When Ideology Undermines Public Health


Workshop for traditional indigenous midwives, San Mateo del Mar, Oaxaca, Mexico. Photo by Mathew Gutmann

Distortions in the U.S. Foreign Aid Program

By Bonnie Shepard

Recently I reviewed a request for proposals to evaluate a USAID-funded organization in Latin America, and was dismayed to see the following description: “an evaluation of the adolescent programs, compliance with the Tiahrt Amendment and the Mexico City Policy and the post-abortion care activities of X, an NGO dedicated to reproductive health and family planning programs.” I told the agency asking me to take the lead that I found the assignment ethically unacceptable.

Using illustrations from Latin America, I want to take a look at how these recently imposed compliance issues in U.S. foreign aid affect reproductive health programs. In doing so, I aim to provide a general introduction to the multi-faceted distortions in U.S. foreign aid based on conservative interpretations of religious tradition. These distortions undercut the effectiveness of U.S. investments in foreign aid in health, wasting scarce resources and allowing preventable illness, suffering and death to continue.

U.S. government support for public health programs in Latin America and the Caribbean has diminished drastically in the past two decades. Indeed, only one high priority “joint programming” country–Peru–is left, along with 13 others where the reduced support goes for special issues or initiatives such as HIV/AIDS. Three of the five major goals of the USAID global health strategy are related to sexual and reproductive health , and suffer from policies based in conservative interpretations of religious traditions. (The two relatively unaffected goals are related to infant and child health, and infectious diseases.)

The issues described here affect both policy and program levels. For example, the U.S. government joined forces with Saddam Hussein’s Iraq, Iran, Libya, Sudan, Syria, and the Vatican during the 2002 UN Special Session on the Child to oppose comprehensive sexual health education and services for adolescents. During the recent 10-year of Programme of Action of the International Conference on Population and Development (ICPD), at the ECLAC Latin American and Caribbean regional meeting in Puerto Rico in June 2004, the U.S. government’s lobbying against ICPD was unanimously repudiated by the Latin American delegates. The Latin Americans actually increased their level of commitment to reproductive and sexual health policies, compared to a similar meeting in 1999.

The effects of U.S. policy on sexual and reproductive health issues are felt most strongly, however, at the program level. Comparing the USAID strategic goals in health to the current policies illuminates the negative impact of ideology-based distortions in public health practice.

Goal #1: “reduction of unintended and mistimed pregnancies.” According to well-known public health evidence, achieving this goal requires national coverage for provision of a full array of contraceptive education and services to all sexually active people, in ways that are accessible and culturally acceptable. However, many of the “mistimed” pregnancies are among adolescents. In Latin America, political pressures from the Catholic hierarchy combine with the growing political pressures on USAID, UNICEF, and UNFPA from conservative religious sectors in the U.S. government. The result is widespread failure to provide comprehensive sex education and reproductive health services to the region’s adolescents. A significant portion of the USAID budget is dedicated to “abstinence-only” programs, even though research on sex education programs clearly shows that these programs are not effective once adolescents have begun sexual activity. The logic is perverse: since it is morally frowned on for adolescents to have sex before marriage, programs should not protect their health when they do, thus subverting the very health goals of USAID strategy.

Another area of political pressure in U.S. global health policy relates to emergency contraception. Even though the World Health Organization has certified that this method is not an abortion (the technical word is “abortifacient”), religious pressure groups fight to exclude emergency contraception from U.S. family planning assistance, and eliminate provision of emergency contraception from guidelines for health services treating rape victims.

Goal #2: Reduction of HIV transmission and the impact of the HIV/AIDS pandemic in developing countries. A tragic consequence of the widespread failure in Latin America and the Caribbean to serve adolescents’ sexual health needs is that it also stymies many serious efforts to achieve both country-level and USAID goals to stem the progress of the HIV/AIDS epidemic. In the region, an estimated 560,000 youth (15-24) live with HIV/AIDS and approximately half of all new HIV infections are among youth ages 15-24. Yet the US government consistently discourages programming that provides condoms to sexually active youth, and provides grants for adolescent programs worldwide that provide incomplete and skewed information on contraception. Political pressure led the Center for Disease Control to alter a key HIV website: “Facts about Condoms and their Use in Preventing HIV Infection” to emphasize abstinence and condom failure rates, and eliminate the section on correct condom use. Unfortunately, most “abstinence-only” educational programs exaggerate the failure rates of contraceptives, especially condoms. In effect, this type of program discourages sexually active young people from protecting themselves against HIV.

Goal #3: Reduction in deaths and adverse health outcomes to women as a result of childbirth. USAID-supported programs in several countries have provided support to a comprehensive array of strategies to reduce maternal mortality, with one glaring exception. Unsafe clandestine abortion is a significant cause of maternal mortality and morbidity, causing an estimated 800,000 hospitalizations a year in Latin America, according to the research conducted by the N.Y.-based non-profit—Alan Guttmacher Institute. Yet the “Mexico City Policy,” otherwise known as the “global gag rule,” forbids any organization receiving U.S. funds from advocating for legalization of abortion, or even referring women for an abortion. Movimiento Manuela Ramos, a Peruvian feminist non-governmental agency, signed the policy after much internal soul-searching, in order to continue their USAID-funded program, Reprosalud, which provides culturally-sensitive reproductive health education and links to services for more than 2,500 communities in poor, rural communities. Susana Galdos, the former director, had to ask a federal judge for dispensation in writing so that her testimony on the negative effects of the global gag rule before the U.S. Senate in 2001 would not jeopardize their program. Since no organization can receive contraceptive supplies—not even condoms—from the United States, without signing an agreement to adhere to this policy, it affects all HIV-related programs as well. As pointed out by the “Access Denied” website on the Global Gag Rule, research in several countries in the world has highlighted the negative effects of loss of reproductive health coverage when organizations decide that they cannot in conscience sign the policy. Indeed, the Global Gag Rule violates two central tenets of U.S. foreign assistance: 1) to administer taxpayer funds efficiently, with maximum benefits to the recipients of U.S. aid and 2) to promote and support American democratic values abroad. Indeed, the Gag Rule is contrary to freedom of speech, a basic principle of democracy historically defended by the U.S., and also to a key foundation of international relations: respect for national sovereignty. To end this article on a positive note, another policy that came into being under pressure from conservatives—the Tiahrt Requirements—is a positive force protecting reproductive rights and informed choice. The policy forbids all quotas in family planning programs, so that health services are not pressured to achieve a certain number of users of any particular contraceptive method. The policy also mandates full information on both benefits and risks of the full range of methods. In other words, it attempts to ensure that all programs supported by the United States adhere to principles of voluntary, informed choice. The amendments were passed in the aftermath of the media scandal surrounding President Fujimori’s coercive sterilization program in Peru in the 1990s. While conservative congressmen from the United States led the movement to pass this bill, feminists in Peru took the lead in exposing rights abuses in Peru’s family planning program. The amendments are a welcome protection of reproductive rights, in face of potential threats to reproductive freedom from anti-natalist governments.

Bonnie Shepard, a consultant and researcher who has worked in the sexual and reproductive health field in Latin America for 25 years, was a 1998-2000 DRCLAS Visiting Fellow. She has been based in the International Health and Human Rights Program of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard School of Public Health since 2000. Email: bshepard@hsph.harvard.edu