President Trump reinstated a policy on 23 January 2017, called both the Mexico City Policy after the place where it was first signed, and the Global Gag Rule, because it blackmails people like us by threatening to withhold funding if we not only provide but even give anyone information about safe abortion. It originated in 1984 under the Reagan presidency and was reinstituted under both Bush governments, all Republicans. It has been in force for 17 of the last 32 years. The policy in the past required non-US NGOs to certify that they would not “perform or actively promote abortion as a method of family planning”, even with non-US funds, as a condition for receiving US global family planning assistance.The phrase “abortion as a method of family planning” is an anti-abortion invention; it refers to any abortion that is carried out because a pregnancy is unwanted, i.e. the vast majority of abortions. The rest are considered “different” because they are requested for health reasons (risk to woman’s life) or as a result of a crime (rape or incest). The Gag Rule represents the ultimately self-defeating attempt to separate the need for contraception from the need for abortion.Policy as it applies to non-US NGOsA detailed, coherent report by the Kaiser Family Foundation, published on 23 January 2017, explains that before the Mexico City policy, US aid recipients could use non-US funds to engage in abortion-related activities but were required to maintain segregated accounts for US assistance. The Mexico City Policy said foreign NGOs were no longer allowed to use non-US funds, maintained in segregated accounts, for voluntary abortion-related activities if they wished to continue to receive or be able to receive US family planning funds.Under the Trump version of the policy of 23 January 2017, NGOs who are receiving any US global health assistance must sign the Gag Rule, including those running HIV programmes (under PEPFAR), maternal and child health programmes, infectious diseases programmes, or for dealing with Zika virus – as well as family planning programmes – and not just if the funds come from USAID, as in the past, but from any US government agency or department (assuming the latter is found to be legal).This policy applies to international and regional NGOs that are based outside the USA, and local NGOs in assisted countries who receive US funding for family planning or other global health assistance. US NGOs are not directly subject to the Gag Rule, but they must agree to ensure that they do not provide family planning assistance to any foreign NGO sub-recipients unless those sub-recipients have first certified adherence to the policy. If they don’t sign, their funding will be cut off.NGOs are required to certify they do not provide abortion services, even with non-US funds. Other restricted activities include:> providing advice and information about and offering referral for abortion – where legal – as part of the full range of family planning options,> promoting changes in a country’s laws or policies related to abortion as a method of family planning (i.e. engaging in lobbying), and> conducting public information campaigns about abortion as a method of family planning.The policy has not prohibited foreign NGOs from providing advice and information about, performing, or offering referral for abortion in cases where the pregnancy has either posed a risk to the life of the woman or resulted from incest or rape; or responding to a question about where a safe, legal abortion may be obtained when a woman who is already pregnant clearly states that she has already decided to have a legal abortion (passively providing information, versus actively providing medically-appropriate information). However, fear of unknowingly crossing a line and being penalised has often meant NGOs do nothing whatsoever related to abortion in order to feel safe about retaining their funding.Policy as it applies to recipient governmentsThere are also other US foreign policy directives, in place since 1973, that forbid governments receiving assistance from the US government, even countries where abortion is legal, from funding abortion services. Some news articles this week have confused this. These restrictions do not come from the Gag Rule. The restrictions on governments who receive funding are as follows. They cannot:> pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion (the Helms Amendment, 1973, to the Foreign Assistance Act);> pay for biomedical research related to methods of or the performance of abortion as a means of family planning (the Biden Amendment, 1981, to the Foreign Assistance Act); or> lobby for or against abortion (the Siljander Amendment, first included in annual appropriations in 1981 and included each year thereafter).The Helms amendment states that “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”.Shortly after the Mexico City Policy was first announced, in 1985, the Kemp-Kasten Amendment was passed, prohibiting the use of US aid to fund any organisation or programme, as determined by the US President, that supports or participates in the management of a programme of coercive abortion or involuntary sterilisation (it is now included in annual appropriations). In Trump’s reinstatement of the Mexico City policy, the memo included, for the first time, directions to the Secretary of State to enforce the Kemp-Kasten Amendment. Such directions had been provided separately in the past.The consequences: some examplesHere are some examples of the consequences of the Global Gag Rule in its past iterations from a recently published paper by the Center for Health and Gender Equity:>A 2011 Stanford University study, published in the Bulletin of the World Health Organization, examined the effects of the Gag Rule in sub-Saharan Africa after President GW Bush reinstated it in 2001. It found that the “policy is associated with increases in abortion rates in sub-Saharan African countries” due to reduced access to contraception leading to increased unintended pregnancies and more reliance on abortion to prevent unwanted births.> It hampered HIV prevention efforts because of the closing of health clinics and disruption of relationships and supply chains of commodities – leading to reduced access to condoms and sexual health services generally. For example, during the Clinton presidency, the Lesotho Planned Parenthood Association received 426,000 condoms over two years from USAID. When the Gag Rule went back into effect in 2001, USAID had to suspend condom shipments to Lesotho because Planned Parenthood was the only provider of condoms in that country. At the time the condom shipments were ceased, one in four women in Lesotho was infected with HIV.> The Gag Rule also resulted in the closure and consolidation of clinics in countries whose USAID funding was stopped. For example, a 2015 study found that the Planned Parenthood Association of Ghana had to close and/or consolidate many family planning clinics because they could not receive USAID funding after the imposition of the Gag Rule. In the aftermath, there was an increase in unwanted pregnancies across the country.> Research conducted from 2002 to 2006, found a devastating impact on the health of women in Kenya. The Family Planning Association of Kenya and Marie Stopes International Kenya, leading providers of health care in poor and rural communities in the country, refused USAID funding rather than comply with the Gag Rule. A 2005 study from the Joseph R. Crowley Program at Fordham University found that this forced them to drastically curtail community-based outreach activities for contraceptive counselling and provision, condom distribution, and HIV testing, and the flow and availability of contraceptive supplies. A consortium of NGOs led by PAI also found that USAID had to cut off shipments of contraceptives – already in short supply – to 16 countries in sub-Saharan Africa, Asia, and the Middle East.What cannot be forgotten or under-estimated is how much governments, health service providers and other NGOs work together, so that restrictions on one affect them all. Reports published by Engender Health in 2006 on Nepal, Kenya and Zambia, for example, describe the history of what happened in detail when they lost their USAID funding. The situation for abortion in Nepal is nevertheless a success story. The country successfully reformed their abortion law in 2002 to allow abortion on request in the first trimester, managed to maintain as much as possible their family planning programme and slowly began to rebuild these services and provide abortions in the public health system. This year, these abortion services will be free to women who receive them, thanks to government subsidy. Nepal has managed to improve women’s health indicators over these years, even though they paid a high price.From South Africa, Marion Stevens, Chair of the Sexual and Reproductive Justice Coalition, writes: “Following the re-imposition of the Gag rule by Bush, in 2000 the HIV treatment movement moved to exclude practically any intersectional analysis that included reproductive rights and abortion. The women’s rights, reproductive rights and abortion rights movement in South Africa was decimated. Folks flocked to jobs in the HIV treatment and social justice world and resigned from boards and groups doing abortion work. The effect was insidious because the Department of Health then moved to exclude committed programming on abortion provision. The focus is on maternal health only, with a ‘family planning and population control framework’. We have not recovered and deaths from unsafe abortion have increased, accounting for almost 10% of maternal deaths in South Africa.” This is despite a liberal abortion law, in place for 20 years now.What is likely to happen in South Africa this time around? A report by TimesLive in South Africa, quotes US Embassy spokesman Cynthia Harvey who said: “No US agency is currently funding abortion abroad including in South Africa.” However, Provincial Specialist of Obstetrics and Gynecology in the Mpumalanga Department of Health‚ Eddie Mhlanga‚ said that the rule would stop any NGOs that offer HIV services and prevention options from giving women who come for ARVs information about termination of pregnancy even if they have an unwanted pregnancy. He said the state had been “captured by Americans” and the funding had allowed Americans a huge say over health policy. Marion Stevens is quoted as saying that Trump’s law was already enforced locally as the Department of Health does not promote the legal right to termination of pregnancy for fear of losing US funds.Globally, however, the financial loss depends on how some aspects of the new iteration are interpreted, whether they are legal. According to PAI, “In monetary terms, the expansion of the coverage of Trump’s Global Gag Rule means that more than 16 times the amount of funding may be impacted than if the Gag Rule was applied only to bilateral family planning assistance – US$ 575 million for family planning versus a total of at least US $9.5 billion for global health assistance, government-wide.What to do when a tyrant makes you dependent on him for money?When a tyrant makes you dependent on him for funding, and then threatens to cut off your funding, whether you are a government, a UN agency or an NGO, you have only two choices. Either way, there will be serious consequences. In the past, the Gag Rule created serious problems for everyone who was dependent on USAID. The funding and services of those who refused to sign were badly affected, while the reputations of those who signed and stopped providing any abortion information or services were badly tarnished. There was a lot of conflict and bitterness between them too. International and national work for abortion rights has been dealt a terrible blow by every Republican president since Reagan, and even Bill Clinton accepted restrictions for one year, but abortion work also recovers. Today, perhaps it is stronger than ever.Whether our movement can collectively and individually stand up to Trump today and insist that we will keep doing our work for safe abortion, whatever he and the anti-abortion movement throw at us, is a conversation we need to start having right away, and with our governments too. But the bottom line is, as in the past, that we either tell the man to keep his money – or we cave in, stay on the payroll. Either way we will take the consequences.The fightback has already begunBoth the International Planned Parenthood Federation and Marie Stopes International published statements on 23 January stating they will not sign the Global Gag Rule. IPPF stands to lose US$100 million for programmes that provide comprehensive sexual and reproductive health services for millions of women and youth. Their statement concludes:”We cannot – and will not – deny life-saving services to the world’s poorest women. We will work with governments and donors to bridge the funding and service gaps the Global Gag Rule creates. We will ensure that women can exercise their rights and access safe abortion and family planning.”Statements condemning the policy are being published daily by numerous individuals and NGOs based in the USA, and by politicians from several countries.In the past, US funding to UNFPA was also dealt an enormous blow. It is not clear whether this will happen this time around, but some say it is highly likely if not definite.The question of how we as advocates can talk to our governments about how to approach this is complicated by where our governments stand on this issue, whether they are donor governments or recipients of US government funding, and the situation of abortion law and services nationally. But this is the place where the real work must happen.In Canada, Joyce Arthur, executive director of the Abortion Rights Council of Canada, called on the Canadian government on 23 January to step into the breach as well: “The Canadian government needs to help fill the moral gap created by the Trump administration by investing more to save women’s lives,” said Joyce Arthur, executive director of the Abortion Rights Council of Canada. “Canada can’t do it alone – developed nations around the world should be prepared to step up their foreign aid programs to advance women’s rights and health around the world.”The response from governmentsThe Dutch government responded first, and strongly. The Minister for Foreign Trade and Development Cooperation, Lilianne Ploumen, announced on 24 January that the Dutch government wants to launch an international fund to finance access to birth control, abortion and education for women in developing countries, which could be supported by governments, businesses and social organisations to “compensate for this financial setback as much as possible”. She got immediate feedback.On 25 January, she announced that up to 20 countries had indicated support for the Dutch plan to set up an international fund to plug the funding gap caused by the Gag Rule. ‘We’re in talks with 15 to 20 countries and we’ve also spoken to foundations,” Ploumen told the Guardian. “As well as contacting a number of European countries that we work with on these issues, we’re also in touch with countries in South America and Africa, as well as the foundations. It’s important to have the broadest possible support for the fund.”She said the aim would be to continue support for existing programmes being run by organisations such as the United Nations Population Fund, the International Planned Parenthood Federation and Marie Stopes International. She said she hopes to be able to start arranging funding within the next two to three weeks, given that the funding is being stopped immediately. As to possible tensions with the Trump government: “I’m pro-choice and pro-women’s rights. It’s important to stand your ground,” she said. “We respect the decisions of a democratically elected president, but we’re democratically elected too and we can make different decisions.” Dutch national elections are in seven weeks’ time, but Ploumen is confident that given the long tradition of standing up for sexual and reproductive rights in the Netherlands, the plan will continue.From Australia, on 25 January, in what was described as a rare intervention on US policy from a senior Australian politician, deputy Labor leader Tanya Plibersek said her party was “deeply concerned” about a policy “that could cost the lives of women in developing countries”. She said: “Labor calls on the Turnbull government to lobby for the repeal of this damaging and dangerous policy and immediately rule out any move to reinstate the Howard-era restrictions on Australian aid for reproductive health services.” This refers to similar government restrictions that Labor repealed after it won government in 2007. A spokeswoman for the Australian Foreign Minister, Julie Bishop, said the government “remains committed to the protection and promotion of sexual and reproductive health rights on our foreign policy and aid program”.In the USA itself, Democratic Senator Jeanne Shaheen has introduced the Global Health, Empowerment, and Rights (HER) Act in the US Senate and Representative Nita Lowey has introduced a companion bill in the US House of Representatives, which are aimed at repealing the Gag Rule by law, which would stop further presidents being able to introduce it as a directive. Journalist Christine Grimaldi notes in Rewire that this: “marks a cohesive effort among Democrats in the early days of Trump’s presidency to push back against legislative assaults on reproductive health care”. In a Republican-controlled Congress, this won’t get far enough, but it’s a good sign of early fightback in the US as well.What’s coming down the road?The most complicated conversations will be within global south governments who have been considering positive abortion law reform, and with national NGOs who have been encouraging and supporting abortion law reform, particularly in Africa. Can they be convinced they can survive (and eventually still thrive) without USAID money? That this is an opportunity as well as a threat? Can advocates develop a blueprint for how to fund family planning, safe abortion, sexual health and other affected public health services with their governments? The question of where the money formerly provided by USAID might come from greatly affects the answers. Other governments seeking to influence countries’ national policy may offer to step in. Can the affected countries find the funds in their own coffers, reducing dependence on any major outside power? What will it cost?This is only one of the many egregious blows Trump will deal. On 24 January, he eliminated all grants in the USA to programmes on violence against women, including all 25 of the programmes managed by the Office on Violence Against Women, housed in the Department of Justice. The grants, established under the 1994 Violence Against Women Act and other federal legislation, go to organisations working to prevent domestic violence, sexual assault, dating violence, stalking, and elder abuse. They also support survivors of assault and abuse, including for transitional housing assistance, legal aid, and training to help civil and criminal justice systems better respond to sexual and domestic violence, grants specifically targeted at protecting child victims, residents of tribal lands, women with disabilities, children who’ve witnessed the abuse of a parent, and rural women.Then, he turned his attention to institute two major projects that will cause serious environmental damage and threaten indigenous peoples’ lands and water. Then it was “security” and immigrants – all as he had promised. Now he’s talking about the wall on the Mexican border.We showed a united international front of millions of people on 21 January who stand for women’s rights as human rights, led by women. What did we expect, when we upstaged a Republican presidential inauguration? Of course, it’s all our fault, ladies!!!So let’s work together to do our best to upstage the Gag Rule too, and tell the bully where he can go.HISTORY: For a detailed history of the policy, details of how the new iteration of the policy expands the number of affected NGOs hugely, and thus the harmful effects it will have, and details of related US government policies that restrict funding to recipient countries’ governments for provision of information and services related to abortion as a method of family planning, see Kaiser Family Foundation, The Mexico City Policy: An Explainer, 23 January 2017.OTHER SOURCES: MSN, by Edith M Lederer, 25 January 2017 ; Guardian.au, by Adam Gartrell, 25 January 2017 ; Salon, 24 January 2017 ; E-mail from Susan Yanow, 24 January 2017 ; New York Times, by Serra Sippel, 24 January 2017 ; New York Times, by Somini Sengupta, 23 January 2017; iPolitics.ca, by Amanda Connolly, 23 January 2017; Rewire, 19 January 2017. PHOTO 2016 ;Editor: Marge Berer