Over the course of his first term, President Bush—with the tacit approval of Congress—has moved to isolate the United States ever more sharply from the global consensus on critical matters of sexual and reproductive health policy. On day one of his presidency, he reimposed an antiabortion gag rule on recipients of U.S. family planning assistance overseas as the first salvo in his administration's campaign to export its antiabortion agenda to the rest of the world. For the last three years, he has refused on ideological grounds to authorize a contribution to the United Nations Population Fund (UNFPA), rendering the United States the only donor country to deny funding to UNFPA for nonbudgetary reasons. And while—to his credit—he has made addressing the global HIV/AIDS pandemic a high U.S. priority, public health experts from around the world condemn his administration's overemphasis on morality-based approaches to HIV/AIDS prevention coupled with constant questioning about the effectiveness of condom use.

As for the agreements reached at the 1994 International Conference on Population and Development (ICPD), the president's accumulated actions have distanced the United States from its own position in Cairo and from governmental reaffirmations of the Cairo Program of Action from every region of the world. The Bush administration has tried repeatedly to win converts to its approach; still, the United States—even as it begins to recognize the importance of global cooperation on the larger world stage—stands virtually alone on the eve of the commemorations of the ICPD's 10th anniversary, siding with the Vatican and a handful of other countries such as Sudan and Libya on sexual and reproductive health and rights issues.

Payback Time

During his first presidential campaign in 2000, President Bush assured his antiabortion base that he would resurrect the so-called Mexico City policy instituted by President Reagan in 1984 and continued by his father during his own presidency; the policy, revoked by President Clinton, requires foreign nongovernmental organizations (NGOs), in order to be eligible for family planning aid from the U.S. Agency for International Development (USAID), to forego use of their own funds to provide abortions or abortion counseling, or to engage in any advocacy aimed at liberalizing their country’s abortion laws. It was no surprise, therefore, when he reimposed the policy on his first full day in office, as tens of thousands of abortion protesters convened in Washington for their annual march on the anniversary of the U.S. Supreme Court's Roe v. Wade decision.

Many indigenous NGOs, desperate for U.S. funding, have succumbed to the policy. But the price for doing so has been high. In Ethiopia, for example, NGOs continue to provide U.S.-supported family planning assistance but at the cost of their ability to engage in a discussion—solicited by the Ethiopian National Office of Population—about liberalizing Ethiopia's abortion law in response to the widespread occurrence of septic abortion. Maternal mortality in Ethiopia is among the highest in Africa, and unsafe abortion is a major contributor. Here and elsewhere, the gag rule's reimposition has had no effect on "mak[ing] abortion more rare," the president's stated rationale, but it has certainly helped to maintain the status quo when it comes to the public health tragedy of unsafe abortion.

Other NGOs—among them, the developing world's leaders in family planning services and health care provision generally—resisted. Almost immediately, in fact, the gag rule's reimposition served its unstated but primary purpose: to defund International Planned Parenthood Federation (IPPF), which is reviled by antiabortion activists around the world but is also the single largest provider of primary health care services internationally through its affiliates in over 100 developing countries. Beyond IPPF, the gag rule forced out Marie Stopes International, a widely respected, London-based NGO that supports contraception and safe abortion services in developing countries but also provides services such as malaria screening and treatment and childhood immunizations. Another prominent victim was BRAC, the largest and most successful NGO in Bangladesh, which at the request of the Bangladeshi government offers a form of very early abortion. BRAC is recognized worldwide not only for its work in providing family planning and a wide range of primary health care services but also for its income-generation projects aimed at some of the world's poorest women.

In losing these and other valuable partners, the gag rule is taking its toll on family planning service delivery, despite the administration's protests to the contrary. While USAID's overall contribution to family planning overseas has not diminished under the global gag rule, investigations of the gag rule's real-life impact demonstrate that women are the paying the price in lost family planning and related primary care services in those areas where the U.S. cutoff forced clinics to close ("Gag Rule Revisited: HIV/AIDS Initiative Out, Family Planning Still In," TGR, October 2003, page 1).

Indeed, even President Bush seems to recognize that the gag rule impedes access to services. To date, he has resisted intense pressure from his far-right political base to extend the gag rule to U.S. global HIV/AIDS programs, which would have precluded a wide range of otherwise highly qualified reproductive health care providers in developing countries from participating. According to Assistant Secretary of State for Population, Refugees and Migration Arthur E. "Gene" Dewey, the president wanted to save lives from the ravages of AIDS and he saw the gag rule policy as interfering with that mission. By contrast, the president is apparently indifferent to the obstacles he has created when it comes to the opportunity to save women's lives by preventing a high-risk pregnancy or a septic abortion.

Defunding UNFPA

Unlike his reimposition of the gag rule, which was widely anticipated, the president’s attack on UNFPA in 2002 did come as a surprise, as he had affirmatively requested funds for a UNFPA contribution in his FY 2001 and FY 2002 budgets. Indeed, the State Department had even granted UNFPA a special infusion of $600,000 in November 2001 after the fall of the Taliban in Afghanistan to help reduce the astronomically high rates of maternal mortality in that country.

Nevertheless, over the objections of Secretary of State Colin L. Powell and despite the conclusion of a handpicked investigative team that UNFPA was not complicit in promoting coercive abortion practices in China, the president in July 2002 deemed UNFPA ineligible for U.S. support. The administration justified its decision based on a tortured interpretation of a long-standing anticoercion law—the same law under which just one year earlier and with the same set of facts the administration had found UNFPA to be in full compliance ("Bush Bars UNFPA Funding, Bucking Recommendation of His Own Investigators," TGR, October 2002, page 13). Thus, the administration made it eminently clear that it would find the facts to fit its conclusion that UNFPA does not and cannot qualify for U.S. support.

As if punishing UNFPA directly were not enough, the administration recently has signaled its willingness to punish other recipients of U.S. funding for their association with UNFPA. Just weeks before the annual conference of the Global Health Council in June, which USAID had supported for 30 years as a way to bring public health professionals from developing countries to Washington to exchange information on best practices, USAID informed the council that it would lose $360,000 in U.S. support for the conference. Administration officials say, informally, that they withdrew their support in part because UNFPA Executive Director Thoraya Obaid was a featured speaker (on the topic of the dangers of early marriage and motherhood). According to a report in The New York Times that same month, the administration has gone so far as to warn other United Nations (UN) agencies such as the UN Children's Fund (UNICEF) and the World Health Organization (WHO) that if they work too closely with UNFPA, their U.S. support could be jeopardized as well. "The Bush administration's [threatened] isolation of groups such as WHO and UNICEF that work with UNFPA represents nothing less than a global assault on women's health," retorted Rep. Barbara Lee (D-CA).

Moralizing on HIV/AIDS

Donor and recipient countries alike are welcoming the ramped-up U.S. support for the effort to prevent and treat HIV/AIDS in the developing world. At the same time, the Bush administration’s campaign against condoms, along with its aggressive promotion of "abstinence until marriage" programs and repetition of the mantra that abstinence is the only 100% effective method of preventing HIV/AIDS, are causing consternation in the global public health world. At the XV International AIDS Conference in Bangkok in July, Britain’s international development minister, Gareth Thomas, commented diplomatically that the United Kingdom "work[s] with the Americans in a whole variety of ways, but we have a difference of view on abstinence-only campaigns" and "a different approach on access to condoms." Lieve Fransen, head of the human and social development unit at the European Commission and the top European Union official at the conference, echoed Thomas' sentiments. Thomas used the occasion of the conference to announce Britain’s plan to boost global HIV/AIDS funding, including supporting the "excellent HIV, sexual and reproductive health work" of UNFPA and IPPF.

The Bush administration remains committed, however, to an HIV/AIDS prevention strategy that is largely reduced to "ABC"—promoting abstinence, being faithful and condom use in that order. In line with that hierarchy, the United States eschews condom promotion efforts aimed at the general population, which it prefers receive the "A" and "B" messages. The administration still sanctions condom promotion to target groups believed to be unreceptive to those messages, such as commercial sex workers ("Beyond Slogans: Lessons from Uganda's Experience with ABC and HIV/AIDS," and "Understanding 'Abstinence': Implications for Individuals, Programs and Policies," TGR, December 2003, pages 1 and 4). To counterbalance services provided to sex workers, however, U.S. law now requires that indigenous NGOs using U.S. HIV/AIDS funds for any purpose have a formal policy opposing sex trafficking and prostitution. TGR,

Standing Alone

The cumulative effect of these radical policy shifts has been to isolate the United States from the groundbreaking consensus among the world's governments, which it had been a leader in forging in Cairo in 1994. The extent of U.S. isolation has been made clear over the last two years at a series of UN regional meetings convened to review the first decade of the ICPD Program of Action's 20-year plan. The United States made its first formal break from its historical position at the Asian and Pacific regional meeting in Bangkok in December 2002 ("Bush Administration Isolates U.S. at International Meeting to Promote Cairo Agenda," TGR, March 2003, page 3). It did so again at the regional meeting in Santiago, Chile, in March of this year; at that meeting, 37 Latin American and Caribbean countries, almost all predominantly Roman Catholic and some quite conservative, reaffirmed the Cairo Program of Action while the United States stood alone in opposition.

At the final meeting of Latin American and Caribbean countries in Puerto Rico in June, the United States reluctantly joined the consensus—but only after failing to persuade any of the other countries in the region to dissent. The United States lodged a host of official "reservations" to what it characterized as "far-reaching language that could be interpreted as promoting abortion" and that called for "unlimited rights for adolescents to access to reproductive health services with absolutely no recognition of parents' rights and responsibilities." Earlier, and with supreme irony, the U.S. delegation challenged other countries to remain consistent with the positions they had taken in Cairo (some of these countries did refuse to join the consensus at that time) and to reflect the views of their own people and laws. Their lobbying efforts even featured a personal appearance in Puerto Rico by a leading family planning opponent, Rep. Chris Smith (R-NJ), who made a direct—albeit unsuccessful—appeal to the president and first lady of Guatemala.

Frustration with the United States among other donor nations is growing wider and deeper. Outgoing European Commissioner for Development and Humanitarian Aid Poul Neilson used the occasion of the June UN Development Program/UNFPA Executive Board meeting in Geneva to blast the United States for its reversals. He noted that the European Development Fund, for the first time, would be channeling support to UNFPA and IPPF in direct response to the U.S. withdrawals of support. He expressed "dismay" over the U.S. actions to defund UNFPA and IPPF and to undermine the Cairo consensus, as well as U.S. efforts to promote abstinence while disseminating "negative and factually wrong messages about condoms."

For its part, Britain's Department for International Development (DFID) published its new sexual and reproductive health strategy in July, asserting that "women, especially, need more choice and control over their sexual and reproductive lives." DFID recommitted itself to remaining in the "forefront of the international debate on controversial issues...to uphold everyone's right to sexual and reproductive health. These rights have their opponents who feel threatened by them and we must therefore continue to explain why they are important and relevant to everyone."

In September, NGOs will gather in London for "Countdown 2015" to look ahead toward fully implementing the ICPD Program of Action's plan for the next decade. The UN General Assembly will formally commemorate the 10th anniversary of the ICPD on October 14. Once again, the United States will have an opportunity to take a stand—either with the overwhelming majority of the world's countries or basically alone with its small coalition of the "unwilling." If recent history is any guide, the signs are not positive. Yet, even as the United States announced on July 16 it would not fund UNFPA, Obaid gamely noted: "Historically, the United States has been a world leader in promoting reproductive health and family planning and we hope it will take up that role again."