Speak Evidence to Power Campaign

When we develop accurate evidence and combine that with action, we enforce justice.

During this time of increasing pushback on access to reproductive health services in the United States, it is critical that evidence is the driving force for policy and not lost due to ideological zeal. The sexual and reproductive health of millions of people in this country and globally is at stake.

Health is a human right.

That is why I am thrilled to announce that the Heilbrunn Department of Population and Family Health is officially launching an evidence-based campaign for reproductive health justice, #SpeakEvidencetoPower.

We will provide a platform for the multitude of scientific evidence that supports access to and the importance of a range of reproductive health services. By supplying consistent and comprehensive information and analysis, we will bolster research and advocacy partners, decision-makers, and the public.

Information is power. It will lead to informed action, and it will promote justice for reproductive health.

We are launching a blog here on our Department’s site, where researchers and advocates in the sexual and reproductive health fields will share their expertise and related evidence to unravel current issues and news, and to enrich public discussion and understanding. The posts below are some of what you can expect to find.

We hope you will join us in our work to ensure that evidence is not forgotten in the fight for reproductive health and justice.

If you would like to learn more or contribute to our campaign, please contact us at msphpopfam@cumc.columbia.edu.

Terry McGovern, JD
Harriet and Robert H. Heilbrunn Professor and Chair
Heilbrunn Department of Population and Family Health
Columbia University Mailman School of Public Health

As the Supreme Court both strikes down and upholds anti-reproductive health policies, we must remember why reproductive justice is so important and who is most affected by lack of access to reproductive health services and information. At our Speak Out for Reproductive Health & Justice in November, Dr. Goleen Samari, Assistant Professor of Population and Family Health, 

emphasized the significant and devastating effects restrictions to reproductive health services and access have on women of color and minority populations especially, and how reproductive justice stems far beyond access to and the freedom to choose abortion-related care. Read the full transcript of her speech below, and see a video of it on our YouTube channel.

 
"What is reproductive justice? It's a human right, it's about access, not choice, and it's not just about abortion. Abortion access is critical, but woman of color and other marginalized women also have difficulty accessing contraception, comprehensive sex education, STI prevention and care, alternative birth options, adequate prenatal and pregnancy care, intimate partner violence assistance, and adequate wages to support families and safe homes. Reproductive justice is about all of these things, reproductive justice combines reproductive rights and social justice and it's a human right to maintain personal bodily autonomy, to have children, to not have children, and to parent the children we have in safe and sustainable communities.
 
Reproductive justice was founded by the Women of African Descent for Reproductive Justice when they recognized that the women's rights movement led and representing middle-class and wealthy white women could not defend the needs of women of color and other marginalized and trans people. The mainstream narrative surrounding abortion often centers around cisgender, heterosexual white women, excluding key groups. Those excluded groups include people of color, immigrants, disabled individuals, queer people, people in rural areas, and gender non-conforming and trans folks. As states attack women's rights to reproductive healthcare, marginalized groups are the most affected and the most vulnerable because their access to reproductive healthcare is already limited.
 
Structural and explicit racism has already disinvested in the reproductive care of mostly women and gender non-conforming people of color, particularly black and Native American women, disabled women and low-income women. For many patients, lacking safe appropriate and dignified abortion care and other reproductive care is an ongoing reality. There's a long history of black women being systematically deprived of their ability to exercise control and agency over their own bodies and these state policies that further restrict abortion only exacerbate this existing reality."

On July 13th, a federal judge suspended a rule that would require patients seeking medication abortions to make in-person visits to clinics, medical offices, and hospitals to obtain abortion medication. Healthcare providers can now consult with a patient via telemedicine visits and arrange mifepristone, a medication used in medication abortion, to be delivered or mailed to the patient during the COVID-19 public health emergency that the U.S. is currently facing. 

Mifespristone is an FDA approved drug used in combination with a second drug, misoprostol, to end an early pregnancy or manage a miscarriage. The FDA's approval of mifespristone is subject to a Risk Evaluation and Mitigation Strategy (REMS), a risk management plan that sets restrictions for medications with a high potential for serious adverse effects. These restrictions set distribution limitation to registered providers in clinics, medical offices, and hospitals, preventing mispristone from being dispensed at pharmacies.

Reproductive health advocates have advocated for making medication abortion available without an in-person visit — especially during the COVID-19 emergency — as the risks of an in-person visit (to the patient, to the providers, and to individuals the patient would encounter in traveling to the visit) outweigh the documented risks of medication abortion. As Dr. Sam Garbers, an Associate Professor within our PopFam Department previously stated in interview with SEP, "Evidence shows that medication abortion is safe (a major complication rate of only 0.31 percent), and effective, with 96.7% of medication requiring no further care to complete the abortion through 63 days of gestation." 

While already medically unnecessary, the restrictions are especially burdensome to patients seeking medication abortions during the pandemic, when travel increases their risk for exposure to COVID-19. “By causing certain patients to decide between forgoing or substantially delaying abortion care, or risking exposure to COVID-19 for themselves, their children, and family members, the In-Person Requirements present a serious burden to many abortion patients,” U.S. District Judge Theodore Chuang wrote in his decision. Judge Chuang agreed that the In-Person Requirements infringed on the constitutional rights to an abortion and that such an infringement would constitute irreparable harm.

According to the Center for Reproductive Rights, a seven-year cohort study with tens of thousands of patients, systematic reviews, and an evaluation of a telemedicine abortion service across five states has shown that medication abortion is just as safe and effective through telemedicine as it is in person. Judge Chuang agreed with experts that testified that the REMS requirements could be met through telemedicine, writing that "In-Person Requirements do not demonstrably further the stated interest of counseling patients before the prescription of mifepristone." Chuang also noted that federal regulators have already waived in-person requirements for other drugs during the COVID-19 public health emergency.

In light of the recent ruling from the U.S. Supreme Court, which allows employers to deny birth control coverage due to religious or moral beliefs, we are reiterating the points voiced by PopFam faculty in our public comment from December 2017:

We, the undersigned public health practitioners and members of the faculty of the Heilbrunn Department of Population and Family Health at Columbia University Mailman School of Public Health, respectfully submit the following comments on the interim final rules on moral and religious exemptions for coverage of contraceptive coverage. The decision to allow moral and religious objections to covering contraception under the preventive services requirement of the Affordable Care Act threatens to undo recent gains and stymie further progress. These rules roll back decades of public health progress and place the lives and well-being of women and all Americans at risk.

1. Women have an established right to decide how, whether, and when they want to become pregnant.

The struggle to protect women’s rights to control whether, how, and when they become pregnant has a long history. The federal ban on birth control was lifted in 1938. In 1965, the Supreme Court, recognizing that couples have a right to privacy, ruled that married couples could use birth control in Griswold v. Connecticut. And finally, in the 1972 case Baird v. Eisenstadt, the Court legalized birth control for all citizens regardless of marital status. The Women’s Health Amendment to the Patient Protection and Affordable Care Act of 2010 included a contraceptive mandate requiring employers to cover the cost of contraceptive methods with no cost-sharing for the patient. These interim rules threaten to dismantle this contraceptive mandate, depriving women of an established right to make decisions about whether, how, and when to become pregnant.

2. Unintended pregnancy is prevalent, and it adversely affects women, children, and society.

Nearly half (45%) of the estimated 6.1 million pregnancies in the US each year are unintended[1], with significant health, social, and economic costs.[2]  Unintended pregnancies are significantly more likely to result in adverse birth outcomes, including low birthweight and preterm birth.[3],[4]  The effects of unintended pregnancy persist after birth for both the mother and child. Mothers who carry unintended pregnancies to term are less likely to breastfeed their infants and more likely to suffer from postpartum depression.[5],[6] Children and young adults whose births were the result of unintended pregnancies are more likely to have low self-esteem[7] and to have siblings with behavioral problems in school.[8] Unintended births contribute to a cycle of socioeconomic disadvantage for both mothers and children as a result of deferred educational and employment opportunities.[9],[10]

3. Programs to make contraception available without cost have been demonstrated to reduce unintended pregnancy, abortion, and unintended and teen births.

At the close of the 20th century, the Centers for Disease Control and Prevention (CDC) recognized the ability to achieve a desired family size and birth spacing made possible through contraception as a key achievement in public health.[11] In the last decade, one of the most positive public health trends has been a steep reduction in unintended pregnancy. The rate of unintended pregnancy fell by 18 percent in the time period 2008-2011 alone.[12] This decrease has been attributed to concurrent increases in contraceptive use.[13]

The cost of contraception is a barrier for many women, and the methods most effective at preventing unintended pregnancy are also the most expensive.[14] Even before the ACA expansion, numerous studies showed that when cost barriers are addressed, the use of the most effective contraceptive methods increases,[15] and the rate of unplanned pregnancies decreases—a fact the Administration is disputing as rationale for allowing a roll-back of women’s access to contraception.

Programs that reduce the cost barriers to contraception have been shown to significantly reduce unintended pregnancy and abortion rates. A large prospective study in St. Louis that removed cost barriers to contraception showed significant reductions in abortion.[16] When Colorado made long-acting reversible contraception available without cost, the unintended pregnancy rate among women age 20-24 dropped by 20% and the abortion rate by 18%.[17]

Reducing access to contraception therefore has the potential to increase unintended pregnancy rates.

4. Employers should not be able to impose scientifically unsound, personal beliefs that affect the health and well-being of women, no matter how sincerely held these beliefs are.

Expanding the range of objections to providing coverage of contraception with no out-of-pocket cost to include moral objections can allow employers to impose their “sincerely held” beliefs, even when they are not scientifically sound. The phrasing “This Mandate concerns contraception and sterilization services, including items believed by some citizens to have an abortifacient effect—that is, to cause the destruction of a human life at an early stage of embryonic development.” (Page 47844, II. A.) [underline added] exemplifies the extent to which this interim final rule would allow employers to restrict access to contraception based on unfounded views. It has been demonstrated and agreed upon by scientific experts, including in an amicus brief in the Hobby Lobby case (2013), that contraception, including emergency contraception (colloquially referred to as the “morning after pill”) are not abortifacients.[18]

5. This rule is being implemented without regard for the potential adverse public health impact.

As shown by the language above, the potential range of objections that individuals could cite as a rationale for denying covered entities access to contraception is very broad. Yet these rules are being implemented without an understanding of the extent to which these rules would deny access for women: “The Departments acknowledge that expanding the exemption to include objections based on moral convictions might result in less insurance coverage of contraception for some women who may want the coverage. Although the Departments do not know the exact scope of that effect attributable to the moral exemption in these interim final rules, they believe it to be small.” (Page 47856, V. 2.) 

Given the demonstrated public health benefit of making contraception available without cost, and the potential for a broad range of objections to be cited by employers and universities covered under these rules, we urge the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services to rescind in their entirety these regulations.

Samantha Garbers, PhD
Associate Professor
Heilbrunn Department of Population and Family Health
Columbia University Mailman School of Public Health

Terry McGovern, JD
Professor and Chair
Heilbrunn Department of Population and Family Health
Columbia University Mailman School of Public Health

Kelli Stidham Hall, PhD, MS
Associate Professor
Heilbrunn Department of Population and Family Health
Columbia University Mailman School of Public Health

Goleen Samari, PhD, MPH, MA
Assistant Professor
Heilbrunn Department of Population and Family Health
Columbia University Mailman School of Public Health

[1] Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. New England Journal of Medicine. 2016 Mar 3;374(9):843-52.

[2] Gipson JD, Koenig MA, Hindin MJ. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Studies in family planning. 2008 Mar 1;39(1):18-38.

[3] Orr ST, Miller CA, James SA, Babones S. Unintended pregnancy and preterm birth. Paediatric and perinatal epidemiology. 2000 Oct 1;14(4):309-13.

[4] Shah PS, Balkhair T, Ohlsson A, Beyene J, Scott F, Frick C. Intention to become pregnant and low birth weight and preterm birth: a systematic review. Maternal and child health journal. 2011 Feb 1;15(2):205-16.

[5] Logan C, Holcombe E, Manlove J, Ryan S. The consequences of unintended childbearing. Washington, DC: Child Trends and National Campaign to Prevent Teen Pregnancy. 2007 May;28:142-51.

[6] Cheng D, Schwarz EB, Douglas E, Horon I. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception. 2009 Mar 31;79(3):194-8.

[7] Axinn WG, Barber JS, Thornton A. The long-term impact of parents' childbearing decisions on children's self-esteem. Demography. 1998 Nov 1;35(4):435-43.

[8] Barber JS, East PL. Children’s experiences after the unintended birth of a sibling. Demography. 2011 Feb 1;48(1):101-25.

[9] Allen RH. The role of family planning in poverty reduction. Obstetrics and Gynecology. 2007 Nov 1;110(5):999-1002.

[10] Sonfield A, Hasstedt K, Kavanaugh ML, Anderson R. The social and economic benefits of women’s ability to determine whether and when to have children.

[11] Centers for Disease Control and Prevention. Achievements in public health, 1900–1999: Family planning. MMWR Weekly. 1999 Dec 3; 48 (47): 1073-80.

[12] Finer, L.B., and Zolna, M.R. (2016). Declines in Unintended Pregnancy in the United States, 2008-2011. The New England Journal of Medicine, 374(9), 843-852.

[13] Jones J, Mosher W, Daniels K. Current contraceptive use in the united states, 2006-2010, and changes in patterns of use since 1995. InSexual Statistics: Select Reports from the National Center for Health Statistics 2013. Nova Science Publishers, Inc..

[14] Pace LE, Dusetzina SB, Fendrick AM, Keating NL, Dalton VK. The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance. Medical Care. 2013 Nov 1;51(11):959-63.

[15] Postlethwaite D, Trussell J, Zoolakis A, Shabear R, Petitti D. A comparison of contraceptive procurement pre-and post-benefit change. Contraception. 2007 Nov 30;76(5):360-5.

[16] Peipert, J.R., Madden, T., Allsworth, J.E., and Secura, G.M. (2012).  Preventing Unintended Pregnancies by Providing No-Cost Contraception. Obstet. Gynecol., 120(6), 1291-1297.

[17] Ricketts S, Klingler G, Schwalberg R. Game Change in Colorado: Widespread Use Of Long‐Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low‐Income Women. Perspectives on Sexual and Reproductive Health. 2014 Sep 1;46(3):125-32.

[18] Dreweke J. GPR. Guttmacher Policy Review. 2014;17(2):3.

We reached out to recent #PopFam grads to hear their thoughts on the decision made by the Supreme Court this week to block the Louisiana Law, and what they think that means for the future of access to abortion in the United States:

Thank you to everyone who was able to join us for the "Gender Justice in the Global COVID-19 Response” webinar and provide so many thoughtful questions for our panelists. 

Below is the full transcript of responses from Phumzile Mlambo-Ngcuka, PhD, the Executive Director of UN Women, who provided our final set of answers from our panelists. Follow the Heilbrunn Department of Population and Family Health and UN Women on Twitter for more on these responses.

Full Q&A with Phumzile Mlambo-Ngcuka:

Are there times when an important case/issue you wanted to put across the table did not see through? And how did you take it/handle it?
 
When working on advancing women’s empowerment and gender equality, there will be, unfortunately, occasions when you cannot reach the desired outcome because the resistance is too strong. Therefore, we need a unified movement with strong allies and be innovative and apply different strategies. And importantly, never to give up.
 
Sometimes it seems that when we talk about “gender” we use it synonymously with the word “women.” Can you talk about the importance of involving men and male gender roles in the conversation about gender?
 
Men and boys must be engaged in order to achieve gender equality and empowerment of women and girls. We all have, regardless of sex and gender identity, a shared responsibility of advancing human rights for women and girls and making sure that we are not leaving anyone behind. Men and boys have a role to play in all aspects of life, as partners, friends, parents and leaders. UN Women’s HeForShe movement calls on men and people of all genders to commit to gender equality, and to do this in all aspects of life, at work, in their communities and within their families. Over 2 million people have committed to the movement, including Heads of States, CEOs, and Vice-Chancellors. During the COVID-19 outbreak, UN Women launched a the #HeForSheAtHome campaign to encourage men and boys to help balance the burden of care in their households.  When we all work towards the same goal, women and girls can live to their full potential, free from violence and discrimination - we all will also enjoy a just society built on feminist principles.
 
How do grassroots organizations mitigate losing donor funding during this pandemic, especially on SRH?
 
Grassroots and community organizations are doing remarkable work for SRH and continue to do so during this pandemic. It is grassroots organizations that will ensure that no one is left behind and all men, women, and children, regardless of their background, have access to accurate information on COVID-19, including how to protect themselves and their communities.  Grassroots organizations need to voice their role and value in the fight against the pandemic, and governments and donors need to listen and amplify these voices.
 
Urban and rural poor grassroots women’s organizations are providing extraordinary leadership – public and private – in addressing basic needs, supporting women shouldering extreme caregiving burdens, and defending women’s rights as informal marketers and small farmers. How are your agencies publicizing these actions to ensure these women’s organizations are seen as key to the recovery?
 
UN Women is bringing the voices and stories of women into the spotlight. We are sharing human interest stories of women and their role in the pandemic, as frontline workers, caregivers, entrepreneurs and leaders. For example, Libyan Women’s Network for Peacebuilding are meeting online and staying connected via their phones to continue to rebuild peace in their communities. Rohingya refugee women are preventing the spread of COVID-19 in Cox’s Bazar, and women living with HIV in Tajikistan managed to supply over 23000 masks in 10 days. We are working closely with women’s organizations to support them to carry out their work and to broker space for them to share their knowledge and experiences to inform the response.
 
How do you make sure that your good advocacy work is working for improving access to services at the ground for the marginalized women and girls? What do you really do? We have seen the girls not receiving contraceptives, abortion cares and even starving.
 
UN Women work to address barriers that are preventing women and girls from demanding and realizing their rights to health services. This is done by ensuring that rights-based normative frameworks and policies are established, advocating to change laws that are discriminating against women; equal gender norms, attitudes and practices on women’s rights promoted, and women and girls are empowered to exercise their rights and seek services. UN Women together with partners recently launched an assessment that examines how COVID-19 impacts women’s access to justice. UN Women is working closely with women’s community organizations to support them in their work with communities on rights education and to promote equal gender norms, and for their voices to be heard at the decision-making tables. Women’s organizations are critical to supporting women and girls, especially those who are hard to reach. In Nepal, UN Women convened 17 leaders representing women’s and marginalized groups’ organizations and networks, including organizations of persons with disabilities, LGBTI organizations, and Dalit women from different provinces who strategized on key priorities and advocated with the government and the Humanitarian Country Team. A platform that includes more than 30 women’s organizations and partners in Gaza and the West Bank in Palestine was created to amplify the voices of women’s organizations in COVID-19 preparedness and response plans. A recent report by UN Women describes the impacts of COVID-19 on women in Palestine. Based on a rapid survey and gender analysis, the report describes how 68 percent of Palestinian women have reported increased unpaid care work, and a women’s organization reported in a 2-week period over 510 calls for support, including from survivors of domestic violence.
 
Do you think COVID-19 will create a new discussion on the meaning of “health care” and what new services may end up being covered by insurance companies or government programs?
 
In 2019, the UN Member States adopted a political declaration for universal health coverage. I believe that the COVID-19 pandemic has evidenced that universal health coverage is a precondition for all social and economic dimensions of life and the foundation for advancing the 2030 Agenda for Sustainable Development. Women’s fear and experience of various forms of violence in public and private settings are likely to escalate as COVID-19 takes a foothold. UN Women is advocating for governments to include GBV services in the ‘essential services package’ to ensure that survivors of violence have access to quality services, including in times of lockdown. The UN will continue to advocate that UN member states keep their promise to realize Universal Health Coverage to ensure healthy lives and well-being for all. The 2030 Agenda for Sustainable Development, which the world has committed to, makes clear that development will only be sustainable if its benefits accrue equally to both women and men; and women’s rights will only become a reality if they are part of broader efforts to protect the planet and ensure that all people can live with respect and dignity. Similarly, health is interconnected with all the development goals, and particularly to gender equality. The COVID-19 pandemic has reminded the world of this. I trust that this pandemic will teach us to take a holistic approach to health and to fight the underlying inequalities that are preventing people from enjoying healthy lives.
 
The pandemic response may roll back the gains made on women's rights, whether you are a mother who needs childcare to work in New York, or a schoolgirl, abused and made pregnant in Freetown. We need a systems response because the impact and needs are so distributed. What is the first fire the panelists need to put out in the upcoming battle to reclaim any ground that might be 'temporarily' lost?
 
It is important to remember that all ‘fires’ are connected, which is why we need to tackle this on all fronts at all times. We need to ensure that women as frontline healthcare workers, carers at home, and community leaders and mobilisers, are supported and have access to personal protective equipment in order to respond to the pandemic without putting her life at risk. Women and girls who are experiencing or witnessing violence need to get access to essential GBV services. Women are often in insecure jobs without health insurance and are overrepresented in industries that are hardest hit, such as tourism and hospitality. The response must put attention to these women and make sure that they can continue to earn their livelihoods, and social protection and economic stimulus packages must serve women and girls. We have seen in previous epidemics that resources are diverted from sexual and reproductive services, resulting in increased maternal and newborn mortality. To ensure that sexual and reproductive health services remain available and accessible for women and girls saves lives. To attend to these ‘fires’ we need sex and age disaggregated data to understand how the pandemic impacts women and girls. Less than 50 countries report sex and age disaggregated data on COVID-19 cases and deaths. UN Women is collaborating with partners, including WHO, to bridge the gender data gap on COVID-19. To this end, UN Women is expanding its Women Count data portal to be a publicly available database on the impact of COPVID-19 on gender equality and women’s rights. We also need women and women’s advocates at the decision-making tables, ensuring that resources are allocated to address women and girls’ needs.
 
Re-opening countries/economies discussions are everywhere, but not so many women leaders are in these rooms. And, they are framed as being about economics, but we know, of course, this is about much more. What is being done to ensure more of a gender justice focus on re-opening discussions/strategies? Women leaders, etc.? What about the deep concerns of feminists and many others about the too-quick re-opening of countries, secondary/re-infections, effects on frontline workers, women already doing so much care work, etc.?
 
Women are underrepresented among political, health and economic decision-makers worldwide, including in spaces where decisions are being made about the reopening of economies. This is despite the fact that research shows that women are better equipped for handling pandemics and other health crises, as they outperform men in emotional intelligence [1]. Recognizing this important role of women leaders, UN Women and the OECD convened the Women Leaders´ Virtual Roundtable on COVID-19 and the Future to discuss ways of leveraging women’s leadership in the COVID-19 response and recovery, and last month together with African Union, we hosted a meeting of African Minsters for Gender and Women’s affairs to discuss a gendered framework for COVID-19. Our concern is that we backslide on the gains that we have made in the past decades of progressing gender equality and women’s empowerment, instead of building back better. Every crisis comes with an opportunity to do better; let us take that opportunity and move away from systems and structures that do not serve our objective of creating a gender just world, where everyone can live to their full potential.
 
As Africa faces its first economic recession in 35 years, what impact on realizing the aspirations of SDG 3,4 +5 does the panel foresee – especially in the context of Africa harnessing its demographic and gender dividend potential? What can youth leaders do to negotiate around the fiscal space to ensure that we don't fall behind?
 
Young people are part of the solution of mitigating the impact of the pandemic, as community leaders in their role who are disseminating accurate information and counteracting misinformation that is fueling the pandemic. They also have a critical role in building back better and contributing to creating an economy that harnesses the power and innovation of young people. The future belongs to the youth, and leaders must listen and act to realize young people’s vision of their future. Young people need to do what they do best: creating movements, raising their voices, and building alliances with government representatives, the private sector, and other stakeholders to amplify their messages. Young people hold the key to our future, so let them lead in how we build back better!
 
As has been mentioned by each of you on this call, there are various factors impacting gender justice in the COVID-19 response, many of which are aimed at women and bodily autonomy, but which are also having an outsized impact on LGBTQI people, sex workers, disabled people, and youth. When it comes to SRHR, the confluence of actors – conservative domestic governments, transnational anti-gender movements, conservative US aid conditionalities, like the GGR – all of these actors are harming access to sexual and reproductive healthcare. With so little agreement among member states, how can UN agencies (and civil society allies) provide evidence-based leadership to ensure that SRH remains critical in our collective COVID-19 response?
 
The UN must continue to advocate for women’s rights to SRHR as basic human rights, and for SRHR as a key enabler of gender equality and women’s empowerment, as well as advocate that funding is available for programmatic interventions where they are needed. The UN must continue to protect women’s human rights defenders and support those CSOs that are in the line of fire for their advocacy, as well as those providing life-saving services for SRHR.
 
The UN also need to keep building the evidence base of what is working to secure positive impacts on the lives of women and girls, including lived experiences and stories. 
 
We need to build women’s leadership and engagement as advocates and change makers. This must be complimented by the engagement of boys and men as partners and community members, including traditional and faith-based leaders.
 
We launched the Generation Equality movement this year, with six Action Coalitions to drive change, including one Action Coalition on bodily autonomy and sexual and reproductive health rights. The Action Coalitions are constituted by partners from different sectors and gather to accelerate a transformative agenda through increased financing, transforming unequal gender norms, policy and law reform, data addressing intersectional discrimination, and changing structural inequalities. The Action Coalitions is an opportunity to come together as one movement with all our allies to ensure that the human rights of all are respected. The Action Coalitions and fostered networks will soon start their work to implement the 5-year commitment of accelerating actions on the six identified thematic focus areas. Civil society and youth-led organizations will be equal partners in the Action Coalitions in securing transformative change for women and girls, as well as holding governments and stakeholders accountable for their commitments.
 
To what extent will this affect the implementation of ICPD 25 resolutions? Have the governments that committed financial aid released the money?
 
The UN will continue to advocate for the realization of the ICPD and Beijing + 25 agendas. As mentioned, the Generation Equality movement, which includes, governments, donors, civil society partners, and the UN, will play a vital role in advocating for funding the implementation of the commitments made in Cairo and Beijing 25 years ago. In the UN Secretary-General’s latest report on the implementation of the Beijing Platform for Action, it was noted that ending preventable maternal deaths, covering all unmet needs for family planning, and eliminating gender-based violence by 2030, has a funding gap of over 220 billion USD.  Governments and Generation Equality has an important role in bridging the financing gap so all have the means and power to make their own decisions concerning their own bodies – without fear of violence or discrimination.
 
Now that we are all going virtual, another barrier to engagement for AGYW is access to internet. What is being done to ensure that this inequality is dismantled?
 
The crisis has exposed the technological gaps that continue to be exacerbated because of the lockdowns, restrictions on gatherings, and social distancing. Technological companies are now working to provide solutions to the different modalities of working, education, and innovation. There is a need to ensure that these advancements do not disproportionally continue to marginalize adolescent girls and young women, particularly those that live in developing countries.
 
A study by UNESCO in late April found that half of all students currently out of the classroom do not have access to a computer, which makes up nearly 830 million learners globally. Additionally, more than 40 percent have no internet access at home, which leads to a lack of continuity of education during school closures, severely impacting the learning of young people. In homes where there is minimal capacity for remote learning, the education of boys may be prioritized over that of girls. 433 million women are unconnected, and 165 million fewer women own a mobile phone compared with men. Boys are 1.5 times more likely to own a phone than girls in many countries, and among those who do own phones, boys are more likely than girls to own smartphones. The global internet user gap is 17 percent, and the digital gender gap exists in all regions of the world — and continues to grow [2].
 
UN Women is working hard to draw attention to this and ensure this gendered digital divide is reduced. We believe that to achieve the Sustainable Development Goals and leave no one behind, we need digital literacy for everyone. Giving girls and women access to digital resources, as well as the knowledge, training, and confidence to design and use them, will assist in reducing the gendered digital divide.
 
The majority of girls won’t be able to go back to school post COVID-19 because many African governments don’t allow teenage mothers to access education. Is there a plan to ensure post COVID-19 that all girls will go back to school?
 
Adolescent girls and young women are often less likely to have their need for contraception met than older women. Pregnant adolescent girls face stigma and are more vulnerable to complications of unsafe abortion and pregnancy. It is therefore important to address the education around SRH for adolescent girls and offer contraception in order to prevent adolescent pregnancies and the subsequent implications faced.
 
Discrimination against pregnant adolescent girls and teenage mothers is a major issue for AGYW. In most cases, policies that restrict pregnant teenagers or adolescent mothers from returning to school have the negative implications of ending a girl’s chances of ever going back to school, which in turn leaves young women and girls vulnerable to child marriage, hardship, and abuse. This further exacerbates the gender education gap.
 
The right to education should not be conditional to marital or motherhood status. Government policies must protect AGYW from being excluded and further marginalized, as well as ensure re-entry and continuation policies are properly implemented and do not have any punitive or negative impacts on adolescent girls and young women. Support must also be provided to adolescent girls and young mothers, including counseling for young mothers, affordable or free day care near schools, and accommodating practices such as leniency with time off schooling.
 
Another form of support that can be provided to adolescent girls is education on SHR, particularly on contraceptives, in order to prevent adolescent pregnancies. Currently, only about 42 percent of 15-19-year-old girls, compared to 66 percent of older women have their needs for contraception met. This needs to be addressed in order to support adolescent girls.
 
As we are navigating the COVID-19 pandemic, AGYW are further being left behind. As one of my friends and advocate said, "We are not even on the menu but slowly becoming appetizers." What institutional steps are you driving to ensure that AGYW remain a priority, and what kind of support from AGYW leaders would you require to make these visions a success?
 
Adolescent girls are at the heart of Generation Equality Campaign and Generation Equality Forum that will take place in Mexico and France. UN Women has actively been working with various partners and stakeholders to ensure that the issues facing adolescent girls are made visible. UN Women is supporting the design of 6 Action Coalitions that will work towards ensuring a transformed future by 2025. They will ensure that there is one concrete action within each Action Coalition that will specifically and intentionally focus on the rights of adolescent girls and young women. This means that AGYW will actively engage in setting priorities and will be involved in monitoring results. Support from AGYW leaders can be expressed through championing the Generation Equality Campaign and the Gender Equality Forum. This vision aims to amplify the voices of and issues facing AGYW and is committed to the principles of leaving no one behind.
 
With the outbreak of COVID-19, the most voiceless are the child head of households in many countries. They exist and have special needs and are our most venerable large communities. How do you advocate for a group of young children, a majority of whom are girls?
 
Children and adolescents are already among the most affected by the socio-economic impacts of COVID-19, and it is critical to recognize these multiple and diverse impacts on youth, particularly adolescents and young women. Efforts to mitigate and address the impact of the COVID-19 pandemic must include provisions that are responsive to these impacts and adolescent and children's needs, upholding their rights and including adolescent- and children-specific provisions when needed.
 
Governments must provide targeted support to interim care centers and families, including child-headed households, as well as emphasize initiatives that emotionally support children, encouraging and creating safe opportunities to support. Providing financial and material assistance will also be of upmost importance to vulnerable households whose income-generating opportunities have been affected.
 
COVID-19 had adverse impacts on the lives of women and girls. In male dominant societies, social laws and cultural values revolve around women and girls. Men are staying at home and many have no work; now engagement of girls for marriages is increasing. It is expected that whenever lockdown ends, child marriages will be increasing. What is UN Women doing in this regard?
 
We know that levels of domestic violence and sexual exploitation, which is already an epidemic in all societies, spike when households are placed under the increased strains that come from security, health and money worries, and cramped and confined living conditions. UN Women and our partners are raising awareness of what we call the Shadow Pandemic, which is the increase of violence against women and girls who may be in lockdown with their violent partners and family members. High levels of poverty, caused by the pandemic, is adding further financial burdens onto families, causing them to marry off their daughters early. The closing of schools may result in increased child labor, transactional sex and FGM. The UN Secretary-General has called for all governments to take action to prevent and respond to violence against women as a key part of their response for COVID-19, and 140 governments have voiced their support for this call. UN Women’s response includes: prevention and awareness raising; rapid assessments; access to essential services, including helplines and shelters; ending violence against women in public spaces; and support to women’s groups.
 
How can we prioritize Adolescent Sexual and Reproductive Health and Rights among vulnerable/last mile/remote populations in the “new normal”?
 
Every crisis provides an opportunity to do better. By working with community organizations, especially youth and women’s organizations, we can reach adolescents who have previously been left behind. We also need to listen to young people and review policies and programmes to overcome the barriers adolescents face when seeking services. Young people are part of the solution; let us ensure that they have a seat at the decision-making table as equal partners.
 
How do we empower the youth to feel they can be as expressive and invested? How do women as a group encourage youth to be heard and seen? We have all ethnicities on this panel, but youth, which hold the keys to all futures, are not represented on this panel and most all panels around the world.
 
Despite the challenges, most marked being the COVID-19 pandemic, young feminists are mobilizing and challenging implicit hierarchies of power by fighting for equality and justice, and by accelerating change for the realization of gender equality and the empowerment of women and girls. In a global context of shrinking civil society space and rising conservative governments, the voice of young women and girls is at greater risk of being silenced than ever before. As you have expressed, lifting up the aspirations and achievements of young people is the key to building back better from this pandemic, and to achieving a just and equal future.
 
It is not enough to recognize the unique capabilities, innovation and dynamic ideas and solutions young people bring to the table. We must ensure young people are not only seen, but also heard. There are two key elements to this: The first is promoting and amplifying the voices, leadership, and agency of young people. We must create opportunities for girls and young women to forge their own networks of solidarity and mobilization, and to serve as agents of change in their communities in ending the inequities that impede their economic and social inclusion. This includes creating, promoting, and protecting safe spaces for young people. This also means lifting up and amplifying the work of young women in our networks and on our platforms.
 
We are also engaging young people as equal partners. This ‘partnership approach’ when working with young people means treating young people as equal stakeholders, working with them and alongside them, and valuing their knowledge, experience, expertise, and input. It means encouraging a sense of ownership in processes and ensuring they feel empowered and motivated to engage with the United Nations system in the future. This starts as representation on panels and in events and extends to ensuring that young people are continuously involved in the structure and decision-making processes. This engagement needs to be continuous, representative and meaningful.
 
What are the best mechanisms for young folks within the business sector (high tech and engineer fields) to support these efforts? When we are working to bring an equity and justice lens to development/deployment of technologies within our companies, it would be great to have mechanisms or processes to engage with the UN and humanitarian partners as we try to frame human rights and gender justice issues.
 
The best mechanisms for young people in the business sector to support gender justice efforts are to start by primarily creating environments that are conducive to discussions on gender equality and gender parity. Young people can advocate for their companies to adopt strategic and holistic plans and processes that apply an equity and justice lens.
 
Further, in terms of engaging in UN Women processes, young people are encouraged to join UN Women’s global campaigns, which reach mass audiences and are designed to inspire them to action, such as the Generation Equality Campaign and Planet 50-50 y 2030: Step it Up for Gender Equality. Within these campaigns there are processes that youth, the general public, civil society organizations and the private sector can all engage in the work that UN Women does.
 
GBV managers are not categorized as essential workers in Nigeria. We do not have PPE. How can we help vulnerable groups without exposing ourselves to the risk of COVID-19?
 
It is very concerning to hear this. UN Women continues to advocate for governments to recognize GBV services as essential services and that all women at the frontlines have access to PPE. Women cannot continue to risk their lives in their efforts to save others. UN Women is monitoring and/or undertaking rapid assessments of violence against women and girls to raise awareness of the magnitude of the issue. We are working with partners to strengthen access to essential and quality services for women survivors of violence during the pandemic, including supporting organizations and shelters to provide online and helpline services to support those in need in a safe manner.
 
We have increased cases of girls being sexually molested by their fathers, and the state is slow to respond; girls even get pregnant, plus there is shame and stigma. How can the UN fund CSO effectively?
 
We know from our work the home is not a safe place for many women and girls, and that adolescent girls are most at risk of sexual violence from someone they know. This is a grave human rights violation. Unfortunately, more than half of countries do not yet have laws that protect women and girls from rape. UN Women continues to advocate for the important role CSOs, especially women’s organizations, have in the pandemic, and for governments and financing partners to recognize this important role and allocate the much-needed resources. As mentioned, UN Women is working with disseminating evidence and supporting organizations to prevent and respond to the surge in gender-based violence during the pandemic.
 
What measures help address domestic violence in the context of a lockdown? If women have nowhere to go to escape their abuser, what must public systems offer?
 
We know that levels of domestic violence and sexual exploitation, which is already an epidemic in all societies, spike when households are placed under the increased strains that come from security, health and money worries, and cramped and confined living conditions. The public system must recognize GBV services as essential services, and the public must be made aware of their availability. Shelters and women’s organizations need to be supported to be able to offer helpline and online counseling and have access to PPE. UN Women is also supporting partners to update safe referral pathways and service delivery protocols, including with police and justice institutions, for example in Bolivia, Ecuador, South Africa, Sudan, Trinidad and Tobago and Vanuatu. Recently, UN Women put out a statement together with eight other organizations on violence against women and girls in the context of COVID-19. The statement calls for flexible funding that support health and social services to respond to gender based violence and that these services are regarded as essential, as well as mandate police and judicial systems, and put in preventative measures that only collect data if it will be used to improve services so that ethical and safety standard can be met.  
 
With the impact of COVID-19 on the global economy, would you expect that international development funding will be decreased, especially for Gender and SRH programs?

In previous economic recessions, the UN has experienced a cut in funding. UN Women hopes that governments and financing partners continue to see the value and the return on investment in funding sexual and reproductive health and rights and gender equality programmes. We must ‘build back better’ and therefore we cannot compromise the human right to health. The resources that have been made available, such as social protection mechanisms and economic stimulus packages, must be used to create a better, more gender just world, where all call live to their full potential, free from violence and discrimination.

[1] https://www.forbes.com/sites/victorlipman/2016/03/11/new-study-shows-women-consistently-outperform-men-in-emotional-intelligence/#5b5e4067335d

[2] https://www.devex.com/news/opinion-we-cannot-allow-covid-19-to-reinforce-the-digital-gender-divide-97118

Thank you to everyone who was able to join us for the "Gender Justice in the Global COVID-19 Response” webinar and provide so many thoughtful questions for our panelists. 

Below is the full transcript of responses from Winnie Byanyima, MSc, the Executive Director of UNAIDS. Follow the Heilbrunn Department of Population and Family Health and UNFPA on Twitter for more on these responses. Coming shortly is our next set of responses from Winnie Byanyima, MSc, Executive Director of UNAIDS!

Full Q&A with Winnie Byanyima:

Sometimes it seems that when we talk about “gender” we use it synonymously with the word “women.” Can you talk about the importance of involving men and male gender roles in the conversation about gender?

Gender, as we all know, is about the socially constructed roles, responsibilities and relations at any given time in history. Women’s roles as well as men’s have changed and evolved over the centuries, and even today are shaped by economic, cultural, social and geographical, political and locational factors – so that they may be very different even in neighboring countries and homes in the same neighborhood.

The systematic patriarchal domination of societies and cultures has perpetuated widely held concepts of femininity and masculinity which are harmful to one sex and have placed unfair burdens on women and girls in all their diversity. Without changing harmful masculinities – such as the use of force and violence, sexual relations without protection, no participation in child, elderly or home care, for example – there will be no transformation of gender relations.

Men and women have nurturing, caring capacities, and involving men in the conversation systematically and especially from a young age has been shown to have a transformative impact inside and outside the home.

Dr. Byanyima, you spoke about cross-cutting themes of health resilience. Can you please expound? This is critical in light of COVID-19, and the sustainability of health systems in the future.

COVID-19 has taught us a lot about health resilience. It’s a concept which in essence refers to the readiness of health systems to deal with crises, whether from climate change or pandemics, like the one the world is facing today.

It’s about making sure people have the means, and societies the health system capacities and organization, to not only cope and mitigate the health risks of crises, but to go further – enable thriving and going about our business, healthy – despite the crises.

How do you make sure that your good advocacy work is working for improving access to services at the ground up for marginalized women and girls? We have seen girls not receiving contraceptives, abortion care, and who are even starving.

UNAIDS prides itself on our record in managing data to see if services are reaching people, so that is one key way to know what is or isn’t working for women and girls. But we don’t stop there. We rely and operate hand-in-hand directly with the communities at greatest risk of HIV, the most vulnerable – and the most likely to be left behind, their health needs and rights ignored, and too often denied, with rights violations fueled by gender inequities, and pernicious stigma and discrimination. This is especially so when it comes to adolescent girls and the policy resistances, legal barriers, societal and gender-based judgements placed on them, which sometimes seem insurmountable.

It isn’t perfect, but we work hard to be agile and responsive to what our communities active in the HIV response alert us to. On the issue of hunger for example, we reacted to ensure sex workers, who were confined and left out of food distribution and without work during COVID-19, received funding to ensure that they and their children have access to food.

Re-opening countries/economies discussions are everywhere, but not so many women leaders are in these rooms. And, these discussions are framed as being about economics, but we know of course this is about much more. What is being done to ensure there is more of a gender justice focus on re-opening discussions/strategies? What about the deep concerns of feminists and many others about the too-quick re-opening of countries, secondary/re-infections, effects on frontline workers, and women already doing so much care work, etc.?

These concerns are being articulated widely at all levels by civil society, development partners, and increasingly by the private sector. It is important that we recognize and clearly articulate and correct the deep gender injustice that prevailed systemically in the economy and society pre-COVID to ensure that women are not left even further behind during the recovery. But I am heartened by the clear call for gender justice and rights, whether it is the Secretary General’s call-to-action on human rights, within which gender equality is a clear theme, or the combined call for ending violence against women in all its forms by stakeholders across the public-private spectrum.

As has been mentioned by each of you on this call, there are various factors impacting gender justice in the COVID-19 response, many of which are aimed at women and bodily autonomy, but which are also having an outsized impact on LGBTQI people, sex workers, disabled people, and youth. When it comes to SRHR, the confluence of actors – conservative domestic governments, transnational anti-gender movements, conservative U.S. aid conditionalities like the GGR – all of these actors are harming access to sexual and reproductive healthcare. With so little agreement among member states, how can UN agencies (and civil society allies) provide evidence-based leadership to ensure that SRH remains critical in our collective response to COVID-19?

Firstly, I think it is important to challenge your first assumption: there is a great deal of agreement across UN Member States on the centrality of sexual and reproductive health and rights, including in the context of COVID-19. That is why we have landmark agreements of Cairo and Beijing, which are so very alive today; and joint appeals – specific to protecting these rights during the pandemic.

What’s harming SRHR in the COVID-19 response is lagging political will in some countries and the limited preparedness of health systems to respond – the health resilience issue we were discussing. It also relates to the pervasive levels of gender-based and sexual violence against women and girls – which are not new, just exacerbated during the pandemic – and which has put a spotlight on the limited response and services available to violence survivors to begin with. Intimate partner violence in the context of confinement and limited access to contraceptives, for example, greatly increases women’s and girls’ chances of unwanted pregnancies and unsafe abortions.

The biggest fear is that so many adolescent girls may come out of the pandemic pregnant, and/or having acquired HIV; and their life trajectories dampened because they never return to school. This is one of the reasons so many partners are increasingly calling attention to ensuring COVID-19 responses are not only gender-responsive, but that they be adolescent- and youth-responsive too.

At UNAIDS, we have worked hard to ensure that all people living with HIV have continued ARV treatment. The implications of discontinuation are devastating. We have also been at the forefront of protecting the human rights of most vulnerable populations, such as sex workers, gay men, and transgender persons, who have faced persecution, harassment, and violence during the pandemic. On contraceptives, UNFPA has moved to ensure continued contraceptive supplies and innovation in this regard.

The majority of girls won’t be able to go back to school post-COVID because most of the African governments still don’t allow teenage mothers to access education. Is there a plan to ensure post-COVID that all girls will go back to school?

I am personally worried about this, given the pre-COVID gender gap in educational achievement and enrollment at the secondary and tertiary education levels. Adolescent girls and boys – currently at home due to COVID-induced shutdowns – may never go back to school. This increases the risk especially of girls being married off early, engaging in transactional sex to overcome economic hardship, not acquiring any skills and entering a spiral of poverty, dependence and vulnerability in an already gender-unequal world.

In November 2019, I announced my commitment to develop an initiative for AGYW, promising a world in which every adolescent girl and young woman completes secondary education and is empowered to lead a secure, healthy, fulfilling, and productive life – free of gender discrimination, violence and AIDS. This was pre-COVID, but the urgent need for coordinated advocacy, investment, and action to ensure that every young woman is fully equipped to dream and take control of her own future has never been more acutely felt.

As we are navigating the COVID-19 pandemic, adolescent girls and young women (AGYW) are further being left behind. As one of my friends, an advocate, said, "We are not even on the menu but are slowly becoming appetizers." What institutional steps are you driving to ensure that AGYW remain a priority, and what kind of support from AGYW leaders would you require to make these visions a success?

1. UNAIDs is developing its new strategy 2021-2026, and gender equality, with an emphasis AGYW in all their diversity, will be a central focus of this strategy.

2. I am excited and privileged to be working to develop an initiative focused on adolescent women and young girls along with my four passionate colleagues heading UNESCO, UN Women, UNFPA, and UNICEF. This high-profile, high-level political advocacy drive is to accelerate investments for the empowerment of adolescent girls and young women and gender equality in sub-Saharan Africa by 2025. It responds to the urgency of effectively addressing the alarming numbers of adolescent girls and young women acquiring HIV, many of whom are also unable to access and enjoy basic fundamental freedoms and entitlements. With only a decade left to 2030, this initiative aims to place the voice, agency, full participation, and leadership of AGYW at the center of the development agenda through the collaborative and complimentary mandates of the education, health, gender equality, economic opportunity, poverty reduction, and peace and security agendas. By positioning AGYW as the catalytic entry point, we can achieve multiple goals, including putting an end to AIDS.

3. UNAIDS at all levels – country/local, regional, and HQ – has institutionalized consultation, engagement with, and support to young people’s voices, participation, initiative, and mobilization. We are committed to increasing this in the next strategy period.

4. UNAIDS regularly reports on the gender equality institutional UN system-wide action plan led by UN Women which analyses women’s voice, participation, representation, and leadership within UN organizations. Conscious of the intersectionality of gender with so many other forms of vulnerability, UNAIDS has also just submitted its completion of analysis on attention to disability within the organization and its programs.

How can we prioritize adolescent sexual and reproductive health and rights among vulnerable/last mile/remote populations in the “new normal”?

Every crisis also reveals opportunities. Reaching the most vulnerable and last mile populations is something that we are constantly concerned by – resulting in a range of creative support mechanisms and strategies to ensure that the most remote, invisible, or unheard populations are well represented. Our country offices have harnessed the strong collaborative spirit and good will of our networks of well-wishers, creative professionals and committed partners to ensure that support – whether it be medication, counselling or legal aid – continues to be easily accessible for those who need it most. This has resulted in new ways of working, but also efficiencies, as we have moved to multi-month dispensing in many more countries, or partnered with local CSOs on helplines and shelters for survivors of abuse and sex workers and migrants who are increasingly being rendered homeless.

COVID-19 has shaken us out of our comfort zone. Under the ‘new normal’ we must:

1. Unflinchingly continue to focus on the most vulnerable, marginalized individuals and groups, including those rendered jobless, homeless, and stateless by the pandemic;

2. Consult these individuals and groups, especially adolescent girls and boys and young people, using the combined power of innovative technologies and approaches to reach communities where there is no bandwidth or infrastructure of any kind – to solicit their inputs and make sure that we hear their demands, and ground strategies and interventions in reality;

3. Embrace and appreciate the efficiencies and cost savings that new ways of working can bring – learning lessons from the innovations in telemedicine, information systems, and communications, to name a few.

How do we empower the youth to feel that they can be as expressive and invested? How do women as a group encourage youth to be heard and seen? We have all ethnicities on this panel, but youth, which hold the keys to all futures, are not represented on this panel and most panels around the world.

Indeed! We can perhaps emulate the examples set by the Panel Parity Pledge, which has really catalyzed the inclusion of women on more panels. This pledge seeks to correct the preponderance of male-only panels across sectors, themes, and topics worldwide. Men sign this pledge, too, promising not to participate on a panel without equal numbers of women. Could we now extend this to include young people – it can only add to the dynamism and rootedness of discussions and the solutions we all seek!

How easily accessible will PrEP be for hard-to-reach target populations (conservative patriarchal societies and diaspora migrants), at a community and local activist level? Will this be something we advocate for younger populations, especially vulnerable young women, to access as an HIV/AIDS preventative method?

No doubt PrEP is, and will continue to be, an invaluable prevention tool. Advocacy is ongoing to expand access. At the same time, I think one of our greatest priorities is making sure all the conditions are in place that enable adolescent girls and young women, who are especially at risk for HIV, to prevent acquiring the virus – and in the process, improve their quality of life and life prospects more broadly. This includes access to PrEP alongside completion of secondary education, fulfillment of their SRHR – such as access to contraception – and CSE, freedom from gender-based violence and economic empowerment.

What measures help address domestic violence in the context of a lockdown? If women have nowhere to go to escape their abuser, what must public systems offer?

Public health systems must offer recourse with confidentiality to victims/survivors of abuse. This includes help lines and immediate support, such as shelter, food, and medical care, as well as legal aid if necessary. UNAIDS country offices have been able to leverage their strong partnerships with civil society and government to offer this kind of support in many countries.

So wonderful to hear about commitment at the leadership level to realizing the rights of transgender and gay individuals. Ms. Byanyima, your words and stories are motivating and inspiring. How do you work to ensure that essential topics like this, which are often taboo, make it into the conversations (or don’t fall out of conversations) without shutting yourself out of the space?

If every human being recognizes diversity and difference as part and parcel of the human race, there will be no embarrassment or barriers at the level of the individual. This is the first step to eliminating taboos and stigma. It must start with each person.

The next step, as you point out, is to ensure that we talk about it whenever possible to make these words, ideas, and discussions a part of everyday conversations. After all, history has shown that taboos and stigma are socially constructed – and therefore quite changeable. What shocked our grandmothers yesterday is ‘de rigeur’ today.

Personally, I see myself as a ‘disruptor’, fighting to make visible the invisible, make heard the unheard, and always working to eliminate the silence, misconceptions, and many walls around open conversations on sexuality.

Thank you to everyone who was able to join us for the "Gender Justice in the Global COVID-19 Response” webinar. There were so many thoughtful questions asked during the discussion, and we are thrilled to be able to share responses from some of our panelists! 

Below is the full transcript of responses from Natalia Kanem, MD, MPH, the Executive Director of UNFPA. Follow the Heilbrunn Department of Population and Family Health and UNFPA on Twitter for more on these responses. Coming shortly is our next set of responses from Winnie Byanyima, MSc, Executive Director of UNAIDS!

Full Q&A with Natalia Kanem:

Sometimes it seems that when we talk about “gender” we use it synonymously with the word “women.” Can you talk about the importance of involving men and male gender roles in the conversation about gender?

Gender equality is about equality for all, so everyone must participate.  And it cannot be achieved without the involvement of men and boys.  Change is slowly taking place and men are increasingly working alongside women to support gender equality and the empowerment of women and girls.

UNFPA works with men and boys around the world to advance gender equality and end violence against women and girls, including during our COVID-19 response. Our programmes encourage men and boys to abandon harmful practices - including child marriage and female genital mutilation - and harmful stereotypes, to embrace respectful, healthy relationships, and support women’s rights and empowerment.

How do you make sure that your good advocacy work is working for improving access to services at the ground for the marginalized women and girls? What do you really do? We have seen the girls not receiving contraceptives, abortion cares and even starving. 

This is a very complex question and our answer will depend on many factors, including the legislative situation in a country, the capacity of its health system pre-COVID, whether we are talking about rural or urban populations and whether the women and girls are affected by other kinds of discrimination.

Our main strategies of course revolve around adapting services so that they not only reach as many people as possible, but also comply with physical distancing and other infection prevention measures.

Communication is essential. We share information with individuals, families and communities about how to avoid getting infected and receive health services. We do this through a variety of partners and communications channels including community leaders, youth networks, women’s networks, communication campaigns, SMS and WhatsApp messaging amongst others. Our messages particularly target hard-to-reach groups, such as indigenous populations, ethnic minorities, people living in remote areas, people with disabilities, adolescent girls, LGBTQ+, sex workers and others.

Wherever possible, we adapt our face-to-face services to make them available via tele-medicine, hotlines and digital apps. We also enable clients to practice “self-care” by providing them certain types of contraceptives they can administer themselves. And we engage in task sharing and task shifting of services between different types of health workers to bring our services to as many people as possible.

Protecting service providers with personal protective equipment and other means to strengthen their capacity remains one of our priority activities, so that they can continue to provide services and remain healthy and safe.

To what extent will this [COVID-19 pandemic] affect implementation of ICPD 25 resolutions? Have the governments that committed financial aid released the money? 

A significant number of the voluntary commitments made in Nairobi included pledges of financial support from national governments, bilateral partners, civil society, and the private sector. UNFPA is very fortunate that our bilateral partners already made substantial contributions early in the year (pre-pandemic) at a level that was unprecedented for UNFPA.

Furthermore, as the focus of the COVID-19 response is largely on strengthening public health systems, and the achievement of the "unfinished ICPD agenda" is also dependent on building effective health systems, we are making efforts to ensure there is as much convergence as possible between our COVID-19 investments and our own strategic plan priorities.

However, looking beyond 2020, and the tremendous impact of the pandemic on economies around the world, and the subsequent shifting of priorities away from international development assistance to countries’ own domestic recoveries, there will likely be fewer resources available across the entire development spectrum, including for the ICPD, in the medium term.

As we are navigating the COVID-19 pandemic, AGYW [Adolescent Girls/Young Women] are further being left behind. As one of my friends and advocates said, "We are not even on the menu but slowly becoming appetizers." What institutional steps are you driving to ensure that AGYW remain a priority and what kind of support from AGYW leaders would you require to make these visions a success?

We know that the pandemic is making existing inequalities worse, with gender and age being chief among those inequalities. A steep increase in sexual and gender-based violence, school closures, disruptions in access to contraceptives and efforts to end harmful practices against women and girls are all factors that impact girls disproportionately. 

Through the #YouthAgainstCOVID19 campaign we launched in partnership with Prezi, we reached more than 500,000 views over the last two months in more than 30 countries. The campaign focused on young voices sharing how COVID-19 affects them, how to protect their sexual and mental health, and ways to support each other. 

Today more than ever, programmes focusing on adolescent girls are essential to prevent them from being exposed to harmful practices that violate their basic human rights.

Together with UNICEF, we are also working tirelessly to empower adolescent girls, their accompanying young mentors and their communities to end child marriage. 

As the UN system, and as UNFPA, we are with adolescent girls and young women. We support their agency and action as the strongest path to ensuring their rights and choices. In this pandemic, all young people can play an important role to stop discrimination and to stop violence and harmful practices in their tracks. It is important for all adolescent girls and young women leaders to speak out when things are wrong, but also when things are right. 

How can we prioritize Adolescent Sexual and Reproductive Health and Rights among vulnerable/last mile/remote populations in the “new normal?” 

Our priority is to find a way to connect vulnerable youth with services to address the variety of interlinked health, social and education issues affecting them. Therefore, to respond to emerging sexual and reproductive health and gender issues, UNFPA used our pre-existing resources for out-of-school comprehensive sexuality education to reach out to people who otherwise would have been left out. 

One way we did this was by using our online instruments such as our mHealth Starter Pack and the TuneMe mobisite.  And in Ethiopia, UNFPA and its partners supported a free telephone line for voice and text support and information related to sexual and reproductive health. The platform is called “Minch,” which means "information" in Amharic.

Although mobile Internet access is becoming more widespread and cheaper, children and young people do not have uniform access, particularly in low-income countries. There are also disparities in access due to geography and poor infrastructure, gender, language, and levels of literacy and digital literacy. Creative and flexible community-based outreach strategies should therefore also be used to reach children and young people, particularly girls, facing these challenges.

What are the best mechanisms for young folks within the business sector (high tech and engineer fields) to support these efforts? When we are working to bring an equity and justice lens to development/deployment of technologies within our companies it would be great to have mechanisms or processes to engage with the UN and humanitarian partners as we try to frame human rights and gender justice issues.

Promoting youth leadership and participation is key to UNFPA’s work. Our efforts enable young people to develop the skills, knowledge and support needed to make informed decisions about their bodies, lives, families, communities, countries and the world. 

I would like to reiterate that your actions matter. Young people are playing and will continue to play a critical role in the response to and recovery from COVID-19. The key to this is taking appropriate action, disseminating accurate information and mobilizing in your communities. As UNFPA, we are with young people. We trust in you and we are here to support you, amplify your voices and your actions. 

My personal advice would be to be well organized and active in your communities, do not wait your turn to express what you need and want, be strategic and strong in sharing your voice and holding others accountable. Know your facts, propose solutions and reflect the change you want to see in your own actions. This way, you will be even stronger in your presence and contribution.

UNFPA is also building on the skills and talent of young people that are at the cutting edge in sectors such as innovation and technology. For example, our Innovation Accelerator initiative implemented in five countries in the East and Southern Africa region aimed at sourcing innovative solutions to UNFPA-related challenges by tapping into networks of young entrepreneurs and providing them with seed funding, mentorship and technical support to develop scalable and sustainable solutions.

What measures help address domestic violence in a context of lockdown? If women have nowhere to go to escape their abuser, what must public systems offer? 

First, we must increase funding for women’s rights organizations in national and international aid budgets. They are the first responders during this and every crisis. We must also ensure that services for survivors of violence are regarded as essential, remain open and are resourced, and that staff and clients can be protected from COVID-19. 

We should plan ahead and integrate an expansion of specialist GBV services within countries’ recovery plans to be ready for the expected increase in survivors seeking support post-lock downs. As part of this, we should ensure that shelters and other safe accommodation are protected and available, allowing for women and adolescent girls to bring their children with them, and can receive tailored services to address their needs.

We must identify and provide information about services available locally for survivors, including whether services can be offered remotely. We should also inform other health providers of the risks and health consequences of violence against women and offer support and medical treatment for women who report violence. And we must ensure that immediate post-rape care is still provided and made accessible at all times.

Police and judicial systems must be ready to promptly respond to violence against women and children. Court processes should continue despite the lockdown, and applications for protective measures (including for children) should be allowed through remote and electronic modalities. Perpetrators must be removed from the home, and protection and restraining orders should be extended and enforced. Victims should be supported at all times and the safety risks concerning the release, granting of bail, parole and probation of offenders must always be taken into consideration. Survivors must always be informed when and where perpetrators are released. 

And finally, we must reduce the risk of violence occurring by putting in place measures like providing financial and material support to women and households. These include positive public messaging around gender equality, supporting access to mental health services, curtailing or banning alcohol sales, and identifying opportunities to challenge gender stereotypes and roles, and social norms around gender and violence. And we must promote socially minded and equitable behaviour including among men.  

Natalia, I really appreciate your point about language earlier, especially from a clinical perspective. How would you reframe the conversation so that language does not create division but rather encourages people to commit to the rights of their daughters/sisters/mothers/friends, particularly when people do not want to listen to us? 

The key to bringing people together is finding common ground - including in your choice of language - expressing empathy and equality for all parties. As a storyteller and representative of the United Nations, it is not my role to point fingers, rather, it is my role to champion the examples that should be followed by others. 

UN organizations, particularly ones like UNFPA with a strong field presence and lifesaving mandate, are providers of news. We will always talk about what the problem is, what the facts are, and we will be the neutral source of information. But we are also putting a human face on the issues and telling the stories of real people. 

Wherever possible, we must tell stories of success and hope. We want to show the blueprint for solving the problem because while the problems of our world are daunting, they’re not insurmountable. And as Executive Director, I do not want to be the story. I want our inspirational clients and heroic service providers from over 150 countries to be our message. And everyone must be a part of this positive, inclusive, hopeful storytelling: women, men, girls and boys are all our messengers!

With the impact of COVID-19 on the global economy would you expect that international development funding will be decreased especially on Gender and SRH programs? 

Development assistance is generally calculated as a percentage of Gross National Income (GNI). As all OECD countries are currently experiencing a contraction of their economies, GNIs will shrink and we should be concerned about funding for development assistance and multilateral organizations in 2021 and beyond. 

For this reason, advocacy and outreach to governments and other partners is important to ensure that funding to gender and sexual and reproductive health and rights programmes are not neglected, as the gains we have made in both areas could easily be reversed. 

UNFPA is supported by a wide coalition of member states, international financial institutions, such as the World Bank, and private sector partners. We have appealed to them to prioritize support for UNFPA also for next year, 2021, and beyond.   

For our part, UNFPA commits to continue to forecast and plan our finances prudently, and as a global multilateral partner to effectively work in every country where our assistance is required.

On May 21, 2020, PopFam hosted a webinar with some of the public health world’s most celebrated feminist leaders, including Winnie Byanyima, the Executive Director of UNAIDS; Natalia Kanem, the Executive Director of UNFPA; and Phumzile Mlambo-Ngcuka, the Executive Director of UN Women. Our Chair Terry McGovern – with the help of Latanya Mapp Frett, President and CEO of Global Fund for Women; and Dazon Dixon Diallo, Founder and President of SisterLove, Inc. – led a conversation centered on how to incorporate women, particularly women of color, and girls into the global response to COVID-19. An enlightening and inspiring discussion, each panelist talked through how to ensure sexual and reproductive health justice during the pandemic, as well as responded to the recent commentary in The Lancet, “Centring sexual and reproductive health and justice in the global COVID-19 response.”

You can watch a recording of the webinar via this link, and below are some of the key points the leaders made that emphasize the importance of prioritizing SRH justice during a global health crisis.

Inequality, particularly patriarchal inequality, historically and currently is threaded within the response to global pandemics:

“Every pandemic has a gender dimension, and this one is no different.” -Phumzile Mlambo-Ngcuka

“While we’re seeing patriarchal structures at their worst, we’re seeing more spending on saving big corporations rather than the midwives referenced earlier. We’re seeing remarks that separate us by race, class, geography, ethnicity, and yes, gender. But we’re also seeing women pulling out their sewing machines to make masks. We’re seeing female-led microbusinesses pivot to make hand sanitizer. We’re seeing female leaders insisting on basic needs being met for all of their communities.” -Latanya Mapp Frett

“We have been building on years and years and years of inequality. Sexual and reproductive health and rights permeate every aspect of the existence of the school child who has to collect the water before the day begins. We’ve got to always insist, whether it’s a crisis or not, that investing in adolescent girls is the most protective thing we can do.” - Natalia Kanem

“We are very concerned about two colliding epidemics: HIV and COVID-19. The virus has found a very unequal world, and this pandemic gendered, no doubt. It is highlighting and worsening gender inequalities.” -Winnie Byanyima

The global response to COVID-19 has uniquely - and drastically - affected women:

“The added burden of gender-based violence will add some 30 million girls and women to the baseline, which was already a pandemic within the pandemic, for every six-month period of so-called lockdown. We also estimate that 7 million unintended pregnancies will be added for every six-month period.” -Natalia Kanem

“Sex workers are one group of women who have been hit hardest by this crisis. Because sex work is criminalized in almost every country, sex workers are vulnerable to the punitive measures linked to enforcing COVID-19 regulations. In many countries we are seeing compulsory COVID testing, arrests, threatened deportations of migrant workers. The criminalization of sex works also means they cannot access the services that are being put there to mitigate the effect of the lockdowns.” -Winnie Byanyima

“The primary thesis of [The Lancet] commentary is that for people whose human rights are least protected, they are also likely to experience unique difficulties because of COVID-19. Women, girls, marginalized groups carry a heavier burden of devastating downstream economic and social consequences during the pandemic.” -Dazon Dixon Diallo

Addressing the pandemic responsibly, effectively, and with empathy requires an intersectional approach:

“We can no longer talk about HIV/AIDS without talking about housing. We can’t speak of sexual and reproductive health without talking about food and water. And that GBV without talking about women in the labor market makes no sense anymore.” -Latanya Mapp Frett

“For me, intersectionality is about seeing how the different axes of inequality come together and then address them together: gender inequalities, race inequalities, economic inequalities, health inequalities. Leadership is about finding those points of convergence and addressing them.” -Phumzile Mlambo-Ngcuka

“Only when public health responses to COVID-19 leverage intersectional human rights-centered frameworks, trans-disciplinary science, driven theories and methods, and community driven approaches will we deal with the sufficiently complex health and social adversities of women, girls, and vulnerable populations.” -Dazon Dixon Diallo

Women leaders are essential to responding to COVID-19 in the right way. Our panelists provided great insight into how they lead at a global level:

Natalia Kanem:

“We stand on data. We can prove to you that SRH matters. We can show you the statistics that go along with loss of life, loss of limb, loss of dignity.”

“In order to lead, you have to be open to hearing about how difference does affect people... The statistics for people with disabilities facing gender-based violence is usually double compared to people without difference in ability.”

Winnie Byanyima:

“It is so important that we don’t return to where we were… We are trying to get into all those spaces where the new normal is being defined, where a new global health architecture is being discussed.”

“It’s always important when you’re a leader to live your values, and to know how to negotiate and stand your ground. There are times when being confrontational is actually powerful, and it’s important not to evade the fight. A good fight is good sometimes for the needle to move. But there are times when it’s not the best way, when you’re trying to convince or win people over. As a leader, you’re always making choices about when to fight, when to retreat, when to fall back and come back at it in another way.”

Phumzile Mlambo-Ngcuka:

“We have to live feminism ourselves, as women leaders. So, when we get into spaces of leadership, we ooze it... In our feminism, we need to ensure there is no element of homophobia, of racism, of climate denial.”

“All of us have a right to fight for and defend women wherever we are. I really believe there’s a place in hell for women who don’t support other women. It’s a given that no woman can truly say I am where I am just because of my talents. Women have their talents, but the ecosystem we live in denies them the right to use those talents. To the extent we’ve been able to make this space, it’s because we stand on the shoulders of those who fought for us to be here.”

“No matter how difficult and frustrating it is, stay in the fight. You may be surprised that one finger [raised] can actually start a tsunami that brings about change.”

In a time bereft of certainty and brimming with injustice, we are so grateful for all of our speakers for sharing their wisdom and example of leadership, when it is needed now more than ever.

Watch the full discussion here, and follow UNFPA, UNAIDS, UN Women, and PopFam on Twitter to see more information on sexual and reproductive health during COVID-19.

Join us for a webinar in which prominent feminist leaders will discuss gender justice in the global COVID-19 response, as well as respond to the recent Lancet commentary, “Centring sexual and reproductive health and justice in the global COVID-19 response.”

Thursday, May 21, 2020
Online Webinar via Zoom

11:30 a.m. - 1:00 p.m. EST

Please register in advance for this webinar:

https://columbiacuimc.zoom.us/webinar/register/WN_Ybs8B_JQRkG01x3pmOyIkQ

Panelists:

Winnie Byanyima, MSc 
Executive Director, UNAIDS

Natalia Kanem, MD, MPH 
Executive Director, UNFPA

Phumzile Mlambo-Ngcuka, PhD 
Executive Director, UN Women

Moderated by:

Terry McGovern, JD
Harriet and Robert H. Heilbrunn Professor and Chair,
Heilbrunn Department of Population and Family Health 
Columbia University Mailman School of Public Health

Opening and Closing Remarks by:

Dazon Dixon Diallo, DHL, MPH
Founder and President of SisterLove, Inc.

Latanya Mapp Frett, JD, MPP
President and CEO, Global Fund for Women

Authors of The Lancet commentary:

Columbia University Mailman School of Public Health:

Kelli Stidham Hall, PhD
Associate Professor of Population and Family Health

Goleen Samari, PhD
Assistant Professor of Population and Family Health

Samantha Garbers, PhD
Associate Professor of Population and Family Health at CUIMC

Sara Casey, DrPH
Assistant Professor of Population and Family Health at CUIMC

Rachel Moresky, MD, MPH
Associate Professor of Population and Family Health at CUIMC

Micaela Martinez, PhD
Assistant Professor of Environmental Health Sciences

Terry McGovern, JD
Harriet and Robert H. Heilbrunn Professor and Chair, Heilbrunn Department of Population and Family Health

External:

Dazon Dixon Diallo, DHL, MPH
Founder and President of SisterLove, Inc.

Miriam Orcutt, MBBS, MSc
Executive Director of the Lancet Migration and Senior Research Fellow at UCL Institute for Global Health

Dr. Samantha Garbers, a beloved faculty member within PopFam, has been working with our partner the Center for Reproductive Rights on several fact sheets that address domestic issues on abortion access during the COVID-19 pandemic. The latest partnership is a resource guide for expanding telemedicine services for abortion, a safe and effective method for providing an essential service during this public health emergency. You can find the resource on the CRR website, and read more below about what we learned from Dr. Garbers about abortion access here:  

May D. Sifuentes: Can you tell us more about your work in PopFam and outside of the classroom?

Dr. Garbers: I am really lucky to work in PopFam, because with our interdisciplinary team and strong collaborations with partners in advocacy and clinical spaces, my work has relevance to practice and policy. I collaborate with a wide range of folks – lawyers, pediatricians, demographers, sociologists – in my role as what I would call a “public health methodologist.” 

Q: So, what is a public health methodologist?

A: In this role, I conduct formative research to guide the development of interventions for specific populations; I design and implement rigorous evaluations of 

interventions; and I work with clinic-based or community-based stakeholders and advocacy partners to build capacity on data analysis, interpretation of data, and dissemination of findings. In any of these roles, I focus on using evidence to guide decision-making, whether it’s in the development of intervention content or the framing of policy statements.  Most – but not all – of my work focuses on sexual and reproductive rights.

Q: Speaking of sexual and reproductive health and rights, what are we seeing right now regarding access to abortion care and the COVID-19 pandemic in the U.S.?

A: The direct health and social effects of COVID-19 have been profound, wide-ranging and are still unfolding.  Sexual and reproductive health services have been disrupted, and resources have been diverted.  Of particular concern is the inequitable impact of the COVID-19 pandemic, directly, but even more so indirectly, on women and girls given these disruptions. (Read more about this in a commentary for The Lancet in which Dr. Garbers is a co-author.) We know from prior emergencies that disruption in SRH care can have long-term consequences, with some vulnerable groups disproportionately affected.

Abortion is an essential component of health care; it’s a time-sensitive procedure, and delays can increase risks or even make abortion inaccessible.  For this reason, national reproductive health organizations, including ACOG, unequivocally stated back in March that they “do not support COVID-19 responses that cancel or delay abortion procedures.” 

But several states have used the COVID-19 emergency as a rationale – a Trojan horse, really – to restrict access to abortion care.  Texas, Ohio, Alabama, Louisiana, Oklahoma, and Arkansas are just some of the states that have attempted to restrict access to abortion during the COVID-19 pandemic, generally using the argument that delaying or canceling abortion services will save health care resources, including personal protective equipment (PPE).

This argument, in fact, does not stand up.  In April, with other epidemiologists from Mailman and other institutions, in collaboration with the American Public Health Association, we submitted public health amicus briefs to the courts in Oklahoma, Tennessee, Arkansas to lay out the evidence as to why restricting access to abortion during the COVID-19 pandemic will endanger public health.

Restricting abortion access requires women to carry their pregnancies to later gestational ages, or even to term. Women who remain pregnant longer because of these restrictions will likely have more contact with the health care system than if they received a timely abortion, requiring the use of more resources like PPE. For example, on average, pregnant women attend 11 prenatal visits during their pregnancy. Alternatively, some women may travel across state lines to obtain a timely abortion, increasing contacts with more people, and increasing the risk of COVID-19 transmission.

Q: Considering the legislative barriers you mentioned, what are some ways public health professionals can help bridge the gap between the need for abortion services and access?

A: Well, given my background, my role is to synthesize, contextualize, and communicate evidence that can inform decision-making about abortion access. The fact is that in the U.S., abortion is safe and effective. One of the largest cohort studies, among more than 50,000 women who received abortion services (including in emergency departments), found a major complication rate of only 0.23 percent.

Public health professionals, like myself, need to collaborate with SRH providers and policy makers to promote evidence-based decision-making around SRH and specifically abortion. We need to conduct the studies using rigorous methods and multiple data sources (quantitative and qualitative); to analyze and interpret the findings; synthesize across multiple studies, settings, and disciplines; and then to communicate clearly with a unified voice outside our silos.  We need to advocate for policies that support the health and well-being of all women and girls…using evidence.  

Q: What are some of the evidence-based approaches to bridging the gap?

A: Well, one essential step to increasing access to safe abortion services in the time of COVID-19 is to reduce barriers to medication abortion using a combination of mifepristone and misoprostol, which was first approved by the FDA in the U.S. in 2000. In the U.S., medication abortion accounts for 39 percent of all abortions—it has high patient satisfaction because it is non-invasive and can be completed at home or in a setting chosen by the patient.

Evidence shows that medication abortion is safe (a major complication rate of only 0.31 percent), and effective, with 96.7% of medication requiring no further care to complete the abortion through 63 days of gestation.

Despite this, there are restrictions in place that limit the availability of medication abortion.  Mifeprex ® (mifepristone) is subject to “outdated” FDA requirements (per ACOG) substantially limiting who can prescribe the medication, and in what settings. For example, Mifeprex cannot be distributed to or dispensed at pharmacies.

And, access to medication abortion should be further expanded through the use of telemedicine. There is a ton of evidence – cohort studies with tens of thousands of patients, systematic reviews – that the safety and effectiveness of medication abortion provided via telemedicine is the same as in-person. This not only expands access to medication abortion, but it also reduces opportunities for COVID-19 transmission.

Finally, it’s important for us to remember that all of this is intersecting with the gutting of access to SRH services, including contraception, through the administration’s “domestic gag rule,” which reduced the capacity of the federal family planning program (Title X) to provide women with contraception by almost half.  Family planning through contraception was one of the ten great public health achievements of the last century – we need to double-down our work to ensure that we don’t undo that progress.

Q: Thank you so much for your insight on this, Dr. Garbers, and for highlighting the collaborations happening within PopFam and beyond to share information on abortion access during this public health emergency.

A: One of the nicest parts of this collaborative work – in between worrying about the health of the people in my community, and worrying about the future of SRHR in the United States more broadly – is working with so many PopFam alumni who are working to promote SRHR in the U.S. and internationally. They – along with so many organizations and researchers globally – are shining light on essential health care services, especially in this time of great need.

Dr. Samantha Garbers
Dr. Garbers teaches methods courses at the Mailman School: in the MSPH Core, a course on program planning and evaluation, and in the PopFam Department, the course on quantitative data analysis. Dr. Garbers is an epidemiologist, and before PopFam, she spent 15 years at the public health institute Public Health Solutions, an organization that included both a research unit and a network of reproductive health centers.

May D. Sifuentes
MPH Candidate 2021
Department of Population and Family Health
Certificate in Epidemiology, Chronic Disease

Repeatedly in times of crisis, particularly events that require staying inside, gender-based violence (GBV) is shown to increase. PopFam faculty members Neetu John, 

Sara E. Casey, and Chair Terry McGovern reviewed how previous emergencies and their impact on GBV are being reflected in the COVID-19 pandemic in a paper for the journal Bioethics. While evidence indicates that history may already be repeating itself when it comes to GBV and COVID-19, there are ways that the response to this current global emergency can shift for the better and make lasting changes to how sexual and reproductive health issues, and how women are included in the response, are approached. Below are some key points from their paper, which you can read in full here:

Gender-based violence has been shown to increase during global emergencies. Early evidence indicates it is the same for the COVID-19 pandemic:

• Early evidence from China suggests that domestic violence has dramatically increased: a police station in China’s Hubei Province recorded a tripling of domestic violence reports in February 2020 during the COVID‐19 quarantine.

• Reports suggest that police have been reluctant to intervene and detain perpetrators due to COVID‐19 outbreaks in prisons.

• In some locations, authorities have reportedly converted women’s shelters into homeless shelters.

Gender norms and roles relegate women to care roles in times of crisis, are still undervalued, and put women at greater risk of exposure:

• Globally women perform three‐quarters of unpaid care work, including household disease prevention and care for sick relatives, and there is not a country in the world where men provide an equal share of unpaid care work. 

• 90% of frontline healthcare workers in China’s Hubei province as in many other parts of the world are women. 

It is not too late to include the voices of women in tackling COVID-19: 

• Governments can incorporate gender considerations into their response.

• Technology can be leveraged to ensure women continue to receive essential services when they need them most.

• Emergency services and victim support can be maintained via text, phone, and online services.

• Court hearings can be heard virtually.

• Telemedicine should be considered an alternative and secure way to provide women and girls access to contraceptives and abortion medication.

From the authors: “Recognizing, valuing, supporting women’s roles and giving them a voice in global health governance can go a long way in avoiding unintended consequences, building resilient healthcare systems, and reducing intersectional inequalities and vulnerabilities across gender, race, class and geography.”

In partnership with the Center for Reproductive Rights (CRR), PopFam helped develop a resource to share facts on why reproductive health care, including abortion, is critical, time-sensitive, and should be prioritized during a health crisis, not restricted.

Below is part of CRR's explanation for why this resource was created. You can find the rest of the explanation and the fact sheet on their website via this link.

"Prominent public health and medical organizations, including the American College of Obstetricians and Gynecologists (ACOG), the World Health Organization (WHO), and the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) agree that even in emergencies, abortion care is essential and should remain available.  

And yet, throughout the country, officials in several states, including Texas, Alabama, Iowa, Ohio, and Oklahoma, have exploited the current emergency to push their anti-abortion agenda and impose severe limits on abortion care. These policies are harmful to the health and well-being of pregnant people and families and undermine public health efforts to respond to COVID-19."

Abortion is essential health care. It is critical that during this challenging time, access to this type of care is not lost. Help share facts about the essential nature of reproductive health care by checking out this resource.

Globally, we all are facing a variety of public health orders to stay at home and adjust to new normals to stay safe and stop the spread. But increasingly we are learning of groups facing broader strains on their health and social and economic well-being; the detrimental impact of the pandemic on women, girls, and vulnerable 

populations is becoming all the more clear. Several members of the PopFam Department - along with vital 

external partners - highlight the detrimental impact of the global COVID-19 pandemic response on sexual and reproductive health and rights (SRHR) in The Lancet commentary “Centring sexual and reproductive health and justice in the global COVID-19 response”.

The piece emphasizes the threat to SRH services, caused by policies designating these services as non-essential and diverting resources, and calls for vigilance from the SRH community to prevent access to these services from being lost.

“Global responses to the coronavirus disease 2019 (COVID-19) pandemic are converging with pervasive, existing sexual and reproductive health and justice inequities to disproportionately impact the health, wellbeing, and economic stability of women, girls, and vulnerable populations,” write the authors. 

The group emphasizes the disproportionate social and economic burden on women, girls, and vulnerable populations exacerbated by the pandemic, arguing that “a sexual and reproductive health and justice framework—one that centers human rights, acknowledges intersecting injustices, recognizes power structures, and unites across identities—is essential for monitoring and addressing the inequitable gender, health, and social effects of COVID-19."

We're proud of the work of this group of academics and practitioners to outline recommendations for how to address the needs of women, girls, and vulnerable populations during the COVID-19 pandemic. From PopFam, this includes Dr. Kelli Stidham Hall, Dr. Goleen Samari, Dr. Samantha Garbers, Dr. Sara Casey, Dr. Rachel Moresky, and Chair Terry McGovern. Dr. Micaela Martinez of the Environmental Health Sciences Department in the Mailman School, as well as Dazon Dixon Diallo of SisterLove, Inc., and Dr. Miriam Orcutt of the Institute for Global Health at the University College London, also co-authored the piece.

“Advocates must continue to fight the exploitation of the COVID-19 crisis to further an agenda that restricts access to essential sexual and reproductive health services, particularly abortion, and targets immigrants and adolescents.” Read their commentary in full here.

More and more, we are seeing sexual and reproductive health services and access threatened in the response to the COVID-19 pandemic. This week, PopFam Chair 

Terry McGovern and Emily Battstini, a physician and Mailman School alum, wrote an op-ed in the New York Daily News about how groups with historically exclusionary views and agendas - in this particular case, the group Samaratin's Purse, which is operating a field hospital in Central Park in New York City - are weaving their political agendas into the pandemic response in NYC and beyond that do not support reproductive health access to all. Terry and Emily write, "Just as viruses do not discriminate, health is a human right and everyone in our city, state and country is entitled to the same high standard of care." We couldn't agree more.

While the COVID-19 pandemic has drastically changed the way of life in the United States, it hasn't deterred political activists from pushing to severely limit safe and legal access to abortion. 

On April 7th, a U.S. appeals court ruled that "Texas can enforce limits on the ability of women to obtain abortions as part of the state's policy requiring postponement of non-urgent medical procedures during the COVID-19 pandemic."

Make no mistake: abortion is, and will always be, an essential and time-sensitive part of reproductive health care in America. Limiting abortion rights during a pandemic is not only unethical, it will also put people's lives at risk. We are thankful to all the incredible reproductive justice warriors fighting for our right to essential care, especially during these uncertain times.

May D. Sifuentes
MPH Candidate 2021
Department of Population and Family Health
Certificate in Epidemiology, Chronic Disease

At the Mailman School, many of our faculty are vital researchers and advocates within the fields of sexual and reproductive health and rights. A shining example is Dr. Samantha Garbers, an Associate Professor in the PopFam Department, who utilizes her training as an epidemiologist to integrate public health research methods into interventions that focus on reproductive health. Below, Dr. Garbers shares why the intersection between research methodology and reproductive justice matter:

Thank you, Dr. Garbers, and many of our Mailman School faculty and staff members, for your incredible efforts to expand our understanding - and encourage greater access - to reproductive and sexual health services.

We sat down with PopFam Chair Terry McGovern to discuss how the department, the Mailman School, and its students are adjusting to the COVID-19 pandemic - and more broadly - how the world is approaching public health issues impacted by the outbreak.

May D. Sifuentes: What does life look like for the PopFam department in the midst of the COVID-19 pandemic?

Terry McGovern: I really have to thank Dr. Linda Cushman, our Academic Director, and Chelsea Kolff, our Academic Coordinator - they have been instrumental in getting all of our classes online. All of our faculty have been so great and creative when it comes to transferring our activities online - it’s been a very busy time. 

In terms of our research, our faculty have continued to collaborate with each other and have been on the phone non-stop. We seem to be busier now than when we were in the office. We are producing some great COVID-19-related content, connecting the COVID-19 response to issues like sexual and reproductive health, gender justice, gender-based violence...issues that we can’t overlook. Our Program on Forced Migration and Health has drafted up a “lessons learned” piece from quarantines in the past - it’s been really great. We want to make sure we do everything we can to assure our students of this new way of life, particularly our graduating students. We are thinking about how we can make this experience less strange. 

May: What are some issues that must not be forgotten in our (the government and Columbia's) COVID-19 response?

Terry: First of all, issues that particularly affect women and girls tend to be left out or overlooked at the beginning of pandemics. There are honestly so many answers to this question. Biology is one of them, for example. It’s simple to say more men than women are dying, but we must think a little more about what it means to put out statements like that. Sometimes when we put out statements like “children are safe,” or “older people will be the most affected,” we subconsciously communicate that it’s okay for people not in those groups to act as if nothing is happening, which is absolutely not the case. We all need to be part of public health measures like social distancing for them to effectively work. 

Other issues that have to be part of the COVID-19 response are sexual and reproductive health issues, as well as gender-based violence - we know rates of gender-based violence are increasing, especially during this time of social distancing and quarantine. These things need attention, they should be labeled as “essential” in any pandemic/epidemic response. We should know this by now. In a country where we don’t have a human right to health, our responses should be carefully deconstructed to make sure our response is appropriate and figure out where and why we failed. Technology can and should be our friend throughout all of this. 

May: We are seeing a wave of states (such as Ohio and Texas) attacking reproductive health and rights in their COVID-19 responses. Share your thoughts with us on that.

Terry: It is truly reprehensible to me that some policymakers keep trying to sneak in anti-abortion language in the COVID-19 relief packets. It is reprehensible that politicians are trying to exploit this tragic moment to push forward an anti-abortion agenda that could potentially hurt thousands of people - of women - in this country. There is no doubt that this anti-choice agenda has, in many ways, contributed to some of the weak points we are now seeing in our COVID-19 health care responses...of us having a sort-of collapsed system. The Global and domestic gag rules, the public charge rule. 

The COVID-19 pandemic is bringing to light all the vulnerabilities of our public health system, illustrating the shortcomings of our reproductive care, maternal health care, elderly care, and others. It is also showing us, in the midst of this public health crisis, just who exactly is able to access the care they need and who is not, who is able to work from home to stay safe and who is not, and many other injustices. 

May: What can students and alumni do to help PopFam and Columbia during this time?

Terry: Our students have been incredible during this pandemic - I could not be more proud to be part of this community. Our students have been engaged in sharing accurate, evidence-based information with their networks, volunteering with the city and the state, and volunteering with our own medical center and school of public health. The COVID-19 Student Service Corp was just created last week, and is made up of hundreds of students from the Columbia Mailman School of Public Health as well as the medical school. They are helping out the folks at the hospital, at Mailman, and in the community. There is a sign-up sheet if folks want to be involved. [Please note that the volunteer sign-up sheet is for students only.]

I know times are scary right now. Students are a very important part of our COVID-19 response. Use your voice! You’ll be in good company.

May D. Sifuentes
MPH Candidate 2021
Department of Population and Family Health
Certificate in Epidemiology, Chronic Disease

The world has drastically changed within a matter of months in response to the coronavirus pandemic. As we all continue to adjust and do our part to help mitigate the spread of COVID-19, other facets of health are still a part of our everyday lives.

Access to sexual and reproductive health services is still *essential* health care during this outbreak. But already these services - especially abortion - are being threatened. From Texas to Ohio, the right to abortion is being taken away in the name of COVID-19.

The threat to these services is part of the gendered impact of the coronavirus pandemic, and it is fundamental that researchers, health care workers, policymakers, and others approach this disease outbreak in a way that considers how all genders are impacted differently - some more significantly.

The Gender and COVID-19 Working Group published a commentary within The Lancet on how policies and public health efforts must address the gendered impact of the outbreak. Read the article here, and continue to check the Speak Evidence to Power webpage for more information on the impact of COVID-19 on sexual and reproductive health and rights.

The Mailman School has a strong history of advocacy for sexual and reproductive health access and rights. Students can choose to be a part of the Sexuality, Sexual and Reproductive Health (SSRH) certificate, which examines sexual and reproductive health from all sides: physical, emotional, mental, and social well-being.

One of our students, Amanda Nagle (MPH 2021), is pursuing the SSRH certificate. In the fall of 2019, she interned at the Reproductive Health Access Project, which trains and supports clinicians to make abortion, contraception, and miscarriage care accessible to everyone. As she continues her education and career, Amanda hopes to work in increasing access for reproductive health in the U.S. and around the world. Below, she shares why reproductive rights matter to her.

Thank you, Amanda, and all of our Mailman School students working to support reproductive health services and access!

One of the most effective ways we can strengthen conversations about reproductive health services and access is to make sure our guidelines for what reproductive health, rights, and justice are align. Especially in political spheres, these definitions often get blurred, but when we emphasize their importance, we can ensure that the foundation for building robust, inclusive policy is kept intact. See our definitions below, and you can share them on your own platforms by visiting PopFam on Twitter, or search for #SpeakEvidencetoPower.

Monique Baumont, Department of Population and Family Health Class of 2019, currently works as a Research Associate for the Center for Reproductive Rights in New York City. She was present in the courtroom to hear the oral arguments in June Medical Services v. Russo. Our team had the chance to interview her to hear a bit more about her experience in D.C. on March 4, 2020. 

Kathryn: What were your immediate impressions of the oral arguments or rally?

Monique: All of my impressions were really positive. I found it truly incredible to witness our lawyer, Julie’s argument. I’d never seen an oral argument before and she was incredibly poised, respectful, calm, and she knew the facts of the case to a T. It made me very proud of our work and Julie’s performance.. Coming out of the argument, we were all really hopeful that the lack of health benefits from the law came across to the Court. And it was also just really interesting to see the justices in action and kind of see how they really strategically ask questions as a way to engage the other justices and to point out issues that they want the other justices to focus on. So that was really interesting.  

I didn’t attend much of the rally because it ended soon after I got out of the court.  But I will say, when I emerged out of the court, it was really beautiful to witness the energy of the rally. It was definitely a very positive space, very uplifting and powerful messaging and really diverse representation in terms of the speakers who were involved in the organizing.  So it was nice, even though this is such a contentious issue, to kind of be in this space where everyone was very warm and supportive and you had so many individuals together who all advocate for reproductive rights and who are engaged in the work who are kind of there uplifting each other. 

K: What are some of your takeaways from the day?

M: I did come away hopeful based on how the oral arguments went. It really seems like the big question that we’re left with is, whether the justices will think that we need to address this question state by state in examining the evidence, or whether it can kind of be applied more broadly and generally when the evidence is based on nationwide findings. And that’s what it may boil down to.

My broader takeaway was really just how powerful this movement can be when everyone comes together. There were lawyers, medical professionals, researchers, reproductive justice advocates, community organizations who all came together both to work on the rally, to attend the rally and support,  to work on the case, file amicus briefs. It was really beautiful on March 4th to really see all of this work coalesce and to see how powerful we are as a movement when we are able to leverage all of our resources. 

K: What were some of the key differences between a public health approach, which you're more familiar with, and the arguments you saw play out at the Supreme Court?

M: I think the approaches are actually quite different. I have found legal arguments tend to take a pretty narrow, case-specific view and they really hone down and focus on the facts in the record [...] I find that public health takes a much broader view and we tend to think about who is disproportionately affected by these laws, how do other external factors interact with the law to produce certain burdens and we’re kind of trained to look at disparities and structural factors rather than to zoom in on particular people in the case or their individual actions.  

K: How do you think your experience at Mailman informed your work now with respect to reproductive health justice?

M: I really see my role as trying to contextualize these cases and bring in a broader, more intersectional lens. I think public health really teaches you to follow the power dynamics and also to look at areas, areas that we might be overlooking or particular groups who might be disproportionately impacted. So for instance, in this case, I think there was a big role for public health evidence in amicus briefs. That’s what really contextualized the issue and highlighted the disparate impacts and connected the case to issues like maternal mortality in the state of Louisiana and in the U.S. more broadly. Issues of poverty and how that intersects with abortion access; how people are differentially impacted based on their race, whether they identify as LGBTQ, whether they have a disability or based on their immigration status. And so, I find that my training has allowed me to really make sure that when I am supporting these cases, I am being mindful of bringing in these other perspectives and trying to ground these cases in broader evidence, to really show how these burdens play out differently among different populations and how they also interact with other structural factors.

Kathryn Gibb
MPH Candidate 2020
Department of Epidemiology
Certificate in Health and Human Rights

Batul Hassan
MPH Candidate 2020
Department of Population and Family Health
Certificate in Public Health and Humanitarian Action

As the Supreme Court considers arguments in June Medical Services v. Russo, it’s important to examine the case in the greater context of women's health in Louisiana. While proponents of the Louisiana law argue that it is in place to promote women’s health and safety when seeking an abortion, the reality is that two of the three existing abortion clinics in Louisiana would close. The current status of women’s health in the state makes clear that women’s health is not at the top of Louisiana’s priority list. 

Maternal Mortality

Louisiana has one of the highest maternal death rates, with 44.8 deaths of mothers out of every 100,000 live births. This equates to more than double the national average. The racial gap in Louisiana’s maternal mortality is even more striking, with a rate of 72.6 per 100,000 live births for black women compared to 27.3 for white women. Furthermore, a recent study examining maternal deaths in Louisiana found 59% of pregnancy-related deaths among non-hispanic black women were preventable, with just 9% preventable among non-hispanic white women. 

Sexual Health 

Louisiana has some of the highest rates of adolescent sexually transmitted infections in the country. In 2015, Louisiana was ranked 1st in adolescent syphilis diagnoses. It ranked similarly, coming in second place amongst 50 states for chlamydial and gonorrheal infections. Ironically, Louisiana does not require sexual health education. When a Louisiana school does offer sexual health education, the state encourages it to emphasize abstinence. This lack of comprehensive sexual health education partially explains the high rates of unintended pregnancies in Louisiana.  

Cervical Cancer

Louisiana’s cervical cancer mortality rate is the third highest in the United States. Black Louisiana women disproportionately carry the burden of cervical cancer incidence and mortality. The incidence rate for black women is 11.1 per 100,000 women compared to 7.9 for white women. The mortality rates are 4.3 per 100,000 black women and 2.5 per 100,00 white women. These data points are tragically preventable, as the HPV vaccine is effective at reducing infection, and in turn HPV associated cancers.  

Evidence indicates that the Louisiana Act 620 was never about promoting women’s health. The Louisiana Law was about placing greater restrictions on abortion - within a definitively political context - via medically unnecessary requirements. If Louisiana wishes to implement a policy in favor of advancing women’s health outcomes, it should be based in evidence and the guiding principles supporting human rights.

Kathryn Gibb
MPH Candidate 2020
Department of Epidemiology
Certificate in Health and Human Rights

On March 4th, hundreds of reproductive health and rights activists rallied in Washington D.C. on the first day of oral arguments in the U.S. Supreme Court’s consideration of June Medical Services v. Russo. The case relates to a Louisiana abortion law that would require doctors who perform abortion to have admitting privileges at nearby hospitals. The heart of the case is Louisiana’s Act 620, which is identical to a Texas law, which the Court declared unconstitutional in 2016 with Whole Woman’s Health v. Hellerstedt. It is the first consideration of an abortion-related case heard by the Court since President Trump’s appointment of conservative Justices Neil Gorsuch and Brett Kavanaugh, which strengthened the conservative, anti-abortion leanings of the court.

(A more detailed overview of the case can be found in our article below, “Background on the Louisiana SCOTUS Case: June Medical Services v. Russo".)

Here are a few key takeaways from the day:

Oral arguments lasted one hour, but the case may take months to be settled. In the Court session, attorneys from the Center for Reproductive Rights represented June Medical Services. Louisiana Solicitor General Elizabeth Murrill defended the restrictive abortion law on behalf of the state of Louisiana, and U.S. Principal Deputy Solicitor General Jeffery Wall presented oral arguments against June Medical Services on behalf of the Trump administration. Supreme Court Justices will issue a decision on the case until their session ends in late June or early July of this year.

The legal standing of abortion providers to file cases on behalf of patients was a key issue. Imani Gandi, senior legal analyst for Rewire.News, described the argument as a “sleeper issue.” Despite the case being active for five years, yesterday’s hearing was the first instance in which Louisiana challenged the legal standing of doctors and clinics who bring certain claims on behalf of their patients. In 1976, the Supreme Court held that a person may represent their patients as ‘third parties’ in a case if they have a close relationship with the patient, and if the patient has obstacles preventing them from suing on their own behalf. Chief Justice Roberts’ position on the question is currently unclear, but this legal standing ruling will be an important outcome of the final decision.

Admitting Privileges offer no medical benefit for abortion procedures. The evidence demonstrates that physician admitting privileges are not necessary and do not impact the ability of patients to seek care. If patients require care after discharge, they often go to an emergency department, where they will receive emergency medical care under the federal Emergency Medical Treatment and Labor Act of 1986 (EMTALA). In addition, complications necessitating inpatient hospitalization or hospital level care are exceedingly rare. In the March 4th arguments, Justice Kagan noted, “Hope Clinic has served over 3,000 women annually for 23 years, so that’s around 70,000 women, and has transferred only four patients ever to a hospital. […]  I don’t know of a medical procedure where it’s lower than that of any kind.” Furthermore, to have admitting privileges, a physician often is required to admit a minimum number of patients a year. In the context of physicians who provide medical abortions, admitting privileges are even more difficult to obtain. Justice Sotomayor, referring to a medical abortion provider, went on to say, “In virtually all of the hospitals, if not all of them, […] even if there wasn’t a minimum number of patients that had to be admitted before you got privileges, you had to see a certain number of patients in the hospital per year to maintain your privileges. And he couldn’t meet that requirement.” Admitting privileges serve no legitimate purpose and impose a barrier to individuals seeking an abortion.

Hundreds of reproductive health justice activists rallied in Washington D.C. in support of evidence-based policy and law, and the fight to ensure access to a range of reproductive health services, including abortion, will continue. The work of activists, researchers, and constituents to protect access to abortion has never been more important. Through “Speak Evidence to Power,” our goal is to develop accurate evidence and combine it with action to enforce justice.

As the Supreme Court case hangs in the balance, we hope you will join us in our work to ensure evidence is not forgotten or discarded in the struggle for reproductive health and justice.

Batul Hassan
MPH Candidate 2020
Department of Population and Family Health
Certificate in Public Health and Humanitarian Action

Kathryn Gibb
MPH Candidate 2020
Department of Epidemiology
Certificate in Health and Human Rights

PopFam Chair Terry McGovern joined thousands of protestors in Washington, D.C., at a rally for reproductive freedom - the same day that the U.S. Supreme Court is hearing oral arguments for a major abortion rights case, June Medical Services v. Russo (read an overview of the case below). As we continue to learn more about the arguments heard by the Court on March 4th, our Department is resolute: PopFam is committed to standing up for the right to bodily autonomy, and for the use of accurate evidence to inform law. 

Check out photos of the rally from Professor McGovern below.

June Medical Services v. Russo is the United States Supreme Court case also commonly referenced as “the Louisiana law” case. It is the first abortion restriction case to come before the Supreme Court since Justice Brett Kavanaugh replaced Justice Anthony Kennedy, shifting the Court to a more strongly held conservative ideological lean. This case has been discussed frequently in the news, as it has the potential to be a first step in dismantling the right to abortion established by Roe v. Wade. On March 4th, 2020, the Supreme Court will hear the oral arguments of the case. 

What’s Happened So Far? 

Louisiana passed Act 620 in June 2014, requiring abortion providers to have admitting privileges at a hospital located no more than 30 miles from where the abortions are performed.  

Several abortion providers and clinics challenged Act 620, as they do not have admitting privileges or are outside the 30-mile range. In effect, this law would limit abortions to one provider in the state. While this case was in the district court, an almost identical law in Texas was challenged in the Supreme Court in Whole Woman’s Health v. Hellerstedt (WWH). The district court placed the challenge to Act 620 on hold until the Supreme Court made its decision in WWH. In 2016, the Supreme Court found the Texas law unconstitutional, as it imposed an “undue burden” on women’s right to have an abortion. As a result, the district court permanently enjoined the enforcement of Act 620, meaning that the law was not put into effect. The state of Louisiana appealed to the U.S. Court of Appeals for the Fifth Circuit. The Fifth Circuit reversed the district court decision, concluding that it overlooked differences between Texas and Louisiana and found that the Louisiana law would not pose an undue burden on women’s right to an abortion. The plaintiff’s petition for an en banc hearing, a session in which a case is heard before the entire panel of judges, was denied. As a result, the plaintiffs requested an emergency stay on the law from the Supreme Court. The Supreme Court put the statute on hold and decided to hear the case in early 2020. In addition, the Supreme Court granted the cross-petition of Louisiana that challenges doctors’ and clinics’ standing to challenge abortion laws and assert their patients' constitutional rights.  

Going Against Legal Precedent

Appeals courts do not usually consider new evidence. An appeal is not a new trial of the case, but rather is based on the idea that there was an error in the lower court judge’s interpretation of the law. The rule of law requires following Supreme Court precedent, yet the Fifth Circuit court did not apply Supreme Court precedent from WWH. Instead, the Fifth Circuit concluded that the district level court was wrong about the facts. The district court’s clear and well-supported findings include that Act 620 does not serve “any relevant credentialing function,” “would do little or nothing for women’s health,” and would inflict significant burdens to abortion access, leaving approximately 70 percent of women in Lousiana seeking an abortion unable to get one. Despite this evidence, the Fifth Circuit Court of Appeals said the facts of the Louisiana case were “remarkably different” from the Texas case and argued that Act 620 did not place a substantial burden on women seeking an abortion. 

Louisiana’s Cross Petition

Historically, doctors and clinics have had standing to challenge abortion restrictions in court and assert their patients' constitutional rights. Louisiana asked the Supreme Court to abandon third-party standing of abortion providers, which would in effect eliminate much of the abortion litigation in the courts. The Supreme Court’s decision to grant Louisiana’s cross petition signifies the court’s willingness to limit abortion access, despite historical precedent in the courts and protections established by Roe v. Wade.  

Impact of the Potential SCOTUS Decision

The Fifth Circuit’s decision and the Supreme Court’s willingness to hear June Medical Services v. Russo signals a threat to abortion access across the United States. Importantly, the Supreme Court has shifted since WWH, with conservative justices Brett Kavanaugh and Neil Gorsuch joining the bench. June Medical Services v. Russo is the first abortion-related case that the Supreme Court will hear since Kavanaugh joined the court, whose case history has aligned with traditionally socially conservative beliefs. Despite no evidence that admitting privileges are relevant to health outcomes, Louisiana is using Act 620 as a way to restrict access to abortion under the pretense of protecting women’s health. If the Supreme Court upholds the Louisiana law, it will be chipping away at the right to abortion by allowing arbitrary regulations to take place in one state and potentially opening the door for others to follow suit.

Kathryn Gibb
MPH Candidate 2020
Department of Epidemiology
Certificate in Health and Human Rights

Title X (pronounced “ten”) of the Public Health Service Act was enacted by Congress in 1970 - before Roe v. Wade - with strong bipartisan support.  Title X was, and is, the only federal grant program “dedicated solely to providing individuals with comprehensive family planning and related preventive health services.” The program was designed to ensure that all individuals, regardless of income - including adolescents - have access to comprehensive and quality voluntary family planning services. Priority is given to individuals from low income families, with most patients paying nothing out of pocket, or by utilizing sliding scale fees.

Title X is able to reach individuals who do not have any other access to care. According to the National Family Planning and Reproductive Health Association, “In 2016, Title X-funded providers were the sole source of medical care for 60% of their contraceptive clients.” In the fiscal year of 2018, the Title X program served almost 4 million family planning clients. Approximately 65% of clients had family incomes at or below the poverty level, and 40% of clients were uninsured - more than triple the national average uninsured rate for adults. (Throughout this explainer, we refer to those who are served by Title X as “individuals,” because in 2018, 13% of Title X clients were male.) 

Title X provides a whole range of sexual and reproductive health services, so that when and if an individual decides to get pregnant, they can have a healthy pregnancy that supports the health of the mother and the infant. But Title X services encompass much more than care related to pregnancy. According to the Title X Family Planning Annual Report for 2018, at Title X centers that year, over 2.1 million chlamydia tests, 2.4 million gonorrhea tests, 651,920 pap tests, and 816,202 clinical breast exams - lifesaving exams that are a critical part of basic preventive health care - were performed by Title X providers.

Title X is just one funding stream that can be used to cover family planning services; there are also Medicaid and maternal-child health block grants. Both Title X and Medicaid cover the costs of providing care for individuals who meet certain income requirements. However, Medicaid only reimburses providers for services rendered to those who meet their respective Medicaid state eligibility requirements. Title X is more than an insurance program like Medicaid, and it supports more than direct medical care: It covers the design and deployment of community-specific outreach strategies that address barriers to seeking and receiving care, supports administrative functions, and secures services that are left unfunded if patients are not Medicaid-eligible. 

Title X funds are disbursed to a wide range of local grantees: Planned Parenthood affiliates, Federally Qualified Health Centers (FQHCs), but also smaller community-based organizations. By funding this range of organizations, the program has the flexibility to deploy community-specific outreach strategies. This design is significant, as some of the most common reportable sexually transmitted infections (STIs), such as chlamydia, are asymptomatic. Community-based education and outreach about the importance of getting tested is essential, particularly for those at greatest risk (sexually active adolescents and young adults who are age 24 and younger). 

No matter where they go, patients know that the Title X funded health centers will be providing care in accordance with nationally recognized, evidence-based standards. Title X has provisions to ensure that individuals have access to appropriate and acceptable care. Title X grantees must offer a “broad range” of contraceptive services, with guidance that providers should offer methods that are most frequently requested by clients (42 CFR 59.5(a)(1)), and grantees must provide services for adolescents (Section 1001). Title X must provide services “in a manner that protects the dignity of individuals” ((42 CFR 59.5 (a)(3)). Related, national training centers are funded in order to strengthen the capacity of Title X providers to effectively deliver high quality FP services.

In past years, national studies have shown that Title X-funded grantees provide more comprehensive care than other family planning providers. FQHCs, a type of community health center, are required to provide family planning as part of their services; however, there is no guidance about what this must include or to what standard of care family planning care must adhere. A 2013 nationwide study on community health centers (covering more than 1,900 sites) found that the level and quality of family planning services varied significantly. Moreover, receipt of a Title X grant was significantly associated with the provision of comprehensive family planning services, including the full range of contraceptive methods, confidential services, and adolescent-focused services. Patients at Title X-funded health centers were also more likely to receive contraceptive information by a specially trained counselor, allowing for a more patient-centered approach.  

The interpretation of Title X has changed under the Trump administration. These changes have not taken the form of de-funding the program, but rather “revisions to the….regulations” that re-interpret Title X’s standards of care, and which may profoundly affect what services are offered, and by whom.  Guidance that was specifically enshrined in the Title X program to increase access to quality care and a full range of methods is being re-interpreted, expanding program eligibility to providers - such as crisis pregnancy care centers - who do not offer care according to evidence-based standards. Protecting Title X from losing its original purpose requires all of us to understand the significance of access to quality sexual and reproductive health care.

Samantha Garbers, PhD
Associate Professor
Heilbrunn Department of Population and Family Health
Columbia University Mailman School of Public Health

Rachel Baum, MSW
Vice President Program Services
New Jersey Family Planning League, Inc.

Kathryn Gibb
MPH Candidate 2020
Department of Epidemiology
Certificate in Health and Human Rights

The U.S. Supreme Court case has provided the legal basis for abortion rights and access in the United States for decades. Below is a history of the case, how it categorizes abortion, and where it stands now.

Kathryn Gibb
MPH Candidate 2020
Department of Epidemiology
Certificate in Health and Human Rights

On November 6 - a day after elections - the Heilbrunn Department of Population and Family Health (PopFam) hosted an event on the front steps of the celebrated Allan Rosenfield Building: “Speak Out for Reproductive Health & Justice”. Faculty and students from across the Mailman School used their platforms as researchers to share evidence-based perspectives on how obstructing access to reproductive health services via policy and funding mechanisms impacts various populations across the United States, and makes it a critical public health issue for everyone.

Along with many Mailman School students, faculty, and staff who came to the Speak Out, several incredible speakers provided insight and nuanced expertise in support of reproductive justice. 

Terry McGovern, PopFam Chair, provided a compelling welcome to attendees: “Policies that block women’s and girls’ access to sexual and reproductive health services will neither reduce abortion nor improve health outcomes for women and children. Instead, we know via evidence that unsafe abortion will achieve the opposite.”

“That’s why we’re here. We are here to say: ‘We are going to push for science and evidence.’” 

Below are the remaining speakers, and some of the powerful words they shared:

Carolyn Westhoff
Professor of Epidemiology and Population and Family Health at the New York Presbyterian Hospital at Columbia University Medical Center 
Sarah Billinghurst Solomon Professor of Reproductive Health, Department of Obstetrics and Gynecology
Editor-in-Chief of Contraception

Dr. Westhoff shared the history of the Title X Family Planning Program, a federal grant program designed to provide comprehensive family planning services, emphasizing the importance of access to these services for better sexual and reproductive health outcomes, and how new regulations will drastically affect these outcomes and access for patients.

“It’s against medical ethics to not let doctors provide all-encompassing medical advice to patients seeking care and who want to know all of their options.”

Goleen Samari
Assistant Professor of Population and Family Health
Faculty Affiliate, Columbia Population Research Center

Dr. Samari emphasized the significant and devastating effects restrictions to reproductive health services and access have on women of color and minority populations especially, and how reproductive justice stems far beyond access to and the freedom to choose abortion-related care.

“Reproductive justice is a human right. It’s about access, not choice, and it’s not just about abortion. Abortion access is critical, but women of color and other marginalized women also have difficulty accessing contraception, comprehensive sexual education, STI prevention and care, alternative birth options, adequate prenatal and pregnancy care, intimate partner violence assistance, and adequate wages to support families and safe homes. Reproductive justice is about all of these things. 

“Reproductive justice combines reproductive rights and social justice, and it’s the human right to maintain personal bodily autonomy, to have children, to not have children, and to parent those children in safe and sustainable communities.”

Micaela Martinez
Assistant Professor of Environmental Health Sciences

Dr. Martinez, an instructor within the Department of Environmental Health Sciences, reminded attendees that the research community - not just political representatives - can play a significant role in the shaping of policy that can support or tear down access to reproductive health services.

“Many times, I’ve looked up how many papers I can find studying testosterone versus the menstrual cycle, and I find hundreds more on testosterone. As we have this push for conversations on reproductive justice, we must remain aware that it’s not just societal issues we’re facing. We have to reflect inwardly within the scientific community on where we’re putting our efforts, and what questions we are asking, and what data we generate to inform the public on these issues.”

Samantha Berg
MPH Candidate 2020
Department of Sociomedical Sciences
Certificate in Sexuality, Sexual and Reproductive Health

Sociomedical Sciences student Samantha Berg discussed how there are shifts to where Title X funding is being directed - that crisis pregnancy centers (CPCs), which can offer limited reproductive health care options and do not have to provide counseling on abortion options for patients, are receiving Title X funding. She referenced a recent evidence-based joint position statement made by the Society for Adolescent Health and Medicine and the North American Society for Pediatric and Adolescent Gynecology, which includes PopFam Professor John Santelli, about the lack of medical and ethical standards for CPCs, and made clear that access to comprehensive reproductive health services should be available to all, no matter where they go to receive services. 

“It’s time that our elected officials prioritize reproductive and sexual health, and stand up to [those] that think it’s okay to control our bodies and exacerbate health inequalities.”

May Sifuentes
MPH Candidate 2021
Department of Population and Family Health
Certificate in Infectious Disease Epidemiology

PopFam student May Sifuentes called to action students from across the Mailman School, stressing that as future public health practitioners, they are responsible for providing accurate medical information and supporting their patients’ right to health.

“[The] stakes are high, and the questions for us then become: Will we, as public health practitioners, uphold these systems that make inequalities so possible, or will we work to defy them? Will we work to ensure that EVERYONE, no matter who they are, where they come from or how much money is in their wallet, has access to the health care that they need? Will we unite public health with the advocacy efforts that it requires to ensure access for all?”

May’s words, and those of all of the speakers, make clear that when we provide accurate evidence and combine that with action, we can enforce reproductive health justice.