美國的「堵嘴法規」每年導致 90,000 例額外的 HIV 感染
資料來源：勞拉·洛佩茲·岡薩雷斯 / 2022 年 6 月 24 日 / aidsmap / 財團法人台灣紅絲帶基金會編譯
圖片來源：Rena Schild/Shutterstock.com
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對美國反墮胎墨西哥城政策影響的第一項大規模研究顯示，它可能導致每年估計有 90,000 例新的 HIV 感染和近 30,000 例孕產婦和兒童死亡，其中大多數是兒童。該研究揭示了其他捐助者透過提供替代性資金來減輕這些影響的潛在能力。
美國自1973 年持續的一項法律禁止所有聯邦資金資助本地或國外的墮胎。此外，美國共和黨總統羅納德·雷根在 1984 年推出了墨西哥城政策，該政策阻止美國向提供墮胎、甚至只是討論此議題的外國組織提供資金。
在實務上，該政策取消了可能提供墮胎但同時也提供一系列基本生殖健康服務組織的資金，例如避孕、愛滋病毒檢測和子宮頸癌篩檢。
自雷根以來，每一位共和黨美國總統都曾在其四年的總統任期內援引這項政策——通常被稱為「全球禁言法規」——卻被每一位民主黨繼任者撤銷。
據新聞機構 Bhekisisa 報導，近期的禁言法規至少導致了一半附屬於國際醫療保健提供機構 MSI Reproductive Choices 的農村外展站點關閉。 2017 年，MSI Reproductive Choices 預測這將導致辛巴威新增 110,000 例意外懷孕和 32,000 例不安全墮胎。
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愛滋病毒感染發生率和兒童死亡人數激增
醫療工作者和研究人員記錄了在禁言令期間，無論是在新聞報導中，還是在特定國家研究或在美國某一總統任職期間之影響的研究中，均發現愛滋病毒感染病例和孕產婦死亡人數增加的情況。
5 月發表在《美國國家科學院院刊》(Proceedings of the National Academy of Sciences, PNAS) 上的一項研究首次評估了 25 年來堵嘴法規對愛滋病毒發生率和孕產婦和兒童死亡率的影響。為此，博科尼大學政治學助理教授 Kerim Can Kavakli 和牛津大學研究員 Valentina Rotondi 選擇了 134 個有可用數據的國家。
他們透過詢問建立了國家基準線：在美國制訂禁言法規之前的一年，每個國家的愛滋病毒感染和孕產婦和兒童死亡情況如何？然後，科學家們追踪了禁言法規實施後四年內感染和死亡人數的變化情況。
接下來，研究人員使用迴歸分析比較了 1990 年至 2015 年間 134 個國家的這些結果，並控制了其他方面如財富和武裝衝突等可能影響健康結果的因素。
最終，他們發現，在南非、海地和阿富汗等高度依賴美國援助的 38 個國家中，重新引入堵嘴法規導致全國 HIV 發生率增加 4%（每 10,000 人中有 1 例新感染）。墨西哥城政策實施後，這些國家每年總共新增 90,000 例愛滋病毒感染病例。
在這些國家，全球禁言法規還導致平均每年有 2,700 名產婦死亡和 24,000 名兒童死亡。
「我們的分析顯示，當全球禁言法規生效時，更依賴美國外援進行計畫生育 [資金] 的國家會經歷更高的孕產婦和兒童死亡率以及 HIV 感染」，Kavakli 博士說。「我們聲稱這種關係是由於對孕婦、新生兒和尋求計畫生育服務者的服務惡化所致」。
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對高度依賴美國援助之國家的影響更糟
當透過配對比較一個國家對美國援助的依賴程度來分析結果時，他們發現在嚴重依賴美國援助而缺乏替代資金的國家中，影響最為嚴重。
如果一個國家幾乎完全依賴美國的援助，該研究預測，在該政策實施的每一年，每 100,00 名活產嬰兒中大約會增加 80 名兒童死亡和 9 名產婦死亡。
「這些數字分別比基準線上的兒童和孕產婦死亡率增加了 1% 和 3%」，作者寫道。「相較之下，這些影響大於其國內衝突所造成的影響估計」。
相比之下，獲得美國援助很少而依賴其他資金來源的國家則不受該政策的影響。
「數據顯示，其他捐助者對國家的投資可以減少全球禁言法規的負面影響」，卡瓦克利說。「這不僅是與美國政策制定者談論解除禁言法規的另一個原因，也是與非美國決策者談論的另一個原因：如果禁言法規即將到來，協助受援國度過難關」。
當使用嬰兒死亡率和愛滋病毒發生率不同的測量去重複進行分析時，結果仍是相似的。為了檢查該研究的結果是否歸因於與堵嘴法規同時發生的其他一些現象，Kavakli 和 Rotondi 還使用「安慰劑結果」（貧血、交通事故和獲得安全衛生設施）重複了分析，這些結果不會受到生殖健康服務變化的影響。
儘管如此，由於該研究依賴的是觀察之數據，因此無法證明堵嘴法規直接導致愛滋病毒感染數和死亡人數之增加。
Kavakli 警告說，這項研究可能低估了墨西哥城政策的真正影響，部分原因是它沒有包括美國前總統唐納德 . 川普領導下最新和深遠迭替的墨西哥城政策的影響。
川普擴大了禁言法規以影響更多類型的美國發展援助，包括美國總統的愛滋病緊急救援計畫 (PEPFAR)。川普的共和黨前任喬治 . W . 布希於 2003 年創建了 PEPFAR，並將其排除在他的全球禁言法規之外。
川普的限制政策版本不僅適用於直接接受美國資金的組織，也適用於較小的團體或次級接受者，可以與他們合作，即使他們自己不接受美國資金。透過這種方式，川普擴大的墨西哥城政策限制了來自其他捐助者的資金。例如，愛滋病研究基金會 (AmfAR) 發現，川普擴大的全球禁言法規將美國的條件附加到全球抗擊愛滋病、結核病和瘧疾基金支付給各國的資金約 10% 左右。
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美國政策減少了獲得避孕和嬰兒接受愛滋病毒篩查的機會
研究中包含的一項單獨的個人層面分析，證實了愛滋病毒感染和死亡增加可能與禁言法規有關的發現。
該研究考察了來自 30 個國家/地區的人口健康調查，這些調查要麼是在禁言法規實施前不久進行，要麼在禁令解除後不久進行。人口健康調查是具有全國代表性的調查，可以包括數以萬計的參與者，並從獲得避孕措施到人們如何接收健康信息等追踪所有的事情。各國大約每五年進行一次人口健康普查。
透過這些調查，Rotondi 發現在堵嘴法規下女性不太可能報告可獲得面對面的生殖健康和愛滋病毒諮詢、避孕和產後護理。相反，女性更有可能報告透過媒體收到健康信息。
同樣，在墨西哥城政策實施時，女性接受產後護理的可能性較小，或者對於感染愛滋病毒的女性來說，她們的嬰兒接受了愛滋病毒檢測的機會。 Rotondi 發現，女性更有可能報告意外懷孕。
「我對我們在數據中發現的牢固關係感到驚訝」，她說。
研究人員寫道，這項政策的最大影響是在較貧窮的女性中感受到的，他們補充說，他們的研究結果支持了對性別平等和教育進行長期投資的必要性，以緩解未來的援助削減之衝擊。
未來可能會有更多限制性的禁言法規
Kavakli 說，這項研究以系統的方式證實了當地的醫護人員和活動家多年來一直在說的話：全球禁言法規對基本衛生服務造成致命的破壞，遠遠超出了墮胎。
「我們不是在說什麼新東西」，他說，「但我認為現在的論點現在可以更有力了」。
他說，他希望未來的研究將繼續更廣泛地關注這些影響——以及各國的國家政策如何能夠反擊全球禁言法規。許多人擔心美國共和黨人會繼續追隨川普的腳步，推出更具壓制性的墨西哥城政策。
AmfAR 公共政策副主任 Brian Honermann 警告說：「禁言法規回歸的形式可能會變得更加嚴格或限制更少，這取決於共和黨的行動方式」。
在今天美國最高法院投票推翻 1973 年 Roe V Wade 保護安全墮胎權的決定之後，幾乎可以肯定會有更嚴厲的禁言規則。1973 年的判決保護了作為憲法隱私權一部分的墮胎權，也為該國保護同性婚姻奠定了基礎。
根據生殖健康研究組織古特馬赫研究所的數據，預計美國一半以上的州將在該決定後禁止墮胎。
霍納曼繼續說：「目前對性別平等的攻擊以及共和黨的方向顯示情況會更糟」。
參考文獻：
Kavakli KC & Rotondi V. 美國對外援助限制與母嬰健康：來自「墨西哥城政策」的證據。 PNAS 119：e2123177119, 2022（開放存取）。
https://doi.org/10.1073/pnas.21231771
US ‘gag rule’ leads to 90,000 additional HIV infections annually
Laura Lopez Gonzalez / 24 June 2022 / aidsmap
Rena Schild/Shutterstock.com
The first large-scale study of the impact of the United States’ anti-abortion Mexico City Policy shows it likely has led to an estimated 90,000 new HIV infections and almost 30,000 maternal and child deaths annually, mostly among children. The study revealed other donors’ potential power to mitigate these effects by providing alternative funding.
A standing 1973 US law bans all federal money from funding abortions locally or abroad. Still, in 1984 US Republican President Ronald Reagan introduced the Mexico City Policy, which blocks US funding to foreign organisations that provide or even discuss abortion.
In practice, the policy defunds organisations that may offer abortions but that also provide a range of essential reproductive health services, such as contraception, HIV testing and cervical cancer screening.
Since Reagan, every Republican US President has invoked the policy – often referred to as the ‘global gag rule’ — during their four-year presidencies only to have it revoked by each Democratic successor.
The most recent gag rule led to the closure of at least half of rural outreach sites affiliated with international healthcare provider MSI Reproductive Choices, news organisation Bhekisisa reported. In 2017, MSI Reproductive Choices predicted it would lead to an additional 110,000 unintended pregnancies and 32,000 unsafe abortions in Zimbabwe.
Spikes in HIV incidence and child deaths
Healthcare workers and researchers have documented increases in HIV cases and maternal deaths during gag rules, either in news stories or studies looking at the impacts in specific countries or during a single US presidency.
A study published in May in the journal PNAS is the first to assess the gag rule’s impact on HIV incidence and maternal and child mortality over a quarter of a century. To do this, Bocconi University assistant political science professor Kerim Can Kavakli and Oxford University research fellow Valentina Rotondi selected 134 countries with available data.
They established national baselines by asking: what did HIV infections and maternal and child deaths look like in each country in the year before the US instituted a gag rule? Then, the scientists tracked how infections and deaths changed in the four years after a gag rule was in place.
Next, the researchers used a regression analysis to compare these results among the 134 countries between 1990 and 2015, controlling for other aspects such as wealth and armed conflict that may also affect health outcomes.
Ultimately, they found that reintroducing the gag rule led to a 4% (one new infection per 10,000 people) increase in national HIV incidence rates among 38 countries highly dependent on US aid, such as South Africa, Haiti and Afghanistan. In total, these countries saw an additional 90,000 new HIV infections each year the Mexico City Policy was in place.
In these countries, the global gag rule also resulted in an average of 2,700 maternal deaths and 24,000 deaths among children annually.
“Our analysis shows that when the global gag rule is in effect, countries that are more dependent on US foreign aid for family planning [funding] experience higher maternal and child mortality and HIV infections,” says Dr Kavakli. “We claim that the relationship is due to the deterioration of services for pregnant women, newborns and people who seek family planning services.”
Impact worse in countries highly dependent on US aid
When the pair analysed the results by the how reliant a country was on US aid, they found that impacts were the most dire in countries heavily dependent on US aid which had scarce alternative funding.
If a country was almost entirely dependent on US aid, the study predicts it would see roughly 80 additional child deaths and nine maternal deaths per 100,00 live births for each year the policy was in place.
“These numbers represent 1 and 3% increases over baseline child and maternal death rates, respectively,” the authors write. “For comparison, these effects are larger than the estimated effect of civil conflict.”
In contrast, countries that received very little US aid and instead relied on other funding sources were protected from the policy’s impacts.
“Data shows that investments by other donors to countries can reduce the negative consequences of the global gag rule,” Kavakli says. “It’s another reason to not only speak to US policymakers about lifting gags but also to non-American decision makers: if a gag rule is coming, help aid recipients ride it out.”
When the analysis was repeated with different measures of infant mortality and HIV incidence, the results were similar. To check that the study’s results were not attributable to some other phenomena happening concurrently with the gag rule, Kavakli and Rotondi also repeated the analysis using ‘placebo outcomes’ — anaemia, traffic accidents and access to safe sanitation — that would have been unaffected by changes to reproductive health services.
Nonetheless, because the study’s relied on observational data, it cannot prove that the gag rule directly led to increased HIV infections and deaths.
And Kavakli cautions that the study likely underestimates the Mexico City Policy’s true impact, in part because it did not include the most recent and far-reaching iteration of the Mexico City Policy under former US President Donald Trump.
Trump extended the gag rule to affect more types of US development assistance, including the United States President’s Emergency Plan for AIDS Relief (PEPFAR). Trump’s Republican predecessor, George W Bush created PEPFAR in 2003 and excluded it from his version of the global gag rule.
Trump’s version of the policy applied not only organisations taking US money directly but also smaller groups, or sub-recipients, working with them even if they did not take US money themselves. In this way, Trump’s expanded Mexico City Policy restricted money from other donors. The Foundation for AIDS Research (AmfAR), for instance, found Trump’s expanded global gag rule attached US conditions to about 10% of the money disbursed to countries by the Global Fund to Fight AIDS, TB and Malaria.
US policy reduces access to contraception and HIV screening for infants
A separate individual-level analysis included in the research corroborates the finding that increased HIV infections and deaths were likely linked to the gag rule.
This looked at Demographic Health Surveys from 30 countries conducted either shortly before a gag rule was implemented or soon after it was lifted. Demographic Health Surveys are nationally representative surveys that can include tens of thousands of participants and track everything from access to contraception to how people receive health information. Countries conduct Demographic Health Surveys about every five years.
Through these surveys, Rotondi found that women were less likely to report having access to face-to-face reproductive health and HIV counselling, contraception and post-natal care under the gag rule. Instead, women were more likely to report receiving health information via the media.
Similarly, women were less likely to receive postnatal care or, in the case of women living with HIV, have had their baby tested for HIV when the Mexico City Policy was in place. Women were more likely to report unwanted pregnancies, Rotondi found.
“I was amazed by the strong relationships we found in the data,” she says.
The policy’s greatest impacts were felt among poorer women, write the researchers, who add their findings bolster the need for long-term investments in gender equity and education to mitigate against future aid cuts.
More restrictive gag rules possible in the future
Kavakli says the research confirms in a systematic way what healthcare workers and activists on the ground have been saying for years: that the global gag rule causes deadly disruptions to essential health services, far beyond abortions.
“We’re not saying something new,” he says, “but I think that now argument now can be even stronger.”
He says he hopes future research will continue to look more broadly at these impacts — and how national policies in countries can work to push back against global gag rules. Many people fear US Republicans will continue to follow in Trump’s footsteps by introducing more repressive versions of the Mexico City Policy.
“The form that the gag rule comes back in may morph to be more restrictive or less restrictive, depending on how the Republican party moves,” AmfAR Public policy deputy director Brian Honermann warns.
A harsher gag rule is almost certain following today’s US Supreme Court vote to overturn the 1973 Roe V Wade decision that protected the right to safe abortion. The judgement, which protected the right to abortion as part of a Constitutional right to privacy, also laid the foundation for the protection of same-sex marriage in the country.
Over half of all US states are expected to ban abortions following the decision, according to the reproductive health research organisation, the Guttmacher Institute.
Honermann continues: “The attacks on gender equality that are going on at the moment and the direction of the Republican Party suggests that it will be substantially worse.”
References
Kavakli KC & Rotondi V. US foreign aid restrictions and maternal and children’s health: Evidence from the “Mexico City Policy”. PNAS 119: e2123177119, 2022 (open access).
https://doi.org/10.1073/pnas.21231771