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The Trump Administration’s Global Gag Order: What Lies Ahead for Abortion and Gender Equality

Trump and the Global Gag Rule

In Donald Trump’s presidential campaign, he promised to wage a war on abortion rights. He did indeed keep that promise; one of his first executive actions in office was reinstating the Global Gag Rule, which defunds international nongovernmental organizations (NGOs) that provide abortion services or even discuss abortion with their patients.

This rule has been through a kind of political rollercoaster since its inception in 1984. That year, the Reagan Administration implemented it at a population conference in Mexico City. Known as the Mexico City Policy, Reagan declared any NGO that includes abortion or abortion consultation among their family planning services ineligible for U.S. funding.

This policy is different from the Helms Amendment, which prohibits the use of U.S. aid directly for abortion services. The Gag Rule prohibits funding organizations that have anything to do with abortion–which includes a majority of family planning programs. As a result, it is not just abortion that will be affected but every aspect of sexual and reproductive health.

Republican administrations since Reagan have upheld the gag rule, while the Democratic administrations of Bill Clinton and Barack Obama have renounced it.  

But this time, Trump did not merely reinstate this policy. He intensified it by a factor of 15, according to Population Action International. Historically, the gag rule has applied to $575 million in family planning and reproductive health funding. Trump’s Global Gag Rule applies to all global health funding, which amounts to $9.5 billion. This cuts funding from the National Institutes of Health, Centers of Disease Control, the Food and Drug Administration and various agencies of the United Nations.

In the past, international NGOs could still receive funding from the United States Agency for International Development and the U.S. State Department under the Mexico City Policy. Not anymore. Trump offers no exceptions.

This extreme cut in U.S. funding could destabilize health organizations worldwide. HIV prevention and treatment, maternal health care and Zika prevention programs will suffer as a result.

Northwestern Professor Sarah Rodriguez, who is a medical historian specializing in women’s reproductive and sexual health, said other aspects of women’s health will be affected. “A NGO, for example, can provide services beyond those that pertain to pregnancy. It can be doing mammograms, cervical cancer screening, pap smears and more.”

The NGOs that received U.S. funding from the Obama Administration now have to face a choice: cut funding and limit the scope of their care, or receive funding but cut the abortion services they provide.

 

What It Means for Abortion

The Gag Rule aims to cut down abortion rates, but a 2011 study by Stanford researchers found that it actually results in the opposite. Examining the policy’s impact in 20 sub-Saharan African countries from 1994 to 2000, they found that the rate of abortions actually increased. Unsafe abortions, that is.

This correlation could be due to a number of reasons. The researchers suggested that NGOs contributing to contraceptive distribution lost the funding to do so, leading women to become pregnant without wanting to.

Out of desperation, women will still seek abortions, whether they are safe or not. Reducing the availability of abortion services will not change a woman’s desire to terminate her pregnancy. In fact, it makes sense that making abortion illegal–criminalizing it–forces women to turn to harmful practices. In Kenya, women will resort to drinking battery acid, using wire coat hangers and asking others to stomp on their stomachs until they are no longer pregnant.

One of the most frustrating global health issues is the high rate of unsafe abortions; they hugely contribute to the maternal mortality rate even though they are the only entirely preventable cause. 47,000 women die from childbirth-related causes every year, almost exclusively in developing countries.

There are areas in the world where abortion rates have sharply declined: rich countries where abortion is legal. This includes the United States. Since abortion was legalized in 1973, the number of total abortions performed every year has been on a steady decline.

The Gag Rule is a way to satisfy anti-abortion supporters in America, but it is those in remote rural areas of developing countries who suffer most. The policy limits the ability of organizations to increase birth control access, resulting in more unwanted pregnancies. Combined with a ban on abortion, women face horrifying realities.

 

Response and Reparation

“When the policy was first installed in 1984, only a handful of groups refused the money,” Rodriguez said. “By and large in the past, most groups continued to receive funding and chose to limit the kind of services they offered.”

Shortly after Trump put the gag rule in order, the International Planned Parenthood Federation (IPPF) confirmed that they will not abide by these conditions. Their U.S. funding will be cut off, meaning that the organization will lose about $100 million in the next four years for sexual and reproductive health services. When the Gag Rule was in effect under the Bush administration, IPPF said their partners in Nepal, Kenya and Ethiopia had to close clinics and offer fewer contraceptives.

The Netherlands openly opposes Trump’s decision. Lilianne Ploumen, the Dutch international development minister, said they plan to fund family planning programs with about $600 million over the next four years to help fill the financial gap Trump’s Gag Rule will cause. As many as 20 other nations indicated that they plan to do the same.

However, this additional funding may not have as much impact as it seems. Historically, aid from foreign governments tends to fail without serious political pressure from the countries that need it. And with Trump’s version of the gag rule, $600 million would only fill a small portion of a vast gap in funding. To weather the storm of this new administration, civic engagement and commitment to public health advocacy will be more important than ever before. 

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Global Health and Climate Change Agenda in Jeopardy

Less than a week following the inauguration of America’s 45th president, news outlets began pumping out stories about the chief executive’s silencing of two major governmental groups. The administration banned employees in the Environmental Protection Agency and the U.S. Department of Agriculture from publishing any social media posts, including tweets, or press releases about their recent scientific findings.

The ultimate purpose of this gag order has not been officially established. However, this action, and Trump’s previous statements about climate change being a “hoax” have concerned climate change activists, as well as global health organizations. As more and more research demonstrates that climate change impacts the health of individuals around the world, supporters of climate change action and global health advocates are uniting to address both problems. The Centers for Disease Control and Prevention (CDC) scheduled the Climate and Health Summit, a three-day conference in February to discuss the intersection of the two issues, but the new government’s transition is making officials reconsider.

During the week of January 23, the CDC announced to the media that it was indefinitely postponing the conference, originally planned for February 14-17. No public statement was given by the agency to explain the action. The Trump administration did not directly order the cancellation, but likely played a large role in the decision, according to other sponsors of the event. A co-sponsor of the event stated that organizers felt uncertain about the amount of support the administration would offer the event, given the president’s previous statements about climate change. Rather than potentially face conflict with the administration over the conference, the CDC decided to postpone holding the event until officials could discuss details with the new administration.

Friday, former vice president Al Gore announced in a release from the Climate Reality Project, that there would be a replacement for the conference. A number of organizations, including the American Public Health Association, the Climate Reality Project, Harvard Global Health Institute, and the University of Washington Center for Health and the Global Environment will sponsor the Climate and Health Meeting in Atlanta, Georgia. While the goals of the meeting are very similar to the summit, the timeline has been shortened to a single day.

As global temperatures continue to set records, the consequences of climate change are already affecting the health of individuals around the world, particularly in vulnerable regions. Increases in heat have been clearly tied to the increasing number of heat-related illnesses. However, climate change also impacts many intermediary factors that result in worsened health conditions. For example, changes in temperature have allowed mosquitoes to expand their habitats, putting more of the world at risk for diseases like dengue, malaria and Zika. Scientists have also linked global climate change with increased and worsened episodes of natural disasters like floods, droughts, and hurricanes. Not only do these disasters often result in direct death and injury, they place added burdens on countries whose health systems lack the resources to effectively deal with the aftermath.

While officials in the United States continue to debate the reality of global climate change, much of the rest of the world is taking steps to study and solve the complex health problems associated with a warming planet. In July, the WHO hosted its second annual conference on Health and Climate. Although there is a growing number of countries involved in these efforts, it will be key for the United States to join them to bring about effective and impactful changes.

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A Look at the Israeli Healthcare System

In the quest to create a healthcare system that provides universal health coverage to all Americans, it is important to evaluate other healthcare systems throughout the world. While conversations typically focus on the European Union’s health insurance programs, I believe that further investigation of the universal healthcare system in Israel is necessary.

Under collaborative supervision by the Israeli Ministry of Health and the Palestinian Authority, all citizens and residents of the state of Israel receive compulsory health insurance and medical services. This means that all people inhabiting the state of Israel, even those who accept Palestinian Authority citizenship and deny Israeli citizenship, receive health insurance regardless of religion, gender, race, or socioeconomic status. Not only do all people residing in Israel receive health insurance, patients have the freedom to choose from one of four competing health plans on the market, allowing them to select the program that best fits their medical needs.  Besides giving patients freedom of choice, the competition amongst the health insurance plans drives down costs. Further ensuring the success of the system, all persons are required by law to enroll in a health insurance plan.  Because it is illegal to be unenrolled in the health insurance program, high-income low-risk individuals subsidize low-income high-risk individuals.  In the United States, many opponents of the Affordable Care Act fear that the lack of competition on the market will cause prices to sky-rocket for patients. More so, they fear that high income low risk individuals will chose to pay the small fee associated with not enrolling in the health insurance, thus threatening the financial stability of the U.S. healthcare system. Israel’s healthcare system addresses these concerns, while still maintaining a system that reflects the fundamental ideals of the Affordable Care Act: providing healthcare for all people.

In addition to the distinctive structure of the Israeli healthcare system, Israel’s Magen David Adom and their method of caring for senior citizens make the healthcare system unique and particularly interesting in its own right. Magen David Adom (MDA) is the Israeli version of the Red Cross and acts as Israel’s emergency medical service providing first aid assistance by ambulance, a blood bank, and first aid and disaster relief courses. While the government mandates that this organization serves as the first responders in a medical emergency, they do not receive any government funding. Thus as Israel’s sole EMS system, they are entirely reliant on donors for funding as well as the 10,000 volunteers who make up their staff. These volunteers are trained through a 60-hour rigorous course and serve as assistant medics and dispatch center employees, among other roles. The donors and volunteers have created a qualified and effective emergency service system in Israel that successfully operates without government funding.

Another identifying aspect of the Israeli healthcare system is the way in which it cares for senior citizens. Since Israel is a developed country, characterized by a less intact community structure in which family members often live far way from the aging, the country’s health system is forced to handle disabled elderly citizens. Further complicating the issue, in Israeli culture, sending elderly persons to retirement homes is considered immoral and disrespectful. Hence, the majority of elderly people are taken cared for at home. Currently, community health organizations provide many necessary services for the elderly, including preserving at home independence, providing financial assistance for in-home caretakers, ensuring safety at home, and providing meals-on-wheels, medical equipment, and transportation.

However, the healthcare system is not without flaws and it presents a number of challenges to the public health status of the country.  Many politicians assert that the immense military spending budget has undermined the need for budget allocation to health care (Reeves & Stuckler, 2013). The inadequate funding has led to high copayments and a turn towards privatized medicine, placing low socioeconomic individuals at risk. Many Israelis also complain about the wait times to see specialized physicians and the fact that many life saving medications are not approved because of the cost-benefit ratio (“Overview of Israeli Healthcare System,” 2016).

Overall, however, the Israeli healthcare system is considered efficient because the health status levels of the population are relatively similar to that of other developed countries, even though a lower proportion of GDP is spent on health care. Israel’s healthcare expenditure comprises 7.5% of its Gross Domestic Product (GDP), which ranks 10.4 % lower than the United States’ share of GDP spent on healthcare, and 1.4 % lower than the OECD country average. (Chintz, 2014). While still considered a form of socialized medicine, the competition amongst healthcare insurance plans provides fair market pricing and physician choice for the patient.

This past summer I spent two months living in Tel Aviv and working in Israel’s health sector. I chatted with young professional Israelis who appreciated having the ability to chose their own health insurance plan. I met children who had been waiting over a year to see a specialized physician for their rare condition. I encountered economically disadvantaged patients receiving similar treatment as their economically advantaged counterparts. I worked alongside health care providers who were not only multi-lingual, but were able to provide culturally and religiously competent care to all patients they treated. As Israel is a mecca of religions, cultures, languages, and ethnicities, I personally witnessed a healthcare system which is responsive to the needs of the community. While of course no system is perfect, as American leaders work to create a healthcare system that provides quality, culturally competent, and affordable healthcare to all citizens, I believe that we could learn a thing or two from the Israeli healthcare system.

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Working at the Intersection of Human-Centered Design and Healthcare Technology: An Alumna Interview with Eleanor Burgess (SoC 2015)

Eleanor Burgess has been passionate about the intersection between human-centered design and healthcare technology since her days as a global health student here at Northwestern. After graduation, she received a Fulbright scholarship to obtain her Master of Science in Technology Entrepreneurship at University College London (UCL).

During her time in London, she completed a Fulbright research project in which she worked to create an online health community for chronic kidney disease patients in the UK. In addition to her research Ellie and three of her colleagues co-founded the company drfocused to provide clinician-focused digital solutions for the medical community. Currently Ellie is working toward her PhD in human-computer interaction at Northwestern.

Techstars London Headshots - Image ©Dan Taylor/Heisenberg Media.

Techstars London Headshots – Image ©Dan Taylor/Heisenberg Media.

What did you learn from your Fulbright project?

“Ever since I was a global health minor at Northwestern, I have been excited about the intersection between technology and health. While working toward my masters degree at UCL, I started a research project to build an online health community for chronic kidney disease patients. However, after conducting interviews with patients, I learned a key insight: many patients actually did not want to use an online health community. This experience emphasized the importance of talking to the people who will use the technology to accurately address their needs when developing healthcare tech.”

How did you create the idea for your company drfocused?

“After learning the importance of user-centered design, I went on to co-found my own company, drfocused. One of my classmates at UCL was a physician who pointed out the many issues doctors face when completing their arduous yearly mandatory appraisal, essential to maintaining their license to practice medicine. This appraisal is a yearly compilation of a doctor’s educational learning. Using my software design experience and my colleague’s experience as an Accident & Emergency doctor, we agreed to work together to create a solution for this problem.

Initially, we wanted to help doctors with their appraisals, but ultimately our vision is to improve the working lives of doctors. Until recently, many companies have created healthcare technologies and sold them to hospitals without much design input from health professionals. This method of tech design often fails to involve the clinician – the end-user – in the creation of tools to support medical practice.”

Tell us a little bit about the company you co-founded, drfocused.

Drfocused involves doctors at every design stage of our healthcare technology. My company has created an online community of doctors, called the Doctor’s Digital Collective (DDC), which provides opportunities for collaboration between physicians to design, build, and disseminate technology solutions. In collaboration with this community, we created an innovative app, and our first features support education and safety reporting for doctors in the . The drfocused app helps to streamline these processes, while simultaneously reducing the burden these reports inflict on doctors. Our future aim is to support all non-clinical administration tasks for doctors worldwide.”

Techstars London Headshots - Image ©Dan Taylor/Heisenberg Media.

The co-founders of drfocused

Can you explain how human computer interaction research supports global health?

“From my studies in the field of global health I have learned that many health interventions which had good intentions were often unsuccessful and had unintended consequences. Human-Computer Interaction (HCI) research works to prevent these unintended consequences in technology interventions. One major question is: how do we make a technology practical for those who use it? Many HCI scholars focus on improving access, personalizing, and reducing the complexity of technology. If we can accomplish these goals, we can ensure that our health technology works effectively for those who use it. Most importantly, global health and human computer interaction urge me to remain self-critical in my work as a technology designer and to be aware of the possible consequences of new technologies.”

As you are probably well aware, many global health scholars warn against “quick fix” healthcare technology solutions. How do you address this concern in your work?

“I always remember that every decision I make as an innovator has repercussions. Through my PhD work here at Northwestern, I have investigated how technology fits into a society and how that society changes as a result of implemented technology. I think critically about the effects of technology so that it can be accessible and beneficial to as many people as possible.

The recent , a new, evidence-based approach for addressing many of the complex and serious problems facing the world today, talks about the continued failed attempts to design and implement large, multi-stakeholder projects to revolutionize health systems. This is exactly the kind of “quick fix” we need to avoid. Instead we must focus our work on smaller projects that address specific problems. By addressing acute problems, we can better design systems and ensure that updates to the system happen quickly. We must also ensure long term adaptability of the technology. By asking user-centered questions and continually critiquing our own work, we can avoid failed ‘quick fix’ solutions.”

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New Faculty Spotlight: Beatriz Oralia Reyes

Beatriz O. Reyes is a new professor in the Department of Global Health who will be teaching Community-Based Participatory Research in the Winter 2017 and 301: Intro to International Health in the Spring 2017. She is a member of the Native American Indigenous Studies Steering Group and researcher at the Foundations of Health Research Center at Northwestern.

img_3208Reyes, who is Tepehuán and a citizen of the Navajo Nation, earned her bachelor’s degree in Zoology from the University of Oklahoma. As a recipient of the Gates Millennium Scholarship and a first-generation student, Reyes initially thought being a medical doctor best suited her interests. Growing up, her experience with the U.S. health system—in particular the Indian Health Services—was less than ideal. She dreaded becoming sick because she would have to wait at the hospital for hours to be seen, which also meant her mom would have to take time off work. For her, health care was an inefficient system, and only at college did she realize that this was not an experience shared with many of her peers.

While she enjoyed studying Zoology at OU, it was connecting science to sociology and history that sent her on a path to realizing she was more interested in health policy and health disparities. As an indigenous person, she was cognizant of the ways policy shapes society’s view of her existence and the ways her experiences in the world are shaped by policy-makers. Everything from the types of foods you have access to, what land you live on, everything about your identity is shaped by these systems. Further, Dr. Heather Ketchum’s courses on Parasitology and Entomology highlighted for Reyes how human health is heavily impacted by the life cycle of insects and parasites. Reyes realized she had multiple interests but still struggled to determine where they intersected.

Reyes’s multiple experiences as an intern in the federal government provided her with a roadmap to public health. She was accepted into the Washington Internship for Native Students, a summer internship where students work for an agency in the federal government and take two classes at American University, one course being Federal Indian Law.

After this experience, she enrolled at East Carolina University to earn a master’s degree in public health. This was the first time she was exposed to public and community health, and was drawn in by its complexity. Her research project looked at the policy and implementation of recommendations for Division 1 NCAA athletes with sickle cell trait. While it was an interesting project, she wanted to further gain experience and knowledge in qualitative research methods and community-based participatory research. She then decided to pursue a doctorate in Health Policy and Social Justice at the Dornsife School of Public Health at Drexel University in Philadelphia, Pennsylvania. Her doctorate research focused on evaluating a faith-based 16-week prediabetes prevention program. This larger study was conducted by her advisor, Dr. Nicole A. Vaughn and was an adaptation of the National Diabetes Prevention Program (DPP). Reyes’s dissertation study was a qualitative analysis of the ways lay health educators adapted and utilized program materials to fit the needs and concerns of their specific communities.

Reyes hopes to provide Northwestern undergraduates with an introduction to the benefits and challenges of collaborations between researchers and communities, in her Winter 2017 course on Community-Based Participatory Research (CBPR). She told me, “The thing about CBPR is that it’s not a method, it is a paradigm, it’s an approach to research.” It begins with asking yourself questions like: where does the community fit into developing the research question, decision-making process and resulting intervention? Does the community find value in the research and intervention? Is there joint ownership of the data, its presentation, and implementation? While there is no standard way to do CBPR, it is so important to remove the barriers that prevent researchers from working with communities, and one of the most powerful ways of doing this is by coming together with a shared vision of improving health in a socially just manner with the intent to eliminate health disparities.

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