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Reproductive Health

Problems on the Wards

Front Page

Global Gag Rule Hinders Reproductive Health in Peru

Photo by Jeff Cleary Tarayn Grizzard

There’s a crowd protesting, chanting, and waving banners 15 floors below my window here in Lima, Peru. Police in full riot gear encircle protesters and occasionally restrain the 1,000-plus demonstrators voicing their demands in front of the Office of the President’s Cabinet. It’s the third protest this week, one of innumerable ones I’ve seen since moving here. Peruvian television is equally assertive. An assortment of parody shows exists, ready to make fun of any and all political foibles. To my North American eyes, accustomed to a more apathetic citizenry, Peru seems to be a kaleidoscope of civic involvement, the epitome of how a democracy should respond when problems surface.

For all the political ruckus, however, I’ve been surprised to hear practically nothing about abortion. The practice is illegal in Peru, as it is in much of Latin America. As a result, unsafe clandestine abortions pose a major health risk and a serious burden to the country’s already struggling health system. It is estimated that more than 350,000 clandestine abortions took place in Peru in 2003, with about 14 percent—or 50,000 women—requiring medical treatment or hospitalization for complications. During that year approximately 800 women died as a result of illegal abortions.

Deafening Silence
Since Peru has one of the world’s highest rates of abortion—more than 50 per 100 live births—I had expected to hear at least something about the subject on TV or in the news. I’d certainly seen posters and the occasional talk show on abortion while living in the equally conservative Chile. I had anticipated hearing about women’s organizations rallying together to demand that the government liberalize abortion laws or about Ministry of Health family planning campaigns stressing prevention as a life-saving measure.

It seems that in Latin America, where abortion is largely illegal, the gag rule has gone beyond the bounds of nongovernmental organizations (NGOs) and clinics to public forums in its limitation of advocacy and lobbying for abortion rights.

Instead, in my seven months here I’ve heard nary a public word about abortion even though the number of abortions is on the rise. I haven’t even heard it discussed among my liberal and educated circle of friends, most of whom are Peruvian or long-term expatriate doctors and researchers. Despite Peru’s staggering abortion rate and the resulting drain on health system resources, I know of no one doing projects even vaguely related to abortion. It doesn’t make sense. In a country so unafraid of protest, where are the Peruvian women’s groups and feminist organizations?

Of course, they’re around. Among them are the well-known Movimiento Manuela Ramos, Flora Tristán, and others, which continue to work in Lima and the provinces to provide women with reproductive health care, economic resources, and other development tools. Yet one of the central roles of these organizations, advocating for the right to a safe abortion, has been silenced due to the signing of the so-called “Global Gag Rule.”

On Jan. 22, 2001, President George W. Bush reinstated the Mexico City Policy for U.S. aid, which asserts that any organization receiving U.S. federal funds is prohibited from discussing abortion in any context with its clients. The rule and the controversy surrounding it did not originate with Bush; the policy was originally enacted by President Reagan and later repealed by President Clinton. It seems that in Latin America, where abortion is largely illegal, the gag rule has gone beyond the bounds of nongovernmental organizations (NGOs) and clinics to public forums in its limitation of advocacy and lobbying for abortion rights.

The Big Chill
In Peru, a major recipient of U.S. aid, the effects of the Global Gag Rule have been especially strong. Prior to the institution of the policy in 1984 and to its reinstatement in 2001, a more open environment existed toward discussing abortion and unplanned pregnancies. According to Susana Chavez of Flora Tristán, which refuses to conform to the order and no longer receives U.S. aid, this openness led to research on abortion by NGOs and feminist organizations, helping them develop and propagate public education campaigns and open debate about the idea of abortion as a public health issue rather than as a criminal offense.

Now, with half of the organizations silenced due to dependence on U.S. aid and the others less funded and more isolated, this open environment has virtually disappeared, making abortion a topic non grata. Those organizations that chose to sign the gag rule now sometimes struggle to negotiate the dangerous gray areas of the policy—or avoid the subject of abortion rights altogether. As one feminist organization leader in Peru said, speaking confidentially to the Center for Reproductive Rights, “We used to hold debates, invite medical doctors, produce research publications. We cannot speak as freely now. No one knows at what point it becomes prohibited speech.”

Yet the real victims of the Global Gag Rule—and its impact on public discourse—aren’t the organizations, but rather the more than 350,000 women in Peru who suffer through illegal and frequently unsafe abortions every year. The indirect effects of the Mexico City Policy are the hundreds who continue to die, the women unable to obtain a safe abortion due to the lack of reproductive health services available to them, as well as the many others whose stories are yet to be part of these statistics.

—Tarayn Grizzard is a lactation counselor
and medical student at HMS.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

Related Online Resources
Ferrando, Delicia, Clandestine Abortion in Peru, Facts and Figures 2002, Centro de la Mujer Peruana Flora Tristán, Pathfinder International (36 pp.), Lima, April 2002. PDF online (3.1 MB*) at www.pathfind.org/site/DocServer/Pathfinder_English_FINAL.pdf?docID=509

Chavez, Susana, “The Global Gag Rule from the Perspective of the Women’s Movement in Peru,” Transcript of testimony before U.S. Congress, Washington, D.C., Oct 22, 2003. Online at www.crlp.org/hill_int_ggr_chavez_speech.html

Breaking the Silence: The Global Gag Rule’s Impact on Unsafe Abortion, Center for Reproductive Rights (43 pp.), N.Y., October 2003. PDF online (1.3 MB*) at www.reproductiverights.org/pdf/bo_GGR_impact_1003.pdf

*PDF downloading and viewing may be delayed due to large filesizes

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Model Behavior: Toolkit for Students Facing Incidents on the Wards

Anyone in education will tell you that one of the most powerful ways to teach a behavior is through modeling. Modeling is a common tool in medical education—residents and attendings demonstrate how to care for patients, and medical students integrate these behaviors into their own practice. Unfortunately, sometimes the behaviors medical students observe during their rotations are not ones we want them to emulate.

There are many different possible responses to incidents of inappropriate behavior.

Throughout the first two years of medical school, students are taught to recognize incidents of racism, sexism, or other inappropriate behaviors. Yet we do not always provide them with the tools they need to address these incidents, especially in a clinical setting. In my conversations with students, they have expressed feelings of helplessness and often view their choices as limited to two extremes: confronting the person behaving inappropriately or allowing the incident to pass without response.

Both options come at a price. Students are often too intimidated to confront a person in a position of power and fear that by doing so they put their clerkship grade and their potential residency at that institution in jeopardy. Ignoring the incident can be equally costly. Students suffer emotional and intellectual stress when they feel they have betrayed their own convictions by doing nothing. None of us perform at our best when we are uncomfortable with the people around us. Additionally, students may make major career decisions based on negative experiences or feelings associated with a particular clerkship.

One mistake we make is thinking about the choice in such a limited fashion—confront the person or do nothing. There are many different possible responses to incidents of inappropriate behavior. I have gathered potential strategies and compiled them below. Each response is at some level an active strategy, even if it is only to avoid participating in the offensive action.

Any student who witnesses offensive behavior must decide to respond at that time and place. The strategies below may be helpful when thinking through troubling incidents.

At the Moment
• Resist joining in the behavior.
• Physically remove yourself from the situation.
• Contribute a positive comment of your own.
• Use humor to lessen the impact of hurtful words or actions.
• Request a private conversation with the responsible person.
• Use an “I” statement to express your discomfort.
• State a contradictory opinion.

Preparing for Another Incident
• Examine your own comfort level with confrontation.
• Anticipate other potential incidents or remarks and formulate a response to them ahead of time.
• Seek coaching on how to manage confrontations at work.

Getting Advice and Support
• Discuss the incident with your peers on the clerkship or your PD-II or PD-III group.
• Present the incident to the Multicultural Fellows Committee.
• Utilize existing relationships with those in power.
• Address the incident with your society master or associate master.
• Request that a trusted faculty member speak with the responsible person.
• Contact the HMS ombudsperson, Linda Wilcox.
• Seek out allies within the hospital system.

Documenting Behavior
• Report the incident on the clerkship evaluation.
• Write up the offensive situation for possible inclusion in the “Incident Report” column in Focus (see Focus, Feb. 21, 2003).
• Process the incident in a PD-III reflection paper.
• Make a formal complaint once your rotation is completed.
• Collect examples of similar incidents and distribute them to people in power.
• Work within the hospital system to identify or create a reporting structure.

Regardless of the strategy a student selects, we want him or her to feel empowered, not helpless, if these situations arise. I welcome dialogue on this topic and any additional suggestions for how students might respond to the upsetting behavior they may observe.

—Emily Paige Rickards is a program officer in the HMS Program in Medical Education.

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