In Ethiopia, health clinics for teenagers once supported by U.S. foreign aid closed down. In Kenya, a decades-long effort to integrate HIV testing and family planning unraveled. And in Nepal, intrepid government workers who once traversed the Himalayas to spread information about reproductive health were halted.
Around the world, countries that depend on U.S. foreign aid have scrapped or scaled back ambitious public health projects, refashioning their health systems over the past four years to comport with President Donald Trump's sweeping anti-abortion restrictions that went further than any Republican president before him.
The effects have been profound: As groups scrambled to meet the administration's strict ideologically driven rules, they severed ties with health care providers that discuss abortion in any way, deleted references to abortion on websites and in sexual education curricula, and stopped discussing modern contraception for fear of forfeiting vital American aid.
President-elect Joe Biden has pledged to reverse the policy when he takes office, and he campaigned on a promise to enshrine abortion rights in federal law. But for many foreign aid groups, the changes may be permanent.
"The U.S. has lost its position as a leader and lost its credibility," said Terry McGovern, of Columbia University's Mailman School of Public Health who has overseen research of the Trump policy in multiple countries.
Since Ronald Reagan, Republican presidents have barred foreign aid organizations from using U.S. global health funds to counsel women about abortion or refer them to a safe abortion provider. But the Trump administration vastly expanded those anti-abortion restrictions, known as "the global gag rule" by opponents. Under Trump, the rule applies to some $9 billion of aid touching nearly every facet of global health funding, including groups working on HIV, malaria, tuberculosis and water sanitation. Under President George W. Bush, the policy applied to a fraction of that, $600 million in foreign aid.
The Trump administration proudly touted these efforts to protect "the unborn abroad," but the rules have left international aid groups deeply skeptical of U.S. promises and deepened the nation's rift with European countries that have long viewed abortion access as vital to women's health and safety.
Some major organizations opted out of any U.S. funding rather than comply with the new strictures, including Marie Stopes International and International Planned Parenthood Federation, among the largest providers of reproductive health care in the developing world. Untold numbers of front-line health care workers — in large cities and remote villages alike — have been confused by what seem like sudden swings in American policy.
And that trepidation may not be quick to dissipate even with a Democrat in the White House.
"Biden and Trump may seem radically different to Americans," said Jennifer Sherwood, a policy manager at Amfar, the Foundation for AIDS Research. "But if you're a small organization in sub-Saharan Africa, you may not understand what this new [Biden] administration means and if you can trust the United States."
The restrictions intentionally constrict the activities of foreign aid groups, many of which have worked in close coordination with American counterparts for decades. The rules also have a ripple effect on their funding: U.S. funding to foreign groups is contingent on their not accepting money from other countries, or even private foundations, to underwrite abortion-related services. They are not allowed to subcontract with other organizations that run separate abortion-related projects.
Trump telegraphed the worldwide anti-abortion gains in appeals to evangelical Christians. In early October, Secretary of State Mike Pompeo touted the policy during a speech to the Florida Family Policy Council, a conservative anti-abortion group, calling it an "unprecedented defense of the unborn abroad."
"Our administration has drawn on our first principles to defend life in our foreign policy like no administration in all of history," said Pompeo, who is an evangelical Christian.
The hard-right policies of the Trump administration stand in stark contrast to the steady liberalization of abortion laws in countries around the world over the past two decades. Since 2000, more than two dozen countries have eased abortion laws, including Ireland, South Korea, the Democratic Republic of Congo and Ethiopia.
Even in countries where abortion is forbidden, the rules are having an impact on reproductive health care. In Madagascar, where abortion is illegal with no exceptions, the largest provider of contraception, Marie Stopes, turned down U.S. money, endangering its ability to offer unfettered medical care to women, ending support for nearly 200 public and private facilities.
Mamy Jean Jacques Razafimahatratra, a researcher at the Institut National de Santé Publique et Communautaire in Antananarivo, found that led to shortages of contraception, in a poor country where travel to nearby towns is difficult.
"The women asked us, 'What is the cause of this rupture?'" said Razafimahatratra. "We tried to explain to them the reason, and [they say], 'But that regulation is for abortion, so we don't understand why we are also penalized?'"
Researchers at Amfar and Johns Hopkins, in a study published in Health Affairs, found the anti-abortion policies could have deadly consequences, specifically in preventing the spread of HIV/AIDS. Sherwood said young African women face the highest risk of HIV and many clinics had combined HIV testing and treatment with family planning services.
But, fearing they would run afoul of the Trump policy and thus forfeit funding, clinics have curtailed family planning for patients, reducing the number of women seeking care in African countries.
"A lot of the times, they want contraception," said Sherwood. "That is what's on their mind, and HIV is the secondary thing, something we can tack on to meet their needs all at once."
Jennifer Kates, director of global health and HIV policy at KFF said, "I have no doubt some groups are going to say, 'We are not going to play there anymore.'" (KHN is an editorially independent program of KFF.)
The practical challenges of restarting these programs are steep: rehiring staff, reopening clinics, retraining employees, rewriting curricula.
"You can imagine being a health care worker that was under threat of losing their funding for counseling a patient on abortion," Sherwood said. "To us, it's like a light switch that can turn off and on, but to them, this is a very opaque and confusing process. It's not how health systems work. You can't just change the way they work overnight."