When Donald Trump reinstated the Global Gag Rule on January 23, 2017, nurses, doctors, lab technicians, advocates, and, most importantly, patients all felt the impact. International family planning providers were faced with a stark choice: They could keep quiet about abortion as an option, or they could refuse, and lose their U.S. funding.
To make matters worse, as if the original version of the Global Gag Rule, levied previously by Reagan, Bush One, and Bush Two, wasn’t bad enough, the Trump administration announced that it would expand the rule from its traditional application to family planning aid (currently $525 million) to all $8.8 billion in global health assistance. This means providers working on child nutrition, malaria prevention and treatment, and antiretroviral (ARV) provision for HIV/AIDS patients are all subjected to the mandate: sign, or lose funding.
Established in 1962, Family Health Options Kenya (FHOK) is one of the longest standing providers of reproductive health services in Kenya, reaching diverse groups through its clinics, its outreach services to remote communities, and its youth friendly centers. FHOK has provided millions of Kenyans with access to contraception, cervical cancer screenings, antenatal care, HIV/AIDS testing, counseling, and treatment, and general health services for decades. An International Planned Parenthood Federation (IPPF) affiliate, FHOK has historically refused to sign the Global Gag Rule because its service providers believe that access to the full range of reproductive health care, including abortion services, is a human right.
In November, on the heels of attending the International Conference on Family Planning (ICFP) in Rwanda, my colleague Lindsay Apperson and I had the opportunity to visit a few of the sites where FHOK provides safe, comprehensive, and client-focused services in the Nairobi area. What we witnessed was not a community broken by the policies of a heartless leader halfway across the world, or an organization torn over how to react to the threat of losing funding in exchange for the stifling of its free speech by a government that claims to be an ally. Instead, we saw a resilient organization fueled by the fight that lies ahead. Despite the harmful policies of the U.S. government, FHOK showed an eagerness to work alongside American allies like Population Connection to achieve a collective goal: permanent repeal of the Global Gag Rule.
Since Trump’s Gag Rule was imposed, FHOK has had to close clinics and cut back on its services in hard-to-reach communities. While in the past, many clients received services free of charge, depending on their financial standing, they may now have to pay. A once free consultation may now cost 100-150 KSh ($1.00-1.50) — unaffordable for people struggling to put food on the table.
At the FHOK clinic in Kibera, the largest slum in East Africa, the likelihood of a patient being unable to afford services is high, but the rate of denial of services is zero. Nearly all — 95 percent — of the services provided at the Kibera clinic are free, thanks to Gag Rule mitigation funds from various sources and grants from organizations like Population Connection. Aggrey Marita, the FHOK Kibera Medical Center Manager, does not allow a single patient to go unseen. He says it’s worth it to forgo clinic improvements to avoid denying vulnerable people service. While there used to be five or six providers at the clinic, there are now only two, each of whom sees 50-60 patients in a single day.
In Kenya, abortion is only allowed in order to protect the health or save the life of the pregnant woman. For women who find themselves with an unwanted pregnancy, but don’t meet the legal criteria, an unsafe abortion may seem like the only option. Aggrey made it clear that back alley abortions are often more accessible to the Kibera community than the safe abortion services offered at the FHOK clinics. The cost of transportation (50-70 KSh, or 50-70 cents) to the Nairobi West clinic for a safe surgical abortion may be prohibitive, or patients may fear they don’t fit the criteria for legal abortion and will be turned away.
Mercy Atieno, a 23-year-old mother of an eight-month-old boy, Liam, came to FHOK after an unsafe abortion left her septic and near death. Mercy’s boyfriend had left her when she told him she was pregnant — when Liam was only six months old — and her family was unable to support her having another child. Feeling she had no other option, Mercy found a quack doctor to terminate her pregnancy.
Mercy was lucky, and with the post-abortion care that Aggrey provided her and some bed rest, she was able to recover. Before she left, Mercy was counseled on family planning — something she knew little about. After learning about her options and what family planning could do to help her, Mercy chose the contraceptive implant. She also decided to take on a leadership role to counsel other young women, and has since become a community advocate for comprehensive reproductive health care in her Kibera neighborhood. She hosts weekly talks with other young women, both with and without children, to discuss how important contraception is. Conversation is open, honest, and led by a woman with a story all too common for many of the people in the room.
Unlike the clinic in Kibera, some Nairobi area clinics have begun to charge clients because they don’t have access to the same Gag Rule mitigation funds that Kibera has. When patients can’t afford fees and clinic expenses cannot be paid, facilities are forced to close. Clinics in Mombasa, previously a hub for mobile outreach services to rural communities; Kitengela, which served one of the most vulnerable communities on the fringe of Nairobi County; and Isiola have closed. FHOK’s Director of Clinical Services, Amos Simpano, anticipates more closures in 2019.
More often than not, FHOK is the only health care provider in a Kenyan community, and even more frequently the only provider of reproductive health care services. Patients have built generations-long relationships with providers, and communities trust the clinics for safe, honest, and comprehensive care.
Closing clinics also has an impact on staff. Olivia Tuti, the former Medical Center Manager at the Kitengela clinic, and her staff lost their jobs due to the reinstatement of the Global Gag Rule. In the short while that Olivia struggled to find work in the competitive Nairobi job market, Amos had applied for a grant from IPPF, which manages a Gag Rule response fund that its affiliates can access. That grant was awarded to FHOK, and Olivia now leads the Global Gag Rule Mitigation Project for the program.
The FHOK Nairobi Youth Center in the neighborhood of Eastleigh, run by Josephine Kimani, is more than just a place where young people go to receive health care. It’s a place for young people to be themselves; to discuss intimate-partner violence in the weightlifting gym; to share emotions and bond over pop culture in the henna salon; to talk about the changing political atmosphere in the barbershop; and to celebrate each other’s individuality in the photography studio.
Through the Young People Advocating for Health (YAH) program, youth leaders are trained to facilitate discussions within their communities about reproductive health care, something that has helped break down cultural barriers. For Muslim youth leaders, many of them Somali refugees, the time spent communicating with religious leaders has paid off. As a result of these discussions, sheiks and imams have given the youth permission to facilitate conversations about sexual and reproductive health with other members of their faith communities.
Through the drama club, they create messaging calling for women’s empowerment and access to contraception. Through the YAH program, young people are advocating with county leaders about the importance of funding contraceptive services and encouraging comprehensive sexuality education in schools.
When we asked the young people at the youth center why family planning was important to them, we got the usual range of responses: “I’m not ready for children,” or “I want to start a career first,” or “I want to be able to space my births so that I can have healthy pregnancies.” But one young person offered a much more grim response: “My area is not safe to be there because maybe there are rape cases, so it’s a sense of security.” The idea that contraception provides a “sense of security” in the event of sexual assault is the reality for so many young women in Nairobi, in Kenya, and around the world.
During our discussion, one young man demanded that the leadership at FHOK, present in the room with us, increase commodities at the youth center. There are shortfalls of antibiotics and other medications, and sometimes of contraceptives. But these stockouts have nothing to do with bureaucracy at FHOK, and everything to do with foreign assistance bureaucracy in the United States. The Gag Rule, combined with Trump’s refusal to fund the United Nations Population Fund (UNFPA), which provides FHOK with medications and supplies, is having a devastating effect on the availability of commodities.
About an hour outside of Nairobi lies Thika, a peri-urban center with an economy based on livestock and pineapple farming. Brian Waithaka, Medical Center Manager of the FHOK Thika clinic, delivered a clear message as we sat down: “We don’t turn patients away.” While a list of service costs is available, clients who are unable to pull together the funds may be given a subsidized cost, or receive a cost-free service, dependent on their income level.
That includes HIV/AIDS clients, who sometimes travel long distances to reach the clinic. Brian and his colleague Moses Okanda, SRH/HIV/AIDS Counselor, discussed how the stigma of being HIV positive is still very prominent. For many patients, that means seeking care within their own communities is not an option. Some travel the 200 kilometers from Nakuru to Thika to receive their ARVs for the month just to protect the confidentiality of their status. When clients arrive at the clinic, they are not quarantined in an HIV/AIDS specific counseling room, as is common at many medical facilities. At FHOK Thika, clients are seen in any clinic room regardless of HIV/AIDS status in order to protect their privacy; this is the standard at all FHOK clinics. If the FHOK Thika clinic were to close, patients who rely on the confidentiality of its HIV/AIDS testing, counseling, and ARV provision services could lose access to their only trusted provider.
When asked what they would do with hypothetical additional funding, Brian and Moses didn’t hesitate: more outreach services to the remote rural communities in Thika, and a 24-hour maternity ward. “That is the pressure we are having at the moment — the maternity ward. The clients are streaming in saying, ‘You guys, why don’t you have a maternity?’ That actually is the only thing we are missing at the moment,” Moses explained.
Clinics choosing not to bend to the harmful rhetoric of a president who is on the other side of the world are champions of free speech and of a commitment to comprehensive health care. Service providers and program managers like Aggrey, Amos, Olivia, Josephine, Brian, and Moses are saving lives through their work every single day. Though Trump’s Global Gag Rule puts a strain on their ability to provide care, it doesn’t stop them.