When you start researching unsafe abortion, the photographs and stories are so visceral that they carve themselves into your mind like a scalpel. You find yourself able to quote details of the internal damage caused by drinking a litre of bleach. You dream at night about the news story describing the effects of a uterus being stabbed, repeatedly, with a bamboo stick.
A report published by the US non-profit agency the Centre for Reproductive Rights includes a typical tale. In Breaking the Silence, an anonymous Kenyan health worker recalls the story of a pregnant 17-year-old he encountered, "a house-help with no money . . . [who] went to somebody to try to remove the pregnancy. And the person she went to did not know the anus from the vagina. He destroyed her anus, rectum, uterus and some of the small intestine. The girl now has a permanent colostomy."
There's a reason that the health worker chose to remain anonymous, a reason which rests, bizarrely, on the political interests and religious beliefs of a man on another continent.
In January 2001, on his first day in office, President George W Bush issued an executive order that had lain dormant throughout most of the Clinton administration. The Mexico City Policy, more commonly and descriptively dubbed "the global gag rule", had been instituted by Ronald Reagan in 1984, and represented a tightening of the Helms Amendment 1973, which had made it unlawful for non-governmental organisations to use any funds granted by the US Agency for International Development (Usaid) either to provide safe abortion (in countries where it is legal) or to lobby for it (in countries where it is not).
The global gag rule allowed the US to use its huge financial clout (it currently provides 40 per cent of the global aid budget for population programmes) to take its anti-abortion stance much further. From the moment it was signed, NGOs receiving any help at all from Usaid - accepting supplies of condoms, for example - were explicitly prohibited from using any of their other funding to provide safe abortion or lobby for it.
The prohibition goes so far that NGOs which want to keep their Usaid funding aren't permitted to cite statistics on unsafe abortion. Even telling the stories of women who have been maimed by unsafe procedures could be interpreted as lobbying - hence the shyness of that Kenyan health worker.
As such, in areas where organisations accept the gag, the abortion debate is skewed, entirely dominated by anti-abortion voices - just as Bush intended. (In areas where organisations have refused the gag, the effect is often exactly the same, since loss of funds can force them to close.)
The rule is thus fundamentally undemocratic, and also imperialist - after all, in countries where abortion is legal, it overrules national sovereignty. As Laura Katzive of the New York-based Centre for Reproductive Rights notes: "This is a policy that would be unconstitutional if applied to US citizens, because it's a condition on free speech. In the United States, you can't say 'you can express an idea, but, if you do, we'll withhold funding', so it's applying a double standard to NGOs overseas. That's shocking, particularly in the context of a foreign policy which is meant to promote democracy."
According to estimates, between 19 and 20 million unsafe abortions are performed worldwide each year, 97 per cent of them in developing countries. Annually, this kills roughly 68,000 women. That's eight women an hour, or a planeload per day - before you start weighing the toll of maiming and mutilation, infections and lost fertility, that affect many millions more each year.
As Beth Fredrick of the International Wom en's Health Coalition points out, when it comes to those 68,000 deaths, the US government "has blood on its hands". But the destructiveness of the gag rule spreads much further. Those organisations that fall foul of it also run family-planning programmes that provide a huge range of services - from distributing contraceptives to giving sexual health advice to providing information on maternal nutrition and breastfeeding. Organisations that refuse to accept the rule's restrictions, and subsequently lose their funding, can be left with no option but to close clinics that serve some of the world's most vulnerable people. (It is estimated, for instance, that only 10 per cent of the African population has ready access to contraceptives.)
The rule wreaks havoc
To give a few examples of the havoc this has wreaked, in 2003 Planned Parenthood of Ghana was forced to close down a programme that had been distributing contraceptives and providing advice on HIV/Aids to an estimated 2.2 million Ghanaians. The Family Guidance Association of Ethiopia was forced to close a huge range of outreach programmes after losing more than 30 per cent of its external funds, cutting staff and reducing volunteer numbers from 1,000 to 90.
Sixteen developing countries have lost their whole Usaid supply of birth control, because the International Planned Parenthood Federation, the leading NGO in this field, refused to accept a gag. Obviously, it is impossible to calculate the precise effect of the rule on the spread of HIV/Aids, but it is safe to surmise that it has been devastating - there seems a good chance that the resulting death toll will far exceed that caused by unsafe abortion.
And once these clinics close, they can't easily be rebuilt, even if an NGO secures new funding from another source. As Fredrick notes: "The expertise and infrastructure usually take so long to put together, and many health systems are so fragile, that when you lose a clinic it's hard to regain that strength, or even that capacity."
Ironically, it is likely that the policy may have increased rates of abortion. When clinics close, "women don't get other sexual health information or contraception", points out Louise Hutch ins of the UK group Abortion Rights, "so they're more likely to become pregnant again and suffer from sexually transmitted diseases".
The more you read about "the global gag rule", the more hideous it seems. This is a law of poli tical convenience, which sacrifices some of the world's poorest women (and, indeed, men) to appease the anti-abortion fervour of the religious right in the US. It seems no coincidence that the Helms Amendment was enacted in 1973. That was the very year when abortion became legal in the US, and the American right appears to have been determined to redress the balance by using the country's financial advantage to undermine safe abortion abroad.
As the global gag rule stands, it is clearly at odds with US law and the views of the majority of Americans, who support safe abortion. As Marcel Vekemans, senior medical adviser to the International Planned Parenthood Federation, says: "It's a case of, 'do what I say, not what I do'." Knowing how difficult it would be to overturn Roe v Wade in his own country, Bush has instead exported his personal convictions, and those of his closest supporters, worldwide.
As Laura Katzive notes: "If Americans were more aware of the policy, there would probably be more objections to it, but, because it doesn't affect our interests directly, it has been allowed to stay in place." Beth Fredrick concurs. "They were very calculated in putting forward the global gag rule . . . after all, no woman in a Kenyan slum is ever going to be called on to vote for President Bush or any of his cronies, are they?"
Since last November's US midterm elections - with that significant swing towards the Democrats - there has been speculation that it may now be possible to overturn the rule. This was last attempted back in 2005, when Senator Barbara Boxer sponsored an amendment to an appropriations bill that was swiftly passed in the Senate. At that stage, however, Bush threatened a veto, and the attempt faltered.
Despite the new distribution of power, Bush still holds that veto, so it is probably too soon for optimism: the activists I spoke to are holding out instead for a Democratic president in 2008. Last year, the UK made a small dent in the situation by pledging £3m to organisations that had been denied US funding as a result of the gag rule. In financial terms, of course, that's minimal, but it showed the UK boldly - and unusually - opposing US foreign policy and making a strong, clear case for the need for safe abortion services worldwide.
As Fredrick says, the rule denies women in developing countries "their humanity. It's dis respectful and undignified and it's based on an idea that women are something other than full human beings." While the gag rule stands, Bush's hands just get bloodier.
To find out more, visit http://www.globalgagrule.org