Who Dies? The Singular Equation Under Trump’s Global Gag Rule

Warning: This article is a highly disturbing recounting of conversations the author had with real girls and women in three different sub-Saharan African countries. These include graphic stories of sexual abuse, exploitation, and violence.

“I use the implant,” 19-year-old Mercy says, firmly tapping two fingers on her upper arm, as though pointing out a military rank. We are sitting in a reproductive health clinic surrounded by cheery blue-washed walls and health posters encouraging cervical cancer screenings and warning against HIV. Mercy speaks in crisp English, her quick smile and bright eyes framed by bouncy curls. “They are for three and five years. I took the five. So by that time, my daughter will have grown a little bit. Even after five years, I’ll come again and replace it.”

Beyond these clinic walls lies Kibera, the largest urban slum in Africa, where Mercy grew up and is now raising her own daughter. Here in Kibera — a maze of rusting metal sheets patched together to form narrow corridors, weaving around open sewers clogged with garbage and human waste in Nairobi, Kenya — 50 percent of the residents are unemployed. Though 99 percent of girls in Kibera begin school, few finish. Between ages 11 and 14, one out of every three girls experience domestic or sexual violence. And nonprofit Kibera UK reports, at any given time, about 50 percent of 16–25-year-old girls are pregnant. “Most of these pregnancies are unwanted.”

“I was a naïve girl,” Mercy says. Like so many girls in Kibera, Mercy had little knowledge of or access to reproductive health services. At age 16, she became pregnant. At that time, Mercy faced a choice: seek an unsafe — and potentially deadly — abortion in a local “curtain clinic,” named after the curtain-only doorways, or drop out of school to become a single mother. She chose the latter.

Most teen moms find themselves quickly trapped in a brutal game of survival: sex for money, pregnancy, malnourished babies, disease, and extreme poverty. But for Mercy, things took an unexpected turn. In 2014, with support from the United States Agency for International Development (USAID), Family Health Options Kenya (FHOK) opened a free reproductive health clinic a few hundred yards from Mercy’s home. Established in 1962, FHOK offers a range of reproductive health services: free contraceptives, cervical cancer screening, sexually transmitted infection testing and treatment, rape kits, primary care for children, and — in accordance with Kenyan law — referrals for safe abortions.

Mercy seized this support, securing long-acting birth control, allowing her to care for her daughter while making plans to go to beauty school. “I’m not willing to make that kind of mistake again. So that’s why I seek family planning — so that my daughter can have the best. I want to be a responsible mother.”

A typical curtained doorway in Kibera

Teen mom Aisha agreed to speak with me only after I shared my own family history that touched on her experience. Tucked inside a single-room hut, she speaks in hushed tones as her friends wait outside: Even her best friends don’t know the most painful chapters of her life.

Aisha was only 16 when her mother became ill and the family ran out of funds for her school fees and meals. The family’s survival fell on Aisha. “There was some guy who…” She pauses a long while, burying her face in her hands, searching for the words, “…liked me.” Sex with the 32-year-old married father for $1.50 per encounter became Aisha’s last-ditch routine.

Aisha became pregnant. The man disappeared, leaving her with no means of supporting her child or her family. She birthed the baby, and slipped into Kibera’s no-choice track for girls. Locally, they call it “the hustle”: odd jobs, alcohol, and clubs where older men linger, looking for teen girls. The going rate per condom-free “shot” is about $1. Aisha made about $20 on Saturday nights.

Soon, Aisha again became pregnant. This time, her mother pushed her to get a curtain clinic abortion. For $30, she was given a pill and a suppository. The bleeding was intense. Armed with a story of miscarriage, Aisha went to the hospital. But upon examination, the medical staff found the half-dissolved suppository inside of her. “They kicked me out,” Aisha says, dabbing away tears. “Told me to just go.”

Aisha went to another hospital that did treat her. The fetus had gotten stuck on expulsion from her womb, and her incomplete abortion went septic — a life-threatening complication. At home, it took her a month to recover.

Around that time, friends told Aisha about FHOK’s clinic. She is now on long-acting birth control, and, anxious to leave behind clubs and sexual exploitation, has enrolled in culinary school.

Aisha’s story is common among those who frequent the FHOK Kibera clinic.

Aisha requested that her identity be protected because of the sensitive events of her past.

“I have so many friends who did abort, but I’ve been talking with them to come to the clinic to get family planning,” says 22-year-old Tery, who supports herself and her 3-year-old son on an income of $36 per month. A proud smile spreads across her face, “They have done so…they are doing well.”

FHOK’s work has steadily supported young women in making life-affirming choices, allowing them to create their own narrow pathways out of extreme poverty. But this fragile success is on the edge of collapse, thanks to the Trump administration’s re-imposition and expansion of the Global Gag Rule. The policy requires any organization receiving funding from USAID to sign a pledge that they will not offer abortion services, nor refer clients to those that do. The ban extends beyond services offered with U.S. funding to all services supported by any funder.

FHOK has no illusions about the grave costs of this lethal policy. They’ve been through it before. In the early 2000s, FHOK would not agree to the requirements of the Global Gag Rule as instituted under the Bush administration. They lost funding, and subsequently closed six clinics.

But between 2009 and 2017, with USAID support, FHOK reopened clinics and expanded services. In 2016 alone, they provided patients with three million instances of reproductive health services at 17 clinics.

This time, as the Global Gag Rule is imposed under Trump, FHOK estimates they will lose 60 percent of their funding. They are currently making plans to close about half of their clinics.

The results to come are well documented from past impositions of the Global Gag Rule: When women have no birth control options, rates of unwanted pregnancy spike. Unsafe abortions, like the one that nearly cost Aisha her life, skyrocket. Women die.

“The Kibera clinic will be our first casualty,” explains Amos Simpano, Director of Clinical Services for FHOK. “Expect this to translate to many young women dying.”

And the looming threat is not limited to maternal health…

Mercy, Tery, and friends wait for appointments at FHOK in Kibera

In a garment factory district on the outskirts of Nairobi, 30-year-old Faith lives alone. With only a third-grade education, Faith migrated here from eastern Kenya in search of a job, but has never found formal work. Like many women who live in this area — including those employed full time at the garment factories — Faith has sex for money. “I have done it. It’s not like I go out looking for men. But I have responsibilities, like house rent, and once in a while I won’t have money to pay. So, I’ll tell a man. And he’ll say, ‘I can help with that.’ If I tell a man about my rent issues, he will say, ‘Would you accept $2?’ ”

Staff at FHOK’s garment district clinic estimate that 90 percent of their clients who have sex for money are HIV positive. Faith is no exception, though she stares at the floor for a long while after I ask about her HIV status, silent, before she can bring herself to say the words out loud, “It’s true.” Faith manages her viral load through medication she receives at the FHOK center.

Faith invites me to visit her home, but on one condition: I must hold her hand in front of neighbors. “So they’ll think we’re friends, I’m someone important.” I oblige, wrapping my arm around her shoulder when introduced to those I can only assume are judging neighbors, declaring, “Any friend of this wonderful lady is a friend of mine!”

Walking away, I think back to what she said when I asked what she will do when they close the clinic. Her self-worth so shaky, Faith responded, “I will feel ashamed to go to another clinic.”

I believe her. She likely won’t go elsewhere at the risk of ridicule. That means a spiking viral load, mixing HIV strains, and perhaps death. “Our focus is to prevent any new infections, and to manage people who are living with HIV,” Amos Simpano explains. “Once we are unable to provide [antiretroviral medication], they will die. They will die.”

While the repercussions of the expanded Trump Global Gag Rule loom heavy on the Kenyan horizon, the Democratic Republic of the Congo (DRC) and Somalia both serve as sharp warnings of what life — and far too much death — looks like without reproductive healthcare.

Faith carries medicine she got at FHOK

For more than a century, DRC has been ruled by an unbroken lineage of kleptocrats. Decades of civil war wiped out any existing infrastructure, and government services are now next to non-existent. The nation is also known as the rape capital of the world.

Julie wears smudged, hard-stenciled eyebrows, ratted and pulled hair extensions, and a lacy yellow top that looks like lingerie — her attempts to manufacture sexy. I’ve rarely met someone so visibly worn by indignity layered upon indignity, never mind at only age 15. She speaks in a raspy voice, as she starts from the beginning. Julie was 12 when she was orphaned. She worked as a house servant, and was on her way home from collecting water when four men gang raped her. “I cried so hard so people would come. I screamed for help, but the men just added volume to the music.”

After hours of rape, Julie was so badly injured she literally had to crawl on her hands and knees back through the slum. Her employer wouldn’t let her back inside the house.

Since that day, Julie has found only one means of survival: a daily routine of sexual exploitation — child rape, really — for which she pays $6 per day just to cover the costs of a room in a brothel. It takes seven “clients” just to net $1 a day.

Julie is now two months pregnant. Her “madame” has set a limit: Men will only pay for sex up until seven months of pregnancy. After that, Julie is no longer welcome at the brothel. She is at a loss as to how she will survive. “My friends are encouraging me to terminate my pregnancy,” Julie says. The unsafe abortion method of choice in the area is a fistful of the malaria medication quinine, from which Julie recently witnessed a friend overdose and die. “I refused. I am afraid of dying.”

Julie’s fear is legitimate. According to Dr. Neema Rukungh of Panzi Hospital in Bukavu, a city in eastern DRC, the demand for abortion following rape is high. “If they could have the choice, at least 80 to 90 percent would say, ‘We need to abort.’ Because even when the law doesn’t agree, many try to make an abortion one way or another. They arrive here at the hospital bleeding, with strokes and severe infections. Young girls who couldn’t make abortion, they tried suicide.”

Julie is 15 years old and two months pregnant. She works at a brothel as a sex worker to earn money to survive.

Suicide was Darlene’s first thought. At age 13, following a rape over a school break, Darlene was told she was pregnant. “That day, I felt worthless. My decision was to end my life. My plan was to go and throw myself in the Ruzizi River or the lake,” Darlene recounts. “So I didn’t have to continue to witness how my life became nothing.”

When asked if she would have taken an emergency contraceptive pill to prevent pregnancy in the 72 hours following the rape, if given the option, she says, “I would take it. I would take it and keep my life.”

Instead, as the community learned of her pregnancy, Darlene was summarily rejected. “My friends abandoned me. My family did not continue to love me the way they did before I was pregnant. So everything changed. They isolated me, and saying I am raped. So I’m dirty. Everybody. Everybody.”

For married women, too, the reproductive landscape in the DRC is dire. Despite widespread family planning education programs, birth control supplies are low, prohibitively expensive, and limited to urban centers.

Darlene considered suicide after being raped at age 13.

“I am not happy. My youngest child is only eight months,” says Nsimire. She is 29 years old and now pregnant with her eleventh child. “I am four months pregnant. I want this to be my last child, to have this baby be the youngest forever. I am afraid I can die, or I’ll not be able to take care of these children.”

There is a government clinic in Nsimire’s village, with a new maternity ward. But the center can’t afford a trained midwife. The center’s only income is from patient fees — about $150 per month, split between five staff members. To deliver with a midwife, women must walk three hours to the nearest hospital while in active labor. If it’s after dark, the clinic recommends eight or more people accompany her, to prevent militia attacks. Because of this, Nsimire has given birth at the hospital only two of ten times. The other deliveries happened at home, or while walking to the hospital. “I gave birth on the road. Several times.”

Nsimire’s village is also a half-day walk from the nearest supply of contraceptives, which are prohibitively expensive. “We need contraception. I can’t afford it, otherwise I would have gotten it.”

So I ask her the obvious — if intrusive — question: If having so many children is a problem, why not just abstain from sex? “I don’t have the power to say no. He will not accept, he will go run after other women.”

In the meantime, a visit to Nsimire’s home reveals the heavy toll paid by her children: Instead of school, Nsimire’s 10-year-old daughter takes the burden of care for younger siblings. The youngest child, an 8-month-old baby, wails, her hair white from malnutrition.

Nsimire and her children in front of their home

Nsimire’s 10-year-old daughter cares for her younger siblings instead of attending school.

On the heels of two decades of state collapse, rule by Islamic militants, and civil war, Somalia has routinely been labeled the most dangerous place on Earth, the world’s most failed state, and one of the worst countries on the planet for women.

In a private house, tucked into a dusty residential neighborhood in Mogadishu, 23-year-old Jamilah holds a 9-month-old baby girl dressed in pink lace. Jamilah gave birth for the first time at age 13. Since then, she has delivered eight times in ten years. After watching three of her babies die, Jamilah wants no more children.

But even in urban areas like Mogadishu, women like Jamilah have no birth control options. Somali gynecologist Dr. Asha Omar explains, “If you are Somali woman, and you don’t want to have more kids, you have nothing to do. You don’t have access to contraceptives or other alternatives. You can’t. You can’t.”

Jamilah tried street-bought contraceptive pills, recommended by her aunt. Both women conceived while taking the pills. That’s how she came to be pregnant with the baby resting on her lap. Her daughter’s eyelids grow heavy and she slips into a nap as Jamilah speaks softly. The family’s sole breadwinner, Jamilah returned to work immediately following the most recent birth. One day, when her baby was four months old, her husband went out on an errand and a neighbor broke into the hut and raped the baby girl, who was left alone. When the father came home, the baby was hysterical, covered in blood.

Now terrified for her children’s survival, Jamilah begged her husband to not ejaculate inside of her during sex. He did anyway. So, she threw him out. 

I gathered a focus group at the Elman Peace and Human Rights Center in Mogadishu to talk in more depth about the reproductive health challenges facing Somali women. In a shady back yard, community outreach workers, mothers, small business owners, and sexual violence survivors broke it down: “If the girl is pregnant before she’s married, it is considered the duty of the nearest male relative to kill her.”

The stories abound. A schoolgirl being intimate with a classmate, a video of the act posted online, her father burning her to death. A mother of seven, raped and impregnated by African Union soldiers, receiving death threats from al-Shabaab: Kill the newborn, or we will kill you.

But young women have figured out a gruesome escape: Under layers of Muslim chadors — a covering draped loosely over the body — it is relatively easy to hide a pregnancy bump, even at full term. Girls deliver in secret. As long as they return without a baby, family and community are often none the wiser.

What happens to the newborns? Sometimes, they are abandoned on doorsteps or in hospitals. More often, they are thrown out — in open latrines or garbage piles, strangled with their own umbilical cords. According to Ilwad Elman, Program Director for the Elman Peace and Human Rights Center in Mogadishu, it happens about three or four times a week in Mogadishu alone. So common is the practice that one focus group member passed around a photo on her phone, taken only a week or so before the meeting, of a dead infant she found wrapped in a clear plastic bag, thrown out among beer bottles and candy wrappers.

As Dr. Asha Omar explains, “They hide the pregnancy, they hide, they deliver, and they throw the baby. That is what mostly happens. Instead to do abortion, they wait until the delivery, and then they throw.”

A woman named Ismael relayed how she came to adopt her infant son resting beside her, including the birth mother’s admission: Yes, she suffocated her first newborn, and attempted to kill this second baby with his umbilical cord before Ismael intervened. But, the girl apparently told her, it was self-defense. Murder or be murdered. “If you knew my father, you wouldn’t ask why.”

Focus group participants at the Elman Peace and Human Rights Center in Mogadishu

Dr. Asha Omar

Focus group participants look at a photo of a dead infant who was left out with the trash

These are the horrific ends in a world with no reproductive healthcare. Without support, for millions of women, the options are reduced to a singular equation: Who dies?

In the coming four years, Trump’s Global Gag Rule will snare millions of women, babies, and barely pubescent girls in a web of death-only choices.

Some, perhaps many, of the women I spoke with will not outlive this policy. Under a moralistic banner of “life,” this policy will blot out the lives of thousands of Mercys, the would-be creator of sassy hair-dos, thousands of Darlenes, future human rights attorney, thousands of Faiths, happy just to hold a hand.

This policy is tantamount to an arms-length mass stoning.

Ismael with the baby boy she adopted after his birth mother attempted to strangle him with his umbilical cord

Lisa Shannon is an author, activist, and speaker. Earlier this year, she traveled to DRC, Kenya, and Somalia on behalf of Population Connection and Population Connection Action Fund to talk to people most affected by Trump’s Global Gag Rule. Learn more about her work and background at lisajshannon.com.

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