• reproductive health politics

In his editorial in this journal’s April 2017 issue, Grossman anticipated that President Donald Trump would have to make changes from his ambitious electoral promises when making decisions in office.1 Whereas the domestic economy, security and health were top priority issues for the USA presidential election, the themes of a political campaign are quite different from the precise positions required during policy formulation, especially when world events intrude on the “America first” transactional perspectives that seek to “make America great again”.

With both health and security knowing no geographical boundaries, a domestic agenda has global repercussions. Reacting to the anticipated international “population bomb” of the 1960s, the USA promoted family planning (FP), which was subsequently recognised as an integral part of maternal and child health, an essential element of primary healthcare as defined by the World Health Organization (WHO) in 1978. Considering that the HIV/AIDS pandemic was a threat to global stability, the United Nations (UN) Security Council passed a historic resolution2 in 2000: it was the first time that it recognised a health issue as a security threat and, interestingly, it was the USA that had placed the topic on its agenda.

Both FP and HIV control are now important components of rights-based reproductive health (RH) as agreed at the International Conference on Population and Development in 1994 and reaffirmed in the Millennium Development Goals in 2000.3 4 In the Sustainable Development Goals of 2015, RH is prominent both in the health goal (SDG3), with its integrated vision for lifelong and interdependent universal health coverage, and in the women’s empowerment goal (SDG5) with its gender implications. Through its Global Gag Rule, the so-called ‘Mexico City policy’, the American government does not fund FP activities of overseas nongovernmental organisations involved in induced abortions, including even just the provision of abortion-related information. With Trump’s introduction of an extended gag rule on 23 January 2017, funds will also be withheld from those organisations for all their health activities, not just for their FP services. This situation affects the clinical management of diseases such as Zika virus infection, where there are legitimate grounds in almost all countries for counselling about, and provision of, induced abortion services.

Despite its leading role in international development, the USA has not ratified the two international conventions that are the most relevant for RH: the 1979 UN Convention on the Elimination of All Forms of Discrimination against Women and the 1989 UN Convention on the Rights of the Child. But as a signatory, it has the moral responsibility to adhere to their principles. The unfavourable view of the Trump administration regarding multilateral, as opposed to bilateral, agreements has already led to proposals to decrease funding of the UN, with possible disruption of productive USA participation in some agencies including the WHO. As the USA’s relations with the UN Human Rights Council are already tense and certain member states leading various human rights entities being in a state of flux, we can only hope that the international human rights framework will not suffer.

The financial contributions of countries to operations and programmes of the UN consist of two distinct parts: assessed contributions for the regular core budget, where the USA’s share is 22%, and voluntary contributions for activities of special interest. However, there is a threat of more selective and restrictive targeting, especially within RH, where conservative positions5 could differentiate between its components: protection of budgets for maternity and child health services which are considered to be sacred, but going well beyond the existing prohibition of safe abortion information and services by slashing of funding for vital components of RH such as FP, prevention and treatment of sexually transmitted infections, and provision of sexuality-related youth services, which are despised as scary. Hopefully, shortfalls will be made up by sympathetic countries as well as by private philanthropic foundations, which have massively increased their financial contributions recently.

International RH has made substantial strides in recent years but continuing, not to mention accelerating, progress requires evidence-based decision-making. The Trump administration’s ideological positions do not give us confidence that such input will be forthcoming from the USA government in the near future.