US anti-UN, anti-abortion orders threaten global health
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* Lauren Vogel

Global health programs funded by the United States are facing potentially devastating cuts as the Trump administration set to work this week on scaling back support for the United Nations (UN) and other international organizations. Meanwhile, there’s a Republican bill before Congress to completely sever ties with the UN and the World Health Organization (WHO), and another in the pipeline to reduce or eliminate funding to those organizations. Individually, each of these actions could cripple global health efforts that rely on the US as a primary donor; in concert, the potential fallout is too huge to predict, say experts.

“It’s clear that the new president is sending out signals that he intends to revisit and revamp some of these big involvements in a number of institutions and a number of members of Congress are also taking steps to signal congressional support for that direction,” said Janet Fleischman, a senior associate with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, DC.

The first blow came Jan. 23, when President Donald Trump [reinstated and vastly expanded a Reagan-era policy](http://www.cbsnews.com/news/trump-expands-anti-abortion-ban-to-all-us-global-health-aid/) that bans foreign nongovernmental organizations (NGOs) which are funded by the US from providing abortion services, information or referrals, or advocating for more liberal abortion laws — even with non-US funds. Every Republican administration since 1984 has revived this ban, known as the Mexico City Policy or Global Gag Rule. But in the past, the policy only applied to monies designated for family planning and reproductive health, about 6% of the US global health budget. Former Republican administrations acknowledged that a [broader application](http://www.slate.com/articles/news\_and\_politics/politics/2017/01/trump\_s\_global\_gag\_rule\_is\_even\_worse_than_it_seemed.html) would make it impossible for some programs to achieve their health aims. Trump’s version of the rule applies to all US global health funding. Roughly $8–$9 billion in aid to foreign NGOs will be affected.

It’s a “dramatic expansion of the application of the policy,” with potentially dramatic health impacts, said Josh Michaud, associate director of global health policy at the Kaiser Family Foundation, a nonpartisan US think tank. Organizations across the spectrum of global health — from HIV/AIDS, to Zika virus, to maternal health — now face tough decisions between restricting reproductive counselling and referrals, and losing funds. “If an organization decided to continue these activities then it would no longer be able to receive US funding, therefore the other activities which are perhaps not related to abortion at all might be reduced,” Michaud explained.

The last time the gag rule was applied, by former US president George W. Bush, more than 20 developing countries in Asia, Africa and the Middle East lost access to contraceptives provided by the US. Ironically, WHO research shows that reduced access to contraception resulted in [higher abortion rates](http://www.who.int/bulletin/volumes/89/12/11-091660/en/) in Sub-Saharan Africa during this period. Other organizations report that the gag rule forced clinic closures, [cutting off access ](http://pai.org/gag-rule/)to all health services in some regions.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/189/7/E287/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/189/7/E287/F1)

The Trump administration is working on executive orders that may mean deep cuts to global health programs, particularly for women’s and reproductive health.

Image courtesy of REUTERS/Kevin Lamarque

But it’s impossible to predict the future impact of Trump’s order based on past policies, given the “potential massive increase” in the number of organizations affected, said Fleischman. “I don’t think anyone has a clear sense right now of what it will mean for funding for groups.”

## Slashing funds

Uncertainty also surrounds [two proposed executive orders](https://www.nytimes.com/2017/01/25/us/politics/united-nations-trump-administration.html?_r=0) that would cancel US support for any international body that meets certain criteria, slash remaining funds for foreign organizations by 40%, and initiate a process to review and revoke multinational treaties, particularly those related to women’s and child health. Once signed by Trump, these orders would be legally binding and could not be overturned by Congress.

The first of the proposed orders, “Auditing and Reducing US Funding of International Organizations,” would axe funding for organizations that support abortion, among other criteria. The order goes on to decree “at least a 40% overall decrease” in remaining funding for international organizations, and establishes a committee to recommend where to make those cuts. The order also asks auditors to especially target peacekeeping operations, development aid to countries that “oppose important United States policies,” and the UN Population Fund, which oversees maternal and reproductive health programs.

A second draft order, “Moratorium on New Multilateral Treaties,” would initiate a review of all current and pending treaties that are not “directly related to national security, extradition or international trade” to identify which agreements can be dropped. An accompanying statement specifically marks for review the UN Convention on the Elimination of All Forms of Discrimination Against Women and the Convention on the Rights of the Child.

These orders are in keeping with Trump’s “America first” mandate, [disparagement of the UN](http://www.businessinsider.com/american-sovereignty-restoration-act-us-withdraw-un-2017-1) as “just a club for people to get together, talk, and have a good time,” and promises that relations between the US and UN “will be different” during his presidency. Nikki Haley, the new US ambassador to the UN, echoed Trump’s remarks in her [Senate confirmation hearing](http://www.vox.com/world/2017/1/18/14311452/nikki-haley-senate-confirmation-hearing-un-ambassador) last week. She said the UN is “often at odds with American national interests” and the US should rethink its “disproportionate contribution,” although she stopped short of promoting a total “slash and burn.”

## Withdrawing from UN

Long simmering anti-UN sentiment in Congress also appears to have reached a boiling point. House Republicans quietly introduced a bill Jan. 3 that would completely [withdraw US participation and funding](https://www.rt.com/usa/374754-us-leave-united-nations-bill/) from the UN and all UN agencies, including the WHO. The bill is now before the House Committee on Foreign Affairs, and if passed, would take effect two years later. Representative Mike Rogers, who proposed the bill, tried and failed to pass similar legislation in 2015.

“There have always been strains in the US of anti-UN sentiment so on one level that’s not new, but clearly those are sentiments that are reaching positions of greater prominence now,” said Fleischman.

Senior Republicans are [preparing legislation](http://www.independent.co.uk/news/world/americas/new-republican-us-congress-american-funding-united-nations-un-donald-trump-president-elect-a7511626.html) that would either decrease funding to the UN or make funding a voluntary contribution that must be approved by Congress every two years. Republican senators, including foreign policy specialist John McCain, have also voiced support for legislation to scale back US obligations to the UN.

Their argument for a US exit is partly made on economic terms, since America provides almost a quarter of the UN budget. However, “it’s important to remember that development assistance is less than 1% of the federal budget,” said Fleischman. “Massive cuts to international development and global health are not going to solve the budget concerns that some have expressed.”

WHO spokesperson Gregory Härtl said the organization “cannot speculate on something that has not happened.” However, he affirmed that the US is one of WHO’s most important partners and donors.

It’s unlikely a Republican-majority Congress will pose much resistance to anti-UN action, “but we’re still in the first week of the administration,” said Fleischman. Traditionally, global health has enjoyed strong bipartisan support, “so there is every hope that will continue going forward, even in an increasingly polarized political environment.”

“With the threats to continued US support for many global health priorities, it will be very important that other key international players including Canada step up to the plate, Fleischman added. Other countries must “make it clear that if there are areas that are threatened by withdrawal of US funding that there may be other donors who will continue to support those programs.”