President Trump’s callous and short-sighted executive order restricting US entry for refugees and travelers from certain countries is rightfully getting a lot of attention, but it risks overshadowing another destructive thing he did for global health during his first week in office: reinstating and expanding the Mexico City Policy, also known more descriptively as the global gag rule. Trump’s adoption of this policy is even more reprehensible than it was for his Republican predecessors, for two reasons: First, he has broadened its scope so it appears to cripple not only family planning, but efforts to fight infectious diseases. Second, he is adopting this policy in the face of evidence that it actually leads to an increase in the number of abortions.

The global gag rule states that in order for foreign NGOs to receive US funds, they must certify that they will not “perform or actively promote abortion as a method of family planning” with any funds they receive from any source. Since 1973, the Helms Amendment has prohibited aid recipients from using US funds to provide abortion services (except in cases of rape, incest, or threat to the mother’s life), so that’s not the issue. The issue is that it’s telling providers that in order to receive US funds, they can’t provide information about or referrals for abortions. Not surprisingly, many groups that work to advance women’s health don’t feel that they can agree to refrain from providing women with comprehensive information about their healthcare options.

Consequences for infectious-disease work – and US health

The Kaiser Family Foundation has created a helpful fact sheet on this policy, and it highlights a crucial difference between the policy’s past and current incarnations. In the past, it has applied only to US family planning funding from USAID and the US Department of State; in 2003, President Bush explicitly stated that it did not apply to funding for global HIV/AIDS programs. Now, though, the Trump administration’s policy applies to all US global health assistance. The KFF fact sheet notes that in addition to USAID and the State Department, other agencies receive direct appropriations for global health: CDC, NIH, and the Department of Defense. The New York Times editorial board adds up the likely impacts:

In the past, the policy has applied only to international family-planning funds, which currently total around $600 million. Mr. Trump’s memorandum, however, would apply the policy to “global health assistance furnished by all departments or agencies.” Although reproductive health groups are still studying the memorandum, this language would appear to apply to any international health funding, around $9 billion, used to fight malaria, H.I.V., Zika, Ebola and many other global health threats.

Taking money away from efforts to fight infectious diseases like AIDS, Zika, and Ebola doesn’t just harm people in the countries where funding has been halted; it also puts US health at risk. Viruses don’t respect borders, so reducing funding for prevention and control of these diseases anywhere in the world increases the risk of exposure for US residents.

Evidence that the global gag rule leads to more abortions

Since the last time the gag rule was reinstated, by President George W. Bush in 2001, evidence of its impacts has accumulated.  The most comprehensive quantitative study is by Eran Bendavid, Patrick Avila, and Grant Miller of Stanford University, and was published in the Bulletin of the World Health Organization in 2011. Using data from nationally representative surveys of women of child-bearing age in Sub-Saharan African countries, they examined the number of abortions between 1994 and 2008. They classified each country as having either low or high exposure to the policy based on how much family planning assistance per capita they were receiving from the US in the years preceding Bush’s reinstatement, and adjusted for a variety of factors that might affect the abortion rate. They found that in countries with high exposure to the policy, abortions increased dramatically in the years following 2001, while the increase was much smaller in countries with low exposure. The authors write:

Our study found robust empirical patterns suggesting that the Mexico City Policy is associated with increases in abortion rates in sub-Saharan African countries. Although we are unable to draw definitive conclusions about the underlying cause of this increase, the complex interrelationships between family planning services and abortion may be involved. In particular, if women consider abortion as a way to prevent unwanted births, then policies curtailing the activities of organizations that provide modern contraceptives may inadvertently lead to an increase in the abortion rate.

Several observations strengthen this conclusion. First, the association is strong: the odds of having an abortion in highly exposed countries were more than twice the odds observed in the reference groups. Second, there is broad agreement among our aggregate graphical analysis and both unadjusted and adjusted statistical analyses, and our main findings are robust across a variety of sensitivity analyses. Third, the timing of divergence between high and low exposure countries is coincident with the policy’s reinstatement: in high exposure countries, abortion rates began to rise noticeably only after the Mexico City Policy was reinstated in 2001 and the increase became more pronounced from 2002 onward. Finally, our findings are consistent with those of previous studies on the relationship between family planning activities and abortion

A closer examination of data from a single country comes from Kelly M. Jones, in a 2011 discussion paper for the International Food Policy Research Institute. To investigate whether the policy affected abortions, she used data collected on pregnancy outcomes from a panel of women in Ghana from 1981 to 2007, and compared pregnancy histories for individual women during and between times when the global gag rule was in force. To see whether any differences in pregnancy occurrences might affect children’s health, she also examined children’s height and weight data and compared these outcomes for children whose births could have been affected by the policy to those of their siblings. Jones writes:

I find no evidence that any demographic group reduces the use of abortion as a result of the policy. On the contrary, rural women significantly increase abortions. This effect seems to arise from their increased rate of conception during these times. The policy-induced budget shortfalls reportedly forced NGOs to cut rural outreach services, reducing the availability of contraceptives in rural areas. The lack of contraceptives likely caused the observed 12 percent increase in rural pregnancies, ultimately resulting in about 200,000 additional abortions and between 500,000 and 750,000 additional unintended births. I find that these additional unwanted children have significantly reduced height and weight for age, relative to their siblings. Rather than reducing abortion, this policy increased pregnancy, abortion, and unintended births, resulting in more than a half-million children of significantly reduced nutritional status.

Did President Trump realize when he signed this executive order that it was likely to increase the risk of infectious disease spread worldwide, including for US residents, and to increase the number of abortions and undernourished children in affected countries? New York Times columnist Nicholas Kristof reports that the White House didn’t respond to his inquiries about the gag rule. Kristof also offers a snapshot of the kinds of outcomes we can expect under this executive action:

This all sounds wonkish and antiseptic, but in poor countries, the most dangerous thing a woman can do is become pregnant. I’ve seen too many women dying or suffering in filth on stained cots in remote villages because of childbirth.

I wish Trump could see them: a mother of three in Cameroon dying after her birth attendant sat on her stomach to hasten delivery; a woman in Niger collapsing from a common complication called eclampsia; a 15-year-old girl in Chad whose family dealt with her labor complications by taking her to a healer who diagnosed sorcery and burned her arm as she lay in a coma.

With this new order, Trump will inadvertently cause more of these horrific scenes. Maybe “war on women” sounds hyperbolic, but not if gasping, dying women are seared in your memory.

Kristof noted that Trump’s executive action came just after millions of women and men turned out for Women’s Marches on January 21^st. He writes, “I hope all of the marchers call the White House, 202-456-1111, or their members of Congress, 202-224-3121, to protest.” I tried calling that White House number multiple times during business hours last week, but only ever got a recording saying the comment line is currently closed. (You can still submit comments in writing by going to whitehouse.gov and clicking the “Get in Touch” link in the top right corner.) I hope the comment line reopens soon. Based on his actions during his first week in office, I don’t think President Trump is hearing enough from people with an adequate understanding of public health.