Not without a fight: standing up against the Global Gag Rule

It is sadly ironic that as we celebrate International Women’s Day 2017, sexual and reproductive health and rights (SRHR) researchers, advocates and practitioners around the world are bracing themselves for the inevitable impact of US President Trump’s re-enactment and expansion of the Mexico City Policy, widely known as the “Global Gag Rule”. Yet, International Women’s Day also provides an important moment to recognise and reflect upon the commitment and tenacity that characterise the ongoing efforts of so many in the SRHR community as they unite against the Global Gag Rule, attempting to find new partnerships, new solutions, and new directions for their work. The Global Gag Rule is, unfortunately, nothing new. Since 1973, the Helms Amendment under the Foreign Assistance Act has prohibited US funding from being used to pay for the provision of abortions. In 1984, US President Reagan took this approach much further by ensuring that non-governmental organisations receiving US funding could not promote or provide access to – or even information about – safe abortion, even using their own funds. Doing so would mean the loss of US funding for any activity provided by that organisation. On 23 January 2017, in one of Trump’s first acts as President, the Global Gag Rule was reinstated. Unlike previous occasions, the new policy applies not only to funding earmarked to organisations that focus on reproductive health (approximately US$575 million in 2016), but to all global health assistance “by all departments or agencies” – an estimated US$9.5 billion. Given the weight of US international aid, the reenactment of the Global Gag Rule will come at a heavy cost, and will undoubtedly have an impact on services worldwide and, by extension, on women’s health, well-being and human rights. To illustrate with one example of an international actor on the SRHR landscape: Marie Stopes International estimates that without alternative funding, the loss of their services due to the imposition of the Global Gag Rule could result in 6.5 million unintended pregnancies, 2.1 million unsafe abortions, and 21,700 maternal deaths by 2020. During Global Gag Rule years under President George W. Bush, other documented impacts include staff lay-offs, disruptions of referral systems, clinic closures, and contraceptive and condom supply shortages amongst some of the world’s most vulnerable populations. The negative implications of the Global Gag Rule extend far beyond access to safe abortion information and services. In much of sub-Saharan Africa, the US Government provides significant funding for HIV prevention and treatment services through organisations that also provide sexual and reproductive health information and services, including in relation to abortion. Many organisations, particularly in lowand middle-income countries, provide a range of health services under one roof, including access to contraceptives, HIV services, sexual and reproductive education and counselling, immunisations, and maternal health screenings, alongside information or access to safe abortion care. Thus, the policy also has the potential to affect much broader public health programmes, including responses to the HIV epidemic, the Zika virus and other infectious diseases. In fact, the Global Gag Rule stands to reverse global progress in promoting integrated EDITORIAL

It is sadly ironic that as we celebrate International Women's Day 2017, sexual and reproductive health and rights (SRHR) researchers, advocates and practitioners around the world are bracing themselves for the inevitable impact of US President Trump's re-enactment and expansion of the Mexico City Policy, widely known as the "Global Gag Rule". Yet, International Women's Day also provides an important moment to recognise and reflect upon the commitment and tenacity that characterise the ongoing efforts of so many in the SRHR community as they unite against the Global Gag Rule, attempting to find new partnerships, new solutions, and new directions for their work.
The Global Gag Rule is, unfortunately, nothing new. Since 1973, the Helms Amendment under the Foreign Assistance Act has prohibited US funding from being used to pay for the provision of abortions. In 1984, US President Reagan took this approach much further by ensuring that non-governmental organisations receiving US funding could not promote or provide access toor even information aboutsafe abortion, even using their own funds. 1 Doing so would mean the loss of US funding for any activity provided by that organisation. On 23 January 2017, in one of Trump's first acts as President, the Global Gag Rule was reinstated. Unlike previous occasions, the new policy applies not only to funding earmarked to organisations that focus on reproductive health (approximately US$575 million in 2016), but to all global health assistance "by all departments or agencies"an estimated US$9.5 billion. 2 Given the weight of US international aid, the reenactment of the Global Gag Rule will come at a heavy cost, and will undoubtedly have an impact on services worldwide and, by extension, on women's health, well-being and human rights. To illustrate with one example of an international actor on the SRHR landscape: Marie Stopes International estimates that without alternative funding, the loss of their services due to the imposition of the Global Gag Rule could result in 6.5 million unintended pregnancies, 2.1 million unsafe abortions, and 21,700 maternal deaths by 2020. 3 During Global Gag Rule years under President George W. Bush, other documented impacts include staff lay-offs, disruptions of referral systems, clinic closures, and contraceptive and condom supply shortages amongst some of the world's most vulnerable populations. 4 The negative implications of the Global Gag Rule extend far beyond access to safe abortion information and services. In much of sub-Saharan Africa, the US Government provides significant funding for HIV prevention and treatment services through organisations that also provide sexual and reproductive health information and services, including in relation to abortion. Many organisations, particularly in low-and middle-income countries, provide a range of health services under one roof, including access to contraceptives, HIV services, sexual and reproductive education and counselling, immunisations, and maternal health screenings, alongside information or access to safe abortion care. 5 Thus, the policy also has the potential to affect much broader public health programmes, including responses to the HIV epidemic, the Zika virus and other infectious diseases. In fact, the Global Gag Rule stands to reverse global progress in promoting integrated EDITORIAL 14 © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group services and people-centred policies across health systems.
The Global Gag Rule will certainly hamper, and potentially reverse, gains in achieving the goals and targets of the 2030 Sustainable Development Agenda. Goal 5, for example, calls for the end of "all forms of discrimination against all women and girls everywhere". Women and girls will be most negatively impacted by the Global Gag Rule, further entrenching, rather than challenging, gender discrimination. Target 5.6 also calls for ensuring "universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences", while target 3.7 calls for universal access to sexual and reproductive health-care services by 2020. The full implications of the re-enactment and expansion of the Global Gag Rule remain to be seen, but with sexual and reproductive health and rights at the heart of so many issues central to the Sustainable Development Agenda, there is little doubt that it will have negative, cross-cutting impacts, particularly on the health, well-being, and empowerment of women and girls.
Further, there is no evidence that the Global Gag Rule has ever been effective in its goal of lowering abortion rates. 2 On the contrary, existing evidence from sub-Saharan Africa suggests the opposite is true, with abortion rates increasing during years when the policy is in force. 6,7 By putting ideology before evidence, proponents of the Global Gag Rule are undermining women's sexual and reproductive health and human rights. Inadvertently, they may also be contributing to increased rates of abortion. That a policy with consequences of this magnitude could be based on such a striking lack of evidence is illustrative of our "post-truth" era, in which policies are shaped and informed not by robust evidence, but by what have become known as "alternative facts".

Holding Ground in Difficult Times
Against this backdrop, it is more important than ever to acknowledge and celebrate the creativity, resistance, and perseverance of the SRHR community. In the wake of the reinstatement of the Global Gag Rule, civil society, NGOs, health practitioners, and government actors have taken a strong stance of opposition through joint statements and advocacy efforts to highlight the well-documented and profoundly damaging consequences of this policy in terms of both health and human rights. While the intention of the Global Gag Rule may be to force organisations to stop supporting safe abortion services, many international organisations are, fortunately, defying the policy by seeking alternative funding mechanisms to support their life-changing and life-saving work.
One emergent and heartening effort to provide a much-needed counterweight to this critical loss of funding is the "She Decides" initiative, launched through the leadership of Lilianne Ploumen, the Dutch Minister for Foreign Trade and Development Cooperation. In response to the reinstatement of the Global Gag Rule, "She Decides" provides a fundraising platform for the international community to help offset damage and maintain access to sexual and reproductive health and rights. Governments, organisations, and individuals can use this platform to improve access to contraceptives, accurate information, maternal care, and safe abortion for millions of women worldwide, particularly in low and middle income settings. The Netherlands launched the initiative with a US$10.7 million commitment, followed by matching commitments from Belgium and Denmark. Canada, Cape Verde, Estonia, Finland, Luxembourg, Norway, Portugal and Sweden have also committed to supporting the initiative. Most recently, on 2 March 2017, representatives from over 50 countries attended a Ministerial Conference in Brussels in support of the fundraising initiative, resulting in commitments exceeding US$190 million. 8 Individuals and civil society have long demonstrated the power of voices of protest: the 34 Million Friends Campaign to support UNFPA after losing US funding in 2003 continues to inspire. While such responses provide cause for optimism, the Gag Rule also reminds us of the precarious nature of global SRHR funding. It reminds us of millions of girls and women in low-and middle-income countries whose lives can, with the stroke of a pen, be so negatively impacted by shifting ideological tides half a world away. Without US support, it is unclear whether and how the SRHR community will be able to fill the hole left in sexual and reproductive health budgets around the world. Nonetheless, initiatives such as "She Decides" are a welcome -indeed criticalmodel for how to move forward.
We also know that in the absence of sustained political pressure, countries often fail to meet their own international aid commitments. It is imperative that all countries, including those contributing to "She Decides," are held to their commendable promises. 9 In the meantime, there will surely be impacts caused by disruptions or cancellations of critical sexual and reproductive health services and research while countries struggle to address the funding gaps. Questions also remain regarding the sustainability of donor commitments. Even if countries can rally together this year to raise the necessary funds, what then for next year? And the year after that? While these new commitments and fundraising efforts are encouraging, they also highlight the urgency of developing a long-term, sustainable and diversified funding strategy that is independent of the domestic political circumstances of any individual country.
On International Women's Day 2017, there is clearly cause for both ongoing, deep concern but also for celebration. The re-enactment of the Global Gag Rule will undoubtedly have devastating effects for millions of women and families around the world, with SRHR, including safe abortion care, also under substantial threat domestically in the US 10,11 Yet, it has also provided an opportunity for governments to step into leadership roles, and for new partnerships in the global SRHR community to develop. This is the moment for the international community to ensure that sustainable SRHR funding mechanisms are put in place to protect the rights of women, girls and families around the world. Now more than ever, we must continue to document the lived experiences of women and girls around the globe, analyse the impact of such policies on their lives, and chart a way forward that supports their health and human rights. At a time when "alternative facts" are building the foundation of damaging policies with global implications, we must re-affirm our commitment to robust data collection and research, and be vocal in our insistence that SRHR policies, programmes and services be built not on ideology, but on data, evidence and human rights.