During the US presidential elections much of the world was watching hesitantly to see what would unfold. This brought a great deal of reflection over the past four years and what Trump has done during his time in office. While reflecting on this presidency, I have also reflected on the impact the administration has had within the global health world, and how both local and foreign policy has influenced global health efforts. With this in mind I have outlined some of the actions taken by the Trump administration that have had the greatest impact on global health.
The Global Gag Rule
The Global Gag Rule is a global health policy that prohibits organizations that receive US funding from providing abortion services and referrals, even if the procedure is legal in their country. The law was first enacted by the Reagan Administration in 1984 and has since been in effect 19 of the past 34 years, typically being implemented by republican presidents and revoked by democratic presidents.
Although this back and forth has been a normal part of US foreign aid policy, the Global Gag Rule was expanded under the Trump Administration. Now, instead of applying to only family planning services, it applies to all global health funding, so that any foreign organization accepting US global health aid (whether it be for malaria, child nutrition, infectious disease, etc.,) must sign the anti-abortion pledge, and agree not to provide abortion, referrals for abortion, or any information related to abortion, even if it uses non-US funding to do so.
What’s more, in 2019 the Global Gag Rule was expanded even further to include subgrantees, so that not only can organizations receiving US funding not provide abortion services, they cannot have any ties or links to organizations that do, impacting organizations that don’t take US money but work with groups that do. One article described the rule as follows;
“Now it works like a virus: Once a foreign organization touches US global health funding, the gag rule attaches itself to all other funding that runs through that organization, infecting every other program and budget”
Not only does the rule impose on a woman’s right to choose, it has also been proven ineffective. Studies have shown that the rule hasn’t actually decreased abortion rates, but that abortions have increased by 40%, and unsafe abortions have nearly tripled. In addition to being ineffective, the rule has had a detrimental impact on global health funding in general. In 2018, the Kaiser Family Foundation found that the expanded policy applied to more than $7 billion in funding – likely affecting more than one thousand foreign NGOs. Marie Stopes International, which provides family planning services in over 37 countries, estimates that 5.2 million women lost health services, leading to 3.4 million additional unsafe abortions and 16,000 additional maternal deaths. According to Boston Globe writer Jina Moore, as most women’s health services are bundled, the rule could also weaken health systems overall, affecting not only their quality of life, or their ability to live with HIV, but now they’re also at risk for contracting diseases like COVID-19. This ghettoization of abortion is a regression in sexual and reproductive health rights and, once again, women are the ones who suffer the most.
The Paris Climate Agreement is an environmental accord enacted in 2015 to address climate change with the aim to limit the global temperature increase this century by two degrees Celsius. The accord was signed by all major emitting countries and, in 2019, the US became the first nation in the world to formally withdraw from the climate agreement. While this decision itself was a step backwards in terms of climate change mitigation, the Sabin Center for Climate Change Law has documented more than 160 steps that the Trump administration has taken to scale back/eliminate federal climate mitigation measures. These steps range from opening millions of acres of protected land for oil and gas drilling to weakening protections for animals, and could result in an excess 1.8 billion metric tons of CO2 by 2035.
There is a large body of research linking climate change to adverse health effects. These effects can include asthma and cardiovascular disease, increase in infectious disease spread due to changes in vector ecology, respiratory allergies, waterborne bacterial diseases, malnutrition, forced migration, civil conflict, and mental health impacts, among others. And, as in most circumstances, the health effects caused by climate change will disproportionately impact already vulnerable groups, both impeding future global health progress and undoing advancements already made.
The Trump Administration took a very strong anti-migration stance from the beginning of its term with its promises to build a border wall with Mexico. The Migration Policy Institute has since recorded 400 executive actions relating to migration from the administration.
In 2019 alone 851,508 migrant apprehensions were recorded at the US-Mexico border, the highest annual level in 12 years (US Customs and Border Protection). The number of refugees admitted to the US also decreased 65% from 2016-2019, denying entry to many migrants coming from countries that have long dealt with with violence, conflict, and economic hardship. Tens of thousands of vulnerable asylum-seekers have been forced to wait at the border in overcrowded and unsanitary camps until their case is resolved, with many human rights groups reporting cases of kidnappings, rapes, and assaults. Families have been separated, hundreds of which are still waiting to be reunited. Muslim people have been unjustly banned entry, to “protect the nation from foreign terrorism”. For migrants that have been allowed into the US, it is nearly impossible for many to access the social safety net system, locking them in a cycle of poor health and vulnerability.
Furthermore, in the midst of the Covid pandemic, all asylum hearings have been suspended, Immigration and Customs Enforcement (ICE) deportations have continued, ignoring public health recommendations advising against such movement, migrant detention has continued regardless of close personal contact and Covid cases within the centers, and anyone who “presents a risk to the US labor market” has been suspended from the country. While the world has gone into turmoil and international cooperation and solidarity is more important than ever, the Administration has continued to turn their backs on migrants.
Global Health Funding
In early April of 2020, Trump announced that he was halting funding to the WHO due to their “mismanagement of the virus, leniency with China, and failure to serve America’s interests”. As the biggest donor to the WHO, US funding accounts for approximately 15% of all funding (27% of polio, 19% of tuberculosis, HIV, malaria, and 23% of the budget for the emergency health operations); their withdrawal from the organization could result in hundreds of millions of dollars lost in global health efforts. Many experts have argued that the decision is irresponsible and very poorly timed, commenting that cutting funding to the only organization with the technical capacity/global mandate to support the public health response to all countries during this time is like “cutting the water supply to a firefighter in the middle of a fire”, or “removing the windows of a plane while it is in mid-air”. Regardless of one’s opinion on the handling of the pandemic by the organization, or the US legal ability to withdraw, many global health professionals have said that now is not the moment to make such claims.
Unfortunately, this is not the first time the administration has cut funding on the premise of political disagreements. The decision to withdraw from the WHO is merely a consequence of the “American First” approach the administration has taken to policy. This nationalistic attitude has created a highly polarized and dangerous climate both at the local and global level. The anti-science approach to policies has greatly damaged global health and climate mitigation efforts, and has surged US Covid cases and deaths. The blatant rhetoric and language used against certain ethnic, racial, and cultural groups has exacerbated tensions and violence, and caused irreversible damage in these communities. Time is needed to analyze the long-term effects of the Trump Administration’s impact on global health, and this blog is only a snapshot of four years of policy, but if global health is defined as improving health and achieving health equity for all people worldwide, it would be difficult to argue that the administration’s capitalistic and egocentric approach has done much to advance this mission.