how much USAID money went to local organizations. So not large multinational, not US. And, and that didn't work out perfectly by any stretch, but what that means is a huge amount of money went towards local groups that do not have constitutional protections for the purposes of the global gag, but also maybe have the language skills, the community involvement, the cultural awareness to be really effective contributors to uh, to life changing global health programs. But you combine integration with local ownership and country ownership and a real focus from the Obama administration on women's centered programming and the things that we saw as huge successes and movement in the right direction during the Obama administration are now setting us up to have a much worse impacts from this global gag rule. And to also say that in same period during the Obama administration, but also before, since 1984 since the beginning of this, over 40 countries have liberalized their abortion laws. So the US, the USs impact on going against the national movement is much stronger now than it was before. We are, we are dragging countries backwards away from their own health and human rights priorities.

Jennie: That brings us to the giant elephant in the room, which is what has happened since the Trump administration took office on gag?

Beirne: So the Trump administration, um, I think advocates knew that this was coming. It happens with, with Republican administrations. I think those who know Mike Pence, uh, expected what happened on January 23rd, which was a presidential memorandum that immediately reinstated the global gag rule as previously applied to that international family planning money, that around $500 million in international family planning money, but then also directed the Secretary of State to expand it to all of global health assistance. That expansion is very, very hard to overstate what that means. The US is the largest global health donor in the world. It is a, you know, it's a minuscule, preposterous portion of our budget, but the good it's able to do around the world. We're currently supporting 11.5 million people on, on ARVs, so HIV treatment worldwide and that, and providing contraceptive supplies and commodities and counseling and support. I mean there are a lot of really good work happening and it is now all touched by the global gag rule. So the White House announced the expansion, uh, on January 23rd. The direction was to sort of figure out how far they can take it essentially. It started applying to international family planning funds in March. That was the sort of the first part of the presidential memorandum. And the expansion and how it would apply to the rest of global health assistance was announced in May. One of the things that makes this a really tricky thing to advocate around and talk about is that it's, it's a contract provision. It's not, there's not a big moment where everybody's in or everybody's out where funding gets slashed, where... There's not a big watershed moment for the most part. It is a contract provision that as organizations bid on new US global health money or have new funding moments in their existing contracts or their, I should say existing grant agreements and then it will attach And that sounds benign. It sounds small. It just sounds like, oh, this is like a contract thing, but what that actually means for an organization is when when all of a sudden they are going to have a new dispersal of funds or a new moment in which they are signing something new with the US government, they either are certifying that they no longer or have not or do not. They, they will comply and so that they will not provide abortion as a method of family planning, provide counseling and referrals for abortion as a method of family planning or advocate around abortion as a method of family planning.

Beirne: If they're a US group, while they themselves can continue to do all of those things with other money, they do have to pass it down to all non US groups with the money. So it's, it's like poison money and it attaches to the money and then poisons every organization it touches. So that poisoned money started coming out of international family planning in March and started coming out sort of early summer and now into the fall in all of our other global health programs. And to really say that scope of that is about 15 times the pot of money that it has ever previously applied to. We went from 450 million international family planning funds in the, in the Bush administration to $8.8 billion in global health money this year.

Jennie: And that's billion with a B.

Beirne: That's billion with a B to really I think really hone in on the scope. So South Africa, which is one country with a really complex and very, very challenging HIV epidemic, a priority country for PEPFAR, which is our President's Emergency Plan For Aids Relief, which is our largest global health program committed to ending the global HIV epidemic or at least doing the US's part. And um, PEPFAR money has, has been really, really important to South Africa. South Africa alone received $456 million in PEPFAR money this year. So one country is having the same amount of impacted money as all of the global gag attached to the last time.

Jennie: That's crazy to think about. And we're still at the time when the maternal mortality rate is quite high around the world and unsafe abortion accounts for not a insignificant amount of. And so this pro life policy, definitely in air quotes, could really cause a spike in maternal, not us, maybe not a spike, but it'll have an impact on the maternal mortality rate by denying women access to contraceptive care. Or if they're, if that group had really integrated their services and now had a maternal health clinic and HIV clinic all within one structure, I mean, and they decide that the best option for them is to refuse the US money, that means these women are losing out on this whole spectrum of care that they could have been getting before.

Beirne: And what we see is that, you know, organizations are, are being forced to make terrible decisions and do the absolute best they can with it. Um, and I think it's, I think it's really important to note it's not...signing the policy doesn't mean you agree with it. Groups are just being put in sort of untenable positions of how many people will lose, what kind of care if we do this, how many people will lose this kind of care if we did this. Really balancing body counts, which is a, just a horrifying position to put health care providers, organizations and the sort of advocates in is making that kind of call for external political reasons by politicians who are not accountable to the people that the policy hurts at all.

Jennie: Absolutely. So I know there's been some preliminary research done and again, like you said, this is kind of a contract. So it, it comes out in waves and it's not all implemented yet, but there have been some primary um, results we're starting to see as to what impact this expanded global gag rule is going to have.

Beirne: Yeah. And to say like, the limitations are, you know, we're not going to get quantitative data, um, for years and years and that's the kind of data that says x million women lost access to contraceptive care, this many people died. That we, that's very difficult data to get. Um, and well, it doesn't matter to everyone. It certainly matters to us. We want to make sure we're capturing things correctly. And, uh, before that though, you know, so we don't have that quantitative data and frankly we're still as a community working on mitigation of harm. We would rather get less terrible data because we did everything in our power to save people's lives and save people's health care, which I think is not necessarily something the White House understands. Um, you know, the, the goal of implementers is not to tell a story of catastrophe. The goal of implementers is to produce good health results and save people's lives. And so I think the majority of energy is going into that still now. I do think some of the early results, I mean the two big foreign organizations that provide huge amount of reproductive health care services globally are the International Planned Parenthood Federation and Marie Stopes International. Neither of them can certify. Abortion as a human right, abortion is a core part of their mission as an organization, as an organizations and they are unable and unwilling to certify. That right there just means a huge number of programs closing. MSI alone has really been a very important implementer for the US government in the last eight years. MSI's internal calculation of sort of what they have done with US money and if they are not able to replace US money, what will happen in the next four years is very staggering as a single organization operating globally, but with with four US contracts and grant agreements, but still just one organization. I mean their, their estimate for the four years of the Trump administration is that the global gag rule will contribute to at least 6.5 million unintended pregnancies, 2.1 million unsafe abortions and 21,700 maternal deaths. And that's, that's just them.

Jennie: That's just MSI. Yeah.

Beirne: Yeah. And I think for people who don't understand health care, the idea that the funding an organization no longer partnering with an organization could have that kind of impact is just sounds crazy. But when you're talking about rural Madagascar, um, what it takes to create a clinic, what it takes to get health professionals there, to have community health workers that are trusted to be able to really build the relationships needed for people to have the conversations about their most sort of intimate health needs, their desires. You can't really overestimate how much work goes into that and how challenging it is for them to be able to continue to do that work with other money. And so they will not be able to continue to do all of that work with other money. They're certainly doing their best to mitigate harm. But those programs, those clinics are going to close. And when women don't have access to contraceptives, there will be more unintended pregnancies. And when there are more unintended pregnancies, if women do not want to stay pregnant, they will not stay pregnant. And the result on that is usually unsafe abortion. And both pregnancies and abortion, unsafe abortion. We're talking about sort of backwoods, do it yourself. Um, anything that works or feels like it might work or your sister told you migh work or your Auntie said it would work, you know, unsafe abortion and unspaced pregnancies both are major contributors to maternal mortality. So even though it's staggering to hear that 21,000 or 21,700 maternal deaths could come from the cessation of MSI services in the next four years, for people who really understand the risk of pregnancy and the risk of unsafe abortion, um, I'm afraid it's not a huge surprise.

Jennie: You have to kind of shift your frame of mind thinking, okay, rural in the US means one thing, right? Like you have a car, you can, you have to drive an hour or two hours to a clinic. That's kind of what you're thinking. But that's not at all what we're talking about here. In a country like Madagascar, we're talking really remote areas, probably with very little vehicle access. And certain times of the year, none because of flooding or any other type of kind of a natural obstacle that makes it really hard for women to get to clinics, to access services. So if they lose their rural access to reproductive health services or just clinics in general, there's a really real danger that they're not gonna be able to go somewhere else to access that service. So they just won't have it.

Beirne: Yeah. And, and not to downplay the clinic deserts in the United States cause it's obviously a very, very serious problem as well. And the amount of energy that women have to go into to get bus tickets and schedules and you know, make it to a city four hours away is still a huge burden.

Jennie: And we will definitely be talking about that at some point on this show. So. Absolutely true.

Beirne: Yeah. But, but I, I mean you are talking about some other infrastructure challenges, communication challenges, um, and also autonomy challenges. I mean, we know that a lot of unsafe abortions globally are young women. We don't have great data on it, but we have really terrible anecdote on the correlation between sexual assault and then unintended pregnancy and then unsafe abortion for adolescent girls who are less likely to even be able to access the clinics even if there are clinics that remain. Youth friendly services is not just a buzzword. I mean it's what makes it possible for young women who are not married, who might otherwise face stigma and financial challenges to be able to access um, contraceptive care testing. Um, good information. The stuff that we know makes a real difference in people's lives. We've made some real strides on that adolescent friendly stuff, but we're not there yet. I mean it's still a big challenge. We've been, people have been working on what, what a mobile clinics look like, what a youth friendly sites look like. And a lot of those are the ones most likely to be closed now.

Jennie: So we talked about how the Obama administration really had an effort to localize services and to push grants out to a local providers. And so you see, you know, maybe that would mean um, sub grantees from larger grantees being local providers versus just going through a larger international group or domestic group. Now these groups have to implement this policy on their grantees. How is this affecting relationships with NGOs and the people that they are sub granting to?

Beirne: It is a lot of work and a lot of very unfun work. It's a even US based organizations that don't have to implement it themselves. It's a, it's a big administrative and compliance burden. The burden is put on people receiving US funds but also the prime partners if you're sub granting to check on compliance. And so that really changes your relationship and not to say, I mean we have very important pieces of legislation around informed consent around you know, good practices in family planning that that implementers are really used to knowing how to comply and also monitor compliance. And that's really important. So I don't want to suggest that sort of all compliance is a burden, but you're being asked to police everything every one of your sub grantees does with anyone's money. And for a lot of groups, we're in a time right now where they're getting their first, their first contract that has this in it and they're having to break off partnerships, long standing partnerships, realizing that when they do that, that 20 person organization is just going to close. There's, there's no alternative source of funding to their sub grantee. And they don't necessarily have another partner that they can find, um, who's, who has the credibility, who has the sort of meaningful relationships in the community, the language skills, whatever it is. It puts a big strain on the prime and sub relationships. But in some ways I think the, the places that we see the sort of the toughest relational work is actually within the advocacy communities. You know, we focus a lot on contraceptive access, HIV testing, access, the sort of the hard tangible supply and service provision. But this also wreaks havoc with advocacy. And that is a real intent to say that if you take any US global health money, you cannot participate and do any advocacy around changes in abortion law means that a maternal mortality coalition is going to be just splintered into pieces. Groups that take US money, will stop participating because you can't talk about maternal mortality without talking about unsafe abortion in most in most countries. And so maternal mortality groups, groups that have been working on, you know, the hard work that you and I do every day on talking to their members, their members of parliament, their ministries of health, trying to push for better guidelines, better guidance. You know, the hard work of advocating for clear, real access to abortion, even if it's in a very restrictive environment. That work requires collaboration. It requires trust. It requires getting stakeholders to see themselves reflected and, and that's being really fractured most. I don't know how that kind of advocacy is going to survive the Trump administration. In, in, you know, 60 countries around the world, which is really, and to say again, that is the goal. That is the goal from the White House. That kind of havoc and undermining of civil society and health priorities is in fact their goal.

Jennie: So talking about advocacy it makes me think of the groups that have made that hard choice to decide that they really need to keep providing. Have we seen a chilling effect? I mean that's kind of a little bit of what you're starting to get at, of groups being scared of even getting anywhere near abortion related issues because they're afraid to lose their funding.

Beirne: Yeah, and and to say this is something that is pervasive with US global health assistance because we do have some legislative parameters on what can and cannot be done with US money. Between that and the on again off again nature of the global gag rule, there is a bit of a global narrative that if you take US money you can't do anything on abortion. And that was not disrupted by the Obama administration as much as it should have been. But there are groups that knew and knew how to, how to work exactly within US law, exactly within US policy, how to navigate those parameters and still be able to do the work that they needed to do. The global gag rule, especially in its expanded, because it's touching so many new organizations. I mean we anticipate it's going to be touching well over a thousand new organizations, probably well over 1500. So it's actually a really hard thing to, to calculate and folks are working on it. But that's every new organization that's now having to start to think, oh my God, like what have we been doing? What can we do? And I think there's a real tendency to want to stay as far back from the line as possible, not be in the room for conversations about abortion, not uh, go to conferences if it's going to be discussed. Um, and, and USAID doesn't do anything to disrupt that. Um, the USAID is a very conservative by nature, um, agency and so they don't have an incentive to encourage people to work up to the line. Um, they really encourage the chilling, the fear, um, even within their own staff. Um, people are afraid to talk about the policy, let alone sort of talk robustly about what different pieces of it mean. Beirne: And, and perhaps the most important thing that advocates can be doing is talking about what can still be done. Talking about it in a proactive way rather than in a defensive way. Um, it is so important, especially in countries that already have restrictive laws for people and clinicians and implementers and USAID missions and other donors to know that you can still provide post abortion care. That you can be providing abortions in the cases of rape, incest in life endangerment, which may be the only legal ways to provide abortion already in that country. That you can be providing counseling and referrals in those circumstances. That you can be providing um, emergency contraception, which is actually a major conflation that's happening in some places because it was separately sort of a sideline during the Bush administration. And so a lot of people sort of think, well, if we're bringing back Mexico City policy, that must include emergency contraception, which it doesn't emphatically. And, and so I think really getting people and groups to focus on what they can and should still be doing is a really important piece of the on the ground work that needs to happen. Um, and will not happen by USAID.

Jennie: Yeah. And I mean, it seems like it, especially heavy lift this time around. Um, before it was the family planning groups and the family planning bureau at USAID, they knew the drill, they knew what was covered, they knew how to do things and now it's expanding to cover so many other bureaus and so many other groups that have never had to touch it before and are kind of having to quickly learn on their feet. Hopefully.

Beirne: Yeah. Hopefully. Yeah. I mean when we talk about global health assistance, the, the largest program is PEPFAR, the President's Emergency Plan for AIDS Relief. Um, but we're, this is also touching the president's malaria initiative, nutrition, maternal child health, all of the sort of pandemic work that we do. So it's a lot of new people, a lot of new actors who haven't necessarily had to give thought to this, particularly in the places where it actually runs up against their own medical ethics or their own law. I will say, you know, this is a pretty wonky side bit, but the expansion does include an affirmative defense that if you are required to provide counseling and referrals for more than just the three exceptions by your law, um, you can continue to do that and won't be considered to have violated the global gag rule. And that sounds super wonky, but it's incredibly important because there are, there's at least one country and potentially a couple others where you have an affirmative obligation to provide counseling and referrals for abortion in all in, in a variety of cases, larger than, than rape, incest, and life endangerment. And if you weren't going to provide, if you did not provide them as a health care provider, you would actually be legally liable. So we were setting up entire countries worth of health providers to violate their own law and basically putting them in a position where they would have had to face their own clients and their own courts saying the United States government paid me to violate the law, which is a untenable position and, and a really morally reprehensible one. But it's a very, very important for those providers, clinicians, implementers to really feel well versed in this. Again, it's a contract provision. It's not sexy, there's not good guidance. It's hard to understand and understanding it is not the primary aim of most of these groups. Their primary aim is nutrition ,or getting anti retrovirals to rural areas, hard work. That is their actual mission and they are not necessarily well versed in US contract law.

Jennie: So speaking of law, I know that you also happen to be a lawyer, so if you could switch and put your little lawyer hat on, if we can talk about are there any legal options to try and attack this vastly expanded policy?

Beirne: Not Silver Bullets. This is a particularly tricky place in US law because the people impacted are not constitutional rights bearers. Um, as far as the US court system goes. So we, there've been a number of court cases launched in the past, uh, 30 years. None of them have been successful. They have not been winning fact patterns, um, in, in a couple of different districts. I would say we have very smart people within the US community looking at what, uh, what a challenge might look like, but it is, it's not, it's not going to be a silver bullet. Um, it's going to be about US stakeholders. Um, which is, you know, an incredibly tough thing to think. Like, we know that women and girls lives are going to be lost. We know that health systems are going to be up ended. We know that, uh, national priorities are going to be undermined and none of those things are things we can sue about. So there is thought going into it. Um, I, I hope, you know, maybe in two years we can have a different conversation, but I don't, I think there's such a sense sometimes, especially right now in the US um, that like something wrong is happening, something terrible is happening, can't the court step in? And unfortunately, because of who is impacted, who and how they are impacted and how the policy is written, there isn't sort of a slam dunk court challenge.

Jennie: That's unfortunate. But hopefully we can see some progress moving forward. So I really like to end all of my shows on a hopeful-ish or positive note, or at least action oriented. So now that people are aware about this terrible policy, what can people do? What actions can people take to make a difference? Beirne: Really important question, both for morale, but also practically speaking, it is a policy that ruins people's lives that don't get to vote. So I think for a US audience, it's really important to know that we're doing this, that it's being done in our name and talk, talk to people about it. Uh, it is not something your members of Congress are hearing about a lot, except from people who say, well, it's pro-life, so, and we want you to be pro-life and we're pro-life so support it. Um, and that's a incredibly superficial level of thought for something that has so much impact on so many people's lives. So I think the most important thing is just putting it on your priority list. And I know we all have activism fatigue right now and we're focused on, on saving US clinics and, um, and doing other really important work. But just leaving a tiny sliver of your, your outrage for this notion that we're exporting an otherwise unconstitutional, really, really problematic, incredibly destructive policy for people to be able to win political points in the US and never have to see the catastrophes that are causing. So talk, talk to people about it. Is, is always a good start. And it's a basic start and it's an easy start. There is a piece of legislation called the Global HER act. It was introduced the day after President Trump did his presidential memorandum in January. It has an unprecedented number of, of cosponsors and is bipartisan in the Senate. It's, oh, it's called the Global HER Act. It legislatively ends the global gag rule. So it takes it out of the executive and says, this is not a thing that can flip back and forth. It is permanently ended. Um, I think supporting it, uh, letting your members of Congress know that you want them to support it is a really important, um, opportunity. But you know, if you're sitting in, um, in Kentucky or um, maybe northern Wisconsin or, uh, West Virginia right now thinking my member of Congress is going to vote pro-life no matter what and there's no way they're coming on this bill, I actually think this is like an amazing opportunity again, to disrupt that narrative that this is a, that this is a prolife policy. This policy is absolutely associated with increased abortion and increased maternal death. And your member of Congress needs to know that. And so calling them and saying, I know you support the global gag rule and think you're pro-life, but this policy is not pro-life is a really important message for them to hear from as many of their constituencies, constituents and constituencies as possible. Um, they are right now just they, they support it. Cause they've heard from some churches that say that this is prolife and it's not. And so even if they are members who truly are people of conscience who think they are doing the right thing, even if we know that that's not necessarily true, it's really important for them to know that it's not the right thing. Um, it's not pro-life, it's not reducing abortions, it's not saving women. It's not anything that's important in their frame. It's not actually doing that. Um, it's inefficient and it's increasing negative health outcomes and it's increasing abortions.

Jennie: And I can't overstate how important it is to call your member of Congress, particularly at an issue like this. They're not hearing from people on this and it won't take very many phone calls for this to get passed up and to get looked at. So if 10 of you call your congress, per your one congress person, they're going to take a second look at this. This isn't like healthcare in the US

Beirne: where you need a large number of phone calls. You only need a couple on something like this. And yeah, and again, a couple to make them look a little more closely, a couple to make them ask some questions. They're really not giving it thought right now. And the level of the lack of scrutiny from US policy makers on something that is catastrophic to health systems globally is very disheartening as as an American voter. Um, and I certainly want to make sure that my members of Congress are looking really closely. And even if they're incredibly anti-choice members, I want to dampen their enthusiasm for this policy. I don't want them to feel like it is a political win with no, no repercussions because it is, it has horrible repercussions for women and girls around the world and they at the very least need to know that.

Jennie: Well thank you Beirne this has been a great conversation. On our website, under show notes, I will have links to all kinds of things about global gag rule that you can check out. So thanks for listening and thank you so much Beirne for being here.

Beirne: Thank you for having me.

Jennie: For more information, including show notes from this episode and previous episodes, please visit our website reprotsfightback.com. You can also find us on Facebook and Twitter at rePROs Fight Back. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.

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