Well.

Shit.

I wrote this piece in the strangest headspace. Like many others, I was left reeling after Donald Trump’s elevation to the White House for a second time. My characteristic fear of doing new things was keeping me from resolving some big girl insurance stuff. At least there were no bagpipes this week (don’t worry, I’ll explain).

I’m South African. Most people know us for Nelson Rolihlahla Mandela, soccer, and Apartheid. My overseas friends used to only remark on those, but things have changed. Online interconnectedness has thankfully made us less prone to silly presumptions.

Being South African, I have very different problems to my Australian accountant bestie and American Autostraddle co-workers. I’m always worried about whether there’ll be water in my taps. Our major cities are choking, and this is my town’s first year in memory of having more days with water than without. I hear about student disputes and drama at my alma mater and hope nobody else’s classmate commits a murder like mine did. This year marks 20 years since my family was held at gunpoint during a home invasion, and I’m anxious to put another decade between myself and that event.

The strangest problem I have in South Africa is that the Scottish private school next door holds bagpipe practice on the field. At 8 a.m. On a Saturday. What kind of absolute balloon subjects people to that? I don’t blame the kids playing the pipes either. I was a pianist. I know that musical learning is a carnival of errors. But bagpipe practice is a true terror. Few things are more dissonant than misplayed bagpipes at the southern tip of Africa.

All of that matters because it contextualizes how different my life is compared to my loved ones and the majority of our darling readership (you). It’s a marvel that this highly interconnected world lets me hear your stories and shout my advice right back. But that connectedness cuts both ways. Some days, I marvel at the fact that I have relevant and helpful things to say to Autostraddle’s predominantly North American readership.

On other days, I get the 2024 US presidential election.

I won’t spill much ink over my emotional response to the outcomes of that cavalcade of unfortunate events. My Autostraddle colleagues in the US are up to their asses in it and have plenty to say. Whatever adjectives and expletives they’re using, they have my agreement.

For now, I will tell you one of the material concerns this election has for us in South Africa. This is a story about interconnectedness. People voted (or didn’t) on one side of the Atlantic and set in motion events felt keenly by people living on the other side. My side. I drive past game reserves filled with elephants and giraffes to an apartment that picks up live bagpipe music. What a time to be alive.

I’m here to talk about the Global Gag Rule (GGR). The GGR (AKA the Mexico City Policy) prohibits organizations receiving US foreign aid from providing abortion procedures, referrals, and information in their countries of operation. It applies regardless of the legal status of abortion in that country. It applies even if the organization wishes to use its own funding for abortion-related services rather than US foreign aid. Lastly, it prohibits organizations from undertaking any abortion law reform activities or advocacy should they promote freer access to abortions. In short, it’s a blanket ban on organizations receiving US foreign aid from doing any abortion-related work in their country, even with their funding.

It was the Reagan administration’s idea.

All that being said, I wouldn’t be so vociferous about the GGR if it were a permanent policy. If it was a fixed reality of US foreign aid, it would just be another politicized and moralistic criterion for obtaining aid. Foreign aid is inherently political, anyway. It’s usually moralistic and frustrating, too. No. The Global Gag Rule isn’t a permanent fixture. It’s so much worse.

It’s a goddamned executive order.

A sitting US president can reinstate or suspend the Global Gag Rule at will. The US Congress may also do this, but that only happened once when Congress under the Clinton administration reinstated it against Clinton’s executive order. That 1999 congressional reinstatement lasted 11 months before Clinton suspended it again by executive order.

Those 11 months in 1999 aside, the GGR has always been a point of presidential discretion. It’s part of the slew of executive orders a US president mows through upon taking office. If the previous president had the same political alignment as the new guy, the orders are generally upheld with little concern. If the new guy is from the other party, he’ll usually flip the proverbial table and undo everything disagreeable from the previous administration and write their own rules for good measure.

You can see how a revolving door approach to critical healthcare aid to impoverished countries might make things difficult for us, right? I hope you don’t have the misfortune of working in an underfunded NGO outside of the USA. Because those people positively shit themselves during each US presidential election. Let me explain.

Let’s say you just had eight years of Team Donkey administration. Your org has established valuable reproductive and sexual health infrastructure, resources, and grassroots trust. Your funding arrives in the well-respected electronic Benjamin Franklin format. Under a Team Donkey administration, things are livable. Not ideal, but they move.

Then Team Elephant reaches White House. Sometimes the other two buildings, too. Three, if you count the Supreme Court (haha. what the fuck tho?). A Team Elephant victory means tossing everything you’ve established these last years out the window if you want to continue existing. Your grassroots connections, community of clients, infrastructure, reproductive health materials…all of it. If you’re serious about having any long-term operations, you’ll start to think that it’s safer for your NGO to never, ever do reproductive health. It might not even be worth investing in it during Team Donkey years because why invest in something that’ll catch a sledgehammer in four to eight years?

That’s why the people who don’t like it call it the Global Gag Rule. It’s restrictive even when it’s not in effect. But wait, there’s more.

Since it’s an executive order, the most a Democratic president can do is undo it. They can’t swing the scale of power much further than that. But a Republican president can write it back in and expand it during their term. When the Global Gag Rule expands under one Republican president, it doesn’t usually contract under the next Republican. This century isn’t exactly famous for its trend toward more moderate Republican presidents, after all.

The GGR works because it’s enough to be effective, but unpredictable enough that organizations can never adapt to it. Its prohibitions can strengthen at will but can only be temporarily withdrawn. I couldn’t invent a better prohibition on the work of valuable healthcare providers if I tried. And I don’t have to, because the US has done it already. Both by being Israel’s primary arms supplier and sometimes taking a more direct approach.

Okay, but I was supposed to tell you about the material impacts of this policy. Where are those?

The GGR doesn’t reduce the number of abortions overall. It reduces the number of safe abortions. In Uganda, the number of women seeking care for damage caused by unsafe abortions increased when the GGR was in effect. It increases the number of maternal deaths due to the inherent risks of unsafe abortions self-administered with tools like knitting needles.

This pattern is repeated in Madagascar, where mortality is only the tip of the iceberg. There, an NGO that did not comply with the GGR lost its funding. It was forced to close clinics that weren’t just providing abortion-related care, but also dispensing free contraceptives to 17,000 people and the associated family planning information attached to that.

Earlier in the article, I switched away from mentioning abortion to sexual and reproductive health. That wasn’t some rhetorical device to avoid talking about abortion by disguising it under other terms. The GGR actively targets wider healthcare.

“No one opens a facility to just provide abortion care, because no one comes in just for an abortion. They leave with a family planning method. You have to screen them for HIV if it’s a case of rape; [you] put them on pre-exposure prophylaxis. We are talking about access to contraceptives; we are talking about cancer screening and treatment.”

– Nelly Munyasia, How the U.S. election has an outsized effect on global reproductive health

Consequently, every organization threatened or destroyed by the GGR isn’t just shuttering abortion care. It’s the loss of family planning and contraceptives. A node in HIV and tuberculosis care is destroyed. Cancer screening, maternity services, and sexual violence advocacy are eradicated. This forces organizations into an aggressively protective approach to what care they dispense.

The damage and confusion sown by the GGR to healthcare beyond abortions is described has a ‘chilling’ effect. It freezes other operations by imposing a fear of funding cuts. To the beneficiaries of US aid, abortions are obviously a no-go. But if abortions are a procedure under consideration in cases of sexual violence, those resources are also restricted. What about research on abortions of any kind, in any context? ‘Plan B’ emergency contraceptives work by preventing a fertilized egg from latching and developing. Is that prohibited? The GGR presents organizations with a false ‘choice’ between gutting their services to remain compliant or jeopardize their existence.

I’m not shitting you around about ‘confusion’, either. The Global Gag Rule isn’t a well-intentioned policy. If it were, its terms would be made clear, communicated well, and organizations would be supported on the path to good-natured adherence. Nah, we get shit like this:

“During the Reagan GGR, an abortion provider in Kenya needed clarity on the permissibility of abortion for a woman living with AIDS, and another questioned if a woman verified by a psychologist to be at risk of committing suicide due to an unwanted pregnancy classified as a case of life endangerment. One organization in Brazil was confused about whether partners advocating for liberal abortion laws could be invited to workshops and receptions, and staff in Bangladesh did not know what abortion research was allowed.”

– Constancia Mavodza, Rebecca Goldman & Bergen Cooper, The impacts of the global gag rule on global health: a scoping review

Back in Kenya, researcher Kenneth Juma says an HIV/AIDS organization was warned by USAID not to share space in its vehicle with groups that might transport “abortion-related commodities in their car since the car was procured with USAID funding.”

The Global Gag Rule sows confusion amongst healthcare providers, breaks working relationships between organizations, and prevents people from accessing comprehensive sexual and reproductive healthcare. This isn’t accidental. Resistance against the GGR has existed since its inception in the Reagan administration. Since its earliest incarnation, it has always been an overreach of US presidential authority into the healthcare functions of other countries.

I must repeat some earlier statements to emphasize that last part. When it’s in effect, the Global Gag Rule prohibits organizations from using US aid to take part in any activities related to providing, supporting, or informing on abortions. Far from a simple ban on performing abortions, it also covers providing referrals, distributing information, advocating for legal reform, and abortion research. The GGR applies even if abortion is legal in that organization’s jurisdiction. It applies even if the organization spends its own funding on any of those activities. It applies if organizations cooperate with others that offer abortion-related services, destroying the critical support networks that underpin NGO work.

Like so much reactionary fearmongering, the GGR is couched in protectionist language. Jim Crow-era bathroom laws were pressed forward under the guise of protecting white women from predation by Black men. A variant of this dated and untrue argument is currently being rehashed against trans people. The target of the GGR’s precious ‘protection’ is fairly clear. It claims to protect the very sanctity of life itself, with emphasis on embryos and fetuses. The 2016 Trump administration named their iteration Protecting Life in Global Health Assistance. Says it right there in the name. It protects life. That’s why it results in statistically higher mortalities among women pushed to unsafe abortions and suicide as a result of unwanted pregnancies. It’s protective. It’s so protective that it severs funding and causes shutdowns of organizations who deliver services including HIV care, cancer screening, provision of contraception, and sexual health training.

Defenders of the GGR will point out its wording doesn’t enforce a total ban on all abortion-related activities. It has an exemption that allows organizations to make referrals for or provide information about abortion when a pregnancy results from “rape or incest, or if the life of the mother would be endangered if she were to carry the fetus to term.” (p. 5, (B)). What follows is the one and only piece of backhanded kudos I gift to the GGR until my dying breath: The GGR’s exemption that permits support for abortions that result from rape, incest, or life-threatening situations is better than what many US residents now have access to after Roe v. Wade went down. So, there’s that.

In spite of its own existence, that exemption is functionally irrelevant. The earlier requirements of the GGR already prohibit organizations from performing abortions or doing anything to promote/inform about them as an option. If a verifiable victim of sexual violence, incest, or life-threatening complications approaches a GGR-compliant organization, it doesn’t actually matter. That organization has already been gutted of any resources, connections, and infrastructure needed to care for their client. This lonesome exemption is just a fig leaf that allows the administration to claim that their policy is not a total ban on abortions, even though its actual outcome is no different.

The Global Gag Rule’s ability to impose these sweeping restrictions on countries where abortion is legal is a persistent sticking point. It’s not an exaggeration to say this amounts to the violation of national sovereignty by leveraging people’s health and lives.

In South Africa, abortion is legal with various restrictions. South Africans have the right to access legal and safe abortions for free at public health facilities. Even though our public health system is besieged by (largely intentional) malfunctions, this misbegotten country still tries its best. The right to abortion access in South Africa is guaranteed during the first 3 months of pregnancy, and includes invasive and non-invasive options, depending on the situation. It’s also unlawful to deny people abortions if they’re under the age of 18 or for any other reason except for valid health reasons.Healthcare workers do still violate these provisions, but at least our laws favor bodily autonomy.

Our position is far from ideal, but it’s legislatively robust, and for that, I am proud.

But fuck all of that if your organization wants US aid to support critical healthcare operations. South Africa is one of the nations most impacted by the Global Gag Rule. During the 2016 Trump presidency, the GGR was vastly expanded. Previously, it applied to family planning funding but was expanded to encompass all healthcare funding. To quote that report: “This extension has far-reaching consequences for programmes and access hereof to maternal and child health, nutrition, HIV, tuberculosis, malaria, among other areas of health funding.”

On the bright side, it hasn’t reached the categories of humanitarian assistance, water, and sanitation. Yet.

For South African organizations, the GGR isn’t just a despicable insult wielded by Republican presidents who barter HIV, malaria, TB, and sexual violence healthcare in exchange for compliance with their opinions on abortion. It contravenes our constitution, which includes a Bill of Rights mandating the right to reproductive healthcare. That mandate includes our right to sexual and reproductive autonomy as it pertains to our bodies. This includes free and stable access to contraception, safe childbirth and abortions, and reliable education on any of these topics.

So yeah, of course I’m pissed. Our Constitution is one of the few good things we have. It prohibits discrimination on the basis of sexual orientation and marital status alongside the usual suspects like disability, ethnicity, and language. We were the first country to enshrine that protection in our constitution. It became the basis for the landmark legal decisions that followed.

We legalized abortion in 1996. Full adoption rights for same-sex couples were granted in 2002. We legalized same-sex marriage in 2006. It came late because the matter had to reach the Constitutional Court before the laws were amended. Our National Assembly then voted 229–41 in favor of legalizing same-sex marriages and civil unions. 2006 was late legalization of same-sex marriage by our legal standards. Capital punishment? We killed that in 1995. The Constitutional Court judgment that invalidated capital punishment here was a masterwork argument on why capital punishment is unreliable, ineffective, and a violation of human dignity. To this day, it’s required reading in introductory law courses, and it’s a work of art.

That crash course in South African landmark cases aside, we’re not perfect. Far from it. I’ve never once recommended that someone move here, and I never will. But sometimes our government gets things right. It only gets things right as an exception, not the norm, sure. But that makes it triply insulting when other countries arbitrarily overrule the bright spots we managed to cultivate.

As it stands, the GGR is already disastrous for access to reproductive health and general health in South Africa, especially for marginalized populations who depend on low-cost NGO services. Clinics are faced with the decision to shutter reproductive health services or shut it all down, leaving highly impoverished and abused groups of women without care. Closures and layoffs are a common tale of woe for struggling NGOs. Organizations who choose compliance are burdened with the money and labor-intensive task of restructuring their materials and services at all levels to meet the GGR’s incredibly broad mandate, a mandate that has now reached malaria treatment.

It started with family planning and has reached into malaria and tuberculosis care. It was written to protect life but gives us about 90,000 new HIV infections and 30,000 maternal and child deaths per year. Successive Republican presidents have made certain to uphold and expand it as soon as they arrived in office. The chair hasn’t even cooled after the last guy’s ass departs before those of us in have-less countries are stiffed out of healthcare.

I mostly do advice columns and talk about sex, but I’m no fool. As the second Trump presidency commences, I don’t see things getting better on our side or yours. I detest the fact that many more Ukrainians will die during this tenure. Palestinians, too. On top of that, numerous people in my South Africa and wider Africa will be born and die in the worst childbearing circumstances on Earth. The truly unfortunate ones will be born and die simultaneously.

As I end this extraordinarily long piece, I must impress two things upon you.

Firstly, you have my thanks. I dragged you through my personality problems, US foreign aid policy, reproductive health in sub-Saharan Africa, and South African legislative decisions. Writing it was difficult, but I can’t imagine reading it was a charmed experience either. Whether you’re my editors or readers, you have my appreciation for listening.

Secondly, I wrote this to impress upon our US readers that for all of your country’s faults, you are still in the best possible position to change these circumstances. For yourself and for us. This election outcome was doubtless surprising, and many of you will need a period of recuperation and bewilderment. I ask you to take the time you need to rebuild your reserves. But afterward, I implore you to take part in your political process. Protest loudly. Be a menace at the dinner table. Vote quietly. Seethe and promise to do better. Whatever act of resistance that fits into your schedule and capabilities counts. I can’t vote in your elections (for good reason), but my peers and I are nonetheless impacted by its results. Some of the people in my town, country, and continent will die for it. Some won’t even receive a name before they die.

If you’re living in the USA or are a citizen there, you have immense power to divert this disastrous course. It may not always feel like it, but I’ve seen the other side, and it’s so much worse. For all of your faults, I can only dream of holding the right to vote in your nation. And for all of our faults, I’ll forever cherish the privilege of not living in a red state.

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