First: Aid

A new presidential administration in Washington inevitably brings its own foreign policy agenda and fresh eyes to old problems. Often too, old policy agendas resurface, whether or not they are appropriate for current global realities. Changes are thus no surprise. However, the arrival of the Trump administration has sent shock waves through the foreign policy community in the United States and around the world. Long-suppressed isolationist factions in this country are coming to the fore, while the president himself has taken a doctrine of “America First” to an entirely new level.

It is early to forecast with any precision how this seismic paradigm change will play out in America’s varied networks of global engagement, including its foreign aid programs, but the directions are clear. Many observers see an unprecedented assault on the principles and values that have shaped the global order since World War II, especially in the areas of human rights, gender equality, global health and sustainable economic growth and development. Advocates for continued US global leadership must undertake the challenge of designing a broad-based, strategic and effective response.

Controversy around US foreign assistance is not new, as it has been buffeted by politics and competing ideologies throughout its history, even as dedicated civil servants in the US Agency for International Development (USAID), the State Department and other implementing agencies have sought to steer a steady course and respond to development and humanitarian imperatives. Based on early signals from the Trump administration, however, it appears that the very existence of USAID is now threatened as never before. While the agency may survive with the inevitable funding reductions as well as new priorities and directions, advocates’ fears focus especially on its programs supporting women’s reproductive health and rights.

These fears were intensified by President Trump’s reinstatement of the Mexico City Policy—also known as the global gag rule—which prohibits overseas nongovernmental recipients of US foreign aid from providing abortion services, counseling or referrals even with their own resources. Trump’s executive order expands the application of the gag rule beyond family planning programs to include all US global health assistance, not only through USAID but also through other federal agencies, including the Department of Health and Human Services and the Centers for Disease Control and Prevention, totaling more than $9 billion annually. Additional actions to end US funding for the UN Population Fund (UNFPA) and reduce funding to other UN agencies have also been announced.

How severe are the threats? What is at stake? What strategies and arguments are needed to reach the new administration, supporters in Congress and the wider public? While the prospects for successful influence from progressive groups seem extremely low, they still need to do all they can to promote accountability to voters. Ultimately, an informed and mobilized citizenry is the strongest bulwark against bad policies and the means to defeat their perpetrators in future elections.

ACKNOWLEDGING THE ENORMITY OF THE THREATS

The normal steps in an orderly transition from one administration to the next have not yet occurred—presidential appointments to key leadership positions affecting foreign aid, briefings of incoming leaders with staff and external stakeholders and development of new policy guidelines. Moreover, the Trump administration is asserting its control over external communications from government agencies, adding to the high level of uncertainty. Still, the dangers to USAID and other foreign assistance programs are evident from actions already taken as well as public statements. Most observers agree that long-term development and “nation-building” goals are destined to take a back seat to immediate issues of national security and the renegotiation of trade agreements. Levels of humanitarian aid are also in great peril. Cuts to funding of UN organizations, including UNFPA, were announced the first week after Trump took office. Reducing funding will be seen as an expeditious way to appeal to the Trump administration’s political base, underscoring commitment to cut government spending overseas and focus on domestic needs, consistent with his “America First” message. What remains of foreign aid will be seen as a bargaining tool to make deals with countries in support of other US strategic, security or business objectives. In that context, health funding, and especially reproductive health, will suffer the most. To the extent global health aid continues, priorities could shift to only protecting the US population against pandemic diseases.

Most Republicans in Congress are predisposed to be willing partners in this new set of priorities. More so than for any other government programs, influence over foreign aid rests with few in Congress who choose to focus on it. These individuals have little accountability to the broader public for their funding decisions, responding often to special interests and US-based implementing agencies that receive the most funds, including faith-based organizations such as Catholic Relief Services and World Vision. Conservatives on the Hill who are most opposed to reproductive health programs will have an even freer hand than before. Rep. Chris Smith (R-NJ), chair of the House Committee on Foreign Affairs Subcommittee on Africa, Global Health, Human Rights and International Organizations, has been a single-minded opponent of USAID’s family planning program since his arrival in Congress in 1980. He has pushed hard not only for the global gag rule, but also for reductions in family planning funding and support for the UN Population Fund in addition to prohibitions on all federal government funding of abortion both domestically and internationally.

It is a testament to the power of the antichoice lobby that President Trump— the “anti-regulation” president who in earlier years was also “prochoice”— signed a regulation that is among the most intrusive and burdensome to implement among all government requirements for funding recipients. Significantly, speakers at the annual antichoice march in January included Vice President Pence and counselor to the president, Kellyanne Conway, an unprecedented level of participation from an incoming administration and a sign of the depth of support for abortion restrictions at the highest levels. An additional major concern is the damage to US leadership in family planning through the likely selection of a USAID administrator aligned with Vice President Pence and other social conservatives in the Trump administration.

UNDERSTANDING WHAT IS AT STAKE

The US government is the single largest development aid donor overall, though still funding at a low level relative to the nation’s wealth. In the area of family planning, US funding continues to account for nearly half of all donor support at more than $600 million annually. These investments over the years have been highly cost-effective, augmented by partnerships with a wide range of international NGOs, the for-profit sector, other donors and UN agencies, and most importantly, with governments and NGOs in developing countries themselves.¹ US-funded global health programs reach millions of women with increased access to technologies for contraception and HIV/AIDS prevention, along with improved services for maternal and child health as well as prevention and treatment of infectious diseases.²

Speakers at the annual antichoice march in January included Vice President Pence and counselor to the president, Kellyanne Conway, an unprecedented level of participation from an incoming administration.

One area that has not been supported by USAID or the State Department is access to safe abortion care, banned under a very strict interpretation and enforcement of the long-standing provisions of the Helms Amendment adopted in 1973. While Helms would legally allow US-funded health providers to offer abortion services for women in cases of rape, incest and life-endangering pregnancies, in practice aid recipients have not been allowed to implement these exceptions—condemning millions of women to unsafe abortions during the years Helms has been in effect.³

As new policies take effect, their consequences over time for women and their families around the world will be measured in lost lives, poorer health conditions, increased poverty and slower progress in gender equality and the global Sustainable Development Goals agreed upon by the world’s governments in the United Nations in 2015.⁴ Apart from the broader losses expected from overall foreign aid cuts, the global gag rule itself will cause more rather than fewer unsafe abortions, due to the ineligibility of foreign NGOs providing contraception and other health services that include abortion and advocacy for abortion law reform. Programs of developing country governments that rely on NGO partners for service delivery will also suffer. Further, the chill cast by changing US policies will do incalculable and long-term harm, inhibiting advocacy by local NGOs to reform abortion laws and policies. The devastating effects of implementing the global gag rule during previous Republican administrations have been well documented.⁵ However, with the newly expanded gag rule, the impact will be much broader, since it will affect not just family planning but also maternal and child health, nutrition, HIV/ AIDS and other programs for disease prevention and treatment. While other donors are announcing new funding commitments in response to lost US aid, especially in the area of reproductive health, they will be unable to compensate fully for these losses.⁶

FINDING ENTRY POINTS FOR ADVOCACY

The dire prognostications outlined above demand a powerful response. Sustained and effective action by a broad coalition of supporters of the health and rights of women and children is required, building on all possible sources of leverage. The goals should be to protect vital global development and humanitarian programs that benefit women and their families and to minimize the damage of ideologically motivated policy restrictions—while making the case to legislators and voters for their complete removal.

What is clear both from the Trump campaign and the early weeks of the new administration is that few policy positions have been consistently embraced by administration leaders, and no monolithic perspective prevails. In the confirmation hearings for Secretary of State Rex Tillerson, he espoused a moderate centrist position concerning development programs benefitting women. He then expressed a noncommittal response on international family planning funding, but at least revealed his awareness of the importance of this long-standing and highly successful program. The company Tillerson led as CEO, Exxon Mobil, supported health and development programs benefitting women through its philanthropic arm, reflecting a pragmatic interest in promoting a positive environment for business activities that could conceivably carry over into his thinking as the highest-level US foreign policy leader. Nikki Haley, President Trump’s choice for UN Ambassador, reiterated her prolife position in her confirmation hearing, but also affirmed her support for contraception. Advocates for women’s reproductive rights should seek to build on any indications of support from these or other administration leaders for family planning at least, even if safe abortion remains off the table.

The chill cast by changing US policies will do incalculable and long-term harm, inhibiting advocacy by local NGOs to reform abortion laws and policies.

Although Republicans are now in the majority in both houses of Congress, differences with the Trump administration are already surfacing, and policy disagreements among different wings of the party and factions in Congress are likely to come even more to the fore.⁷ When certain Republican Senate leaders are presented with compelling moral and strategic arguments, they may be able to resist efforts by right-wing members of the House to impose major funding cuts in international family planning and other global health and development programs. Against a background of ongoing internal conflicts and incoherence within the Trump administration, it may even be possible to build consensus in Congress to respond with additional resources for special needs, such as the plight of victims of sexual violence in humanitarian settings.

Simply having a persuasive case will not be enough, however, to reach President Trump and other decision makers. Demonstrations, phone calls, letters, petitions, and op-eds in the mainstream media and social media are all tools that must be employed extensively. It will be essential to find other progressive allies beyond the usual groups working on foreign aid, such as the growing movement on behalf of the rights of immigrants and refugees. Influence from large donors to the Trump election campaign and from prominent individuals like Bill and Melinda Gates could also make a difference. In the past, one of the most effective approaches to engage members of Congress in support for overseas health and development programs has been site visits and personal interactions with local leaders. Arranging such visits for President Trump and his appointees, encouraging them to talk with women and children in developing countries and experience their realities firsthand, could have a more immediate and powerful impact than the usual methods used to influence policy in Washington.

DEFINING AN ADVOCACY AGENDA FOR US FOREIGN AID

If we set aside, for the moment, the worst fears about the agenda of the Trump administration and its supporters in Congress, what are the most compelling arguments in support of international family planning and other USAID health and development programs? Should Democrats gain enough seats in the mid-term elections in 2018, what is the case for Congress to legislate an end to the global gag rule, push for correct implementation of the Helms Amendment exceptions and repeal the Helms Amendment once and for all? What reforms should be sought in USAID and US foreign assistance more generally?

Answers to these questions must start with an understanding of contemporary global realities and the changing role of official development aid. In the last few decades, most countries in Asia and Latin America have graduated or come close to graduating from their previous status as major USAID recipients. The sub-Saharan African region—containing the poorest countries in the world, with the highest levels of poverty— receives the largest portion of aid aside from Afghanistan, Egypt and Israel. African countries are also where conservatives recognize substantial US strategic and/or business interests, some as actual or potential harbors for terrorist groups, major senders of migrants and refugees, exporters of oil and valued minerals and sources of pandemic diseases. In addition, they are countries where official aid has had a positive impact and can do more—Ethiopia, Tanzania and Kenya are among these. Humanitarian considerations should also be compelling, with sub-Saharan African countries hosting more than 4 million refugees.⁸  In the Sahel and Horn of Africa, climate change and resulting drought and desertification are contributing to deepening poverty and instability, and the average total fertility rate (number of births per woman) remains very high at 5.4.⁹

African women have the least access to the means to manage their childbearing, and with few exceptions, their health is the most at risk relative to women in other regions. Unmet need for contraception ranges from 15 to 38 percent of married women of reproductive age, and higher for unmarried women.¹⁰ More than 20,000 African women die each year due to unsafe abortion, with millions hospitalized at great cost to resource-poor health systems. Maternal mortality is still very high, with more than 200,000 deaths annually from largely preventable causes.¹¹ Without access to basic reproductive health services and the ability to avoid unintended pregnancies and unsafe abortions, it is highly unlikely that African couples will be able to foster a new generation that is better nourished, better educated and more prepared to contribute to economic growth, democratization and peace and stability in the region.

First in the context of Africa today, it is even more harmful to re-impose the global gag rule on family planning programs than was the case when President George W. Bush reinstated it in 2001. Second, it goes against regional advances in reproductive rights, and its expansion to other health programs will greatly increase the damage. US abortion restrictions are also incompatible with global standards as well as national laws and policies. Globally, safe abortion has been recognized as a component of reproductive health programs by the World Health Organization and by human rights treaty monitoring bodies, including the African Commission on Human and Peoples’ Rights. A number of African governments—Ethiopia, Ghana, Mozambique and Zambia among them—and regional organizations and NGOs in the past decade have worked together to reform abortion laws, develop service guidelines and establish access to safe abortion as a human right.¹²

Moreover, it is completely contrary to American values and interests in the region to retain the Helms Amendment, which has been implemented since 1973 as a total ban in US-funded programs on abortion care and women’s access to information about safe abortion. Correct implementation of Helms would at least increase women’s access to services in cases of rape, incest or life-endangering pregnancies when local laws allow. Furthermore, a strong case has been made that denying women who have been raped in conflict settings access to safe abortion violates the Geneva Convention, which establishes the fundamental right of all persons “wounded and sick” in armed conflict to all the medical care their condition requires.¹³ The requirements of the Convention thus override local laws that ban abortion in cases of rape.

In addition to arguments based in international law, the increased number of women suffering in conflict and post-conflict settings points to the necessity of addressing unsafe abortion in the context of humanitarian aid. The plight of the Chibok girls in Nigeria, highlighted in media around the world, has made more visible than ever the failures at all levels to provide care for vulnerable young women coping with sexual violence and unwanted pregnancies. For all women in Africa, increased family planning efforts are needed to reduce the continuing toll of unsafe abortions and maternal deaths. These must be reinforced by improved access to safe abortion, which points to the imperative of repealing the Helms Amendment.

Beyond these most pressing policy concerns and ensuring adequate funding for family planning, the Trump administration and enlightened Republican leaders in Congress should embrace the case for supporting a comprehensive approach to women and girls’ health— within strong global health and humanitarian programs. These programs deliver good value, contributing to sustained development in many countries and, ultimately, to a more peaceful world.

STRENGTHENING USAID

Progress in health and other development programs will also be most effective if USAID itself is strengthened as a government agency, with a focus on its technical leadership role. Needs are changing. A higher level of funding than in the past is certainly warranted, given US resources as the richest country in the world with one of the lowest per capita aid commitments. At the same time, USAID’s impact is less and less based on dollars alone. Increasingly, USAID and its implementing partners serve as catalysts to progress through the technical leadership and the quality of information, innovations and partnerships they foster. The Chinese and others may outweigh USAID in their overall political influence and the quantity of resources they offer in many developing countries, but for the foreseeable future, they will be unable to match the technical leadership USAID can mobilize from American nonprofit organizations, universities and commercial companies, as well as the ability of USAID to forge effective partnerships with other donors and UN agencies. Faith-based groups have key roles to play as well, as long as they are prepared to operate under the same rules as other partners and provide information and referrals for reproductive health services to which they have religious objections.

More than 20,000 African women die each year due to unsafe abortion, with millions hospitalized at great cost to resource-poor health systems.

Priorities for foreign aid reform have been the subject of much discussion and debate in recent years, with thoughtful proposals by organizations such as the Center for Global Development, the Brookings Institution, the Modernizing Foreign Assistance Network, the US Global Leadership Coalition and the Center for Strategic and International Studies. These include measures to continue to increase country ownership in aid programs, strengthen capacity at all levels to use data and evidence and improve management of USAID’s human resources.¹⁴ For those who have worked overseas, the basics for strengthening USAID are clear. Effective development programs, by their nature, depend on taking risks where the optimal interventions may be unknown and applying best practices and lessons learned from other countries. They require adaptation to local settings, partnerships with local communities and enough time to achieve impact. In this context, USAID needs to increase efforts to ensure adequate expertise and staffing in its country Missions and their engagement with country-based counterparts and partners; minimize decrees and unnecessary paperwork requirements from Washington; and set performance standards and metrics for local partners, while building their capacity and giving them latitude in how results are to be achieved. US aid programs must also continue to benefit from the involvement of US-based organizations with proven expertise, as they play key roles in identifying and sharing cost-effective best practices across countries.

While most foreign aid flows through USAID, the State Department, and other federal government agencies, the role of international organizations in advancing women’s health and rights globally must also be recognized and supported, especially United Nations Population Fund and World Health Organization. They set global standards, attract other donors and reach countries that do not receive US bilateral aid. Although the Trump administration has committed to cuts in multilateral partnerships, the survival of these organizations—with other donor support if not US funding—must also be a key focus for advocates.

BUILDING ON THE HISTORIC GOOD WILL OF AMERICANS

The case for the Trump administration and Republicans in Congress to respond favorably to this advocacy agenda is both political and moral. The political risks of ignoring this agenda will become increasingly apparent. We have already seen an unprecedented mobilization across America of demonstrations, petitions and call-in campaigns reacting to early actions by President Trump. The response is engaging millions of voters at the grassroots level, far beyond the normal opposition to a new administration by “inside the Beltway” special interests.

Even more important is the case on moral grounds for the agenda outlined here, appealing to at least some conservatives in Congress and the media. America has always represented certain values and principles to the rest of the world, including first and foremost human rights, as acknowledged by incoming Secretary of State Tillerson in his confirmation hearing. Projection of these values is also a critical source of US power and influence and therefore fundamental to long-term national security. Politically, the majority of American voters understand and appreciate traditional American values in US foreign policy, including many conservative voters who supported the election of President Trump.

Since the Marshall Plan and World War II, foreign aid has been one of the concrete ways that America reaches people overseas directly, helping the nation to be visible and respected. Furthermore, foreign aid paves the way for economic growth and stronger trading partners, as well as more stable governments. Maintaining effective foreign aid programs that include social investments in education, health and strong families through reproductive choice has been and will continue to be the path to “making America great” and keeping it great in the eyes of the world. It is also the path that can save and enhance the lives of millions of women and their families and help to achieve the global Sustainable Development Goals.