2017 – 2018 Alvin F. Poussaint, MD Visiting Lecture

2017 – 2018 Alvin F. Poussaint, MD Visiting Lecture


– Good afternoon. – [Audience] Good afternoon. – My name is Doctor Joan Reed. I’m Dean for Diversity
and Community Partnership here at Harvard Medical School. And I want to welcome you to
our 2018 Alvin F Poussaint MD Visiting Lectureship. This is always an exciting time for us at the medical school. It’s a time that you might
almost call a homecoming for some of our alums and
the illustrious individuals who’ve walked through
our halls, and a time for us to honor and recognize someone who’s part of the foundation of our school and clearly a foundation
as we think about diversity within Harvard Medical
School and nationally and that’s Dr. Alvin Poussaint. We are so pleased that
Dr. Sierra Washington has agreed to be our Poussaint
lecturer for this year, an HMS alum. She is an Associate Clinical Professor in the Department of Reproductive Medicine at UC San Diego and the
immediate Past Medical Director and Chief Medical Officer
for Planned Parenthood Pacific Southwest. Planned Parenthood Pacific
Southwest has 17 locations across three counties
in southern California. She has overseen clinical initiatives in the United States
ranging from California to New York and in multiple countries across the world but
particularly in Africa. Programs and efforts are
really around this intersection of HIV and reproductive
health in Zambia, Cameroon, Kenya, Rwanda and Tanzania. She’s been the Director
of International Programs for the Department of
OB/GYN at Indiana University School of Medicine and Co Field Director for Reproductive Health
at Ampath USAID, Kenya. She’s had visiting appointments
in multiple institutions and has published many journals. But here’s somebody who came
to Harvard Medical School who made a big difference here. She was one of the originators of FABRIC. Does everybody know what FABRIC is? Oh, oh, well maybe she will
tell you towards the end or someone can ask a question. It’s an amazing program
that our students put on here at the medical school
that really represents, in a true sense of the term, the diversity and inclusion and the
richness of our community and our environment. She had the vision to help start that. But she’s someone who’s
been deeply committed to issues of equity and social justice and quality of care for all individuals, but particularly those from the margins. And with that, Dr. Sierra Washington. (applause) – Thank you for the introduction. I have to say when I was
first asked to give this talk, I was a bit shocked and
surprised to be asked to come back to Harvard
because I am not a leading clinical researcher. I am not a author of
some pithy bestseller. I haven’t written a TV best series. And so then I had to
sit with it for a minute and realize that I am a good storyteller and I am a practivist. And I have had the privilege and honor of making my practice my activism. And although the path has not
always been straightforward, it’s been very interesting. So I’m so honored to
speak today about a topic that’s near and dear to my heart. So this is school. Pop quiz, there’s a lot
of melanin in the audience so I’m gonna expect a little bit of audience participation please. So this is a map of a disease distribution where dark orange is a
high prevalence of disease and white is a low prevalence of disease. So what disease am I talking about? And those people who’ve
talked to me already today are excluded from answering. Yes in the back row. (audience member talking) Okay chagas, good try. Anyone else? Only chagas. Any other diseases that
are profoundly affecting the continent, yes? (audience member talking) Okay, maybe tuberculosis. Any other diseases, yup? (audience member talking) Okay, infant mortality, yes. Malaria, mm hmm. Any final additions? – [Audience Member] Maternal mortality. – Maternal mortality, uh huh. One last in the back row. (audience member talking) Syphilis, okay. So I’m just gonna pause
for a minute and tell you about my friend and patient Diana. So Diana was a patient
in Rwanda where I worked from 2012 to 2014 and I was
there teaching residents about contraception and
abortion when I took care of Diana. She was 19 and she was
from a small village. And it’s not uncommon in
Rwanda to walk over hill and mountain to reach the hospital. She came to the hospital
with abdominal pain, fever and foul-smelling discharge. And the residents took
care of her as they do and they decided that she needed surgery. So they opened her abdomen
to find a fetal skull approximately 20 weeks, in her abdomen and a hole in her uterus. In Rwanda, as in much
of Sub Saharan Africa, a woman’s worth is honestly
defined by her ability to have children. And without a uterus,
it’s unlikely that a woman will get married. She may not have access to
land security, food security. She may be socially
ostracized from her community. So the residents subconsciously taking all of these decisions in mind,
decided to save her uterus. And the cleaned out the
fetal parts, sewed up her uterus, washed out her abdomen and sewed her back up again and sent her to the ward and put her on antibiotics. The next day she was still febrile. So they took her back
to the operating room. They found more pus in
her abdomen so they washed her out again and closed
her abdomen back up and sent her back to the ward and added another antibiotic. And then the following
day she was still febrile so they took her back
to the OR and they found that her bowels had become matted together and there was a little bit of black tissue at the top of her uterus. So they cut that away. They washed out her
abdomen and they sewed her back up again. I learned about Diana
after she’d already had three laparotomies in the morning report. And the students and
residents reported a patient who had a burst abdomen on the ward. A burst abdomen is what
Rwandans would call, what we would call dehiscence,
and that she was febrile on the ward with a burst abdomen. And when I went to the bedside
after hearing her story of already having three
laparotomies and being 40 degrees, I saw a small girl who
was 40 degrees Celsius, sweaty and weak and she looked up to me and she said in Rwanda,
(speaks foreign language) which means I’m tired and I need to die. And I looked down at her
and I said in my broken Rwanda/Kiswahili/ki-something,
with some translation, that you don’t have to die but you have to have the will to live. That’s number one. And if you do have the
will to live, I think we can heal you but we’re gonna need to take your uterus out. And she consented. So we took her back to the operating room for a fourth laparotomy and this time what we found was her uterus was black and green and putrid. If any of you’ve left
a steak in the fridge for a little bit too
long, you know that smell of rotting meat. And when we opened her
abdomen, she was rotting from the inside. She had gas gangrene. Her bowels were completely
matted together. It took us about five
hours to remove her uterus and cut away all the bad
tissue, wash her out, put her on antibiotics
and send her to the ICU. The thing is, she’s 19. So four days later she
got up and walked home to her village and went home. So now, which disease
do you think this is? Although this map looks similar to HIV or tuberculosis or chagas,
it’s actually a map of unsafe abortion. And the reason that it
shares the same distribution are that the similar pathologies
of globalized racism, gender inequality and poverty that led to unchecked HIV or unchecked tuberculosis in the global south, have led to unchecked amounts of unsafe abortion. The difference though is that
deaths from unsafe abortion is clearly a political casualty. So let me pause and just say I have no conflicts of interest. Today I’m gonna discuss
the practical implications of the current US foreign
policy on global women’s health with a specific focus on abortion. So a primer in epidemiology. 44% of the world’s roughly
200 million pregnancies are unintended. And 50% of those unintended
pregnancies end in abortion. So half. Of the 56 million abortions
that occur every year, about half are considered unsafe. So that’s about, sorry of
the approximately 300,000 maternal deaths, one in eight
is from unsafe abortion. So I remember 9-11. I don’t know if everybody
in the room remembers what they were doing on
9-11, but I’m sure you do. So on 9-11, I was standing in
the BI on the medicine ward as a third-year medical
student making rounds. And we walked into a
patient’s room, and we walked to see on the patient’s little
kind of airplane television screen up in the corner,
two planes fly into the World Trade Center. And my chief resident at
the time said a racist profanity under his breath, and I remember the flush of anger and
embarrassment that I had that he had spoken these racist words in front of everyone. And it sticks with me. And what I think now is
that the number of deaths from unsafe abortion is the same as eight World Trades attacks every year. Eight of them. So to me, it’s sobering
to consider the billions of dollars that have been
spent fighting the war on terror, the change
in international policy, awareness and global policy,
not to mention the change in airport security that’s
happened since 9-11. To me it throws in stark
reality that women are not dying because we don’t have enough money. No, women are dying
because we’ve failed to put resources towards the issue
and because we haven’t decided yet to put value on their lives. And why not. Well let’s look at the global
burden of maternal mortality. This is a map of the world
where the territory size is made to be proportionate to
the maternal mortality rate. So you can see that the
bulk of maternal mortality is in Africa and the Indian subcontinent. And you can see visually
here that poor women of color bear a disproportionate burden. The top causes of maternal
mortality are indeed hemorrhage, infection,
hypertensive disease. Although globally 13%
of maternal mortality is unsafe abortion. In Sub Saharan Africa, as much
as 30% of maternal mortality can be from unsafe abortion
and the case fatality rate for abortion is 470 times that in the US. So usually the popular press really likes to separate the issues of
maternal mortality and abortion. But I wanna make it crystal clear to you. If we were able to
eliminate unsafe abortion, we would reduce maternal
mortality by 15 to 25% in one fell swoop. So it is the low-hanging
fruit when it comes to global maternal mortality. So how does mortality
interact with the legality of abortion? Well this is a map of the
world’s abortion laws. Red countries are where
abortion is illegal all together or only permitted to save
the life of a mother. And green countries are countries where abortion can be sought
without restriction. Access to safe abortion
is still extremely limited in much of Sub-Saharan
Africa and Latin America as you can see. And in Africa and Latin
America, over 90% of women of reproductive age are living somewhere where abortion is restricted. We know from research
that the legal status of abortion does not predict
the incidence of abortion. I want you to be armed with that fact. The correlation between
the restrictiveness of abortion laws and the
incidence is very low. The authors of this study,
Gilda Sedge at Guttmacher and her cohort, they
researched abortion data across every country and
every major territory in the world using official
statistics, published and unpublished studies. They obtained statistics for
over a thousand countries and then they used statistical methods to correct for under
reporting where it’s illegal. They found that in
countries where abortion is available on request,
34 per thousand women aged 15 to 44 will undergo an abortion compared to 37 women per 1000 in countries where abortion is illegal. And that difference was not found to be statistically significant. In a more granular analysis, they showed that abortion rates in the
world are actually lowest in places where abortion
is freely available and contraception is accessible. So if you look at western
Europe, the case rate for abortion is about
18 per thousand women. However some of the highest abortion rates are found where the laws
are most restrictive such as 34 per thousand
in Sub-Saharan Africa, 44 per thousand in Latin America, and 65 per thousand in the Caribbean where laws are often the most restricted. Based on their work at the Guttmacher, we know that the legality
of abortion doesn’t decrease the incidence of abortion, however it does affect the safety of the procedure. You can see here that as we
move from least restrictive to most restrictive,
abortions become more unsafe. And in the most restrictive
settings, up to 70% of the abortions will
be considered unsafe. On this slide, orange and white-orange are unsafe and green are safe abortions. We also know that low-income countries, those same countries that
tend to have the most restrictive abortion laws,
have the highest percent of women with an unmet
need for contraception. So unmet need for contraception is kind of an interesting and funny measure. It’s the number of women
who are married or in union who are fecunds, so
they could get pregnant, but who want to delay
pregnancy or not be pregnancy but are not using contraception. Shall I say that again? So they are women who
are married or in union, they’re fecunds, so they’re fertile. They want to delay or not
be pregnant all together, and they are not using contraception. So basically they’re saying,
if you don’t wanna get pregnant and you’re not
using contraception, you’re gonna get pregnant. Okay, so that’s the unmet
need for contraception. And not surprisingly, the
lower income countries have the highest unmet
need for contraception and higher income
countries have the lowest unmet need for contraception. Also not surprisingly is
that within each bracket of income, those women who are the poorest and least educated have
the highest unmet need for contraception. So we see this trend even in
the United States of America. Not surprisingly, women with an unmet need for contraception also
have the most unintended or missed time pregnancies worldwide. This graph shows that of
the 89 million unintended pregnancies in 2017, 84% of
those unintended pregnancies were women who had, were
using either no method of contraception or a traditional
method of contraception. So when you add it all
together, women living in the poorest countries,
the same countries with very restrictive abortion laws, the highest unmet need for contraception, therefore have the highest
risk of unintended pregnancy and the highest risk of unsafe abortion. Shown here on the left is the estimated that in the low-income
countries, at least half of all abortions are unsafe. And in some regions in Latin America, as many as, as much as 75
to 90% of the abortions are considered unsafe. So can we measure the impact
of legalizing abortion on maternal mortality? Absolutely, here I’m presenting data from a natural experiment
in the United States that we call Roe versus Wade. This is data from the New
York Vital Statistics Office in the years immediately after Roe V Wade. The black line shows maternal mortality attributable to abortion
with an abrupt decline in the immediate years after Roe V Wade, and the gray line in the
back shows maternal mortality attributable to childbirth with a slower yet steady decline. Another natural experiment is in Romania where abortion was legal
and widely available in the ’50s and early ’60s, and
then was severely restricted as a part of a population growth policy. And so the first red
arrow shows where abortion was restricted and the
second red arrow shows where the abortion law
changed to be unrestricted and freely available. What you see in the yellow
are maternal mortalities from unsafe abortion and the
green maternal mortalities from other causes. So you can see that over
the years that abortion was restricted, maternal
mortality as a whole increases and the proportion of maternal mortality from unsafe abortion rises drastically. The year after abortion
restrictions were removed, that maternal mortality rate
dropped by half in one year. Another example of data. In 1996 after the fall of
Apartheid, South Africa introduced some of the
most liberal abortion laws. In the three years
following the legislation, they set out scale up access
to safe and legal abortion. In South Africa, the annual
deaths from public facilities from unsafe abortions
fell by 91% from 1994 to the year 2000. They had 425 deaths in 1994
and 40 just a few years later. Infection fell by half, and
the number of women displaying evidence of interference,
either by chemical injuries, physical injuries or
foreign bodies fell by 81%. So what’s the best way to reduce deaths from unsafe abortion? Well, what do you think guys? It’s simple, right? Meet the unmet need for contraception and provide some safe abortions, and we’ll reduce death
from unsafe abortion. With universal access to contraception, we would eliminate 75% of
unintended pregnancies. That’s 23 million fewer unintended births, 36 million fewer induced
abortions, 2.2 million few newborn deaths, and
224,000 fewer maternal deaths. So contraception is the
most cost effective way of decreasing maternal mortality. For every one dollar spent
on a family planning program, we would save $2.20 on the
same program for maternal care. So it’s not just cost effective. It’s actually cost saving to
spend money on contraception. And for this relatively modest investment, we’d be able to provide family planning for every woman in the world. We’d decrease maternal
mortality, and we know that delaying childbearing
boosts educational opportunities for women and in turn boosts
women’s status in society. So how much would it cost in total? What’s the price tag? To fully meet the world’s
family planning needs, we’d have to spend an
additional $6 billion. Sounds like a lot of money. But let’s put that in perspective. That’s the 2016 presidential
election, same price tag. That’s one month of the
Iraq War, same price tag. So it seems like a no-brainer to me. Why aren’t we doing it? Well that’s where we come in. The Global Gage Rule. This is what happens
when US public opinion, US abortion law and
policy in America relates to the rest of the world. Simply put, it comes down to money. The lion’s share of
healthcare operational budgets in the global south actually
come from the US government, either in bilateral or
multilateral arrangements. For most of the 50 years
that the United States has been providing international
family planning system assistance, the US
program has been embroiled in abortion politics. The Helm’s Amendment,
which was passed in 1973, I see some folks nodding in the audience, this prohibits federal funding
from providing abortion for the reason for family
planning either domestically or internationally. Nonetheless, anti-abortion
activists didn’t feel that the Helm’s Amendment went far enough. And so the Reagan administration officials agreed by a congressional
bypass, AKA an executive order during the Mexico City
United Nations Conference on International Population,
they wrote the first executive order called
the Mexico City Policy, AKA the Gag Rule. This Gag Rule disqualifies
US non-profit organizations from eligibility to US
family planning assistance if they use non-US funds to
provide abortion services, provide abortion counseling or education, or to advocate for a
liberalized abortion law. We call it the Gag Rule
because effectively what this policy does is
it muzzles free speech and it muzzles public debate
around abortion-related issues. In that same year, socially
conservative activists began accusing the US
foreign assistance program of complicity in coercive
abortion practices and forced sterilization
citing the annual contribution to the UNFPA, which provided
family planning assistance in China. Ever since, since Reagan,
from Clinton to Bush to Obama, republican
presidents have reinstituted the Gag Rule and defunded
UNFPA and democratic presidents have rescinded the Gag
Rule and refunded UNFPA. So on January 23rd, this
conspicuously white group of gyneticians as I like to call them, those are politicians who think
they’re also gynecologists, they signed the expansion
of the Mexico City Policy and renamed it Protecting
Life in Global Assistance. The original scope of
the ban, as I said, was approximately 600 million to cover family planning assistance. And that accounted for 50%
of all the world’s money spent on family planning. The Trump-Pence policy now
applies to all international health aid doled out by the
United States government totaling close to $9 billion. Predictably on March 30th, another law, the Kemp-Caston Amendment,
prohibited the US from donations to the
UNFPA citing the forced sterilization and coercive abortion work because UNFPA used to partner with China. We cut $33 million from
UNFPA and as an FYI for a long time I never really understood what UNFPA actually did. But I’ve come to understand
that UNFPA’s role is to primarily partner with governments in a time of crisis, war
or humanitarian crisis. So basically what happens
in the time of war, take Iraq, take Syria, take South Sudan, they ship out safe delivery
kits and contraceptive supplies to refugee camps because they understand that even in war you still ovulate. And even in war, you still deliver. And so that is the role,
the primary role of UNFPA. So what is the impact
of this expanded gag? I know we’re a room full
of doctors and scientists and public health thinkers,
so I’m gonna share with you the data. So in financial year 2016, the
US provided bilateral growth to 64 countries. And of those 64 countries,
37 of those countries allow for legal abortion
beyond which what is available through the Gag Rule. Most were in Africa. 27 countries did not allow
for abortion in any case legal beyond the Gag Rule. So most of those countries were in Africa. The next largest region was south Asia, and in nearly all of those 37 countries, abortion is legal to preserve
a woman’s physical health and in 28 countries abortion is also legal for fetal indications. So where a country’s
law allows for abortion that is not permissible under the Gag, four non-profits will be
prohibited from providing legal abortion, legal abortion counseling or referral or advocacy even if they use non US funds to do that work. Where country’s laws do not allow abortion beyond the Gag Rule, the
policy wouldn’t curtail access to abortion but
rather curtail advocating for legal changes towards abortion. In all cases, domestic
and foreign NGO recipients of US global health
assistance have to sign a certification and affidavit saying that they are in compliance
with protecting life in global assistance to be
eligible for any US aid. In addition, any non-NGO
that makes a sub grant to another NGO has to prove that that NGO is also in compliance. So this is a map of
abortion laws that receive by countries that receive
bilateral assistance by abortion law. And you can see that light blue countries are countries that’ll be most likely to be affected by the global expanded gag. PEPFAR is also affected. PEPFAR stands for the
Presidential Emergency Plan For AIDs Relief and
was implemented in 2004 by George Bush, and he gave $15 billion to the 15 worst affected
countries plagued by HIV. Now over $70 billion has
been spent of taxpayer money on PEPFAR to bring the global
HIV epidemic under control. It is by far and away the
behemoth of global aid. In this group of 37
countries, you can see here that 25 of those 37
countries also receive PEPFAR followed by 18 who receive
maternal child health funding and 17 that receive non
transmissible disease funding. Together these 37 countries
that will be affected by the gag account for 53% of
all of our global assistance. So unfortunately under
Bush’s previous gag, we witnessed the disruption of funding of the largest and most established family planning programs. Here are two of them. We have International
Planned Parenthood Federation and Marie Stopes. Similar to the Planned
Parenthood Federation of America, the International Planned
Parenthood Federation operates affiliates in each
country, usually called Planned Parenthood Associates of, Lesotho, Planned Parenthood Associates
of, insert the country. Marie Stopes operates clinics
either in their own name or sometimes in a name that fits the local cultural context. But to be sure, whether
they’re in name or not, these two providers are
providing an immense amount of critical services to women. So let me take you through
a few illustrative examples. After President Bush
reimposed the gag in 2001, a consortium of NGOs led by POP Council organized a study to assess the impact of Bush’s gag on countries. What they found is that
USAID had to cut off a condom supply in 16 Sub
Saharan countries all together in Asia and the Middle East. In Lesotho where I take you now, a kingdom in Southern Africa, Lesotho
received 426,000 condoms from USAID and other
contraception during the two years of the Clinton administration. Once the Gag Rule went back into effect, USAID had to end condom supply completely to that country because
Planned Parenthood Associates of Lesotho was the only
conduit that they were using to get condoms to Lesotho. Let me remind you, in
Lesotho at that time, one in four people had HIV. So it’s not difficult
to imagine the impact of cutting off a condom supply
in a very high prevalence HIV environment. Planned Parenthood
Association of Zambia was the primary Planned Parenthood
family planning provider for Zambians. They refused also to
sign the Global Gag Rule and they lost their US funding as a result and they dismissed about
half of their staff, scaled back their
reproductive health services and specifically they
had a community-based contraception distribution
program that they had to end completely. Nepal has some of the highest
maternal mortality rates in the world, and about half
of the maternal mortality in Nepal is attributed to unsafe abortion. And due to the kind of
extreme public health crisis of unsafe abortion, abortion
was legalized in 2002 and now it’s legal for any
indication up to 12 weeks and up to 18 weeks in
cases of rape or incest and up to any time if a
woman’s life or health is in danger. So the Family Planning
Associates of Nepal provides about 25 to 30% of the total
family planning services across the country. Nearly, and they’re in about
75 of the country’s districts. They refused to sign the Gag Rule in 2001 and lost a partnership that
was 32 years with USAID. They lost $100,000 from Engender Health, an implementing partner and $400,000 of contraceptive supplies. So they terminated 60
full-time staff and they had to introduce fee for service
care in place of free care. In that same country,
Marie Stopes International ran 27 clinics providing
primary health care, family planning, pre and postnatal care, abortion, youth friendly
services and child rearing educational services. They also ran a detailed
community health worker program that went door to door providing
family planning education. Sterilization is the most popular method of birth control in Nepal,
and Marie Stopes provided about a third of all the
sterilizations in Nepal. So they refused to sign
the gag and they had to cut their sterilization program. They had to cut their community program and basically just restrict
to in clinic programming. Last example, I moved to
Kenya right out of residency to co-direct a prevention of
mother-to-child HIV program. And at the same time I provided obstetrics and gynecology services
to their second largest teaching and referral hospital. We had a 50-bed ward, a gynecology ward that was 50 beds. Of that 50 beds, 2/3 at
any one time was full of second abortion patients. It was not uncommon for
women to start their abortion clandestinely using chemicals or street medications and
we’d often find evidence of interference when we
went to the hospital. What I realized is I
had moved there to work on the HIV epidemic,
and I realized that HIV is kind of tucked in. And I learned that
expression on the wards here at medical school. Tucked in is when you’ve like
set out the management plan and you just have to kind
of watch it run its course. And so I felt like HIV
was kind of tucked in. We had care and treatment
programs for everyone, great prevention
services, sometimes orphan and vulnerable children
services, sometimes whole micro and macro nutritional programs. But women who were HIV
negative or HIV positive, who suffered unsafe abortion,
were still left out to die. And yet the medical anthropologist
in me saw immediately that those exact same social pathologies that allowed for HIV to flourish, that allowed for women
to be infected with HIV, those are the same women
that were falling victim to unsafe abortion. So in Kenya what happened, Marie Stopes, they decided not to sign the Gag Rule. They cut funding. They had to close their STI program. They ran an STI program on
the banks of Lake Victoria, one of the greatest hot spots
for HIV disease in the world. They had to close that program. Family Planning Associates
of Kenya closed 15 clinics between 2001 and 2005. And what I realized is
that for these women who are walking their entire lives, when you close one clinic,
they don’t have another option to go to. So in Ghana where abortion is permitted to protect a women’s
health as well as her life, her physical health,
her mental well being, and it’s also prohibited in cases of rape, incest of fetal impairment,
so relatively liberal law. The Planned Parenthood
Association of Ghana, who was primarily funded
by IPPF, was the country’s oldest and largest family
planning service provider. They lost 200,000 in US aid as a result of the Global Gag Rule. They laid off 60 staff members. They reduced their nursing staff by 40% and that led to a 45% reduction
in contraceptive provision primarily in rural communities. More than 1300 communities
were affected by the cuts. And the Planned Parenthood
Association of Ghana saw 50% more women come to their clinics for post abortion care the
year after the gag rule was implemented by the
Bush administration. Another study done in
2011 took a deep dive to look at the impact
of the gag rule in Ghana and found that
self-reported abortion rates were much higher during the gag rule than in the pre gag years. While those case studies are compelling, the question is, the data add up. As far as I’m aware, there are two studies that look at the population
effects of the gag rule on contraceptive prevalence and abortion. So Jones et al, they looked,
they took a deep dive into Ghana, and they looked
at where were the clinic closures and who was affected. What they found in this map
shows the service locations before the gag rule and
the service locations after the gag rule. So you can see the people
who are most impacted are people who live inland and away from urban cities on the coast. Key findings findings from another study by Dr. Ben Davide at
Stanford are shown here. They evaluated women
across 20 African countries who had an induced abortions
between 1994 and 2008 through using demographic health surveys. And what they did is
they considered countries who had a high exposure to gag rule or a low exposure to gag rule. So a high exposure to gag
would be if your country received at least the median amount of US family planning
assistance before the gag went in place. And a low exposure to
the gag rule would be if you’re from a country who received less than the median before the
gag rule went in place. So I always get the colors confused. So green shows low exposure to the gag, and black shows high exposure to the gag. You can see, this is a graph
of contraceptive prevalence. And so in countries that
have a high exposure to gag funding, you see that
contraception prevalence just basically plateaus during the gag, and contraceptive prevalence
increases in countries that don’t have exposure to US funding. We see when we pool all 20
nations, here the dotted line is when the gag is implemented. So you see before the gag
the prevalence of abortion, sorry the incidence of
induced abortion and then after the gag you see an
abrupt rise in abortion. They further stratified
abortions by, sorry countries by low gag exposure to high gag exposure and here you can see
in the green countries with low exposure to the
gag rule, abortion incidents stayed the same. But in countries with high
exposure to the gag rule, abortions actually went up. So what are the indirect
effects of the expanded gag? Well remember that before,
in this data that I’m showing you, the gag only
applies to the $6 million spent specifically on bilateral
grants for family planning. And now it applies to all
foreign funding from the US. And important factor to
understand when we look at the indirect effects is that
Bush created PEPFAR for HIV. And Obama’s mark on
PEPFAR was to integrate maternal-child health and newborn
care into PEPFAR programs. So most of the money was
spent in family planning was spent used to
integrate family planning and maternal health programming
into PEPFAR programs. And those same bilateral
grants and those same implementing partners
were using the monies to integrate services. So in much of Sub Saharan
Africa, you have HIV prevention and treatment organizations
that also provide sexual and reproductive health services. Many organizations have
tried to kind of make almost a healthcare home where
they integrate services under one roof. So they’re treating young children. They’re providing immunizations,
growth, nutrition, contraception, reproductive health and sometimes abortion
care or post abortion care. So you see that this new
policy has the potential effect of a much broader public health program including responses to Zika,
HIV, other infectious diseases and it actually stands to
reverse global progress in promoting integrated
patient centered care model. But what does it mean
for us doctors who are just taking care of patients on the ward. As I said, I worked in Kenya
at this program called Ampath. It was a consortium of 11
universities brought together to provide education, care,
treatment and research. They have a $60 million
grant in Kenya for HIV and a $5 million for MCH and primary care. Collectively these 11
universities bring in about $84 million in research dollars. That’s a lot of money. So this one program accounts
for greater than $200 million in total funding. Remember that in Kenya abortion is legal to preserve a maternal health including psychosocial wellbeing, fetal anomalies, rape and incest. And the Kenyan OB/GYN Society
supports liberalization of the interpretation of that law. When I worked there,
I was not under a gag. It was under the Obama administration, and we tried to improve post abortion care in the wards primarily
by providing pain control and infection control. We often partnered with
Marie Stopes to provide sterilization services
within our HIV clinic for patients who had traveled from far. I was writing a small
sub grant to get monies for family planning integration
into the HIV program which USAID called for the application. When I received a phone call
from the USAID representative for maternal child health to remind me that I could not put
anything in the budget for any kind of equipment in the budget for post abortion care
because that same equipment may be used to provide an abortion. And that was under the Obama years. So through my conversations
with USAID representative and subsequent research,
I’ve come to realize that under the gag, none of
these 11 consortium universities or visiting faculty who came to best part of that program, could
do anything construed as promoting abortion, let
alone say the abortion word, could not partner with
Marie Stopes to provide a safe abortion, could not refer a patient to Marie Stopes to provide a safe abortion or advocate for local,
regional or national change. Technically speaking, this would mean that if we received US
government money now, under the current gag, we’d not be able to perform a pregnancy
termination for a diagnosis like this, the OB/GYNs
in the room will know that this is anencephaly. We would not be able to use our own money to provide an abortion
for something like this. We would not be able to
purchase a uterine aspirator to help miscarriage
management or a carmen cannula which is used all the time
for miscarriage management. We would not be able
to purchase misoprostol which is a life-saving medicine used for post partum hemorrhage, as well as post abortion care. And it led me to think,
what about restrictions on medications like methotrexate. Before the advent of mifepristone
or the abortion pill, methotrexate was used as an abortivation for medical abortions. And so potentially this
medication that’s used to treat molar pregnancy and other cancers could also be restricted by the gag. Certainly we’d be
prevented from continuing a partnership with Marie Stopes. And so what’s at stake? Well funding for 180,000
HIV positive patients with life-saving
medications, not to mention partnerships with over 500 Kenyan clinics. But the question that I
continue to have is how much can the US government say
that you can and can’t do before it becomes
unethical morally corrupt. So what about the macro
and microeconomic impacts? So essentially we know that
keeping a woman pregnant or postpartum keeps her
out of the workforce. That leads to less income for the family. And in a macroeconomic analysis, we know that less fertility is
associated with a greater GDP and declining poverty. This happens because of a concept called the demographic dividend. The demographic dividend
is a well-described economic occurrence that a country enjoys when you have accelerated economic growth due to a decline in fertility
and a decline in mortality. The country then
experiences low birth rates in conjunction with low death rates and receives an economic
benefit from the increased years of productivity in
that working population. Fewer births are
registered and the younger of young dependents declines. And so the dependency ratio shrinks. The amount of people who
are dependent on you shrink and that means that you have more people in the labor force,
more money to go around, and resources are freed up to be invested in other things. You see accelerated macroeconomic growth. So essentially we know
that an individual woman’s economic empowerment
and her equality rates rely both on her bodily autonomy
to access family planning and to procure a safe abortion. And with that bodily autonomy
comes economic prosperity. I’m not even gonna get into
the larger implications on democracy and free speech
that the gag rule implements because you can’t even
advocate the government for legalization of abortion. So what is the impact of the gag? Unfortunately under both Reagan and Bush, we saw clear reversal with disruption of established family planning providers. We saw commodity shortages. We’ve seen more unintended pregnancies, increases in abortion, not decreases. We’ve seen decreases in
births spacing which we know worsens maternal health outcomes, and we know worse maternal health outcomes worsens children’s health outcomes. And we know that we have
seen a negative impact on economic development. So for better, for worse,
money does make the world go round. And this is a story of
what happens when our own domestic politics around abortions and reproductive rights
impacts the flow of cash in the global south. While we focus on our local and regional and national problems
around abortion access, let us not forget that
what happens here at home actually has grave impact on the globe. It impacts rates of unsafe
abortion and maternal mortality world wide. So remember that our fight here at home actually will have great
impact on women like Diana, that story that I told at
the beginning of this talk. One more thing for doctors. I think sometimes we think
that we can be cloistered in our care of patients and that our work taking care of patients is enough. But choosing not to be
engaged in elections is not a neutral decision. That is not a neutral decision. If you choose to do nothing
in the next election, it will have great impacts. So one of the cool things about Harvard that I’ve always loved,
is that it draws people from around the nation
and around the globe from districts all over the country. So I would encourage
you to register at home. Get your parents to register at home. And call your congress people at home whichever state your from
and remind that women hold up half the sky. So I hope that today has
been a sobering reminder and a detailed account of
how the US administration actually jeopardizes women’s health by putting ideology before evidence, proponents of the Global Gag
Rule are undermining women’s sexual reproductive health and our global economic development.

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