Newsletter January 2025
U.S. foreign aid for reproductive health may be gone—along with foreign aid as we knew it
Yep, we are now saddled with a second, terrible Trump Administration. I couldn’t watch the Inauguration, if only because I scheduled a colonoscopy that day. Sedation was more than welcome. And the horror and lawlessness began right away after 12h00 noon on January 20, with a firehose of Executive Orders (EOs) each more outrageous than the next. The blanket pardons to the violent, armed seditionists who stormed the U.S. Capitol on January 6, 2021 were a particularly hard blow. As a lawyer, I’m not sure how we recover respect for our already very frayed rule of law after this.
As a public health practitioner, I’m also appalled that Trump announced his intention to pull the U.S. out of the World Health Organization, declared that the U.S. only recognizes two sexes (despite biological fact), froze all funding for the National Institutes of Health and forbade the Centers for Disease Control from issuing any public statements and reports going forward (maybe you’ve heard about the growing threat of H5N1 influenza? or mpox? Never mind…). This is all so much worse than Trump 1.0. They really want to kill us. The folks behind Project 2025 are clearly putting their plans into action. See my July 2024 Newsletter if you want a preview of more.
On the international reproductive health front, the Administration rejoined the Geneva Consensus Declaration, an anti-abortion intergovernmental coalition that the first Trump Administration had created in 2019, and that the Biden Administration had exited in 2021.
Trump also reinstated the Global Gag Rule (GGR), just as it had in January 2017, and as every Republican President had done since Ronald Reagan inaugurated that noxious policy in 1984. Trump chose January 24 to reissue the GGR, the day anti-abortion campaigners held their annual March for Life in Washington, DC, accompanied by numerous masked members of the white supremacist and fascist Patriot Front. Grim.
The GGR requires foreign non-governmental organizations (NGOs) to stay completely away from anything to do with abortion in any of their work if they happen to be parties (recipients, sub-recipients) to a USAID contract for health-related services. No advocacy, no communications, no counseling, no referrals, no service delivery (although abortion services were already banned from receiving U.S. federal funding since 1973 via the Helms amendment, but overkill has never stopped the far-right). This is the case even if the foreign non-profit planned to use non-U.S. funds for these activities, i.e. a single dollar of U.S. federal funding affects an entire organization’s operating budget from all sources. This is also true even when abortion is allowed by law in the country in question, as it is in many countries, such as India, Nepal, Ethiopia, South Africa, Colombia or Argentina. Completely outrageous.
Until now, every Democratic president has rescinded the GGR and every Republican president reinstated it, leaving recipients of U.S. global health aid to face a see-sawing U.S. foreign policy based on the party who gains the White House. Needless to say, the GGR cuts funding to the most effective health groups, those that are committed to comprehensive sexual and reproductive health care and primary care including safe abortion care, and that truly want to reduce maternal mortality. Unsafe abortion remains a significant cause of death in pregnancy around the world, and complications from unsafe abortion saddle health systems with unnecessary medical costs in countries where the practice remains prevalent. But anti-abortion forces have never cared about women’s health and lives or efficiency of care.
The Heritage Foundation’s Project 2025, which is clearly behind many of Trump’s early policy actions, argued for an expansion of the GGR to all of U.S. foreign assistance, not only global health, and to apply it to U.S.-based non-profits, international organizations such as the UN, and foreign governments (!), something that had been considered legal overreach even by the first Trump Administration. Trump appears to have held off on that expansion for now.
Instead, the Administration has reinstated the 2017 version with its attendant rules, which had attached the GGR to all global health funding, including grants by the Department of Defense, Health and Human Services, as well as USAID and the Department of State. Under the first Trump Administration, about $12 billion of U.S. foreign health assistance were thus subject to the GGR. It’s worth noting that this latest EO also specifies that no U.S. funds may support programs of coercive abortion or involuntary sterilization, something already covered by the 1985 Kemp-Kasten Amendment to annual Appropriations Bills. That had, in the past, been used to target UNFPA’s reproductive health programs in China, yet China has abandoned its one-child policy and is now openly pro-natalist. One wonders what this is now about.
But focusing on Trump’s specific actions on global reproductive health and abortion is like looking at the proverbial trees instead of the forest. Trump 2.0 now appears to have foreign aid as a whole in its sights. On the same day the GGR was reinstated, January 24, 2025, all U.S. foreign aid funding was indefinitely stopped (with a few exceptions such as military assistance to Israel and Egypt), as the Administration reviews it to ensure it aligns with its “America First” vision. A first pause in foreign assistance for 90 days issued by Trump on Monday, January 20, was transformed by the State Department into this indefinite stop. Constitutional lawyers will tell you that the President cannot block or delay federal budget appropriations under the Constitution, since the power of the purse belongs to Congress. The 1974 Congressional Budget and Impoundment Control Act made that crystal clear. But here we are, in the middle of an unprecedented power grab by Trump... that Congress and our Courts will have to stop. Right? right?!
On January 22, 2025, Secretary of State Marco Rubio issued a press statement giving us a preview of the America First vision. He declared that “every dollar we spend, every program we fund, and every policy we pursue must… make America safer, stronger, and more prosperous.” America First will entail eliminating, among others, programs that “encourage mass migration” to the U.S., “climate policies that weaken America,” and those that focus on “political and cultural causes that are divisive at home and deeply unpopular abroad.” This will no doubt target programs to advance non-discrimination against LGBTQ persons and support sexuality education, programs that have been critical in their own right, but also as key strategies to eradicate HIV and AIDS and address adolescent pregnancy. It will most probably also target programs to advance gender equality and women’s rights.
Of course, U.S. foreign policy has always been aggressively focused on advancing U.S. interests, and there are many legitimate critiques of the United States Agency for International Development's (USAID) operating model. Still, there were significant resources dedicated to human rights, the rule of law, health, general welfare and more recently, climate resilience and sustainable energy around the world. It seems we are now prepared to ditch all that, and are now entering an era of naked power politics, focused on a very narrow vision of U.S. self-interest around the world. The U.S. "is no longer going to blindly dole out money with no return for the American people," State spokesperson Tammy Bruce said in a statement reported by National Public Radio in which she absurdly called the pause "a moral imperative."
This is obviously causing panic and consternation in countries of the Global South that have relied on financial and technical support from USAID and the State Department, as well as with many non-profits who administer these grants. In FY2023 (the most recent year for which complete data are available), USAID managed more than $40 billion in combined appropriations, and another $27 billion of development assistance came from other agencies and departments.
Major lifesaving programs in HIV prevention and treatment (notably though PEPFAR, the U.S.’s signature, USD 6.5 billion/year global HIV initiative that funds HIV treatment for 20 million people), primary education, malaria, TB, nutrition, infrastructure, child vaccination, water and sanitation, refugee resettlement, humanitarian assistance and more are now on hold. Incredibly, not even payments under already approved agreements may be made, and HIV clinics have even been told they may not dispense HIV treatment medication they already have on the shelves if those drugs were bought with U.S. funds! This will cause great harm to many people, including, ultimately, Americans themselves. I also cannot overstate how much this damages what remains of the U.S.’s credibility abroad. It also leaves the door wide open to China, which has already invested trillions of dollars in aid and loans in Africa, Asia and South America, and to Russia, which has become increasingly active in West Africa.
Whatever the final decision on U.S. development funding—including whether USAID survives as we know it—I expect it to contain strict prohibitions on anything to do with abortion, and probably modern contraception, sexuality education and other bugaboos of the Christian far-right. Project 2025 suggests redirecting funding to faith-based organizations and private sector actors, and in global health, to fund “women, children and families,” which is generally understood as anything BUT sexual and reproductive health care outside of maternity care, and nothing for marginalized groups such as sex workers or LGBTQ persons. We could see a huge shift of funds to right-wing religious groups and corporations associated with the Administration.
For those providing abortion care abroad, and those engaged in advocacy to improve access and change restrictive laws in their own country, what should be the posture when faced with these potentially dramatic changes? The brilliant Monica Oguttu, the Executive Director of Kisumu Medical and Education Trust (KMET) (which provides quality and comprehensive reproductive, maternal, neonatal, child and adolescent health in underserved communities in Kenya) saw the writing on the wall during the first Trump Administration.
KMET had, in 2016, a sizeable USAID grant to support a network of reproductive health clinics in Western Kenya. Oguttu chose not to renew when the funding came to an end in 2021, even though Biden was now in charge. “We’re in fact happy we’re not USAID-funded anymore,” she noted. “We replaced their funding with Dutch assistance and a grant from a U.S. private foundation. The clinics are still going strong, and provide integrated care including abortion care. The funding overall is unfortunately not as large as what we got from USAID. But I no longer have sleepless nights!”
For Beth Schlachter, Senior Director, U.S. External Relations for MSI Reproductive Choices (an international non-governmental organization providing contraception and abortion services in 36 countries), this is an all-too-familiar situation: “Like in 2017, MSI won’t sign the Gag Rule, so we will once again lose our U.S. funding. But it will only be USD 14 million this time, versus USD 120 million last time.” MSI is prepared to weather the change, but Schlachter noted that it will be hard for many groups at global or local level.
In a recent piece published in Devex, Schlachter offered Five ways to thrive despite Trump’s anti-abortion global gag rule. One of these strategies: diversify funding away from USAID, notably by investing in individual and major gifts, but also by charging those patients who can pay for some portion of their services: “We must never again be forced to deprive people of the healthcare they depend on at the political whim of the U.S. government,” Schlachter wrote. In my conversation with her, Schlachter went further, wondering aloud whether “the U.S. should fund sexual and reproductive health at all, if we are going to put folks through this every time?” The answer might be a resounding no.
While KMET’s funding won’t be affected by the latest USAID shenanigans, Oguttu worried about the impact of a reinstated and expanded Global Gag Rule on KMET’s networks of partners on the ground. When some NGOs accept the terms of the GGR, while others don’t and continue to offer abortion services and advocate for access, those NGOs that have agreed to the gag rule often stop working in partnership with non-gagged groups, out of fear they’ll be accused of violating the terms of their USAID funding. (Of course, many of them might also lose substantial funding if U.S. foreign aid isn’t re-started soon).
“Working in silos doesn’t work for us. When there is only one clinic in a community, it has to offer integrated services,” explained Oguttu. “For example, a clinic offers contraception, but also malaria care. And we can’t have stand-alone abortion clinics [a strategy often suggested to local groups to limit the damage caused by the GGR, but that doesn’t take into account the lack of health personnel in remote regions, which precludes duplicative services]. We offer sexual and reproductive health care, including abortion care, integrated with other primary care.”
The widespread disruption of partnerships and the wrecking of coalitions caused by the GGR were well documented during the first Trump Administration. For example, in Nepal, where abortion was legalized up to 12 weeks of pregnancy in 2002, many health organizations stopped working with each other after the GGR was reinstated in 2017, even though most rural areas of Nepal are hard to reach, and coordination between local groups makes the most sense to ensure delivery of services to the poorest communities. The fear caused by the GGR even led to abortion groups being disinvited to meetings they used to participate in.
The right to abortion is guaranteed by Kenya’s 2010 Constitution, but an enabling law was never passed by Parliament despite several High Court judgments ordering Parliament to remedy the situation, leaving in place the 1963 Criminal Code that continues to make abortion a crime. Oguttu shrugged: “No law was ever put forward despite the High Court decisions, so we decided to forget about it. We follow our lawyers’ advice, go where county [local] governments are supportive, and we continue to work.”
Oguttu not only bemoaned the anticipated breakdown of partnerships, but she also feared Kenyan police would begin raiding clinics again to search for evidence of illegal abortion and to demand payments from doctors, using the GGR and Kenya’s ambiguous laws as pretexts. “Whatever the U.S. does has an impact. When Biden came in, fear went away and police raids died down. Now we expect the police to start raiding again and to extort health providers again.”
Schlachter argued for building stronger “pro-choice eco-systems” to avoid abortion being pushed off the stage. “We shouldn’t accept being disinvited! Many of us working on abortion are now on the outside now [that Trump is back], including the United Nations Population Fund (UNFPA), the World Health Organization, MSI, the International Planned Parenthood Federation (IPPF)… These are powerful organizations! We need to band together, push back, challenge those who wouldn’t invite us, create space for everyone.” During the first Trump Administration, MSI continued to sit at the same tables as USAID, as it became clear that talking to each other didn’t violate the GGR. Much will depend on who at USAID calls the shots going forward.
Schlachter also urged those who don’t sign the GGR to be bolder than ever, and to advocate loud and clear that abortion is essential healthcare. There is nothing to gain from being quiet, she felt. Meanwhile, those who sign the GGR should refrain from “over-implementing” it. Last time, she noted, some local health groups even removed contraceptives from their shelves, something that wasn’t called for. To avoid over-implementation, Schlachter suggested those who sign the GGR seek support and guidance from groups with longstanding expertise in the minutiae of the gag rule, such as MSI, IPPF and Ipas.
Investing in local advocacy by partners on the ground will also be critical to ensure progress isn’t reversed. “There has been so much progress to advance access to abortion [in the Global South],” noted Schlachter. “Activist networks at local level are the ones driving this and changing norms in their countries.” And she is right: it’s absolutely true that local groups have transformed access to abortion around the world. Over the last 30 years, over 60 countries worldwide have liberalized their abortion laws, as documented by the Center for Reproductive Rights. The U.S. is the most notable exception to this global trend.
KMET demonstrates how powerful this local leadership has been. They now support distribution to abortion pills for women and girls to self-manage their abortion in 10 counties in Western Kenya. Working hand in hand with county governments, the Kenyan Obstetrical and Gynecological Society (KOGS), midwives and pharmacies, KMET has seen a significant reduction in injuries from unsafe abortion where they provide these services and information. “The idea is to saturate the community with information, so women no longer resort to unsafe methods. There is power in community education. We’ve found ways to reduce the overall cost of abortion (pills, counselling, post-abortion contraception and any follow-up calls) to 2000 Kenyan shillings (USD 15) from 5000 shillings previously. And because it’s self-managed, they don’t need to go to the city and take a lot of time off. Women and girls now come forward early in pregnancy. We now rarely have anyone coming to us with a second trimester pregnancy.”
Oguttu concluded, “If the U.S. is no longer the right leader, we move on. With or without the GGR, we continue.” Her determination gave me much needed hope in this awful time.
In global feminist solidarity,
FG