Gag rules and global partnerships

Over the past fifteen years, global health has emerged as one of the most prominent faces of American influence in Africa.

Donald Trump speaking with supporters at a campaign rally at the South Point Arena in Las Vegas, Nevada. Image via Gage Skidmore Flickr.

On his third day in the White House, US president, Donald Trump, signed an executive order barring U.S. funding to international organizations that discuss abortion as a family-planning option. Women’s rights and reproductive health advocates immediately pointed to the grave effects that reinstatement of this policy, first introduced by the Reagan administration in 1984, would have in Africa. Several cited a 2011 study that offered evidence that enforcement of the “global gag rule” under the George W. Bush administration had the perverse effect of increasing abortion rates in much of sub-Saharan Africa by reducing women’s access to family planning services and causing some women to substitute abortion for contraception. The Trump-Pence administration delivered to their conservative Christian and pro-life voters by expanding the global gag rule to apply to all U.S. global health assistance, not just funding for family planning. Whereas the U.S. government’s current spending for family planning overseas amounts to approximately $600 million, its pot for global health aid totals more than $8 billion.

Together with the reactionary populism of “America First” that helped bring Trump to power, the expanded gag rule presents a challenge to the future of global health work in Africa and to one of its most touted ideals: partnership. It also provides an opportunity to reflect on the vexed history of that work and to reclaim partnership’s progressive political potential.

Over the past fifteen years, global health has emerged as one of the most prominent faces of American influence in Africa. In the wake of 9/11, the Bush administration paired the expansion of anti-terrorist military operations in the Horn of Africa and the Sahel with the extension of global health work through the establishment of the President’s Emergency Program for AIDS Relief (PEPFAR). The U.S. government funding for global health more than quadrupled while a number of private organizations, most notably the Bill & Melinda Gates Foundation, began devoting significant resources to improving health in sub-Saharan Africa.

Partnership was a keyword that accompanied this dramatic expansion. Global health leaders argued that their efforts differed from previous approaches by rejecting paternalism and advocating for equal, collaborative partnerships between wealthy and poor nations. As some declared in 2009, “The preference for the use of the term global health where international health might previously have been used runs parallel to a shift in philosophy and attitude that emphasizes the mutuality of real partnership, a pooling of experience and knowledge, and a two-way flow between developed and developing countries.” Partnership thus became a programmatic priority and affective ideal that global health practitioners struggled to make a political reality.

The privileging of partnership, like the expanded global gag rule, is importantly rooted in the troubled history of reproductive and sexual health initiatives in the Global South and especially in postcolonial Africa. American involvement in such initiatives dates back to the 1960s when the U.S. Rockefeller Foundation, inspired by neo-Malthusian concerns, sought to foster population control and family planning programs in newly independent African countries. The government soon joined their efforts so that by the mid-1980s such programs were the single largest recipients of U.S. international health funding. These programs, which largely entailed the promotion of modern contraceptives, faced mixed reactions in places like Kenya, the first African country to adopt a population policy in 1967. On the one hand, some women embraced the pill, IUD, and Depro-Provera injections, especially as tools for spacing births. On the other hand, some critics argued that population policies were an affront to pro-natalist African values and a piece of racist, neo-colonial relations.

Partnership emerged, in part, as a keyword for some international health practitioners in the late 1980s as a way to avoid the political critiques that plagued family planning programs while attending to the unfolding HIV/AIDS epidemic in Haiti and East Africa. Through partnership, progressive medical clinicians and researchers sought to signal a deep, shared and ongoing commitment to improving health and a rejection of top-down, short-term models. They also sought to signal a rejection of colonial and neo-colonial approaches that cast poor and black communities as sites of promiscuity and disease. Paul Farmer and his colleagues, working in Haiti, gave the term pride of place in 1987 by naming their organization, Partners In Health. Similarly, a team of researchers from the universities of Nairobi, Manitoba, Antwerp, and Washington used partnership to describe their work treating and studying sexually transmitted infections in Kenya during the early 1990s.

Partnership also took hold in the broader realm of development. Beginning in the mid-1990s, the World Bank used partnership to indicate a softening of structural adjustment policies, and a new appreciation for the need of governments, donors, international financial institutions, and NGOs to collaborate in crafting and implementing development policies. As Danny Hoffmann, Ben Gardner, and Ron Krabill document in their essays for this series, by the new millennium, partnership had traveled even further afield to become a keyword of U.S. military policy in Africa as well as university study abroad programs. Yet, in all these realms where partnership talk has proliferated, inequalities persist. In global health work, these inequalities are most evident in who controls the purse strings and makes programmatic decisions, and who earns comfortable salaries and gains professional credibility.

In the 33 years since the Reagan administration first introduced the global gag rule, the scale of U.S. funding for reproductive and sexual health initiatives in Africa has expanded dramatically. Despite often professing partnership, these initiatives have been structured by power imbalances. Yet, they have also been buffeted by progressive political tides. Across the sub-continent, countless civil society organizations now advocate for diverse forms of gender, sexual and reproductive health rights. Over the past two decades, thirty countries, including some in Africa, have liberalized abortion laws while only a handful have made them more restrictive. Just four years ago, the U.S. Supreme Court struck down, under the First Amendment, a regulation that barred PEPFAR funding from organizations that advocated for the legalization of sex work. This ruling against the “anti-prostitution pledge” has left the door open for a similar freedom of speech challenge to the expanded global gag rule. Moreover, the Women’s Marches of six months ago in U.S. and other cities worldwide demonstrate a newfound commitment to protest movements that combine opposition to racism, sexism and homophobia with demands for economic, environmental and immigrant justice.

We live in times when talk of partnership abounds while wealth disparities deepen and backward-looking populism breathes new life into bigoted and isolationist elements within national politics. The Trump/Pence administration’s expanded global gag rule is a product of these times but also the culmination of a much longer history of U.S. initiatives abroad regarding reproduction and sexuality. That prior history and our current times are structured by profound imbalances that resonate with colonialism. They are also filled with people who recognize those resonances and, in some cases, seek to forge alternative futures.

* This series of essays emerges from a project based at the University of Washington that explores “partnership” as a programmatic priority and affective ideal in initiatives between the United States and African countries. We consider the politics of partnership in three different realms of US-Africa relations: military training and disaster relief, reproductive health initiatives and study abroad programs.

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