Will the US be globally stable?
Trump's "Mexico City Policy" or "Global Gag Rule"
Update from June 22, 2017
What is Trump's “Mexico City Policy”, also known as the “Global Gag Rule”?
On January 23, 2017, US President Donald Trump issued a "Presidential Memorandum Regarding the Mexico City Policy". This decree put the so-called Mexico City Policy back into force and even expanded it dramatically. Since 1984, various Republican presidents have breathed new life into this policy over and over again.
On May 15, Secretary of State Rex Tillerson approved the Protecting Life in Global Health Assistance program to implement this new policy. Since 1973, it has been illegal to use US funds for foreign development aid related to abortion.  The Mexico City Policy is an additional regulation that goes beyond that. It prohibits foreign organizations that receive US government funding for health programs from using their non-US funding to do the following:
- Performing abortions;
- Counseling patients on the possibility of an abortion or referring patients for an abortion;
- Commitment to the liberalization of abortion laws.
This policy is known as the Global Gag Rule because it tells organizations how to use non-US government funds. For example, healthcare providers are told how long they can talk to their patients. In addition, they are prevented from advocating for legal changes in the respective country.
Why is Trump's version so much worse than previous versions? Why do health professionals say the consequences will be devastating?
Under previous Republican governments, the Mexico City Policy's restrictions were specifically on US family planning funds about $ 575 million.
Trump's policy is now widening the restrictions all Funds for health care worldwide. That could be up to $ 8.8 billion for funding family planning, maternal and child health, nutrition and HIV / AIDS issues - including The President's Plan for Emergency Relief for AIDS PEPFAR , the prevention and treatment of tuberculosis, malaria (including the President's Malaria Initiative) , Infectious diseases, neglected tropical diseases, and even water, sanitation, and hygiene programs. 
The full effects cannot yet be foreseen, but they are likely to cause serious damage.
- As the largest health donor in the world, the US will hinder progress in health care.
- Women and girls in around 60 low- and middle-income countries will have less access to contraception, which will lead to more unwanted pregnancies and more - often unsafe - abortions.
- The restrictions will lead to higher deaths from unsafe abortions and more cases of unwanted pregnancies in places where maternal mortality is already high.
- Health programs that lose US financial support may also have to cut newborn, infant and child health benefits, including vaccinations. The same applies to the prevention and treatment of HIV and AIDS, malaria and tuberculosis, and nutrition programs.
- The restrictions make financial resources a tool to curtail the activities and freedom of expression of activists and health care providers in other countries, thus preventing them from sharing information about abortions or discussing potential reforms of abortion laws without the financial support the US to lose.
What does this mean in practice?
For example, a non-governmental organization spends 50 percent of its budget on sexual and reproductive health services, such as counseling, referrals, or other abortion-related services. This 50 percent is not provided by the USA. However, she receives the remaining 50 percent of her budget from the US for vaccinations of babies, nutritional supplements or the treatment of HIV / AIDS, malaria or tuberculosis. This organization must now decide whether to forego the US funds - and thereby lose half of its budget - or to cut its reproductive health services. If organizations submit to these guidelines, then they must also make funds available to meet additional reporting requirements.
In any case, health services in poorly served areas will suffer. In many regions, the affected organizations offer the only way to get these measures.
Why is sexual and reproductive health care so important?
Women and girls have the human right - protected by international law - to decide for themselves whether, when and how many children they will have. Unwanted pregnancies can lead to the impairment of other rights, e.g. if the girl concerned drops out of school, if it leads to a child marriage or health complications or even if the woman's life is in danger.
What do we know about the impact of previous versions of the Global Gag Rule?
Earlier versions of the Global Gag Rule meant that organizations that decided against US funding had to cut staff and benefits, and sometimes even shut down clinics. On the flip side, organizations that adhered to the restrictions in order not to lose their US funds reported they had been given a gag preventing them from providing their patients with complete and accurate information and from advocating for reform were allowed to use restrictive abortion laws.
For example, in 2009 Human Rights Watch documented that maternal health care funding in Peru had been severely impacted. Organizations were no longer allowed to be supported that used the funds to disseminate information about so-called therapeutic abortions or to carry them out if the mother's health is preserved or if it is carried out because of severe malformations of non-viable fetuses. A new study by the Kaiser Family Foundation has documented that nearly 40 countries that receive US support for health programs allow legal abortions on at least one indication that is not allowed under the Trump order. 
When family planning funds decline, it leads to more unwanted pregnancies, abortions, and higher maternal mortality rates. A study of the Stanford University examined national data from 20 countries in sub-Saharan Africa that were collected between 1994 and 2008. Accordingly, the number of induced abortions rose sharply in the countries that were hardest hit by the Global Gag Rule. In countries that were less affected, the number remained relatively stable. 
Are there any exceptions?
Trump's Mexico City Policy does not apply to humanitarian assistance, including state Department of State migration and refugee assistance, or Department of Defense disaster and humanitarian assistance. However, the Trump administration has stopped payments to the United Nations Population Fund (UNFPA), which provides vital humanitarian assistance in family planning and maternal health care. The US provided $ 69 million, of which $ 38.3 million was used directly for humanitarian crises. The USA was thus one of the largest donors of the UNFPA.
Other exceptions are basic research in the field of health, a program for schools and hospitals abroad and so-called “Food for Peace” programs. According to the Ministry of Foreign Affairs, however, the new policy applies to application-related, operational or programmatic research, data collection, needs analyzes and the associated capacity building to improve programs.
There are exceptions for abortions, counseling or referrals when life is in danger, for rape or incest, and for post-abortion treatment. This includes injuries from legal and illegal abortion. These exceptions also existed in the earlier version of the Global Gag Rule, but were not known, understood, or applied. "Passive transfers" - ie. a referral in response to a specific question from a pregnant woman who has already decided that she wants to have an abortion - is also possible if medical ethics so requires.
When and how will the Global Gag Rule come into effect?
The plan to implement the Global Gag Rule came into effect on May 15th. Implementation will have an increasing impact on the programs. The “standard provisions”, which make the restrictions explicit, are added to all new grants, cooperation agreements and grants within the framework of contracts or changes to existing financing agreements. The rule applies to organizations that are contractually guaranteed funds. However, what is known as an interagency group is still developing rules to implement the changes.
What can be done
The financial gap in facilities that provide comprehensive sexual and reproductive health services, including safe and legal abortions, needs to be closed and the facilities need support. In fact, Trump's Global Gag Rule will put some organizations in dire financial straits that provide world-class services in some of the worst-served regions and states. The United States is the world's largest financial supporter of health initiatives. The missing US funds will hardly be recovered, but it is now vital to replenish and diversify funds from other sources.
Some governments have made public commitments to stepping up sexual and reproductive health support without adding restrictions on abortion. The Dutch government has launched the international “She Decides” fundraising initiative to support organizations affected by the “Global Gag Rule”. The first summit on March 2, 2017, hosted by Belgium, Denmark, the Netherlands and Sweden, pledged around $ 190 million in funding.
In the long term, it is important that US funds in the health sector are made available reliably. It is unhelpful and counterproductive for health organizations around the world when US politics changes dramatically after each presidential election. A draft law in the USA, the so-called HER Act, would finally repeal the Mexico City Policy (Global Gag Rule). It is highly unlikely that this law will be passed in Congress and implemented by the current US administration. However, support for the design is growing and could be a sustainable solution for the future.
The "Helms Amendment" to the Foreign Assistance Act of 1973 prohibits the disbursement of US funds if they are used for abortion as a family planning tool.
 The so-called “President’s Plan for Emergency Relief for AIDS (PEPFAR)” is an initiative of the US government on HIV and AIDS. It is the largest part of the US President's Global Health Initiative.
 This concerns programs for water supply, sanitation and hygiene for households and communities. This does not apply to investments in infrastructure for water supply and sanitation, if specific households are affected, by schools, health facilities, for commercial purposes and national development programs.
 Eran Bendavid, Patrick Avila and Grant Miller, Stanford University, “United States aid policy and induced abortion in sub-Saharan Africa”, Bulletin of the World Health Organization 2011; 89: 873-880C, http: // www. who.int/bulletin/volumes/89/12/11-091660/en/ (accessed: June 2, 2017).
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