The U.S.' Grades on Global Sexual and Reproductive Health and Rights Policy Are In...

Every day in the U.S., there seems to be a new attack on reproductive health and rights. Still, it is important to remember that the U.S.’ policies also impact sexual and reproductive health and rights for populations abroad. Bergen Cooper with Center for Health and Gender Equity (CHANGE) sits down with us to talk about their organization’s Sexual and Reproductive Health and Rights Index, which grades the U.S. on its international reproductive health policies.

CHANGE’S organization’s Sexual and Reproductive Health and Rights (SRHR) Index was launched one year ago, and the grades for 2018 have recently been released. It is an index that grades the U.S. government’s commitment to sexual and reproductive health and rights through global health assistance. These grades are to the overall U.S. government, the White House, Congress, the State Department, the Department of Defense (DoD), the U.S. Agency for International Development (USAID), and the Department of Health and Human Services (HHS). These actors are graded on the areas in which they work, including domains like HIV/AIDS, maternal and child health, and family planning. Through a series of questions that take into account whether the policy was drafted in response to need, is evidence-based, or is gender-transformative, CHANGE grades these actors on critical SHRH areas and decides whether actions taken by the U.S. government help or hinder global reproductive health efforts.

Since the beginning of the Trump administration, the U.S.’ commitment to global health assistance abroad has dwindled severely. HIV/AIDS commitments have remained consistent, whereas family planning has taken a hit over the past three years due to the global gag rule. Because of the global gag rule, the White House’s grade has plummeted to an ‘F’ in the SRHR index. When the State Department released their 6-month review and a FAQ document in partnership with USAID which ignored a substantial body of evidence about the negative impact of the policy, these agencies grades dropped, as well. 2019 grades will be released in the Spring of 2020.

CHANGE is also a leader in researching the global gag rule and its impact. While the policy was introduced to decrease abortion rates internationally, it is associated with a 40% increase in abortions. This is due to a lack of funding which results in a lack of contraception and sex education.

Links from this episode

Center for Health and Gender Equity (CHANGE)
CHANGE on Facebook
CHANGE on Twitter
CHANGE’s SRHR Index
Global Gag Rule Two Years In: What Are We Seeing?
Vindication of Pleasure

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: Hi everybody and welcome to this week's episode! We are going to look at some of the things that have been happening in the international arena. We have spent a lot of time, I feel like recently focusing on what's happening in the domestic sphere because there's been a lot happening and everything's kind of on fire right now, but there's been a lot happening in the lot that the U.S. is doing internationally as well. It was a great opportunity to talk to the fabulous Bergen Cooper about CHANGE’s sexual and reproductive health and rights index and it grades the U.S. government on how they're doing. So that brings me to the amazing Bergen Cooper. So Bergen is with CHANGE and I am lucky enough to be at her place today and getting to talk to her. Hey!

Bergen: Hey Jennie. I am so glad you're here and I'm so glad we're starting the podcast recording and apologies to your audience because otherwise I would've just kept you here hanging out all day before we even got to this part of the show. So glad to have you in Brooklyn.

Jennie: Yes. It's so nice to be here. It's, it's kinda nice out today.

Bergen: Yeah. You know, we have the Christmas decorations. We're feeling the warm.

Jennie: Yeah. It smells like Christmas in here, y'all. It is like cinnamon and pine and just delightful.

Bergen: Well, we aim to please here.

Jennie: Yeah, I feel like the holidays are everywhere. Maybe I'll finally get in the mood.

Bergen: There you go. New York city will do it for you.

Jennie: Okay. So let's talk about changes, new Sexual and Reproductive Health and Rights Index. Bergen: Yes. I'm so glad you asked about it. We are so excited about this index. So we launched it actually about one year ago today, this month. Uh, we launched it last December and we just released the grades for 2018. So before I tell you about the grades, I should probably tell you a bit about what it is. The Sexual and Reproductive Health and Rights Index is an index that grades the U.S. government's commitment to sexual and reproductive health and rights through U.S. global health assistance. So we grade the actors who have a role in us global health assistance and we grade them within the areas, what we call domains that they work. So the actors that are getting grades, the overall government gets a grade and then the White House gets a grade, Congress gets a grade, and then four different agencies get a grade -- State Department, USAID, Department of Defense and Health and Human Services. And they get grades for the areas in which they work. And those domains are HIV and AIDS, maternal and child health and family planning. Now I was calling it the SRHR index, right. And I'm just talking about HIV and MCH and family planning and what's really cool about this index is the methodology. So…

Jennie: I love that you're smiling when I say that. You don't know Bergen, you don't know that like this… the smile on her face, like the excitement to talk about the methodology…like she's so excited.

Bergen: I just know it. I'm really happy. I'll, well for this joy I have to thank our team at the Global Women's Institute at the George Washington University. CHANGE was so lucky to partner with GWI to develop this methodology because we had to figure out how do we grade the government on SRHR when the government works in these silos. And for that we came up with this fantastic set of cross cutting issues. So for every policy or budget or let's just call it an action, for every action that one of those actors takes within a year, we ask four questions of that action. We say, is this based in evidence? Is it situated within internationally recognized human rights norms? Is it responsive to need and is it gender transformative? So by asking those questions, we can look at say a program that's intended to reach the general population. When we asked those four questions, we're able to say, well, where is abortion here? Where is work around gender based violence? How is this reaching LGBT populations? How does it reach people living in a rural area versus living in an urban area? What about people with disabilities? Where are their needs and rights reflected in this programming? These cross cutting issues allow us to look at every single action that happens under U.S. global health assistance and then come up with a score and that score ,we ask does this action promote or hinder sexual and reproductive health and rights? And we do that for each action that happens throughout the year. And then again, thanks to our amazing team at GWI, we are then able to calculate all of this to come up with an actual letter grade. So U.S. government getting its scorecard, getting its report card every year.

Jennie: Well, I can only imagine with all of those amazing categories and actions, you look at that the U.S. is doing amazing, right?

Bergen: Oh well I have some sad news for you, my friend. So I mentioned that we launched it last year. Well, last year we launched the grades for calendar year 2016 and calendar year 2017 and just last month we released the grades for 2018 so that was the last year of the Obama administration and the first two years of the Trump administration, as I'm sure you can imagine, those grades went down each year. Let me tell you about it. HIV and AIDS is the domain that across all three years across all three actors consistently has the highest grades. There is the program under the state department, PEPFAR, which is our HIV and AIDS programming through global health assistance. And PEPFAR is routinely evidence-based and responsive to need and situated within internationally recognized human rights norms and gender transformative. Now, not always, not every program, not every action, but generally you're going to see higher grades in the HIV, uh, domain. Now, family planning has certainly taken a hit over the past three years. And can you guess why?

Jennie: Oh gee, I have no idea. I feel like I might've heard of this thing called the global gag rule.

Bergen: The global gag rule. Yes, indeed. So I know you've done some great shows on the global gag rule.

Jennie: Always useful to do a refresher.

Bergen: Awesome. All right. I'm sorry for the stands out there who already know this word for word. When president Trump took office through…Jennie just shivered.

Jennie: Still hearing those words together…

Bergen: I know, I know. Well, in the early days of this current administration, the president enacted a presidential memorandum and that was called protecting life and global health assistance. We refer to it as the global gag rule. I'm going to use global gag rule today. So what this says, it says if you take us global health assistance, you cannot provide refer counsel or do advocacy for the liberalization of abortion as a method of family planning. There are exceptions for cases of rape, incest, and life of the mother. Life of the mother is the language that's used in the presidential memorandum. Otherwise, I'd say life of the pregnant person. Now, this policy was in place under previous Republican administrations. Sometimes we talk about it as the light switch or Republican administration turns it on. A democratic administration turns it off. But this, this version is different. So this version applies to all of global health assistance. While in the past it applied to family planning. So it applied to let's say roughly $600 million in the past. Now it applies to about 8.8 billion.

Jennie: That is a huge, huge change.

Bergen: Yeah, and so we can talk more about the global gag rule, but I want to go back to the index to talk about how the grade fell. So remember I was talking about these cross cutting issues. Well family planning is kind of the perfect storm for these issues when during the first year of the Trump administration. Because if you think about the global gag rule, that is not evidence based. In fact, when the policy is in place, abortions rise for up to 40% that's new data from Stanford University on abortion rates in sub Saharan Africa. So it's not evidence-based. It is certainly not gender transformative. It is not sensitive to gender and it is certainly not responsive to need. Now, the other thing that we ask ourselves when we greet as we ask about budgets, when the Trump administration came into power, they suggested zeroing out the family planning budget and they defunded UNFPA. So all of that stuff happens under the family planning domain. So the White House is grade plummeted to an F and not just like you're 59 F, a low F. and I make that point because there's this really fantastic part of the website where you can go and you can click on a button called actions and impacts. And on that page you can say, well, what would happen if the global gag rule were eliminated? What would happen if, say the White House rescinded the presidential memorandum, or if Congress enacted legislation that ended the global gag rule, you could see how an actor's grade would change if you did that in 2017 the White House is grade went from an F, it's just a higher F because if you're proposing zeroing out the family planning budget line and you're defunding UNFPA, there's still a lot of bad that is happening within that domain. So that's certainly some of the, the grades that went down during that time. The grades continued to go down from 2017 to 2018 in a, in a kind of surprising way. The global gag rule continues to have impact on actor's grades, but this year we're looking at different actors. An actor can only be graded on what's within their control. So in 2018 you see the actor's grades go down under agencies, so state departments grade goes down and USAID’s grade goes down. And that is also associated with the global gag rule because this is the time when the State Department released their six month review of the impact of the policy. This review…

Jennie: I mean if you can't tell, review is in heavy air quotes.

Bergen: Yeah. I struggle to understand what methodology was in place, uh, that allowed the State Department to report findings that they reported.

Jennie: It's cute that you thought there was a methodology.

Bergen: I mean, I have to believe, I have to have hope. So this review ignored a substantial body of evidence that has come out on the impact of the policy. Uh, and then State Department and USAID also came out with frequently asked questions about the policy, uh, helping prime partners. And then for prime partners, those prime partners are the ones who get the money from the agencies and implement programs. Those prime partners often give money to what we call sub prime partners. And it's the role of the prime partner to explain the policy to the subprime partner. So these frequently asked questions. It's a document that's intended to help the prime partner and then help the prime partner help the sub prime partner. There is so much information that is lacking in this document in terms of what organization not only can't do under the policy but what they can do under the policy. Yes, it is a free speech restriction but there is still a lot of good work that organizations can be doing and the State Department and USAID failed to acknowledge that work. And so their grade went down in 2018. I mean, I wouldn't say it's surprising, but it's not. So that brings us up to the newer or it wasn't the newer, yeah, 2018 was the new report card and the 2019 grades will come out this spring moving forward that come out every spring. So we work on the calendar year. So the actors are graded based on their work from January through December. So we just have to finish up 2019 and then we'll be able to grade it. But you know, I was thinking this is, this is going to air on December 17th right. So that's the international day to end violence against sex workers.

Jennie: Oh good. I'm sure they're didn't get in that area.

Bergen: Well, yes. So this is one of the interesting things about creating an index. When you create an index, you need a baseline. You need to think about all the policies that have happened in order to grade the policies moving forward. So to do that, we created every policy or out, again, like I said, an action from 1961 to 2015 the SRHR index is your one stop shop for everything related to U.S. global health policy. You can come to the website, you can download every single PDF of every action that we've graded. And now there's rationale so you can read about why each action got the grade that it got. And I just, you know, I love having this historical database where you can find everything that you…it’s kind of like a citation dream.

Jennie: Yeah, for sure. Just nerding out real hard.

Bergen: Um, so in 2003, that was the creation of PEPFAR Congress, Congress enacts PEPFAR and, and, and there's so much good there. PEPFAR is a wildly, wildly successful part of the U.S. government that works on HIV prevention and treatment and care. But there was also something in the creation of PEPFAR called the anti prostitution loyalty oath. Sometimes we call it the APLO. Sometimes we call it the pledge. And what the pledge says is if you are a foreign NGO and you take PEPFAR money, you need to have a policy explicitly opposing prostitution. So let's say there is an organization that works on decriminalizing sex work and perhaps they are working on decriminalizing sex work for reasons situated within human rights or perhaps they're working on decriminalizing sex work because for public health reasons, the decriminalization of sex work could avert new HIV cases by 33 to 43% over the next decade. Uh, so huge. It's huge. It's huge. This data was published in the Lancet, I gosh, maybe about four years ago. And so, so there's many reasons why organizations and individuals would work towards decriminalization. They are working for decriminalization because of the pledge, then they would not be able to take PEPFAR money. And so I think about this airing on that day and, and, and how these harmful policies can contribute to violence against sex workers around the world.

Jennie: Absolutely. Yeah. No, they clearly go together. So we should go back and talk about some of the department grades. And I think there's some that people maybe for sure don't think about when you think about sexual reproductive health and rights. And one of them was the Department of Defense. Do you want to talk a little bit about that?

Bergen: Absolutely. So the Department of Defense does have a role in U.S. global health assistance. As I said, we only grade actors on what's within their control and not every actor works within every domain. Department of Defense is an actor which works in the domain of HIV and AIDS. That might mean they are working with militaries in different countries and doing HIV prevention work. There is something in the index called a transparency grade. So the U.S. government should be transparent about what it is doing with taxpayer's money as it applies to global health. So that means you should be able to go to a website, a government website, and find out what that agency is doing. And if you cannot do that, the index will lower the transparency grade. So that means that there are perhaps agencies that are doing good work, but we don't know about it.They are not putting that information out to the public. The Department of Defense is one of those agencies. As you can imagine, the Department of Defense is not entirely transparent. Um, and so their grade is, is routinely low. The transparency grade really does bring down their grade. Now 2018 was an interesting year. Their grade actually went up a little bit in 2018 yes. And that's because they were able to show some of the work that they were doing around HIV and AIDS. And again, this is, you can go to the website, you can download the PDF, you can see how and why they were graded in that domain. But, but this is an agency whose grade went up a little bit and that didn't really happen so much in 2018 everybody else's went down. Yes, yes. Well Congress also went up…

Jennie: Oh, I forgot that was one of your measures. I was so focused on agencies that I forgot that Congress was one of your measures.

Bergen: Yes, yes. So Congress, that grade did go up in 2018 and as I said, budgets matter. And so Congress appropriating sufficient funding in these domains certainly helps their grade.

Jennie: We will make sure to include links to the report so everybody can see it. It's a great website. It's a great tool. Make sure to check it out, but also Bergen, you should tell people where it is.

Bergen: You can find the index at srhrindex.srhrforall.org

Jennie: Great. It will also be included in our show notes, but it's important to also just include it while we're talking. Okay, so now we're going to talk about Bergen's other hat. So I talked about that Bergen is a researcher and another area that she is spending a lot of her time online is doing research around the global gag rule. Do you maybe want to talk a little bit about that?

Bergen: Yeah, absolutely. CHANGE is very lucky to co coordinate a global gag rule research working group. We coordinate that with our friends at Columbia University's school of public health and this is a group of researchers from around the world who are documenting impact of the policy and we coordinate what types of research we're doing, where we're doing it, when we're doing it. You know, this is a policy that has been in and out of existence since the early eighties and still we do not have the breadth of data that I think we wish as scientists and advocates and policy makers. I recently completed a scoping review with two colleagues from CHANGE looking at what's been published on the policy and we found 43 articles that have looked at the impact of the policy. So that is a substantial amount of research. There always has been this evidence on the impact on coalitions, on advocacy, on abortion, on family planning, on different populations. And you know, as I said earlier, the policy is intended to decrease abortions, restrict access to abortion, when in fact it's associated with this 40% increase, this huge, huge increase in abortion. So, uh, I've spent time in different countries around the world looking at the impact of the policy and you see the impact in what may be surprising areas. For some folks. I was in, I was in Zimbabwe and I was meeting with an organization to get funding from the U.S. government under the DREAMS partnership. DREAMS is this public private partnership from the U.S. government that intends to and is successfully reducing incidents of HIV across a number of countries within sub Saharan Africa. Now, Zimbabwe is one of those countries and I met with this organization Roots and they had been doing economic empowerment. Economic empowerment is one of the areas which we know does reduce incidents of HIV and I was speaking to a handful of girls who had been in the program when it was funded and I asked them about what their life was like when they had DREAMS, the program, and what was like when the DREAMS program was no longer serving their area. They told me that when they had the economic savings club, it was a place for them to save money to work together. One girl told me, she said, now if I were to need enough money, get enough money to buy one sanitary napkin, I would need to sleep with two men to get that amount of money. So this is not about abortion. I mean the policy is about the U.S. government standing between a provider and a patient and telling the provider what they can and can't say, not because of what is medically necessary, but because of what the U.S. government has decided the providers should be able to say. It is a free speech restriction. When I was in Mozambique, I met with an organization which was an affiliate of the International Planned Parenthood Federation and International Planned Parenthood Federation is a huge organization that has affiliations all over the world and these organizations are losing so much funding because of this policy. I was in a rural area and the HIV prevalence rate hovers around 24% and they had just trained 600 community health workers and then lost their funding and had to let those workers go. So you're seeing this policy, it's losing jobs, it hurts the economy as well as it hurts health and of people around the world. So we were in Malawi in July and August of this year looking at global health assistance and I had the privilege of meeting with individuals from over 40 organizations over a number of weeks while we were there and we were not focused on the global gag rule. We were looking at all of global health assistance, but the global gag rule permeated our interviews and we saw what we call the chilling effect. We saw organizations afraid to speak to us and organizations would say, I can't talk to you because of the global gag rule. I am bound by the policy, which means I'm not allowed to participate in research. I am bound by the policy so I cannot talk to you unless I asked the U.S. government if I can talk to you now. This is incorrect. Organizations can of course share their experience and participate in research. So seen how the policy is halting research seen. That firsthand is deeply, deeply upsetting because we know that the policy is causing harm around the world and we now know that there are times that we're not even able to get the data on the harm because people are too scared to share it with us.

Jennie: I mean, I think that's definitely one thing that's really important to talk about. One, it's scary that we're not getting, might not be able to get some of the research that is needed because people are scared, but just the overall chilling effect that a policy like this has, it gets over implemented. People assume it covers things they don't get necessarily correct information from places and all of a sudden the policy which was already so full and detrimental in so many ways become so much more harmful and more detrimental.

Bergen: Absolutely. We spoke with an organization in the early months of the policy coming into place and they said to us, don't worry, we have stopped our adolescent pregnancy prevention program because of the policy. Now. That should not happen. The chilling effect also is organizations stopping themselves from doing work that they can and should be doing.

Jennie: Okay. So if you just want to maybe flush out a little bit why the abortions are going up. I think for us it seems so obvious, but I think maybe it would be helpful to listeners to just explain it a little bit.

Bergen: Absolutely. So when organizations lose funding, they lose funding for all the work that they're doing. That means that they lose funding for providing contraceptives. And so this research that came from Stanford University, what we're seeing is that it is likely that have less access to contraceptives and that is why the abortion rates are going up. Okay. I think that it's something that is important to clarify for people because I think it might not be completely intuitive to people who are absolutely and under a passenger duration of the policy. There was a shortage of condoms because the International Planned Parenthood affiliate was the organization that was responsible for bringing in condoms that were funded by the U.S. government. So when the U.S. government cuts off funding to trusted health organizations, they are cutting off access to condoms, to contraceptives, to cervical cancer screening to gender based violence prevention and treatment to health services related to tuberculosis to malaria. Again, they might present it as an abortion related issue. It is a free speech restriction that impacts all of health. Yeah, and I think that's something important that you touched on is it impacts trusted providers is you know the government also always says, well there's new people who can come in and fill that work, but you're talking about providers that people know and trust and go to and giving new money to somebody else that may not be in the area. It doesn't have those connections is not just filling that same need.

Jennie: Absolutely. You know, if for some reason you had to see a different doctor, would you know how to go find another doctor? Like would there be another one in your neighborhood that you could go to? I mean for us that's probably pretty easy.

Bergen: Yeah. There are areas who when they lose global health assistance and that clinic shuts down, there is not another clinic there to replace it. There is not another provider within the area. You talked about the trust that a patient has with their provider. Trust is so important and when you think about different populations and what services they need. Again, when I was in Mozambique, I met with an organization that ran a night clinic that served female sex workers and if they lose funding and that clinic closes, there is not another clinic that has the trust of the community. You need to have the trust of the community in order to be able to serve a community. So no, in many circumstances there is not another clinic or organization who can step in and do the work that was being done before. The policy and trust goes back to why global gag rule is so corrosive.

Jennie: Right? Can you talk about how it goes away? It comes back, it goes away and comes back, but trust doesn't just come back, right? Like this clinic closed. People aren't going to go back to it. Unless all of a sudden they have money and can open again.

Bergen: Exactly. Uh, again, uh, in Mozambique, those 600 health workers that we talked about when they lost their jobs, uh, I spoke to, uh, the woman who ran that clinic and she told me that they often hear from people who say, where are you? Well, why have you stopped coming to our community? Folks do not necessarily follow us global health assistance policy. And instead they think this is a clinic that I used to trust that used to come and help me and now they don't come. So how does the clinic and how does the patient and how does the provider, how do they all build that trust? Again, that takes a long time. So maybe if the next president takes this policy away, maybe if this policy is not in place in a year and a half from now, well how long is it going to take that clinic director to hire back those staff to get the funding, to train them to get back in the community? You know, it's not, it's not a problem that gets fixed quickly.

Jennie: Yeah. That's one of the things I really think about with the damage this administration is doing is these problems aren't going to be fixed overnight and it's going to be a lot of work to get back to where we were, which already was a space that we needed to be making a lot of gains on.

Bergen: Absolutely. I, you know, I do have a lot of hope. Um, hope is quite literally my middle name and I do have a lot of hope for U.S. global health assistance. The U.S. government has done some extraordinary work around sexual and reproductive health and rights. There are still brilliant people within the agencies, within the government, smart scientists, passionate advocates. We have the brain power to bounce back and we have created in incredible programs that can continue as long as they're funded, as long as they're rights-based, as long as they're gender transformative and as long as they're responsive to need.

Jennie: I mean, I feel like, or getting to a place of hopes that seems kind of like maybe we should stop over, but we always like to end with what can people do. So what can listeners do? How can we help?

Bergen: Yes. I mean I think we are ending with hope and ending with hope is good and you can live with hope and live with anger at the same time. Use it to energize yourself, learn about global health assistance, know what the U.S. government is doing in your name and speak out.

Jennie: Absolutely. Bergen, thank you so much for having me in your home.

Bergen: I'm so happy you're here. Welcome here all the time.

Jennie: We can talk about all the topics but also if y'all want to listen to another amazing episode, you should absolutely listen to the first episode I did with Bergen because it was something kind of outside what we normally talk about, but it is like Bergen's actual pet project that she loves to talk about more than anything and that's pleasure.

Bergen: Absolutely. Sexual pleasure is an important component of health and happiness. It is a normal part of your life and it should be embraced. It is science, it is life. It is happiness. So that is certainly a place to put your advocacy and energy.

Jennie: Yes. Okay. Make sure to check it out. Thanks Bergen.

Jennie: I hope you all enjoyed listening to this week's episode. I have a lot of fun talking to Bergen and I hope you all enjoyed it. Stay tuned for our next episode which will be out on New Year’s Eve and you can listen to an amazing conversation with me and Lauren Rankin doing a year-end review, so looking forward to that. Thank you everyone for listening. Please feel free if you have any comments or you want to reach out to us and talk about a topic you'd like us to cover or if you have any feedback, always feel free. You can email me at jennie@reprosfightback.com or you can always reach out to us on social media and we're at RePROs Fight Back on Facebook and Twitter and reprosfb on Instagram. Thanks and I will see you all next episode. For more information, including show notes from this episode and previous episodes, please visit our website at reprosfightback.com. You can also find us on Facebook and Twitter at RePROS Fight Back, or on Instagram at reprosfb. 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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