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In Ethiopia, health clinics for teenagers once supported by U.S. foreign aid closed down. In Kenya, a decades-long effort to integrate HIV testing and family planning unraveled. And in Nepal, intrepid government workers who once traversed the Himalayas to spread information about reproductive health were halted.

Around the world, countries that depend on U.S. foreign aid have scrapped or scaled back ambitious public health projects, refashioning their health systems over the past four years to comport with President Donald Trump鈥檚 sweeping anti-abortion restrictions that went further than any Republican president before him.

The effects have been profound: As groups scrambled to meet the administration鈥檚 strict ideologically driven rules, they severed ties with health care providers that discuss abortion in any way, deleted references to abortion on websites and in sexual education curricula, and stopped discussing modern contraception for fear of forfeiting vital American aid.

President-elect Joe Biden has pledged to reverse the policy when he takes office, and he campaigned on a promise to enshrine abortion rights in federal law. But for many foreign aid groups, the changes may be permanent.

鈥淭he U.S. has lost its position as a leader and lost its credibility,鈥� said Terry McGovern, of Columbia University鈥檚 Mailman School of Public Health who has overseen research of the Trump policy in multiple countries.

Since Ronald Reagan, Republican presidents have barred foreign aid organizations from using U.S. global health funds to counsel women about abortion or refer them to a safe abortion provider. But the Trump administration vastly expanded those anti-abortion restrictions, known as 鈥渢he global gag rule鈥� by opponents. Under Trump, the rule applies to some $9 billion of aid touching nearly every facet of global health funding, including groups working on HIV, malaria, tuberculosis and water sanitation. Under President George W. Bush, the policy applied to a fraction of that, $600 million in foreign aid.

The Trump administration proudly touted these efforts to protect 鈥渢he unborn abroad,鈥� but the rules have left international aid groups deeply skeptical of U.S. promises and deepened the nation鈥檚 rift with European countries that have long viewed abortion access as vital to women鈥檚 health and safety.

Some major organizations opted out of any U.S. funding rather than comply with the new strictures, including Marie Stopes International and International Planned Parenthood Federation, among the largest providers of reproductive health care in the developing world. Untold numbers of front-line health care workers 鈥� in large cities and remote villages alike 鈥� have been confused by what seem like sudden swings in American policy.

And that trepidation may not be quick to dissipate even with a Democrat in the White House.

鈥淏iden and Trump may seem radically different to Americans,鈥� said Jennifer Sherwood, a policy manager at Amfar, the Foundation for AIDS Research. 鈥淏ut if you鈥檙e a small organization in sub-Saharan Africa, you may not understand what this new [Biden] administration means and if you can trust the United States.鈥�

The restrictions intentionally constrict the activities of foreign aid groups, many of which have worked in close coordination with American counterparts for decades. The rules also have a ripple effect on their funding: U.S. funding to foreign groups is contingent on their not accepting money from other countries, or even private foundations, to underwrite abortion-related services. They are not allowed to subcontract with other organizations that run separate abortion-related projects.

Trump telegraphed the worldwide anti-abortion gains in appeals to evangelical Christians. In early October, Secretary of State Mike Pompeo touted the policy during a speech to , a conservative anti-abortion group, calling it an 鈥渦nprecedented defense of the unborn abroad.鈥�

鈥淥ur administration has drawn on our first principles to defend life in our foreign policy like no administration in all of history,鈥� said Pompeo, who is an evangelical Christian.

The hard-right policies of the Trump administration stand in stark contrast to the steady over the past two decades. Since 2000, more than two dozen countries have eased abortion laws, including Ireland, South Korea, the Democratic Republic of Congo and Ethiopia.

Even in countries where abortion is forbidden, the rules are having an impact on reproductive health care. In Madagascar, where abortion is illegal with no exceptions, the largest provider of contraception, Marie Stopes, turned down U.S. money, endangering its ability to offer unfettered medical care to women, ending support for nearly 200 public and private facilities.

, a researcher at the found that led to , in a poor country where travel to nearby towns is difficult.

鈥淭he women asked us, 鈥榃hat is the cause of this rupture?鈥欌�� said Razafimahatratra. 鈥淲e tried to explain to them the reason, and [they say], 鈥楤ut that regulation is for abortion, so we don鈥檛 understand why we are also penalized?鈥欌��

Researchers at Amfar and Johns Hopkins, in a , found the anti-abortion policies could have deadly consequences, specifically in preventing the spread of HIV/AIDS. Sherwood said young African women face the highest risk of HIV and many clinics had combined HIV testing and treatment with family planning services.

But, fearing they would run afoul of the Trump policy and thus forfeit funding, clinics have curtailed family planning for patients, reducing the number of women seeking care in African countries.

鈥淎 lot of the times, they want contraception,鈥� said Sherwood. 鈥淭hat is what鈥檚 on their mind, and HIV is the secondary thing, something we can tack on to meet their needs all at once.鈥�

Jennifer Kates, director of global health and HIV policy at KFF said, 鈥淚 have no doubt some groups are going to say, 鈥榃e are not going to play there anymore.鈥欌�� ( is an editorially independent program of .)

The practical challenges of restarting these programs are steep: rehiring staff, reopening clinics, retraining employees, rewriting curricula.

鈥淵ou can imagine being a health care worker that was under threat of losing their funding for counseling a patient on abortion,鈥� Sherwood said. 鈥淭o us, it鈥檚 like a light switch that can turn off and on, but to them, this is a very opaque and confusing process. It鈥檚 not how health systems work. You can鈥檛 just change the way they work overnight.鈥�