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A Confederacy of Dunces — Trump White House Advisors’ Views on International Family Planning

Washington Memo Craig Lasher, Senior Fellow

On October 19th, the website Crooked Media posted a news story titled “Leaked Memo Reveals White House Wish List,” reporting on a memo to the Office of Management and Budget (OMB) that purportedly originated in the White House Domestic Policy Council (DPC). The article suggests that the leaked memo is the DPC’s “wish list” for the President’s FY 2019 budget request for domestic and international programs. With regard to the global sexual and reproductive health and rights funding and policy priorities of the Trump-Pence administration, the bulleted list for the State Department, USAID and other international affairs programs reads like the product of a religious fundamentalist’s fever dream.

The text of the memo is included in the news story, transcribed by Crooked Media from the original document to protect its source. The transcribed document is undated. According to a reliable PAI source, the memo was sent this past summer in reference to the forthcoming FY 2019 budget request, but it is perhaps really a running list of DPC priorities. A confusingly timed reference to the United Nations Population Fund (UNFPA), among other listed items in the document, lends credence to well-informed speculation that the memo was written during the post-election transition or in the first months of the Trump presidency and is intended to remain evergreen for the duration of the administration.

The section of the memo on the international programs of the State Department and USAID is devoted almost entirely to global health—including extensive hostile recommendations for family planning and reproductive health (FP/RH) programs—with attacks on existing girls’ education and women’s empowerment activities thrown in almost as an afterthought.

Trump White House DPC Wish List Proposal – Why What DPC is Proposing is a Bad Idea (or Won’t Happen)

Here is an item-by-item dissection and translation of some of the extreme, outlandish and dangerous policy prescriptions from the DPC related to international FP/RH funding and policy:
“Cut [international] family planning . . .”

For the more than 50 years of the program’s existence, USAID has been the global leader in expanding access to lifesaving contraceptive services in the developing world and is one of the greatest public health success stories of the U.S. government (USG). U.S. investments in FP/RH programs are cost-effective and deliver real results. An estimate of the impact of U.S. funding of $607.5 million in FY 2017 by the Guttmacher Institute finds that such investments makes it possible to achieve the following:

  • 25 million women and couples receive contraceptive services and supplies;
  • 7.4 million unintended pregnancies, including 3.3 million unplanned births, are averted;
  • 3.1 million induced abortions are averted (most of them unsafe); and
  • 15,000 maternal deaths are averted.

Investments in FP/RH are integral to the future progress of U.S. global health programs—in particular, achieving the goals of improving maternal, newborn, and child health and combatting HIV/AIDS. For a self-described “pro-life” administration, the prevention of over 3 million abortions as a direct result of U.S. funding of contraceptive access and use ought to be a no-brainer.

The Trump-Pence administration proposed zeroing-out all funding to international FP/RH programs in its first budget request, belatedly submitted to Congress in late May 2017. Fortunately, if the last seven fiscal years are any guide, Congress will in all likelihood ignore this scorched earth proposal and approve an amount for FP/RH approaching current spending during final FY 2018 negotiations.

“. . . and require equal funding for fertility awareness methods (including 100% for kids, no other family planning programming for girls should be provided except fertility awareness methods).”

The promotion of fertility awareness methods (more commonly known as natural family planning or NFP or periodic abstinence) has been an integral part of USAID’s FP/RH programming dating back to the Reagan administration. In fact, USAID bankrolled the development of cycle beads, a low-tech tool that enables women to more accurately track their menstrual cycles. However, requiring parity in funding between NFP and modern contraceptive methods is ill-advised and unethical given the birth control method preference of women and couples in developing countries where unintended pregnancy can frequently be life-threatening. Especially since NFP has a lower use-effectiveness rate than the other modern contraceptive methods such as the pill, injectables, implants, and IUDs offered in USAID-funded projects. The UN estimates that less than three percent of women of reproductive age worldwide utilize NFP as their birth control method.

Mandating that only NFP services be provided (“100% for kids”) to girls and young women, often subject to child, early and forced marriage; gender-based violence; and sex trafficking—and are especially vulnerable to obstetric fistula and post-partum hemorrhage—is potentially downright lethal. USAID’s “Adolescent Sexual and Reproductive Health Programming Priorities” is a balanced, pragmatic, age-appropriate and culturally sensitive strategy and a worthwhile read for a dose of reality.

And then, there is the no small matter of the law. The DeConcinivoluntarism and informed consent amendment, boilerplate statutory language in appropriations bills since 1985, states: “That in order to reduce reliance on abortion in developing nations, funds shall be available only to voluntary family planning projects which offer, either directly or through referral to, or information about access to, a broad range of family planning methods and services. . .” An attached Livingston-Obey amendment ensures that NFP providers are not discriminated against in funding awards based on their “religious or conscientious commitment” to offer only NFP, but does not absolve NFP providers from the requirement to provide information and refer women to clinics that provide modern contraceptive methods.

“UNFPA defund, restart Kemp-Kasten clock.”

Mission accomplished. On March 30, 2017, the Tillerson State Department issued an unjustifiable and indefensible Kemp-Kasten determination, which resulted in withholding the entire U.S. voluntary contribution to UNFPA of $32.5 million, plus approximately $38 million in additional funding for UNFPA’s vital work in humanitarian settings. UNFPA is the only intergovernmental institution with an explicit mandate to address the reproductive health needs of men and women worldwide.

UNFPA complements the U.S.’s bilateral international FP/RH programs and expands the reach of U.S. assistance by working in more than 150 countries, including those affected by conflict and humanitarian crises and many others in which the USAID does not currently operate FP/RH programs. In addition, UNFPA plays an indispensable and critical role today in the provision of reproductive and maternal health services in humanitarian settings, reaching 38 million people (of which over 5.6 million are pregnant women) in 56 countries—including most notably Syrian refugee women in Jordan as well as refugees and internally displaced persons in Iraq, South Sudan and Yemen.

“We also need to wholesale get out of the surgical sterilization business, there is evidence that we are not informing women well about what we’re doing, and that’s a terrible use of funds generally.”

Female and male sterilization represent a significant percentage of the methods utilized by couples to prevent unintended pregnancy in many countries, both developed and developing. Worldwide, the UN estimates that a little over a third of women of reproductive age (married or in-union) overall rely on female (30 percent) or male (4 percent) sterilization as their birth control method. The average American may be surprised to learn that surgical sterilization is the most popular method used by their fellow citizens for pregnancy prevention—exactly one-third of current contraceptive users according the National Center for Health Statistics. In light of the high demand and prevalence, it would be contrary to medical ethics for the U.S. government not to offer tubal ligation and vasectomy as options in the family planning clinics that the USG finances in order for women and couples to have a choice among a wide array of methods, thereby enabling them to choose the method that that best suits their needs.

Contrary to the memo’s assertion, there is no apparent evidence that “we are not informing women well about what we’re doing” when they undergo sterilization in U.S.-funded facilities, nor is any offered in the DPC memo. Having advocated on these issues for more than three decades, one can be assured that if any credible evidence of widespread failures to obtain informed consent from women existed, family planning opponents—both on and off Capitol Hill—would be publicizing and promoting such human rights violations in lurid detail to attack the USAID FP/RH program through congressional hearings and investigations.

First, there is again the matter of such violations of voluntarism and informed consent being against the law. In 1978, the Foreign Assistance Act of 1961, the permanent authorizing statute, was amended to prohibit the use of U.S. funds for involuntary sterilization: “None of the funds made available to carry out this Act be used to pay for the performance of involuntary sterilizations as a method of family planning or to coerce or provide any financial incentive to any person to undergo sterilization.”

Admittedly, occasional violations do occur, but all evidence indicates they are rare, quickly identified and reported (usually by the implementing organization itself or uncovered by USAID mission staff), and promptly addressed and corrected. Compliance with informed consent protections is taken extremely seriously by USAID as reflected both in the elaborate policies and procedures in place to enforce longstanding agency guidance (1982) and the requirements of the Tiahrt amendment (1999) and the amount of staff time and financial resources devoted to monitoring and staff training. In other words, this is a spurious, baseless charge by the DPC.

Other extreme health and gender-related recommendations on the policy “wish list” in the international arena include:

  • favoring bilateral programs over “multilateral stuff” in the case of HIV/AIDS (President’s Emergency Plan for AIDS Relief funding over contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria) and women’s empowerment (defund UN Women and transfer to “actual pro-women bilateral programming”);
  • resurrecting the original, long-discredited “abstinence-until-marriage” earmark for HIV/AIDS prevention programs under PEPFAR;
  • cutting contributions to the World Health Organization “dramatically” because it is “a corrupt, hostile bureaucracy that achieves no actual capacity in countries”; and
  • reducing funding for gender programs such as the Obama administration’s “Let Girls Learn” effort and instead launching something called the “Child Rape elimination initiative that we’re going to try to work up through an interagency process.”

The points of contact (“POC”) listed for the “State/USAID/Function 150” section—and presumably its authors—are Katy French Talento and Alexandra Campau, who are responsible for health care policy formulation at the Domestic Policy Council in the Trump White House. As detailed in the Crooked Media story and in a number of other media reports, Talento is a former Senate staffer and Harvard-trained infectious disease epidemiologist whose views on contraception are far outside the scientific mainstream. Frequently cited are two blog posts Talento wrote for the website The Federalist in January 2015, “Miscarriage of Justice: Is Big Pharma Breaking Your Uterus?” and “Ladies: Is Birth Control the Mother of All Medical Malpractice?” Campau is less well-known and appears to have worked primarily on domestic health care policy in the past.

If the contents of the leaked DPC memo are any indicator, it can be expected that ideology will seek to trump established science and longstanding law for the remainder of the administration when it formulates policies on contraception, domestic and international family planning programs, and women’s health and empowerment.

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