Melvine Ouyo is a reproductive health nurse, a former clinic director at Family Health Options Kenya (FHOK), and a graduate of Harvard’s John F. Kennedy School of Government. Over the past year, she has been working as an independent consultant for Population Connection Action Fund, gathering stories from the field about the impacts of Donald Trump’s Global Gag Rule. In the wake of his defeat by former Vice President, now-President-elect, Joe Biden, who has pledged to repeal the Global Gag Rule, I asked her to sit down with me (over Zoom) and talk about some of what she has seen and heard in the last year. Our conversation has been edited for length and clarity.
If I asked you to use one word to describe the impacts of Donald Trump’s Global Gag Rule on women and girls in the communities you’ve visited, what would it be?
Devastating. The Global Gag Rule has absolutely destroyed access to care for so many people in the developing world. I have talked to so many people—providers, patients, advocates. They all say the same things. The ones who didn’t sign lost much of their funding. They had to cut programs, to lay off staff. It’s terrible. Many of the ones who did sign are less willing to speak publicly about the damage to their programs. There is a definite chilling effect. Privately they say they have lost partnerships, that the services they are providing are no longer comprehensive. They cannot serve their clients the way they want to. The Gag Rule leaves them with no good choices. There are awful consequences no matter what they decide.
For groups that refused to sign the policy and lost their USAID funding, are they seeing the same outcomes in all the countries you’ve looked at over the last year?
The impacts of Gag Rule have been profound everywhere, but of course, all of the countries where I have visited or spoken to providers (Kenya, Tanzania, Uganda, Rwanda, Burundi, South Sudan) have their own local realities. Some have more permissive laws around abortion than others, which changes the nature of the work they are doing. So that changes the way they have responded to the Gag Rule. But all of them have clients they used to serve who now don’t have access to SRHR services.
Are they seeing more unplanned pregnancies and more women and girls seeking abortions than a few years ago?
Yes. In almost every case. One clinician in Kenya said that his program lost funds and now they are seeing a constant flow of women and girls seeking services. Another clinical officer said she sees at least three clients every day seeking abortion care. Both of these providers are worried about where their patients will go if they cannot get safe services.
There is so much need. At one conference I attended in Mombasa in October, a representative from Kenya’s National Council for Population and Development presented vital statistics to help attendees understand the magnitude of the issue. In Kenya, 1 in 4 girls have already had their first baby by the time they are 19. And in many cases, it is much younger. In 2019, one hospital in Kisii saw 22 pregnant girls under the age of 14. Just between January and May of this year, health authorities in Nairobi recorded 11,795 teen pregnancies. The Gag Rule is making all of this worse.
Something you found that I thought was particularly interesting was that even organizations that have never been funded by USAID—and therefore aren’t subject to the Gag Rule and didn’t have to decide whether or not to sign—have still seen big impacts to their programs. Sort of collateral damage from the policy.
Yes, I found lots of those organizations. A good example is the African Sex Workers Alliance (ASWA). They have never gotten any funding from USAID or PEPFAR, so no one ever required them to sign the policy. But they had partnerships with organizations, like FHOK, that were affected and have now closed their clinics and stopped their programs. Sex workers are already one of the most vulnerable populations in many countries, with very few protections. Most programs don’t prioritize them, and they have specialized needs, so it’s not always easy to find new health care partners when they lose them.
The ASWA Regional Coordinator, Grace Kamau, told me that the Global Gag Rule causes a lot of harm to sex workers. She said the Gag Rule is leading to high numbers of unplanned pregnancies and unsafe abortions among sex workers. Many of them go to unlicensed clinics and end up suffering complications. Grace said to me, “If Americans believe in human rights, they should think about sex workers as equal human beings deserving human rights.”
Have any of the groups that lost USAID funding been able to replace it, either from other countries or private sources, or are they all having to cut their programs?
It is a mixture. There are some that have been able to find funding from other donors, but even so, there are cuts. I talked to Dr. Katanta Lazarus Simwanza, who is the Technical Advisor for Adolescent Sexual and Reproductive Health and Rights (ASRHR) and Disability with Engender Health Tanzania. He affirms that Trump’s Global Gag Rule has had devastating impacts on the lives of Tanzanians at different levels. He shared that Engender Health lost lots of USAID funding for refusing to sign the GGR. This forced the organization to lay off staff (about 44%), cut down on their activities, and terminate some projects. They have managed to get some funding from DFID, which is the United Kingdom’s development program, and some funding from an anonymous donor, but that it was not enough to avoid those cuts.
And Robert Ocaya, National Coordinator of Right Here Right Now (RHRN), which is a network of 14 organizations in Uganda, said the same. They lost USAID funding, but were able to get a grant from the Dutch government that filled part of the gap. But it is coming to an end in December. And he said that the Gag Rule made them realize they couldn’t rely on the United States and needed to seek partnerships with other countries.
And RHRN-Uganda doesn’t even offer abortion services, I think. Is that right?
Yes. Abortion is illegal in Uganda, but it’s still very common. And also frequently unsafe. They see a lot of mortalities because of it. RHRN-Uganda advocates for the decriminalization of abortion, so they have been unable to continue receiving funds from USAID because of that, even though they don’t perform abortions themselves, or even give referrals. They’ve had to terminate some of their projects. Clinics have closed, and they have had to lay off staff members.
Other organizations in Uganda are also having these same problems. Joel Sparta, Secretary at the Uganda Youth Alliance for Family Planning and Adolescent Health, says they have been indirectly impacted by the GGR. Their partner Marie Stopes was impacted, and that has led to a reduced number of activities, and subsequently this has impacted the clients who previously benefited from those services. He also reported limited partnerships and collaborations with organizations that signed the policy. He says all of this has led to an increase in the number of teenage and unplanned pregnancies, unsafe abortions, and HIV infection among young people in Uganda.
And Rhoda Namukwana, a service provider and the manager of Reproductive Health Uganda’s Bwaise clinic, says that since they lost funding in 2017, they have terminated services and outreach clinics. She says they have lost thousands of clients. They used to serve 200 clients every time they did an outreach effort, but that has stopped. The Advocacy for Better Health project, which was funded by USAID, was terminated. She says that communities have lost trust, especially for the community health workers and volunteers who previously visited them with family planning commodities.
And they’re also seeing this same uptick in the number of unsafe abortions?
Yes, they all are—and more maternal deaths. Rhoda told me that the clinic was reporting an uptick in unsafe and post-abortion emergencies since the signing of the policy. In January 2020 alone, they reported 13 post-abortion cases. The number of morbidities and HIV rates are spiking too. Dr. Katanta says the same is happening in Tanzania, although he says that Tanzania has very strict rules that scare people away from reporting when there are complications, or even deaths, so even what they are seeing is only part of the problem.
What kinds of rules?
In Tanzania, abortion is restricted, but the exact rules about when it is allowable are very unclear, so women are afraid to report when they have complications—they are afraid of getting into trouble with the authorities.
And Tanzania’s law prohibits girls from returning to school after childbirth, so young girls don’t tell anyone they are pregnant. Most of the time they end up seeking unsafe abortions. There are few resources for them to get good services. The Global Gag Rule makes the problem worse.
I talked to one young advocate—Jennifer Kayombo. She is a fourth-year student studying project and community development, but she has a real passion for SRHR, and that is the motivation behind her advocacy for adolescent and youth SRHR in Tanzania. She told me that “abortion is happening every day. For instance, we witness a lot of cases at college. We find blood and dumped babies in college toilets. Normally, it’s when a girl dies that we get to hear about unsafe abortion complications. Otherwise they are performed secretly.”
How has the COVID-19 pandemic affected these groups?
The COVID-19 pandemic has made everything that much harder. It aggravates the existing GGR impacts, as it causes disruption on the already pre-existing weak health care systems. Additionally, country lockdowns and restricted movement pose a substantial threat to sexual and reproductive health.
Worse still, in some states, politicians are taking advantage of the pandemic to shut down access to critical SRH services. Even where that isn’t happening, many organizations and governments have been forced to put on hold most SRH/FP programs and activities—things like mobile outreaches and youth friendly services—as they try to curb the spread of the virus. This has negatively impacted GGR-hit communities that are still struggling with the existing GGR impacts including clinic closures, staff layoffs, and project and service termination.
I recently spoke to a woman called Angelina, a 24-year-old mother of two living in a slum in Nairobi. She has lost her job due to the pandemic. It has been difficult enough to find money for food, let along contraception. There are lots of women like Angelina—the pandemic’s threat to the economy has left many jobless, has also destabilized individuals’ and family peace, subjecting many households to mental pressure that has resulted to increased reports of sexual and gender-based violence.
The pandemic isn’t over, but now that President-elect Biden will take office in January, we expect him to act immediately to repeal the Global Gag Rule. What has been the reaction to President-elect Biden’s win from the people you’ve talked to?
They are overjoyed. Finally, they have hope that an American president will hear their cries and remove this terrible policy. It has been so hard for vulnerable people. Wealthier people will always manage to get access to what they need. It’s the other groups—the young people, the poor—who are left without resources. I hope President Biden will do the repeal at once, and that legislators will pass the Global HER Act and prevent the Global Gag Rule from ever coming back.
 sexual and reproductive health and rights
 The President’s Emergency Plan For AIDS Relief
 sexual and reproductive health
 sexual and reproductive health/family planning