The Foreign Service Journal, June 2007

imposes restrictions on the free expression of foreign NGOs: they must limit their advice and services to patients, even when financed by non- U.S. sources, or lose U.S. funding. The Mexico City Policy has forced the closure of health clinics in sub- Saharan Africa. In many rural and underserved areas, these facilities are the only source of affordable primary health care. They not only offer reproductive health services and counseling, but provide prenatal and postnatal obstetric care, HIV/AIDS voluntary counseling and testing, management of sexually transmitted infections, pharmaceutical and labo- ratory services, maternal and child health services, Pap smears, minor surgery and well-baby services. In Kenya, the two leading repro- ductive health organizations (Marie Stopes International Kenya and the Family Planning Association of Kenya) lost all U.S. family planning funding after refusing to accede to the terms of the policy in 2001, and were forced to close clinics when other donors were unable to make up the budget shortfall. Thousands of people — primarily women and children — were left with little or no access to health care. Similarly, Zambia’s largest family planning provider, the Planned Parenthood Association of Zambia, lost its U.S. funding and closed clinics due to the Mexico City Policy. By crippling reproductive health care providers, the policy has under- mined HIV/AIDS prevention and treatment efforts as well. Because HIV/AIDS in Africa is primarily transmitted via heterosexual sex, clin- ics offering family planning play a key role in HIV prevention. Funding shortages have decreased communi- ty-based distribution programs, which are also a supply conduit for HIV/AIDS drugs. Making matters worse, U.S. gov- ernment funding for family planning — even to those NGOs that adhere to the Mexico City Policy — has decreased each year of the Bush administration. This is despite the fact that access to family planning and contraception has been shown to help prevent unintended pregnancies and reduce abortions. After reinstate- ment of the policy, a lack of access to reproductive health services has led to an increase in unsafe abortions: this remains a major public health threat, disproportionately affecting women under 25 and contributing to high maternal mortality rates. Abstinence, Not Prevention President Bush announced the “President’s Emergency Plan for AIDS Relief” during his 2003 State of the Union address, and Congress enacted the program later that year by passing the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003. PEPFAR is meant to provide $15 billion over five years (2004-2008) for AIDS-related ser- vices in 15 countries: 12 in Africa, two in the Caribbean and one in Asia. To administer the funds, the administra- tion created the Office of the U.S. Global AIDS Coordinator, housed in the Department of State, and named Randall Tobias, the former CEO of the Eli Lilly pharmaceutical company, as director. (He later succeeded An- drew Natsios as USAID administrator, but resigned at the end of April.) Mark Dybul currently serves as the U.S. global AIDS coordinator. Though primarily directed toward Africa, where the world’s highest HIV prevalence rates occur, PEPFAR does not address the grim realities facing that continent’s women, who contract 60 percent of the infections in sub- Saharan Africa (and comprise a major- ity of those infected with HIV world- wide). Each year almost two million Africans die from AIDS, while over three million more become newly infected. In sub-Saharan Africa, 80 percent of new infections are the result of unprotected sex, often within marriage. Recent data indicate that the rate of new infections is spreading fastest among married women and adolescent girls, who are 2.5 times more likely to become infected with HIV than young men. Women living in poverty across the region are under extreme pressure to enter into sexual relationships for economic or cultural reasons; they are often forced into early marriages (with potentially unfaithful partners) or into sexual associations to support themselves or their families. Compounding the crisis for Afri- can women, those found to have HIV are often blamed for bringing the virus into the home, and abandoned by their families. Unequal property and inheritance rights leave them defenseless. They have little or no recourse when they face abusive rela- tionships or are left homeless when their partner dies of an AIDS-related disease; and they face a nearly-guar- anteed death sentence, for them- selves and their children, from AIDS. Instead of addressing this reality, and getting funding to those who need it most, PEPFAR rewards two key political supporters of the Bush administration: the pharmaceutical industry and Christian conservatives. The pharmaceutical industry benefits because the lion’s share of funding under the initiative is designated for AIDS treatment rather than preven- tion, and the treatment budget goes 48 F O R E I G N S E R V I C E J O U R N A L / J U N E 2 0 0 7 The Mexico City Policy has forced the closure of health clinics in sub- Saharan Africa.