Twice Victimized: U.S. Policy Obstructs Care For War-Rape Victims


This article originally appeared in Conscience magazine, published by Catholics for Choice.

In April 2009, Hillary Clinton appeared before the House Foreign Affairs Committee and voiced the strongest support for global reproductive rights ever heard from an American Secretary of State. She was speaking in response to a question from New Jersey Republican Congressman Chris Smith, who wanted to know if the Obama administration would work to "weaken or overturn 'pro-life' laws and policies in African and Latin American countries," and whether the United States considers "reproductive health" to include abortion.

For most politicians, such a question would evoke nervous hedging and temporizing, but Clinton was remarkably clear. She began by talking about the human suffering she's seen worldwide in places where abortion is restricted: "I've been in hospitals in Brazil where half the women were enthusiastically and joyfully greeting new babies, and the other half were fighting for their lives against botched abortions." She continued, "So we have a very fundamental disagreement. It is my strongly held view that you are entitled to advocate, and everyone who agrees with you should be free to do so anywhere in the world, and so are we. We happen to think that family planning is an important part of women's health, and reproductive health includes access to abortion."

Around the world, women's health advocates cheered. The United States, after all, has a profound effect on reproductive rights across the globe, and during the Bush years that effect was overwhelmingly negative. Already, President Obama had reversed two of the Bush administration's most hated polices. On his third day in office, he repealed the "global gag rule," the executive order that denied US funding to any group that performs abortions or counsels about the procedure, even if it does so with its own money. Then he reinstated American support for the United Nations Population Fund (UNFPA). Clinton's statement suggested that once again the United States could be a leader in pushing for reproductive rights worldwide.

But two years into President Obama's administration, many in the field are grumbling. They are grateful for much that the administration has done, but they complain that it hasn't been proactive in fighting for reproductive rights, and that a disorganized, risk-averse United States Agency for International Development (USAID) interprets restrictions on abortion funding more strictly than it has to. "What we're seeing on abortion-related policy is no change from the Bush administration," says Barbara Crane, executive vice president of Ipas, which promotes safe abortion worldwide.

The United States was once a leader in promoting safe abortion globally. The first head of USAID's population program, Reimert Ravenholt, was responsible for having the manual vacuum aspiration syringe, a device used in abortion care worldwide, engineered for mass production. But since 1973, even sympathetic American policymakers have been hamstrung by the Helms amendment, which says, "No foreign assistance funds may be used to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortions." The restrictions were compounded by the Siljander amendment, which bans foreign assistance funds from being used to "lobby for or against abortion."

Groups advocating for safe abortion were disappointed that the Obama administration didn't come out strongly against the Helms amendment early in his presidency, when there might have been the momentum for repeal. They also wish the president had pushed for permanent legislative repeal of the global gag rule, so that a future Republican president can't simply restore it with the stroke of a pen. "We've lost the opportunity to forever get rid of the policy, and we're likely back now to where it's a political football tossed from White House to White House," says Suzanne Petroni, vice president of global programs at the Public Health Institute.

But even with legislative advances unlikely, advocates say there are things the administration could be doing to expand access to reproductive health care. American aid programs have to abide by the Helms and Siljander amendments, but they needn't interpret them as narrowly as they do. Abortion "as a method of family planning" isn't well defined legally. As Crane points out, there's precedent for interpreting the phrase to exclude cases of rape and incest, as well as threats to a woman's life. Yet not only does the United States refuse to fund abortion care for rape victims -- it actively impedes such care.

In a report issued in January, the Global Justice Center, a human rights legal organization, concluded that US abortion restrictions constitute "a major force behind the daily denial of abortions for girls and women raped and impregnated in armed conflict…. Aid groups fear that education and dissemination of information about abortion services for rape victims may result in the revocation of US funding." It's not just American funds that are affected. According to the Global Justice Center, "US funds are rarely, if ever, segregated from other donor funds," which means that USAID restrictions end up infecting the entire pot of money.

Given the widespread use of rape as a weapon of war, denying abortion services can compound grave human rights abuses. That's why Norway, in a report to the United Nations Human Rights Council, recommended the "removal of blanket abortion restrictions on humanitarian aid covering medical care given women and girls who are raped and impregnated in situations of armed conflict." Speaking to the British House of Lords last October, Labour peer Baroness Uddin urged her country to work around the United States on behalf of rape victims. " We should to what no other country has done: to ensure that the humanitarian medical aid provided to girls and women in places such as Congo, Sudan and Burma -- an endless list of countries -- gives them choices and access to abortion when pregnancy is a direct result of rape as a weapon of war," said Uddin, adding, "Neither criminal abortion laws in the conflict state nor foreign aid contracts with the United States can serve as defense to a state provision of discriminatory medical care to all victims under international humanitarian law." For women raped in conflict situations, the United States remains an obstacle rather than an ally.

Ipas complains that a narrow interpretation of the Helms and Siljander amendments curtails the ability of public health professionals to even talk about the impact of unsafe abortion in the developing world. In Malawi, for example, USAID funded Dr. Chisale Mhango to serve as director of the reproductive health unit in the country's ministry of health. Mhango was a principal investigator on a study of unsafe abort ion in his country -- abortion is highly restricted in Malawi -- which found that around 30,000 women are hospitalized each year for complications from clandestine procedures. But a USAID official at the Malawi mission prevented Dr. Mhango from presenting his results at a national meeting, arguing that doing so would violate statutory restrictions on his funding.

"We had hoped the long overdue legal and policy review would be undertaken under the Obama administration," Elizabeth Maguire, president and CEO of Ipas, wrote in a letter to USAID about the case. Maguire served as director of USAID's office of population and reproductive health during the Clinton administration and understood the legal limits the office was operating under. But she argued that the agency was still being excessively censorious. "Overall, apart from the removal of the global gag rule, we are extremely disappointed that we see continuing confusion and unnecessary chill among USAID staff and grantees about what is permissible," she wrote. "Evidence continues to mount that USAID staff and grantees are still censored and gagged -- prevented from attending meetings where abortion is discussed or engaging in generating or discussing data on the issues.

In response, Susan Brems, senior assistant administrator at the USAID Bureau for Global Health, basically argued that the law is the law. "We believe that the agency is implementing the statutory restrictions in a manner that is consistent with the Obama administration's commitment to family planning and reproductive health while ensuring compliance with the restrictions," she wrote.

The United States remains so fearful of any entanglement with international abortion politics that it even refuses to pay for equipment necessary for post-abortion care, a medical necessity given that, according to the Guttmacher Institute, 5.2 million women are hospitalized each year for complications from unsafe abortion. As Crane explained at a Congressional briefing last spring, while USAID recommends the use of manual vacuum aspiration syringes to treat some consequences of botched abortions, it won't pay for them because they can also be used as abortion equipment. "We have the same situation now with pharmaceuticals like misoprostol that can be used both for abortion care and for lifesaving care in childbirth -- but which USAID, so far as we know, does not provide in its programs," she said.

Part of the problem, say critics, is that USAID has become weak and rudderless, which means few staffers are inclined to challenge the status quo. "The foreign aid program desperately needs a top-to-bottom reorganization and reconceptualization," says Steven Sinding, who ran USAID's population division during the Reagan administration and is now a professor at Columbia University's Mailman School of Public Health. "Everyone agrees on that. The Washington consensus is that USAID is broken, ineffectual, desperately in need of reform."

As Sinding points out, it took almost a year for the administration to find a coordinator for the agency, and many senior positions remain unfilled. In such an environment, bureaucratic timidity takes over. There are, of course, plenty of people at USAID who are committed to women's health. Beth Fredrick, deputy project director at the Gates Institute for Population and Reproductive Health, says that in nations where she's worked, USAID staffers "have really been actively assessing the policy environment to see where services can be improved, where access could be improved, where their leadership role can help the government figure out better ways of serving the women in their country." Without strong support from above, though, few are inclined to push the limits of what's permissible.

"I don't blame the people at AID. They were career people. They weren't in a position to make those decisions," says Sinding. But the White House, he says, failed to show "courage to act in an environment in which they knew that Chris Smith was just waiting to pounce, and now, by God, he's going to."

Indeed, if the administration was trying to placate the GOP and build some sort of consensus around broader issues of global family planning and women's rights, it hasn't worked. In December, a bill to fight international child marriage failed to pass the House

due to baseless Republican claims that the bill would channel funds to NGOs that provide abortions. Abortion is simply not an issue that can be evaded by any effort, no matter how bipartisan.

That's particularly true now that Republicans have control of the House. In the recent budget negotiations, the GOP attempted to slash global family planning programs by 39 percent, from $716 million to $440 million, and to eliminate funding for the UNFPA. It's highly likely that the GOP will try to use deliberations over future spending bills to reinstate the global gag rule. During the Clinton administration, Republicans demanded the return of the gag rule as a condition of paying back dues to the United Nations. In a complicated compromise, Clinton ended up signing a bill that simultaneously imposed the gag for one year and allowed the president to waive it, though the waiver triggered a $12.5 million cut in funds for international women's health. "[T]he House obstructionists held firm, faced down the White House and walked away with a disturbingly large share of what they wanted," the New York Times concluded.

Chris Smith played a leading role then, and he almost certainly will again. "Republicans talk about fiscal austerity," says Petroni. "Foreign aid is an easy target for them. The community needs to do a good job of articulating [the] importance of investing in reproductive health as well as global health and development." The fear is that if the administration wasn't willing to take a strong stand when Democrats were in a position of strength, they'll be even weaker on the defensive. "I don't think we k now yet how [Obama] will do in that kind of environment," says Fredrick, "and whether he's got enough conviction behind women's health to really fight for those issues."

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