[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                     UNIQUE CHALLENGES WOMEN FACE 
                          IN GLOBAL HEALTH

=======================================================================

                                HEARING

                               BEFORE THE

                      COMMITTEE ON FOREIGN AFFAIRS
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            FEBRUARY 5, 2020

                               __________

                           Serial No. 116-96

                               __________

        Printed for the use of the Committee on Foreign Affairs
        
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       Available:  http://www.foreignaffairs.house.gov/, http://
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                                __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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-----------------------------------------------------------------------------------                         

                       COMMITTEE ON FOREIGN AFFAIRS

		 ELIOT L. ENGEL, New York, Chairman

BRAD SHERMAN, California             MICHAEL T. McCAUL, Texas, Ranking 
GREGORY W. MEEKS, New York               Member
ALBIO SIRES, New Jersey		     CHRISTOPHER H. SMITH, New Jersey     
GERALD E. CONNOLLY, Virginia         STEVE CHABOT, Ohio
THEODORE E. DEUTCH, Florida	     JOE WILSON, South Carolina
KAREN BASS, California		     SCOTT PERRY, Pennsylvania
WILLIAM KEATING, Massachusetts	     TED S. YOHO, Florida
DAVID CICILLINE, Rhode Island	     ADAM KINZINGER, Illinois
AMI BERA, California		     LEE ZELDIN, New York
JOAQUIN CASTRO, Texas		     JIM SENSENBRENNER, Wisconsin
DINA TITUS, Nevada		     ANN WAGNER, Missouri
ADRIANO ESPAILLAT, New York          BRIAN MAST, Florida
TED LIEU, California		     FRANCIS ROONEY, Florida
SUSAN WILD, Pennsylvania	     BRIAN FITZPATRICK, Pennsylvania
DEAN PHILLPS, Minnesota	             JOHN CURTIS, Utah
ILHAN OMAR, Minnesota		     KEN BUCK, Colorado
COLIN ALLRED, Texas		     RON WRIGHT, Texas
ANDY LEVIN, Michigan		     GUY RESCHENTHALER, Pennsylvania
ABIGAIL SPANBERGER, Virginia	     TIM BURCHETT, Tennessee
CHRISSY HOULAHAN, Pennsylvania       GREG PENCE, Indiana
TOM MALINOWSKI, New Jersey	     STEVE WATKINS, Kansas
DAVID TRONE, Maryland		     MIKE GUEST, Mississippi
JIM COSTA, California
JUAN VARGAS, California
VICENTE GONZALEZ, Texas                              

                    Jason Steinbaum, Staff Director

               Brendan Shields, Republican Staff Director
                           
                           
                           C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSESS

Lowey, The Honorable Nita, Member of Congress (D-NY).............     6
McMorris Rodgers, The Honorable Cathy, Member of Congress (R-WA).     9
Kates, Dr. Jennifer, Senior Vice President and Director of Global 
  Health and HIV Policy at the Kaiser Family Foundation..........    14
Crocker, Sheba, Vice President for Humanitarian Policy and 
  Practice, Care USA.............................................    31
Mulumba, Moses, Center for Health, Human Rights, and Development, 
  Uganda.........................................................    38
Bos, Lisa, World Vision US.......................................    44

                  INFORMATION SUBMITTED FOR THE RECORD

Costing the Three Transformative Results.........................    68

                                APPENDIX

Hearing Notice...................................................   123
Hearing Minutes..................................................   124
Hearing Attendance...............................................   125

             ADDITIONAL STATEMENTS SUBMITTED FOR THE RECORD

Planned Parenthood Ayers statement...............................   126
Coalition statement Opposing the Global Gag Rule 2019............   131

            RESPONSES TO QUESTIONS SUBMITTED FOR THE RECORD

Responses to questions submitted for the record..................   138

             ADDITONAL INFORMATION SUBMITTED FOR THE RECORD

Chairman Engel letter to Mr. Pompeo..............................   147
Chairman Engel letter to Mr. Esper...............................   151
International Women's Heallth Coalition Doorley..................   156
Tasmin letter in Arabic..........................................   161
Stanford letter..................................................   163
Change letter....................................................   168
Save the Children letter Borsh...................................   176
Human Rights Watch...............................................   182
Champion of Global Reproductive Rights letter....................   188
Columbia letter..................................................   196

 
             UNIQUE CHALLENGES WOMEN FACE IN GLOBAL HEALTH

                      Wednesday, February 5, 2020

                        House of Representatives

                      Committee on Foreign Affairs

                                     Washington, DC

    The committee met, pursuant to notice, at 10 a.m., in room 
2172 Rayburn House Office Building, Hon. Eliot Engel (chairman 
of the committee) presiding.
    Chairman Engel. The committee will come to order. Without 
objection, all members will have 5 days to submit statements, 
extraneous material, and questions for the record subject to 
the length limitation in the rules.
    This morning, we will take a hard look at something the 
full committee has not held a hearing on in more than a decade, 
global women's health.
    I want to welcome our witnesses to the Foreign Affairs 
Committee. It is always nice to have colleagues come and talk 
to us because we know that colleagues have more expertise than 
anybody else, so I want to welcome them. I want to welcome 
members of the public and the press as well. And today, we will 
hear from two panels, first, from two of our distinguished 
colleagues, and from a panel of experts. So we are grateful to 
you for your time.
    I now recognize myself for an opening statement. This is 
one of those topics where I think it is helpful to take a step 
back and look at the big picture so we can understand why this 
issue, global women's health, should be a foreign policy 
priority.
    We know that when women are able to live fuller and more 
productive lives, when they have access to education and 
economic opportunity, when they can be full participants in 
their communities and societies, it acts like a rising tide. 
Entire countries become more stable, more open, and more 
prosperous. When women have a seat at the table, we see better 
results in resolving conflicts and rebuilding after crises. A 
whole host of foreign policy challenges are more easily 
overcome when women are involved, when women can live their 
lives to their full potential.
    And when we dig down it is clear that unleashing that 
potential is directly tied to women's access to health, 
healthcare, particularly family planning. Study after study 
after study has told us improving access to contraception 
improved women's economic well-being. Women who can plan having 
children on their own timetable are more likely to get an 
education, to raise their standards of living, to climb out of 
poverty. And this is where so many women hit a roadblock. Only 
about half of the women in developing countries receive the 
minimum recommended prenatal care and that number drops in Sub-
Saharan African.
    Every year, more than 300,000 women die from complications 
during childbirth. That is a shocking statistic, an estimated 
third, of which could be prevented if the women had access to 
contraception and greater choice over whether or not to become 
pregnant. It is a human tragedy and it wipes away all those 
positive effects that ripple out when women are able to make 
choices for themselves and can get the healthcare they need.
    American assistance has traditionally played a major role 
in helping women and girls get better access to healthcare. In 
fact, global health makes up the largest single share of 
civilian aid overseas. Over the years, American-backed 
assistance for family planning, maternal and child health, and 
PEPFAR have made a real difference around the world.
    Unfortunately, the Trump administration has threatened to 
undo a lot of our progress. It has tried again and again to 
slash America's investment in family planning and reproductive 
health. The administration has tried to hobble the U.N. 
Population Fund, arguably the most important organization in 
the world for helping women get the care they need. And let me 
focus on this for a minute.
    UNFPA purchases and distributes contraceptives, facilitates 
safe childbirth, promotes maternal and reproductive health, 
works to end female genital mutilation, and assists victims of 
gender-based violence in 150 countries around the world which 
includes 100 where USAID does not operate. In war-torn areas in 
the middle of humanitarian disasters, UNFPA is a lifeline for 
the world's most vulnerable women and girls. These are people 
with nowhere else to turn.
    So what has the Trump administration done with this? The 
answer, unfortunately, is eliminated American support for it. 
And of course, the administration has reinStated and expanded 
the Global Gag Rule. This is a policy of--it does, I think, the 
opposite of what its supporters say. I will leave it to our 
witnesses to shine a light on just how much damage it does. It 
would undermine everything we know can be gained when women get 
a fair shot. This policy should be repealed permanently and 
that is what the Global HER Act would do. And one of our 
witnesses this morning is that bill's author, my friend, my 
good friend, and neighbor from New York whose district borders 
mine for 30 years, the chairwoman of the Committee on 
Appropriations, the first woman to chair that committee, Ms. 
Lowey.
    We will also hear from another colleague, a member of the 
Energy and Commerce Subcommittee on Health, the distinguished 
gentlewoman from Washington, Ms. McMorris Rodgers, two great 
witnesses. I look forward opening statements from our 
colleagues, pending which I will yield to my friend from Texas, 
our ranking member, for any opening comments he may have.
    Mr. McCaul. Thank you, Mr. Chairman, for holding this 
important hearing. If I were you, I would answer my wife's 
phone call. I also want to thank my colleagues and friends for 
being here today. Cathy and I came in to Congress together and 
Nita has been a dear friend and the role leader in the 
Congress.
    The United States is the largest donor to global health 
programs by far. We have a long history supporting efforts to 
improve health outcomes of people all over the world for 
providing life-saving treatment, to building the capacity of 
health assistance. The U.S. has also been a global leader in 
founding and funding programs that support women and girls 
around the world. As a father of four young women, I recognize 
the importance of empowering women and girls to succeed and 
that starts with access to health resources and education.
    Through our contributions to the multi-national programs 
like the Global Health Fund that the chairman and I got fully 
funded when some tried to cut it, the United States has been a 
global leader in the fight against HIV/AIDS, malaria, 
tuberculosis, and other diseases that disproportionately impact 
the world's most vulnerable populations. This is largely thanks 
to the visionary leadership, I believe, of President George W. 
Bush. Bilateral global health programs, as well as broader 
initiatives like PEPFAR and the President's Malaria Initiative, 
have saved tens of millions of lives around the world.
    Last year, I had the honor to meet the President of 
Botswana and he told me that thanks to the PEPFAR program that 
the United States saved, in his words, a generation--what is 
going on here? Anyway, he told me that PEPFAR saved in his 
words, ``A generation of Botswanans from extinction.'' From 
extinction. Very profound.
    We can and should be proud of America's continued 
leadership on these issues. And that is why I was proud to 
sponsor House Resolution 517, along with Chairman Engel, which 
reaffirmed the United States' support for the global fund. We 
were successful in these efforts. The year-end spending package 
included $1.56 billion for the global fund and substantial 
increases in assistance for maternal and child health and 
nutrition among other programs.
    In September of last year, the Bush Foundation and 
Ambassador Birx announced the Go Further partnership to end 
AIDS and cervical cancer. It had reached over half a million 
women living with HIV to provide cervical cancer screening. 
This is a fantastic example of how innovative public/private 
partnerships can build on successful U.S. Government programs 
to reach even more women and girls with expanded services. Like 
the Go Further Partnership, there is unique opportunity to 
build on the success of the U.S. global health programs and 
address other health challenges like childhood cancer.
    Last week, along with the chairman, the House unanimously 
passed the Global Hope Act. And I do want to thank Chairman 
Engel for his support of this effort. This legislation supports 
efforts to reduce childhood cancer rates in developing 
countries by facilitating similar public/private partnerships 
between the Federal Government, the private sector, research 
institutions, and non-governmental organizations. The mortality 
rate for children diagnosed with cancer in developing nations 
is 80 percent.
    Tragically, this matches the survival rate in the United 
States. I do not think it depends where you are born to 
determine whether you should receive this critical care. And by 
working together to address the resource gaps that exist and 
leverage private sector expertise on the unique challenges that 
this horrific disease poses, I think we can dramatically reduce 
childhood cancer mortality.
    We must ensure that every child, no matter where they are 
born, has access to the care and treatment that they need.
    So I look forward to working with my colleagues in the 
Senate to see that the Global Hope Act is signed into law. We 
saved over 20 million people in Africa thanks to the PEPFAR HIV 
program. The Global Hope Act has the same opportunity, I think, 
to save millions of children's lives. And I cannot think of 
anything more profound that we can do in the Congress than pass 
a bill that turns into saving millions of lives.
    With that, Mr. Chairman, I yield back.
    Chairman Engel. Thank you, Mr. McCaul.
    I will now recognize our witnesses for 5 minutes each. 
Chairwoman Lowey, we will start with you. Thank you for coming 
this morning. It is great seeing you.

 STATEMENT OF THE HONORABLE NITA LOWEY, MEMBER OF CONGRESS (D-
                              NY)

    Ms. Lowey. It is a pleasure to be here with you, Chairman 
Engel, and Ranking Member McCaul, and so many good friends from 
this committee. Thank you for allowing me to testify during 
this important hearing on the unique challenges women face in 
global health.
    As my fellow witnesses will outline, the number of 
obstacles that women around the world face in their pursuit of 
health services is almost too many to list. But instead of 
tackling these obstacles, President Trump simply created more 
barriers when he quickly imposed the dangerous, ill-informed 
Mexico City policy, also known as the Global Gag Rule in 2017.
    During previous Republican administrations, this policy 
cutoff U.S. family planning funds to any foreign, non-
governmental organization that provided services for, 
information about, or referrals for abortion, or advocated for 
abortion access even where it was legal and even with its own 
private funds. But this administration radically expanded the 
policy to apply these restrictions to all global health funding 
affecting approximately $8.8 billion in U.S. assistance to 
programs tackling HIV and AIDS, family planning, reproductive 
health, tuberculosis, malaria, maternal and child health, 
water, sanitation, and hygiene, and more.
    And just this year, the administration announced it was 
expanding the policy once again, changing the definition of 
providing financial support contained within the Executive 
Order standard revisions.
    When the Global Gag Rule was simply applied to family 
planning programs, we saw disastrous impact, not just for 
women, but also for their families and their communities. Fewer 
women were able to access family planning services, resulting 
in more unintended pregnancies and unsafe abortions. Some of 
our most trusted implementation partners overseas were forced 
to choose between receiving U.S. funding or providing 
comprehensive healthcare, often leaving thousands of women 
without access to the most experienced providers.
    This administration's unprecedented expansion which were 
implemented with no analysis of the potential impact now risks 
multiplying the damage. We have heard of numerous HIV and AIDS, 
maternal and child health, nutrition, and WASH programs that 
were forced to cut services or close because of this policy.
    Meanwhile, implementers have tied themselves in knots 
trying to comply, or even worse, just walked away from 
partnering with the U.S. altogether. And mass confusion about 
the policy has led to a chilling effect causing organizations 
to unnecessarily change or eliminate vital health services. 
Simply put, this policy hurts the very people we are trying to 
help.
    We should be building on our global health successes, not 
reversing the gains we have made. That is why I introduced H.R. 
1055, the Global Health, Empowerment and Rights, HER, Act which 
would permanently end this devastating policy once and for all. 
This bill, which I am hopeful the committee will consider in 
the near future, sends an important message to international 
global health partners and has a record number of cosponsors 
and support from a long list of diverse organizations that know 
the Global Gag Rule is bad for global health, bad for human 
rights, bad for gender equality. Passing this legislation would 
restore our country's role as an international leader and 
ensure that women, men, and children around the world are able 
to access the healthcare they so desperately need. Thank you.
    [The prepared statement of Ms. Lowey follows:]

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    Chairman Engel. Thank you, Chairwoman Lowey.
    Ms. McMorris Rogers.

 STATEMENT OF THE HONORABLE CATHY McMORRIS RODGERS, MEMBER OF 
                        CONGRESS (R-WA)

    Ms. McMorris Rodgers. Thank you, Mr. Chairman, Ranking 
Member Michael McCaul, to all the members, but especially to 
the chairman and the ranking member, I want to just applaud 
your leadership. Both of you are extraordinary leaders and I 
appreciate your leadership on so many issues before this 
committee.
    Since America's founding, we have cherished every person's 
inalienable rights, human rights, to life, liberty, and the 
pursuit of happiness. It is on us, all of us, to uphold these 
values and make sure they are reflected at home and abroad.
    The Trump administration has provided historic leadership 
on this front. In January 2017, President Trump implemented the 
Protecting Life in Global Health Assistance policy which has 
expanded on the Mexico City policy. This affirms the dignity of 
the unborn life in foreign aid funding. It required foreign, 
non-governmental organizations to agree not to perform or 
promote abortion as a method of family planning overseas.
    Organizations that provide and promote abortions abroad 
should under no circumstances be funded by American taxpayers. 
In fact, according to the latest Marist poll, six out of ten 
Americans oppose using tax dollars to pay for abortion. More 
than three in four Americans oppose using tax dollars to 
support abortions in other countries. The terms of PLGHA are 
clear and in line with overwhelming public opinion. NGO's can 
receive global health assistance awards if they agree to abide 
by PLGHA policy. PLGHA does not reduce the amount of global 
health assistance that we make available or prohibit any group 
from receiving U.S. assistance.
    And I want to repeat that. This policy does not reduce the 
amount of global health assistance, nor does it cut funding 
from any organizations. The only organizations to not receive 
funding under PLGHA are those who have chosen not to accept the 
policy restrictions that come with U.S. assistance. It means we 
are using resources for healthcare and life-saving care of both 
women and children. It provides essential healthcare, 
nutritional aid, and humanitarian assistance to people in need 
at every stage of their lives.
    To win the future, America should be leading to affirm the 
dignity and value of both patients, mothers, and children. That 
is why here at home I have led on solutions to reduce maternal 
and infant mortality. Again, as lawyers for human dignity and 
human value, I applaud this administration's historic 
leadership on policy like PLGHA from combating human 
trafficking, to promoting freedom and opportunity, and also 
improving healthcare for women and our most vulnerable.
    America must lead and continue to lead and encourage the 
rest of the world to follow our leadership. I thank you for the 
opportunity to be with you today.
    [The prepared statement of Ms. McMorris Rodgers follows:]
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman Engel. Well, thank you both. I always say that 
words to come out of our colleagues' mouths are always the 
wisest words, so I want to thank both of you who I know care 
very much about this issue.
    And will now recess briefly to reset the witness table and 
seat our second panel.
    [Recess.]
    Chairman Engel. Okay, we will continue with our second 
panel whom I will introduce. First, Dr. Jennifer Kates is 
Senior Vice President and Director of Global Health and HIV 
Policy at the Kaiser Family Foundation. She oversees the 
foundation's policy analysis and research focused on the U.S. 
Government's role in global health and on the global health and 
domestic HIV epidemic. Welcome.
    Sheba Crocker is CARE USA Vice President for Humanitarian 
Policy and Practice and is also currently a Centennial Fellow 
at Georgetown University's School of Foreign Service. She 
previously served as Assistant Secretary of State for 
International Organizational Affairs, Director in the Office of 
Policy Planning, and Chief of Staff to the Deputy Secretary of 
State. Welcome.
    Moses Mulumba is a lawyer with special interests in 
international human rights, global health, and sexual 
reproductive health and rights. He is the founder and current 
Executive Director of the Center for health, Human Rights, and 
Development based on Uganda.
    Lisa Bos is the Director of Government Relations at World 
Vision US. She leads World Vision's advocacy and education 
efforts with Congress and the administration. She previously 
served for nearly 9 years as a staff member here in the House 
including as Policy Director for the Republican Study 
Committee.
    Welcome to all of you. Without objection, your written 
testimony will be made part of the hearing record and I will 
recognize each of you for 5 minutes to summarize your 
statements. We will start with Dr. Kates. Welcome.

  STATEMENTS OF DR. JENNIFER KATES, SENIOR VICE PRESIDENT AND 
 DIRECTOR OF GLOBAL HEALTH AND HIV POLICY AT THE KAISER FAMILY 
  FOUNDATION; SHEBA CROCKER, VICE PRESIDENT FOR HUMANITARIAN 
POLICY AND PRACTICE, CARE USA; MOSES MULUMBA CENTER FOR HEALTH, 
  HUMAN RIGHTS, AND DEVELOPMENT, UGANDA; AND LISA BOS, WORLD 
                           VISION US

  STATEMENT OF DR. JENNIFER KATES, SENIOR VICE PRESIDENT AND 
 DIRECTOR OF GLOBAL HEALTH AND HIV POLICY AT THE KAISER FAMILY 
                           FOUNDATION

    Dr. Kates. Thank you. Good morning, Chairman Engel, Ranking 
Member McCaul, members of the committee and guests. I am Dr. 
Jen Kates, Senior Vice President and Director of Global Health 
and HIV Policy at KFF, the Kaiser Family Foundation, a 
nonprofit, nonpartisan organization that conducts independent 
health policy analysis. Thank you so much for inviting me to 
testify at this important and timely hearing.
    I will briefly summarize my written testimony and focus my 
remarks on three areas: an overview of the U.S. Government's 
role in addressing the health of women in low-and middle-income 
countries; what we know about impacts to date; and current and 
future challenges and opportunities.
    U.S. efforts to address the health of women in low-and 
middle-income countries began decades ago and since then, the 
U.S. has been and today remains the largest donor in this area 
globally. Major efforts include USAID's maternal and child 
health, nutrition, and family planning and reproductive health 
programs, as well as related efforts, particularly PEPFAR and 
its DREAMS Initiative. Studies have shown that improving the 
health of women has significant spill-over effects on the 
health and economic well-being of their families, communities, 
and societies.
    The U.S. footprint is large, spanning more than 50 low-and 
middle-income countries, mostly in Sub-Saharan Africa, and 
reaching tens of millions of women and girls. In Fiscal Year 
2020, the U.S. committed $1.4 billion to maternal and child 
health including nutrition, and $608 million to family planning 
and reproductive health. And PEPFAR estimates that it will 
spend nearly $2 billion on efforts to support women and girls. 
Collectively, these programs support a range of services that 
address women's health including the provision of 
contraceptives, family planning and counseling, protecting the 
health of pregnant women during and after childbirth, 
addressing child marriage, and gender-based violence, and 
increasing access to HIV prevention and treatment.
    It is important to note that the U.S. by law prohibits the 
direct use of U.S. foreign assistance for abortion as method of 
family planning.
    U.S. support has contributed to significant impact. USAID 
reports that its investment has helped to reduce the chances a 
woman will die in childbirth by more than half in USAID-
priority countries. In addition, contraceptive prevalence has 
increased significantly in these countries and new HIV 
infections have fallen among women in almost all PEPFAR 
countries. Despite these successes, numerous challenges remain, 
and progress has slowed.
    Globally, nearly 300,000 women still die during pregnancy 
and in childbirth, and millions more experience illness and 
severe adverse consequences each year, largely from preventable 
or treatable causes.
    More than 200 million women would prefer to avoid or delay 
child bearing, but are not using the modern method of 
contraception. And one in seven girls faces early or forced 
marriage.
    Further, women are at disproportionate risk of HIV, the 
leading cause of death globally for women age 15 to 49.
    Looking ahead, the population of adolescent girls is 
expected to grow significantly over the next few decades, 
particularly Sub-Saharan Africa, yet the global community is 
not prepared to meet their health needs.
    Among key challenges facing the future of the U.S. response 
are first, while the U.S. remains the largest donor to women's 
health in the world, in recent years, funding has been mostly 
flat and cuts have been proposed. Second, although domestic 
resources have increased in many countries, they have not grown 
fast enough or with enough magnitude to replace external aid. 
And many countries with significant need particularly 
vulnerable to any reduction in U.S. support. Third, most global 
health programs, including those that specifically seek to 
reach women, focus on pregnant women or children under five, 
leaving a gap in available services and programming for 
adolescent girls and young women.
    Finally, legal and policy requirements, including more than 
20 specifically related to family planning and reproductive 
health, more than any other area of global health, can present 
barriers. For example, the reinStated and expanded Mexico City 
policy now known as Protecting Life and Global Health 
Assistance, for the first time applies to nearly all bilateral 
U.S. global health assistance including PEPFAR and a much 
greater number of foreign NGO's than ever before. The policy 
has presented implementation challenges and left service gaps 
in some communities.
    A recent empirical analysis found that when in place in the 
past, abortion rates and pregnancies rose, and use of modern 
contraception fell in the countries most exposed to the policy.
    Most of these challenges are concentrated in countries 
reached by the U.S., suggesting additional opportunities for 
impact, including exploring the use of incentives for 
domestically sourced mobilization specific to women's health; 
better aligning and integrating U.S. efforts internally and 
with others and pursuing multi-sectoral approaches; better 
meeting the needs of adolescent girls and young women; and 
reducing implementation and policy barriers. Together, these 
efforts can help ensure that the next generation of women and 
girls is healthier than ever before.
    I look forward to discussing these issues with you and 
anserine any questions you have. Thank you.
    [The prepared statement of Dr. Kates follows:]
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman Engel. Thank you, Dr. Kates.
    Ms. Crocker.

  STATEMENT OF SHEBA CROCKER, VICE PRESIDENT FOR HUMANITARIAN 
                 POLICY AND PRACTICE, CARE USA

    Ms. Crocker. Chairman Engel, Ranking Member McCaul, 
distinguished members of this committee----
    Chairman Engel. If you could just pull the mic a little 
closer to you.
    Ms. Crocker. Sorry.
    Chairman Engel. No, that is Okay.
    Ms. Crocker. Let me see if I can do that. Better?
    Chairman Engel. I think so, yes.
    Ms. Crocker. Thank you for the opportunity to testify today 
as you examine the challenges facing women's health globally. 
These are critical issues and I am thankful for the committee's 
attention to this matter. I have abbreviated my testimony and I 
encourage the committee to consult my full written testimony 
for further recommendations and I ask that they be entered into 
the record.
    My name is Sheba Crocker. And I am the Vice President of 
Humanitarian Policy and Practice at CARE USA. CARE was 
established nearly 75 years ago when a small group of Americans 
sent the first CARE packages overseas to survivors of World War 
II. Today CARE works in a hundred countries to address the root 
causes of suffering and to provide life-saving humanitarian 
assistance to people in need.
    CARE's work focuses on women and girls because our 
experience has taught us that we must help communities address 
gender inequality in order to respond effectively to crises and 
to their underlying factors.
    Before I begin, I would like to take this opportunity to 
thank this committee and Congress for continued bipartisan 
commitment it has shown for development in humanitarian 
assistance. Helping those in need around the world is not and 
has never been a partisan issue and CARE is grateful that the 
United States has such strong champions for continuing U.S. 
leadership on foreign assistance on both sides of the aisle.
    I would like to focus my remarks on four challenges to the 
health of women and girls in humanitarian settings: inadequate 
funding, lack of access of humanitarian workers to populations 
in need and of those populations to healthcare; social norms 
that expose women and girls to greater health risks; and issues 
that heavily affect or are unique to women, specifically 
gender-based violence and access to sexual and reproductive 
health services which include contraceptives, quality obstetric 
care, pre-and post-natal services, and sexually transmitted 
infections, prevention, and treatment.
    First, although the number of people who require 
humanitarian assistance continues to rise, funding particularly 
for emergency healthcare lags. In 2019, the U.N. requested $2.4 
billion to provide healthcare to vulnerable populations around 
the world, but global contributions totaled just 33 percent of 
that request, only some of which was dedicated to the unique 
needs of women and girls. Moreover, of the total humanitarian 
funding allocated between the years 2016 and 2018, gender-based 
violence prevention and response services received just .12 
percent or only one third of the amount identified as needed 
for gender-based violence prevention and response.
    Second, access of humanitarian agencies to people in need 
and of women to healthcare is crucial. If we cannot reach 
people, we cannot help them. Even when humanitarian workers are 
on the ground, conflicts and natural disasters damage 
healthcare facilities and kill, displace or disincentivize 
staff. For example, at least 60 health facilities in northwest 
Syria alone were damaged in air strikes over just an 8-month 
period in 2019, affecting tens of thousands of people. In some 
societies, women are unable to attend clinics if no female 
staff are present or if male family members cannot accompany 
them, further compromising women's access to healthcare.
    Third, social norms can expose women and girls to greater 
health risks. Women and girls are often expected to nurse 
family members and are also typically the last to receive 
assistance. This means that they are both at a higher risk of 
contracting communicable diseases and are less likely to 
receive the timely care they need. For example, 56 percent of 
confirmed and probable cases in the on-going Ebola outbreak in 
the eastern Democratic Republic of the Congo has been among 
women and 28 percent among children under 18 years old. Just 11 
percent of cases have been reported among men over the age of 
18.
    Fourth, there are some risks that particularly affect women 
and girls, namely gender-based violence and sexual and 
reproductive health. Available evidence suggests that multiple 
forms of gender-based violence remain pervasive in emergencies, 
including emotional, physical, and sexual assault, intimate 
partner violence, sexual exploitation and abuse, and child 
early and forced marriage. Gender-based violence can have 
sexual and reproductive health consequences for women 
compounding the risks inherent in pregnancy and childbirth 
which are dangerous even under the best of circumstances. 
However, for the millions of women who require humanitarian 
assistance and may lack access to healthcare, the risks are 
even higher. Sixty percent of all preventable maternal deaths 
and 45 percent of all preventable newborn deaths occur in 
vulnerable States, many of which are affected by conflict and 
humanitarian emergencies.
    I would like to briefly share three priority areas for your 
action based on CARE's experience. First, the United States 
must prioritize funding for women's health services including 
gender-based violence and prevention and response and family 
planning and reproductive healthcare from the outset of the 
humanitarian response.
    Second, CARE strongly encourages strengthening policies 
that promote the health of women and girls in emergencies and 
addressing policies that restrict access. CARE supports the 
Safe from the Start Act, a bipartisan bill that strengthens the 
humanitarian system's capacity to prevent and respond to 
gender-based violence. Policies that restrict NGO's' ability to 
provide life saving health services such as the Mexico City 
policy, have been shown to reduce access to care and lead to 
poor health outcomes for women and CARE calls for this policy's 
repeal.
    And CARE regrets the administration's decision to halt all 
funding to the United Nations Population Fund, despite 
consistent bipartisan support for that agency. CARE urges a 
speedy restoration of funds to UNPFA.
    And finally, to support the protection of women and girls 
and their access to humanitarian assistance including 
healthcare assistance, the United States should continue its 
long-standing commitment to principled humanitarian actions and 
be a global leader in promoting and ensuring compliance within 
international humanitarian law by all parties to conflict.
    The unique needs of services and girls must be treated with 
urgency during humanitarian response. CARE is committed to 
working with women, girls, men, and boys to elevate women's and 
girls' potential so they can help build stronger and more 
resilient societies. Thank you very much and I look forward to 
answering your questions.
    [The prepared statement of Crocker follows:]
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    Chairman Engel. Thank you very much, Ms. Crocker. Mr. 
Mulumba.

 STATEMENT OF MOSES MULUMBA, CENTER FOR HEALTH, HUMAN RIGHTS, 
                    AND DEVELOPMENT, UGANDA

    Mr. Mulumba. Thank you, Mr. Chairman, Ranking Member 
McCaul, and the members of the Foreign Affairs Committee. I 
appreciate the attention this committee is devoting to global 
women's health and I welcome the opportunity to share some of 
the challenges vulnerable communities, notably women and 
girls----
    Chairman Engel. Mr. Mulumba, let me ask you again, could 
you pull the microphone a little closer to you?
    Mr. Mulumba. Thank you. I appreciate the attention this 
committee is devoting to global women's health and I welcome 
the opportunity to share some of the challenges vulnerable 
communities, notably women and girls in Uganda face in 
accessing healthcare.
    I have summarized my opening statement, but ask that the 
full, written testimony be entered into the record.
    For close to 15 years, I have been working as a health and 
human rights advocate. In my current role as the Executive 
Director of my organization, my work focuses on ensuring social 
justice in health systems for the most vulnerable. My 
experience with the health system is much longer than my 
professional life. I grew up with a mother who was a nurse 
working in private not for profit health place, who also had a 
small clinic. I still clearly remember verbal autopsies and 
stories of how women died. The women with babies that flocked 
to the health facility and my mom's clinic who needed treatment 
interventions, but always had difficulty meeting the bills for 
care. As a young boy, I did not inquire into the deaths and 
barriers that women were facing daily. I was not a lawyer and 
not an activist yet.
    I grew up knowing child delivery as ``Lutalo Iwa Bakyala,'' 
that is in my language. This means it is a battle for the 
women. Going through child delivery was and is still a matter 
of life and death. I also remember a number of cases that 
involved young girls, and sometimes married women died after an 
unsafe abortion. Emergency cases of obstetric care after unsafe 
terminations were common then and continue to be common today. 
Lack of access to contraceptives, deplorable maternal health 
services, and a highly restrictive legal environment on access 
to safe abortion services continue to dominate our health 
system to date.
    As a lawyer and a social justice activist now, I keep 
wondering why do women and girls continue to face 
disproportionate gaps in access to care and rights? Why has the 
global community not done enough?
    In Uganda, for instance, we still lose 16 women each day to 
preventable issues in pregnancy and childbirth. I have 
witnessed, advocated, and even litigated cases in which women 
are struggling to have what would ideally be basics for 
controlling their bodies, from access to maternity kits, to 
supporting safe deliveries of women and their newborns, to 
contraceptive methods of their choice.
    I note and I agree that a population's health and well-
being is primarily a national responsibility, Mr. Chairman. But 
at the same time, I note that the health is also a global 
responsibility which creates duties on other States to ensure a 
safe and healthy population, with particular attention to the 
needs of the world's poorest people. This particular 
responsibility on other States is often misunderstood, 
underrated, abused, and lately traded as part of politics.
    The reinstatement and the expansion of the Global Gag Rule, 
Mr. Chairman, demonstrates how a repressive political decision 
from another country can affect population health and well-
being in countries like mine. The Global Gag Rule has led to 
cutting off funding for much needed health services, especially 
among the communities that are already under served. As a 
result of the Global Gag Rule, my organization has lost key 
advocacy grants. We had to close our work halfway into a 4-year 
USAID project on advocacy for better health, despite progress 
and good performance. The accusation then was that we are 
interpreting the laws what a lawyer does every single day.
    So the reason cited then was that we had failed to sign the 
addendum that incorporates the Global Gag Rule. The closure of 
this project brought immediate termination to our advocacy 
interventions. And some of these promoted accountability in the 
supply chain of essential medicines in Uganda, including anti-
malarials and HIV testing kits. The goal of our work was 
ultimately to ensure patients had access to the needed 
facilities where they accessed them. The closure also meant 
immediately terminating the contracts of our key project staff 
and distortion of coalition work that we are doing with other 
organizations that hold the government accountable on health 
systems.
    It is not an easy, Mr. Chairman, to simply comply and keep 
the resources or simply make a choice to lose the access to 
these resources. Jobs and indeed lives are on the line. 
Nonetheless, my organization's work cannot be just in one area 
of health and not another. I think this would highly compromise 
the values of the institution that we have.
    Through my work, I can make the following conclusions, Mr. 
Chairman. I have witnessed a clear linkage between politics, 
the law, and health outcomes. In the area of reproductive 
rights, it is undeniable that political decisions have played a 
critical role in shaping the development of reproductive rights 
approaches and indicators for women. Unfortunately, our 
fundamentalism sometimes has continued to dominate over women, 
girls', and mothers' health, especially when it comes to their 
ability to decide when, if, and how many children to have. 
Maternal and reproductive health should not be a privilege for 
some, a but a right for all.
    My hope for Uganda, Mr. Chairman, and the committee, is 
Uganda and the world that is where a future of women, and 
mothers, and girls, no one dies simply because of their 
biological composition. Thank you very much.
    Thank you
    [The prepared statement of Mr. Mulumba follows:]
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    Chairman Engel. Thank you very much, Mr. Mulumba.
    Ms. Bos.

             STATEMENT OF LISA BOS, WORLD VISION US

    Ms. Bos. Chairman Engel, Ranking Member McCaul, and members 
of the committee, thank you for this opportunity to testify 
today on the important issue of women's health. I greatly 
appreciate your interest in this topic and hope that my 
testimony today will shed some light on how faith-based 
organizations like World Vision are prioritizing and improving 
the health of women, girls, and their families around the 
world.
    As one of the largest faith-based organizations working in 
humanitarian relief and development, World Vision's work 
reaches vulnerable children and families in nearly 100 
countries around the world. We have nearly one million private 
donors across every State and congressional district, partner 
with over 16,000 churches around the country, and work with a 
wide variety of corporations and foundations in addition to 
public donors like the U.S. Government.
    In our work, we seek to ensure that every child has the 
opportunity to reach their full potential and a healthy start 
in life is crucial to transforming the lives of children and 
their families. World Vision is a pro-life organization and we 
believe that human life begins at conception. We do not take a 
position on the Mexico City policy and have not taken a 
position on this policy under any administration.
    Given that World Vision is a child-focused organization, 
much of work on women's health is focused on maternal health, 
ensuring that a woman's reproductive years are also her 
healthiest years. In seeking fullness of life for every child, 
we believe all mothers and their babies deserve to have the 
basic information, medical support, and care needed to ensure 
safe deliveries, protection from preventable disease, but we 
also work on many issues impacting adolescent girls as well, 
including programs that address child marriage, early 
pregnancy, and menstrual hygiene.
    We should be proud of the progress that has been made in 
women's health and maternal mortality and the significant 
contributions of the U.S. Government to that effort, but we 
cannot rest in this work. Progress is possible. We have seen 
it, but it is also fragile. We know from experience that 
vulnerabilities in health systems are easily exposed in crisis 
or disaster. We know that climate change will continue to 
impact health in growing ways. We know that there are places 
where appropriate resources and services are still not 
accessible. We know that we have challenges with quality and 
equitable care.
    To drive all of this, I cannot emphasize enough the need 
for better data. Legislation that this committee has supported 
like the Foreign Aid Transparency Act has focused on improving 
data from USAID, but quality global health data that show what 
interventions are being supported by USAID and where are still 
lacking.
    As an implementing organization, data are crucial to our 
own decisionmaking and program design, not to mention how 
important it is to taxpayers who are funding these investments. 
I would also like to emphasize a point that you will find 
throughout my written testimony which is the critical role of 
faith leaders in addressing global health challenges.
    Faith leaders have considerable influence in their 
communities. Unfortunately, like other leaders, some faith 
leaders spread misinformation creating social barriers that 
prevent women from visiting health facilities, getting tested 
and treated for HIV, and using birth-spacing methods. Misguided 
influence can also encourage child marriage and the poor 
treatment of women and girls and discourage the involvement of 
men in maternal and child health.
    Our training process for faith leaders replaces 
misinformation and stigma with truth and acceptance. Our 
program teaches about birth spacing and the importance of good 
nutrition for children and pregnant women, encourages greater 
involvement of men at all levels of health, and addresses 
difficult issues such as HIV and gender norms.
    We have a moral imperative to transform the lives of women, 
girls, and their communities to give them good health, hope, 
and opportunity. I hope this hearing today will help us all 
recommit to this work and unify us around our shared goals. I 
look forward to our continued discussion and any questions you 
might have.
    [The prepared statement of Ms. Bos follows:]
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    Chairman Engel. Well, thank you very much Ms. Bos and thank 
all of you very much for excellent testimony.
    I will now recognize members for 5 minutes each and 
pursuant to House rules, all time yielded is for the purposes 
of questioning our witnesses.
    So I will start by recognizing myself. And let me say as I 
mentioned in my opening statement, I am very disturbed by the 
administration's reimposition and expansion of a Global Gag 
Rule. In 2018, the State Department released its 6-month review 
of its policy, where they claim there have been no service 
disruption due to the policy. Yet, that is not consistent with 
what we have heard from the field and seen in the media.
    So let me start with you, Dr. Kates. What have you seen in 
the research that has been produced about the expanded Global 
Gag Rule, and what do we already know from previous versions of 
the policy?
    Dr. Kates. Thank you for your question. First, I wanted to 
say on that 6-month review that you mentioned, the review also 
noted that it was too early at that time to assess impact. So 
there is another review that is expected which might have more 
information.
    I can tell you with some of the analyses we have done at 
KFF and some of the other analyses that have been put out. One 
of the things we looked at when the policy was first put in 
place and expanded was how many of the countries in which the 
U.S. provides global health assistance have abortion laws that 
are more permissive than the Mexico City policy would allow. So 
in other words, where is the U.S. working where there might be 
policies of the U.S. at odds with country policies?
    What we found at the time was that more than half of the 
countries in which the U.S. provides bilateral global health 
assistance did have an abortion law that was more permissive 
than the policy in at least one case. We have just updated that 
to the more recent period and found a similar finding. So that 
just shows that it presents potentially some challenges for 
providers and others working in those countries where there is 
a difference between a country policy and the U.S. policy.
    We have also looked at the number of non-governmental 
organizations, foreign non-governmental organizations that may 
be subject to the policy because we were interested to see 
how--what does the expansion look like potentially. We looked 
at this soon after it was announced and we found out that 
conservatively there were probably around 1300, at least, 
NGO's, foreign NGO's, that were subject to the policy. And this 
is a conservative estimate because it is very challenging to 
get data on sub-recipients of U.S. support.
    What we also found is that most of these NGO's were newly 
exposed to the policy for the first time, so they had not had 
to take a position on a policy when it had been in place in 
prior iterations.
    In terms of studies that have come out, probably the most 
well-known and largest that has been done was just published in 
The Lancet last year. It is a large scale, empirical, economics 
analysis that looks across the periods of time to better 
understand when the policy has been in effect, was there a 
correlation between the policy and health outcomes. This is 
often a challenge to look at. You have to look retrospectively. 
What this study found was that there was a pattern. When the 
policy was in place abortion rates went up. Pregnancy rates 
went up and contraceptive prevalence went down.
    There was also a recent analysis that was done by amFAR and 
Johns Hopkins University in which they surveyed PEPFAR 
implementers to assess PEPFAR implementers who were newly 
exposed to the policy having to adjust what they were doing. 
And what they found was that a third had actually altered their 
operations including service delivery. And that included 
services like HIV testing, TA, things that were important for 
the HIV response, closing a youth-friendly clinic. In one 
particular district in one country, a major provider of 
voluntary medical male circumcision had actually stopped 
providing its services leaving a gap there.
    Human Rights Watch has also put out studies showing that 
they have found that providers have canceled services including 
things like cervical cancer and HIV testing.
    And finally PAI has released several studies from the field 
finding similar results. And this is an on-going thing to look 
at to be able to assess what the policy's impact might be on 
actual lives that the U.S. is trying to save and reach.
    Chairman Engel. Thank you, Dr. Kates. Let me ask you, Ms. 
Crocker. The humanitarian system today is facing a whole array 
of crises from Venezuela to Syria to Yemen and we see time and 
again across these conflicts the outsize impact they have on 
women and girls.
    Can you highlight, Ms. Crocker, some of the ways women's 
health is uniquely jeopardized in conflict?
    Ms. Crocker. Thank you for the question, Chairman. Women 
face a range of additional health challenges in the face of 
conflict which include increases in gender-based violence, 
including intimate partner violence, and you know, things like 
access to family planning.
    Health systems are always degraded further during a 
conflict, and as I noted in my opening statement, women both 
have some unique challenges that they face and also are often 
the last to reach--to be able to get assistance either to reach 
it or to have assistance given to them.
    And so what we see time and again, for example, just 
yesterday, we released a statement with a number of other big 
NGO's about the situation in northwest Syria where over the 
course of 2019 in northern Syria as a whole, 85 health 
facilities were targeted. CARE was running, has been running, a 
maternity and pediatric hospital in northwest Syria which we 
just had to suspend services at due to a nearby hospital having 
been hit, but because so many hospitals in the surrounding area 
had been hit with this hospital sort of being flooded with 
people in need of care, and we are seeing almost a million 
people now in northwest Syria because of the increase in 
violence there who have been displaced. And these situations 
always impact women and girls more.
    In camps, some things that sort of not always top of mind, 
but end up being incredibly important to the health of women 
and girls include questions around placement of water and other 
commodities that are needed. When they are placed very far away 
from the center and women have to go, it places them at 
additional risk of facing gender-based violence as an example. 
And again, because health systems generally are degraded, it 
means that things that women just need such as access to family 
planning, access to contraceptive, things the life of CARE's 
work have been shown to be the No. 1 thing to help prevent 
maternal mortality are just more challenged.
    Chairman Engel. Thank you very much. I will now call on 
members for questioning. I will start with Mr. McCaul, our 
Ranking Member.
    Mr. McCaul. Thank you, Mr. Chairman. I want to thank all of 
you for being here today. The NGO's are really vital to our 
missionary work across the world and you really do God's work 
here on earth. Kaiser Foundation, CARE, World Vision, and sir, 
what you do in Uganda, is to be commended.
    Ms. Crocker, thank you for mentioning the bipartisan nature 
of this committee. We have accomplished I think more than any 
other committee in this Congress and in this very partisan, 
hyper-partisan time in our history.
    And I want to list some of those accomplishments because I 
think it is worth mentioning, Mr. Chairman. We re-authorized 
PEPFAR which we know is saving millions of lives. We passed the 
Global Fragility Act. When you talk about conflict, this is an 
attempt to bring our State Department and USAID and Department 
of Defense together to stabilize those destabilized nations, 
particularly in the Sahel region where the conflict is getting 
worse, not better. And we know when that happens it impacts 
women first.
    The Global Hope Act, as I mentioned, Mr. Mulumba, I will be 
Botswana in 2 weeks. So this is at the Texas Children's Clinic 
and they are also in Uganda, in your country, introducing the 
pilot program to do what we do with PEPFAR and HIV, with 
childhood cancer, building on the infrastructure that we laid 
with the PEPFAR HIV program.
    We just passed on the floor the other week the Keeping 
Girls in School Act which I think it was Stated by one of my 
colleagues from the military, the most powerful weapon against 
extremism is a girl with a book and education.
    We passed the Women's Economic Empowerment Act to help 
boost women's rights and economic rights throughout the world, 
particularly in Africa. And finally, the Child Marriage Act 
where we see children at the hands of their governments getting 
married at a very, very young age.
    And so I guess I have a lot of questions to ask, but one 
with respect to World Vision, Ms. Bos. You mentioned, and I 
appreciate the faith-based nature and I think the faith-based 
community is very generous and is leading, but you mentioned 
with some countries how they work actually against women's 
treatment and I wonder if you could expand on that and which 
countries are you talking about?
    Ms. Bos. So when we are talking about access which I hope 
is what you are getting at a little bit, access for women to 
care, there are often a lot of misperceptions about what it 
means to go to a health facility. Sometimes those are cultural 
barriers. Sometimes those are religious barriers. There is a 
lot of misinformation that happens in communities and we found 
that for HIV programs, gender-based violence programs, early 
marriage, pregnancy, and family planning issues.
    So really what we feel is important and the role that we 
can really play uniquely at times as a faith-based organization 
is how are we working with those faith leaders who play such a 
critical role in either sharing good messages with their 
community or sharing at times misinformation.
    So the trainings that we do through our program model are 
really critical. We use biblical text for pastors. We use the 
Quran when we are working with the moms in Muslin contexts. So 
this is an inter-faith approach depending on the context, just 
to make sure that churches, faith leaders, because of the role 
that religion plays in people's lives, that that is not serving 
as any sort of barrier for women to get the care and services 
that they need, both for themselves and for their children.
    Mr. McCaul. And following up with the remaining time I 
have, Ms. Crocker, Ms. Kates, and Mr. Mulumba, if you care to 
talk about this, how can we--what are kind of some lessons 
learned of these private-public partnerships? Where do you see 
improvement? How can we do a better job?
    Dr. Kates. Thank you for the question. Obviously, we have 
to do something different in the future to have greater impact, 
right? So public-private partnerships are one that the U.S. 
Government has pursued and some have been quite successful.
    One I want to highlight is PEPFAR's Dreams Initiative which 
was started a few years ago and the idea behind it was because 
adolescent girls and young women are so vulnerable to HIV, much 
more likely to become infected, 6,000 new infections a week 
among young women, this is a population that faces multiple 
barriers, many of which we heard. What PEPFAR decided to do was 
to try to reach that population with all of the supports and 
address the structural challenges they may fact, lack of 
education as you were talking about, challenges with income, 
needing to find ways to have access to employment.
    How could PEPFAR do that? PEPFAR formed a major public-
private partnership working with many private companies and 
donors to really build this idea out and has since been able to 
expand it to 15 countries. What is really exciting about this 
initiative is that the data show that it is actually working. 
New HIV diagnoses among young women in the districts that the 
intervention is in are going down. And that is a really 
important thing. So the public-private partnership has 
leveraged commodities. It has leveraged other platforms. It has 
leveraged other sectors.
    I actually heard Ambassador Burk speak yesterday about this 
and she talked specifically about the education sector and her 
intention to look to other donors who are specifically working 
in that sector to build on what PEPFAR has done. It is very 
clear that those kind of partnerships, whether it is with 
private companies, foundations, other governments, are really 
essential.
    Mr. McCaul. Ms. Crocker, just very briefly.
    Ms. Crocker. Thank you. I think I will pick up on maybe two 
things. One is just in addition to some of these sort of larger 
public/private partnerships that were just discussed, we have 
seen real success as CARE, for example, in the Great Lakes 
region using village savings and loan groups and other forms of 
collective action to mobilize communities and importantly, to 
engage men and boys to tackle social norms which, as you know, 
are so often what underpin some of these gender and power 
inequities that lead to things like increased gender-based 
violence.
    And so the other thing I wanted to just pick up on was your 
mention of women's economic empowerment which this committee 
has taken such a lead on and just the important link between 
women's health as an underpinning and a basis for a healthy 
economy. And so as the committee continues to pursue the 
importance of women's economic opportunity, just to make sure 
that we all acknowledge and understand the importance of the 
link between a focus on women's health, including women's 
health and humanitarian emergencies and development settings 
and what that can do to help further women's economic 
empowerment.
    Mr. McCaul. That is excellent. Thank you so much for what 
all you do and I yield back.
    Chairman Engel. Thank you, Mr. McCaul. Mr. Sires.
    Mr. Sires. Thank you, Chairman, for holding this hearing 
and thank you for our witnesses being here today.
    Ms. Crocker, CARE released a report last year indicating 
that Venezuelan women and girls migrating to Colombia are 
extremely at high risk of gender-based violence and human 
trafficking. And in my trip to Venezuela and Colombia last 
year, I spoke with single mothers who were deeply concerned 
about their safety and their children.
    Can you speak about the dangers facing these women and 
children, as they flee this this crises and what else can we 
do, the U.S. and international communities to help women and 
children in this area?
    Ms. Crocker. Thank you so much for the question. There are, 
as you are probably aware, 4.7 million refugees and migrants 
already from Venezuela and an expectation that there will be 
4,000 people a day fleeing that country over the course of 
2020. This is due to numerous factors that you are very 
familiar with that are bedeviling the country of Venezuela 
right now.
    And what CARE found in that rapid gender assessment that we 
did on the Colombia and Venezuela border was almost a 
normalization of gender-based violence against Venezuelan 
refugees and migrants that are leaving that country. And what 
we are also seeing is that many of the health systems in a 
number of the host countries which are already overburdened. 
For example, in the Colombian city of Cucuta, births have 
increased by 150 percent and maternal morbidity has increased 
by 71 percent. And for those that remain inside Venezuela, 
there are also increasing challenges. For example, much more 
difficulty in accessing contraceptive care and contraceptive 
services. The price of contraceptives has--it is estimated to 
have increased 25 fold in the past 5 years inside of Venezuela. 
And quality pre-natal and delivery services are difficult to 
obtain which is, of course, partly why, as you know, so many 
Venezuelan women are ending up fleeing or going across the 
border and having to come back.
    So it is very important. It is an enormous crisis at the 
moment that is not getting enough attention from a global 
perspective. And so the totality of the crisis is something 
that we need to be more focused on as both a priority, a place 
for greater U.S. leadership, as well as global humanitarian 
funding, but very important to also recognize the ways in which 
this particular crisis is really impacting women and girls in a 
very direct way.
    And so I really thank you for raising that issue because it 
is one that CARE continues to be focused on. We are also doing 
Rapid Gender Assessment throughout the region to look at the 
health impacts of Venezuelan migrants and refugees who are 
leaving and ending up in a number of other of countries across 
the region as well.
    Mr. Sires. I read an article in The New York Times that was 
stating that the children at the schools because of lack of 
food and lack of medicine. I wonder if you can talk a little 
bit about that?
    Ms. Crocker. I saw the same story. I do not have first-hand 
knowledge of that.
    Mr. Sires. Okay.
    Ms. Crocker. But I think what we are seeing and what 
certainly the U.N. and a number of NGO's have been seeing and 
reporting coming out of Venezuela is an overburdened health 
system, crumbling public institutions and services and 
capacities, a crumbling economy, right? And all of these things 
lead to inability to access basic services, both inside of 
Venezuela itself as well as for those who are fleeing.
    And so it is shocking when we read reports like that and I 
think it only highlights the need that we should all be--the 
need we all have to be paying attention to what is going on 
right near us and to be paying appropriate attention and again, 
focusing on the funding and the prioritization that is needed 
to address the real dire humanitarian challenges inside of 
Venezuela, as well as the needs of those who are fleeing the 
country.
    Mr. Sires. Just a quick question. I know that the 
Venezuelan issue is just not Colombia. Now it has expanded into 
the other countries in the region and not enough attention 
seems to be focused there because those countries really do not 
have the ability to take in all these migrants and the health 
issues, they cannot deal with it because they have their own 
population to deal with.
    I just do not see the world coming to the aid of this 
travesty that is happening. Thank you very much.
    Chairman Engel. Thank you, Mr. Sires. Mr. Smith.
    Mr. Smith. Thank you very much, Mr. Chairman. Mr. Chairman, 
on Friday, there was a White House event and we were asked a 
few of us, including the Ranking Member, marking the 20th 
anniversary of the Trafficking Victims Protection Act. I am the 
prime author of that bill. It has saved countless women and 
children and many men stuck in labor trafficking, especially, 
and none of you have mentioned that. I do hope you will speak 
to that issue because I do believe modern-day slavery is one of 
the most heinous crimes. It is disproportionately focused on 
women and I have met many women who have been trafficked. I 
have had hearings with trafficking victims and they need our 
love, our concern, and they certainly need rescue.
    Second, according to the World Health Organization, between 
2000 and 2017, the maternal mortality rate declined by 38 
percent worldwide and also according to WHO the majority of 
maternal deaths can be prevented if women give birth in 
hospitals or attended to by skilled health personnel with 
access to emergency obstetric care and safe blood is very much 
a part of that.
    I do believe that USAID has embarked and this is part of 
PEPFAR as well, to try to provide a means to assist these 
women. Countries should have a plan. Communities should have a 
plan so that if the woman is pregnant, particularly in the 
final 3 months of that child's life before birth, that she will 
be attended to by someone if there is a problem so that we can 
dramatically continue to reduce maternal mortality.
    Let me also point out that PEPFAR was the brainchild, 
frankly, of George Walker--George W. Bush. And this man over 
here, where is he now? My good friend and colleague, Henry 
Hyde, joined by Tom Lantos, in a bipartisan way pushed through 
the PEPFAR legislation and that has saved countless Africans 
and others from the horrible death due to that terrible disease 
called HIV/AIDS, also malaria and the other issues that are 
attendant to opportunistic infections as well have been greatly 
mitigated.
    In 2018, I was the prime author of the re-authorization for 
5 years of PEPFAR, joined by Barbara Lee and a group of 
bipartisan lawmakers so about $30 billion, roughly, will be 
authorized and hopefully appropriated to help those.
    Now one of the points that is brought out that women 
represent the majority of those served by PEPFAR. ARV therapy, 
for example, 66 percent or 9.8 million of those with ARV 
therapy were women. And I think that is a great thing that this 
policy is having such a positive impact.
    Now on the Protecting Life in Global Health Assistance, 
that legislation or that policy I should say, is designed to 
ensure that U.S. taxpayers do not subsidize foreign non-
governmental organizations that perform or promote abortion as 
a method of family planning and build on what was originally 
called the Mexico City policy created by Ronald Reagan.
    In 1985 and 1984, I offered amendments on the floor to 
affirm the policy and it was widespread statements made on the 
floor in debate that nobody will accept this. Well, the 6-month 
reviews found 99.5 percent of the people that we want to 
support accepted those pro-life guidelines.
    Let me also point out, you know, the issue of abortion, we 
forget somebody when we talk about that. I do believe we need 
to care for both. We need to love both, mother and baby, and do 
everything humanly possible to ensure that there is a safe 
delivery. I am the author of Pain-Capable Unborn Child 
Protection Act. We know beyond any unreasonable doubt that 
unborn children feel pain at least from the 20th week on and 
maybe even earlier and because of prenatal surgery children 
ought to be seen as another patient, the unborn child, the 
other patient, along with the mother when they present to a 
healthcare professional.
    Abby Johnson, some of you may have read her book, maybe 
not, maybe this panel has or has not, but she was a Planned 
Parenthood activist, ran a clinic, an abortion clinic in Texas 
for 8 years. When she assisted in an abortion and this was the 
first, whether it was an ultrasound guided abortion, she held 
the probe and she saw that baby dismembered right before her 
eyes. She walked out the door and said I will never be a part 
of this again. Now she is a very articulate spokeswoman for the 
pro-life cause.
    Birth is an event that happens to all of us. It is not the 
beginning of life. Ultrasound has shattered the myth that 
somehow there is no baby there. So I would encourage you, 
Bernard Nathanson, the founder of NARAL, one of the three co-
founders, he said I have come to the agonizing conclusion that 
I presided over 60,000 deaths. He wrote that in The New England 
Journal of Medicine and became a strong pro-lifer. Let us 
affirm them both. This policy affirms them both and says 
contraception, this does not cut it by one dollar. It says that 
who we support, not just what, matters. And if a group is 
trying to bring down pro-life laws in other countries or 
provide abortions, perform dismemberment or chemical poisoning 
abortions, we have got to look at the facts, just like Abby 
Johnson did and say what actually happens in that abortion? A 
baby is dismembered or a baby is killed. RU-486 starves the 
baby to death, one is a chemical and the other provides a 
expulsion of the child from the womb.
    These children deserve better. Women deserve better. And 
you know, I would ask Mr. Mulumba, you know, you know what the 
three exceptions are to the Protecting Life and Global Health 
Assistance are because you turned down the policy?
    Mr. Mulumba. Thank you, sir, for the question. My expertise 
is on the implications of the policy back home.
    Mr. Smith. So you do not know the three exceptions? I am 
really out of time. The exceptions are rape, incest, and life 
of the mother. We do not want family planning abortions and 
that is what the policy starting with Ronald Reagan was 
designed to ensure.
    Chairman Engel. Thank you, Mr. Smith. Mr. Bera.
    Mr. Bera. Thank you, Mr. Chairman. I disagree with my 
colleague on the perceptions here, but there is a lot that I 
have heard today where we actually agree on. I am glad that the 
minority party really cares about maternal health. I am glad 
that they care about child health. I am glad that we heard the 
President last night talk about wanting to invest millions of 
dollars in reducing maternal health.
    Our foreign policy should be based on American values and 
what we think about. And if we think about American values, 65 
percent of women aged 15 to 49 use contraception methods. 
Ninety-nine percent of women who have been sexually active at 
some point have used contraception. Those are American values. 
And that is voluntary family planning. They are choosing to use 
those methods. Yet, we talk about being a faith-based nation, 
98 percent of Catholic women have used modern contraception. 
Ninety-nine percent of Protestant women have used modern 
contraception. Those are American values.
    So we are talking about making voluntary family planning 
available around the world to reduce maternal mortality, to 
reduce child mortality. In developing countries when you do 
proper pregnancy spacing from 1 year to 2 years, you nearly 
halve infant mortality rates. So we all should agree on making 
voluntary family planning available to women around the world, 
one of the most effective things.
    I am glad that the ranking member talked about the things 
that we passed: PEPFAR, the Global Fragility Act, particularly 
focused on the youth bulge in Sub-Saharan African focused on 
fragile States in that region. The one thing that we actually 
could do to address the youth bulge is make voluntary family 
planning readily available to empower women.
    The Keeping Girls in School Act, the one thing we could do 
is to make sure there isn't that unintended pregnancy by making 
voluntary family planning available to those young girls. 
Women's Economic Empowerment Act, if we actually want to have 
impact for women around the world, we ought to put them in 
charge of their own reproductive health and allow them to do 
active pregnancy spacing.
    Dr. Kates, let me ask you a question. When you look at the 
impacts of the Global Gag Rule, both in past years and through 
this administration's expansion, has it limited access to 
voluntary family planning?
    Dr. Kates. So as has been mentioned the policy--U.S. policy 
supports voluntary family planning and that is part of policy 
and the U.S. provides funding, is the largest donor in that 
area in the world. But as I pointed out, the implementation of 
the policy has presented barriers and there has been documented 
studies looking--going into the field and talking to providers 
and looking at what has happened and doing surveys to say that 
they have faced barriers in being able to implement the 
programs that they are legally able to provide. They have lost 
partners. They have closed services. So it is not as simple as 
something as something is funded and the policy does not affect 
that. I think that is the complication here and what is very 
hard to assess, but is clearly being seen in the field.
    The study I mentioned from The Lancet is important to note 
because it looked back in different periods to try to say is 
there a relationship between certain health outcomes because 
ultimately that is what we are looking at, health outcomes, and 
the policy. And it found a pretty strong relationship. That 
definitely warrants further attention because one of the 
challenges is we cannot immediately measure health impacts, we 
might not see the negative effects if there are any for years 
to come.
    Mr. Bera. My impression is the way the administration 
implemented the Global Gag Rule. It has had this rebound 
effect, closing family planning clinics, et cetera, and 
limiting access.
    In the limited time I have left, Ms. Crocker, I had the 
chance to visit the Zaatari refugee camp in Jordan with the 
chair and visited the maternity clinic that UNFPA is running. 
It was a pretty amazing facility. There was State Department 
funding to help start it and of the 7500 babies that were born 
at the time I visited, there was not a single maternal death. 
Pretty impressive. That is what UNFPA can do.
    Is that clinic still running and what is the impact of our 
not properly funding the UNFPA?
    Ms. Crocker. Thank you for the question and I am so glad 
you had the chance to travel with us. The clinic happily is 
still operating and now there have been 12,000 live births 
without a single maternal mortality at the Zaatari camp, over 
12,000 live births. Until the U.S. stopped funding UNFPA in 
2017 every bassinet in that camp displayed a U.S. flag.
    As of July 2019, the UNFPA was facing about a $200 million 
gap in the over $500 million that it had asked for to date by 
that point. And so while some other donors have stepped in to 
try to help fill the gap since the U.S. has stopped funding, 
there still is a very significant gap.
    What we can talk to is the incredible good work that UNFPA 
does around the world in over around 150 countries. And most 
particularly, I think, with the focus on what they do in 
humanitarian response where they are sometimes the sole 
provider of quality reproductive and obstetric care. But they 
do even more than that. So in the ways in which CARE partners 
with them around the world, they do everything from providing 
clean birthing kits to training midwives to dealing with 
gender-based violence to dealing with prevention and treatment 
of sexually transmitted infections, as well as again the very 
important access to both family planning and reproductive 
healthcare in ways that are deeply needed in the context of 
humanitarian crisis and in certain circumstances where UNFPA is 
the only operator providing those services.
    Mr. Bera. So if we actually care about maternal health, if 
we care about child health, if we care about empower women and 
girls, we ought to fund UNFPA.
    Chairman Engel. Thank you. Mr. Chabot.
    Mr. Chabot. Thank you, Mr. Chairman. Ms. Bos, I will begin 
with you if I can. Back in 2003, I was the lead sponsor in the 
House on the Partial-Birth Abortion Ban Act which went all the 
way to the U.S. Supreme Court. President Bush signed it into 
law. It was appealed with the U.S. Supreme Court and it was 
upheld in the Supreme Court.
    I have also been a long-time supporter of the Mexico City 
policy, both in this administration and I would like to thank 
President Trump for that and under President Bush's 
administration.
    So if I could ask you this, has the administration's 
protecting life and global assistance rule impacted your 
ability in any way to provide life-saving treatment and other 
health services to women across the globe?
    Ms. Bos. The short answer to that would be we have had some 
additional administrative requirements, but we have our own 
internal policy, again as a pro-life organization, where we 
neither receive nor give funding to organizations that provide 
abortions. So from a practical operational standpoint in our 
programs, I am not aware of any impact, but there has been some 
administrative, slight administrative burden, just we have to 
ensure our partners are complying so that we can continue doing 
the work that we want to do.
    Mr. Chabot. Thank you. Ms. Crocker, let me turn to you for 
a different question. A few congresses back, Senator Rubio in 
the Senate and myself and some other members here in the House, 
it was a bipartisan bill, passed legislation, the Girls Count 
Act which, in essence, encouraged the State Department to work 
with other governments to make sure that children, especially 
girls, were actually registered upon their birth.
    We have seen time and again where if especially girls 
aren't registered, they basically can disappear into all kinds 
of horrific circumstances. They can be trafficked, 
international gangs. People do not know they exist, so they can 
be sold off into horrific circumstances.
    So could you discuss how birth registration or lack thereof 
could impact access to healthcare for women and girls?
    Ms. Crocker. Thank you for the question. It is not actually 
something that I am expert in or have knowledge of myself, so I 
wonder if I might ask if my co-panelists might be able to came 
in and address this question.
    Mr. Chabot. If somebody else wants to handle it, I am happy 
to hear that. Yes, Ms. Bos.
    Ms. Bos. I am happy to jump in, Mr. Chabot. I have seen 
some of our birth registration programming in Kenya. It really 
is vital and thank you for championing that issue because if 
any child does not have a birth certificate, the lack of access 
to education, to health services, it is really as if that child 
does not exist. So it is a critical piece. It is something we 
are trying our programming in, just recognizing the barriers 
that follow that child if they do not have that simple piece of 
paper at the beginning.
    Mr. Chabot. Thank you. And then one final question, similar 
to that, Senator Rubio over in the Senate, and myself and 
others here in the House, pushed a bill called Protecting 
Girls' Access to Education Act and it was also signed into law 
by President Obama which seeks to promote education in conflict 
zones, in conflict settings.
    In your work, do you see a correlation between access to 
education and access to healthcare?
    Ms. Bos. Absolutely, and we found that the lack of access 
to formal education really does increase vulnerabilities, 
especially for girls. Being in school actually helps protect 
them from gender-based violence, early marriage, early 
pregnancy. So it is really critical.
    Right now in places like Bangladesh, we are working in 
Cox's Bazar. There is not formal education. We are working with 
UNICEF on some informal mechanisms, but it is really an 
important issue in these protracted crises, working with 
displaced populations, access to formal education is a huge 
need.
    Mr. Chabot. Thank you very much. Mr. Chairman, I yield 
back.
    Mr. Levin [presiding]. Thank you, Mr. Chabot. I now 
recognize myself for questioning.
    Last fall, I was in Bangladesh with CARE on a trip there 
and our trip mainly focused on nutrition. So I was not 
expecting to hear about the impact of the Global Gag Rule, but 
one of the partners we met with highlighted the Global Gag Rule 
as a barrier to their work.
    Bangladesh is a country where more than one in three 
children under the age of five suffer from chronic 
malnutrition. But I heard of cases in which the U.S. could not 
allocate precious global health dollars to the organization 
best suited to meet the needs of those 5.5 million children. 
Tragically, we are only able to fund groups willing to operate 
within this administration's extreme ideology instead of our 
most trusted, capable, and experienced implementers.
    Dr. Kates, I was surprised and disturbed to see the far-
reaching impact of this harmful policy. Would you talk us 
through the scale of the expanded Global Gag Rule outside of 
family planning and reproductive health programs narrowly 
speaking?
    Dr. Kates. Thanks for the question. So the policy as 
announced in 2017 expanded upon all previous versions and now 
it encompasses virtually all of U.S. bilateral global health 
assistance. So that means anywhere between $7 and $8 billion a 
year, depending to the extent that that money goes to a foreign 
NGO. This includes HIV programming, maternal and child health, 
nutrition as you mentioned, the President's Malaria Initiative, 
all of the sort of main areas that the U.S. works in. So that 
opens up a whole new set of programs.
    We have also, as I mentioned earlier, have looked at the 
number of NGO's that might be affected and we found that 
conservatively it is at least 1300, probably many more because 
there are so many other sub-recipients.
    Mr. Levin. Oh, 1300 NGO's.
    Dr. Kates. In the sense that they would have to certify--or 
make a decision about compliance with the policy. And I think 
just to pick up on something you said, what we have seen in 
studies and other things is many of these implementers are 
quite confused about the policy. They are not sure if it 
applies to them. What it means for what they do provide and 
some have over-implemented it, meaning that they think that 
they cannot do a service when they can. And that can create 
service challenges.
    One of the other challenges to think about from the 
perspective of a barrier, as you mentioned, some of these 
partners are the most trusted in their communities and are the 
places maybe the only provider in a particular part of a 
country. So affecting their ability to participate in the 
program could really affect the reach of the U.S. Government 
for its health goals.
    And then finally, one other thing I will mention, 
importantly, PEPFAR right now is putting a big emphasize on 
localization and really trying to build capacity in local 
partners. USAID is also moving toward the Journey of Self-
Reliance. These are critical things to be focused on for 
sustaining capacity and building capacity in country so that 
the U.S. hopefully can work itself out of a job in these areas. 
If you lose partners or if partners are unsure about their 
ability, or make a decision not to participate, it could really 
impede that effort.
    Mr. Levin. So we are shooting ourselves in the foot. Well, 
Ms. Crocker, CARE works with many partners across various 
programs that support women's empowerment. Is it typical that 
organizations would work across a range of women's health, 
education, economic empowerment, and political engagement 
issues?
    Ms. Crocker. Thank you for the question. And I am so happy 
that you also had a chance to travel with CARE. And yes, I mean 
I think you will both at the international level as well as the 
national and local level organizations that do work across a 
range of issues including CARE is one. And while it is 
unfortunate, I think it is not surprising to hear that there 
are implementers who may be affected by the policy when their 
focus might be in the case that you were looking at, nutrition, 
as an example.
    Mr. Levin. So there would be negative ripple effects across 
a range of policy areas.
    Yes, given the shortness of time, I just wanted to offer 
Mr. Mulumba a chance to answer as well whether you have seen 
impacts of the Global Gag Rule reaching beyond family planning 
and reproductive health in Uganda and whether reproductive 
health providers and advocates also work on other health and 
development issues.
    Mr. Mulumba. Thank you so much. What I have actually 
observed is that much of the USAID funds that is withdrawn is 
not funds that we are meant to being doing work on abortions. 
So what we actually observe is that people are losing out on 
resources which are making other interventions in the case of 
the example that I gave you, the funds that we lost as an 
institution were for health systems strengthening. So the 
intervention that we were doing were affected. But we have also 
observed that those that are doing service delivery, they have 
had immediate withdrawal from the communities where they are 
working. So the immediate withdrawal of services, beyond 
reproductive health services to include services--because of 
the integration that everyone is talking about, it includes 
services like HIV/AIDS. So adherence to treatment becomes a 
very big problem.
    But you also observed that many NGO's work in coalitions 
and so when NGO's are not clear on what the policy actually 
means in Uganda we have not seen an intervention where, for 
instance, the U.S. Government is explaining what this policy is 
all about. So you find that very many people have heard about 
the policy in theory, but they do not know the boundaries of 
what the policy means. So working in coalition is extremely 
difficult.
    Mr. Levin. Thank you. My time is up and despite the fact 
that I am sitting in the chair, I am going to move on to my 
next colleague which is Ms. Wagner. You are recognized for your 
questioning now.
    Mrs. Wagner. I thank you, Mr. Chairman. Let us be clear 
here. The purpose of U.S. global health and economic 
development programming is to recognize, promote, and protect 
the dignity of all individuals and extend a helping hand so 
that the marginalized, poor, and vulnerable around the world 
may build a better future. But promotion of abortion is 
incompatible with this mission.
    Abortion is not healthcare. Children and families should 
not be enumerated as barriers to prosperity, but sources of 
strength and beauty, purpose, meaning, and potential.
    I am proud that the United States has recommitted itself to 
global health policies that recognize the inherent worth of all 
people and leverage the boundless human capacity for 
generosity, cooperation, and ingenuity to overcome global 
poverty.
    We will not make the challenge of ending poverty a little 
simpler in the short term by pushing women to end the lives of 
their children. That is not a compassionate position for either 
the mother or child. We will not tell women that they must 
choose between their children and prosperity. Instead, we will 
work in partnership with countries around the world to ensure 
that all women and children have access to opportunity and 
success. The President's Protecting Life in Global Health 
Assistance policy ensures that American tax dollars are used 
for actual healthcare, not awarded to global organizations that 
push abortion on women, instead of doing the hard work of 
helping these vulnerable women to have both their baby and 
their dreams.
    We must continue to build healthcare capacity in 
communities to fill any gaps left by these funding changes. In 
this way, we can best serve women and children around the 
world. Abortion is both a symptom and a tool of the oppression 
of women. Research by the United Nations Population Fund 
indicates that widespread access to prenatal testing and 
abortion in countries with patrilineal and patrilocal 
traditions is linked directly to gendercide, the global 
epidemic of violence against women. One hundred and 26 million 
women are demographically missing around the world due to sex-
selective abortions, female infanticide, and gender-based 
violence against young girls. Sex-selection abortions have been 
banned in many countries, the U.S. notably not included in 
those, but social pressures on women to eliminate their baby 
girls remain.
    In the northern Indian State of Uttarakhand, for example, 
132 villages reported that no girls were born over a 3-month 
period in 2019. In the U.K. medical journal, The Lancet, has 
found that as many as 12 million baby girls were aborted in 
India between the 1980's and 2011.
    Ms. Bos, what is the role of abortion in accelerating the 
global gendercide?
    Ms. Bos. In our experience, and we actually had a program 
on this subject in Armenia that we were very proud of where 
really we did want parents and families and communities to 
understand both boys and girls have value, that they deserve 
love, that their lives had meaning. And so, we really did have 
an approach that worked with both the Government of Armenia and 
the Armenian Church to address those challenges of, really, 
equal value of boys and girls, and address that issue of sex-
selective abortion.
    So we were very proud of that work. I think it is something 
we continue to look at ways we can contribute to both of those 
issues, really, hopefully reducing sex-selective abortion and 
just lifting up the value of girls.
    Mrs. Wagner. Thank you very much. My time is about to 
expire. I have many more questions that I will submit for the 
record, Mr. Chairman. Thank you.
    Mr. Levin. Thank you so much, Mrs. Wagner. I now recognize 
Ms. Houlahan for your questions.
    Ms. Houlahan. Thank you, Chairman. And thank you very much 
to the panel for coming. I have a couple questions. My first 
one is, the current administration has expressed support for 
women's economic empowerment which I wholeheartedly support, 
but globally more than one in five girls is married before--I 
am sorry--one in five girls is married before the age of 18, 
which means the end of their formal education and the very 
beginning of motherhood. The UNFPA along with UNICEF runs the 
U.N. program to end childhood marriage; unfortunately, the U.S. 
does not currently fund the UNFPA.
    I was wondering if you might be able to comment, Ms. Bos, 
on whether or not you couldn't--the economic empowerments of 
child brides and why is ending child marriage central to 
women's economic empowerment, please.
    Ms. Bos. Thank you, Congressman, for that question. You 
know, the economic benefits of girls being in school and not 
being put in the situation of being married early, there is a 
lot of data, a lot of evidence that backs that up. We actually 
did a report that we released last fall that included four case 
studies on child marriage across both development and 
humanitarian contexts.
    Speaking from own experience, you know, the data is there, 
the evidence is there; I think we really need to again focus on 
keeping girls in school. And the committee's support of the 
Keeping Girls in School Act hopefully will be critical in 
enhancing the U.S. Government's approach to really looking at 
the preventive measures we can take to reduce child marriage.
    Ms. Houlahan. And so, if the UNFPA is not there especially 
in places like Yemen and other places that are war-torn, who 
else is there that can help with this particular issue?
    Ms. Bos. It can be a challenge. I do think some of us who 
are in humanitarian context--CARE, World Vision, Save the 
Children, you know, we do attempt to address these issues as 
well. World Vision, we have had past partnerships with UNFPA. 
We do not take a position on the Kemp-Kasten policy, per se, 
but there are contexts, certainly, where, you know, I think we 
have seen UNFPA contribute significantly to this kind of work.
    Ms. Houlahan. Thank you very much. Does anybody else have 
anything to add on, on child marriage at all or--Dr. Kates?
    Ms. Kates. I would just add to those excellent comments 
that I mean we have to understand this has a tremendous health 
impact on girls when they are married young. It is not just the 
economic impact. It is the health impact on having children 
young. And so all of these are very synergistic. Investing in 
women's education, investing in economic opportunity, and 
investing in health serve the same goal.
    Ms. Houlahan. Thank you.
    And my next question is for Mr. Mulumba. Can you describe 
the correlation between laws that are discriminatory between 
the LGBTQ community and countries like Uganda and the health 
outcomes for those communities for women in particular?
    Mr. Mulumba. Thank you very much. I think that one of the 
areas that has often come up as a difficult area in Uganda is 
the LGBTI issues. We have had a history of laws, many of these 
are colonial laws that we still have. Even before the proposed 
introduction of the new legislation that was, we had the 
criminal law that criminalizes the acts.
    So the criminalization does not only affect the target 
people, but it also affects the service providers, so people 
and service providers have been put in a very difficult 
situation on how they go about LGBTI issues. So the laws, in 
fact, have become determinants of access to care where the laws 
are disenabling, then those particular populations are 
affected.
    And in the Ugandan context, the LGBTI community has really 
had a rough time. We know that part of the investments that the 
U.S. Government had done were to remind the State to even 
develop guidelines on mainstreaming LGBTI issues, but at the 
same time the LGBTI communities, just one of those that has 
been affected by some of the funding cuts that we have 
witnessed over the past years. Thank you.
    Ms. Houlahan. Thank you. And I just have one more followup 
question for Ms.--is it Bos or Bos?
    Ms. Bos. Bos.
    Ms. Houlahan. Bos. So, you sort of alluded to the fact that 
CARE and the World Vision organization were trying to fill the 
void that UNFPA is not able to fill in some areas. Is that what 
you are intending to say? It sounded as though you were saying 
that there really was not a solution in places like Yemen to 
address these particular issues without the UNFPA.
    Ms. Bos. I cannot speak specifically to that. I do not know 
if Sheba Crocker is able to. But, yes, I do not know if there 
are gaps. I am just not as familiar with that kind of program. 
I do know that in some of the humanitarian contexts there are 
other partners. I do not know that certainly that is addressing 
all of the gaps that there may be if UNFPA is not present.
    Mr. Levin. Ms. Crocker, did you have a quick word to add?
    Ms. Crocker. Well, I would just note that there are some 
places as I alluded to before where UNFPA is actually the only 
provider of some services in Yemen. For example, they are the 
only international provider of reproductive health services. 
And I also noted that they are currently facing a several 
hundred million dollar gap in their funding in terms of what 
they have put out what they need.
    And so, while I do not have it on my fingertips exactly 
where those gaps might now lie, they are facing gaps because 
they just do not have all of the funding that they need to 
carry out their activities. And, you know, as I noted, in 
humanitarian settings in particular, UNFPA does both incredibly 
important lifesaving work, but is often the only provider on 
the ground.
    Ms. Houlahan. Thank you. And as we know, and I will 
conclude with this, the UNFPA, the United States were one of 
the founding partners of that organization and we had provided 
until the last several years the third largest, I think, amount 
of resources, meaning money, to that organization. And if there 
is a gap, then that gap is probably coming from the places 
where it is no longer provided. And thank you so much for your 
testimony today. I yield back.
    Mr. Levin. Thank you. We now recognize Mr. Perry for his 
questions. Mr. Perry?
    Mr. Perry. I thank the gentleman and I thank the witnesses. 
I would like to expand the conversation, if you will. I do not 
think that women and girls can be successful or really even 
happy members of society when they face forms of gender-based 
violence often resulting in physical harm to their bodies.
    I particularly want to highlight the impact of FGM, female 
genital mutilation, on women and girls. It is a harmful 
practice that severely affects a girl's health, development, 
education, and her quality of life. It is commonly performed on 
girls from infancy to 15 years old, leaving a lifelong impact 
on the most innocent among us. Girls who are subjected to FGM 
are more likely to drop out of school. Girls affected by FGM 
are also at increased risk of becoming child brides.
    Just last week I heard of a devastating story in Egypt, you 
might be aware. A 12-year-old girl bled to death after having 
FGM performed. Her parents and her aunt made the choice to take 
this young, innocent girl to a private clinic, and I said 
``clinic,'' to have the practice done and she lost her life. 
This case exemplifies how difficult it is for the international 
community to end the harmful practice, because Egypt actually 
banned FGM in 2008 and criminalized it in 2016, yet Egyptians 
are still struggling to eradicate the practice.
    In the past year, we have FGM convictions out of the United 
Kingdom and Ireland. In the U.K., a mother became the first 
person convicted of FGM in the country after she was found 
guilty of performing the practice. She performed it herself on 
her 3-year-old daughter. And in Ireland, a married couple was 
found guilty of carrying out the practice on their 1-year-old 
daughter.
    The practice has also been happening right here in the 
United States. We saw the 2017 landmark arrest of two Michigan-
based doctors. I underscore ``doctors,'' accused of performing 
FGM on at least nine underaged girls from 8 to 13 years old. 
The majority of the victims were brought across State lines, 
all traveled with their parents. The testimony of the young, 
innocent girls included in the criminal complaint against the 
doctors, it is harrowing to say the least. Two of the young 
victims believed that they were traveling with their moms to 
Michigan for a fun girls' weekend. I mean that is the ultimate 
betrayal, in my opinion.
    The 2017 Michigan case was the first time the United States 
used our 1996 Federal statute banning the practice. 
Unfortunately, the Michigan case resulted in the Federal 
statute being ruled unconstitutional by a Federal district 
judge. It has now been 16 months since a Federal district judge 
ruled in the United States' Federal ban on FGM 
unconstitutional, putting the onus on Congress to pass new 
legislation. And, indeed, tomorrow, February 6th, is the 
International Day of Zero Tolerance for FGM.
    Now I proposed legislation to not only reinState a ban on 
FGM in the United States, but also to make our laws stronger to 
ensure successful prosecution in the future. And there is a 
new, you know, I mentioned doctors in this and the advent is 
not only overseas, but in the United States where the 
terminology used is, it is being medicalized, a medicalized 
felony practice.
    Ms. Bos, what message do you think it sends to the 
international community including governments that have yet to 
ban the practice that the United States does not currently have 
a Federal ban on FGM?
    Ms. Bos. I do think it is critical that the U.S. show 
leadership in some of these places where we are, you know, 
oftentimes as implementors trying to enforce laws. There are 
many places, thankfully, where there are laws banning FGM. But 
you are right, there is a critical gap in how we enforce them 
even in the work that we do. So we really are focused again on 
working with law enforcement, the judiciary communities to 
really halt this practice, because the kind of tragedy you 
mentioned, unfortunately, it is all too common.
    So, you know, I do hope the U.S. continues to show 
leadership in this space and really continues to model, really, 
the best of what we want to do to the rest of the world.
    Mr. Perry. I appreciate it. I find it hard to find 
proponents, advocates of FGM even in this body, but yet we 
cannot seem to move a bill. And I get it if they do not like my 
bill. One should be offered that they do like. I think it just 
absolutely, we have to send a very strong message.
    Ms. Crocker, Dr. Kates, do you have anything to add in this 
regard? I am sure you work in this space as well.
    Ms. Crocker. I would just like to thank you for your focus 
on gender-based violence and the many different forms it can 
take including in the context of emergencies. And as I noted in 
my opening remarks there is a bipartisan bill, the Safe from 
the Start Act, which would expand and strengthen existing U.S. 
Government policy and efforts to support countering gender-
based violence in its many forms and we would strongly 
encourage passage of that bill.
    Mr. Perry. I thank the chair.
    Mr. Levin. Thank you. And I now recognize Mr. Deutch for 
his questions.
    Mr. Deutch. Thank you, Mr. Chairman.
    Mr. Chairman, the Trump administration authorized, I think, 
what can only be described as a radical, unprecedented 
expansion of the Mexico City policy, the Global Gag Rule, 
extending it to apply to all global health assistance where 
previous iterations applied specifically to family planning 
funds. Earlier this year, Secretary Pompeo announced in a press 
conference that the State Department would be taking action to 
``implement this policy to the broadest extent possible.'' But 
while the purported intention of the Global Gag Rule is to 
reduce the number of abortions taking place, that is simply not 
the result of the policy.
    And, Dr. Kates, you mentioned the new study published in 
Lancet found that when the Global Gag Rule was in effect 
between 2001 and 2008, abortion rates increased by about 40 
percent among women in countries most affected by the policy. 
It also found a symmetric reduction in the use of modern 
contraception while the policy was enacted, coinciding with an 
increase in pregnancies.
    This pattern of more frequent abortions, many of which are 
unsafe in the impacted countries, and lower contraceptive use 
was reversed after the policy was rescinded in 2009. And it 
seems based on the research and our witnesses' testimony today 
that not only does the Global Gag Rule accomplish the opposite 
of its Stated goal, but it puts women already at risk, poor 
women and women in developing countries, at further risk by 
removing their access to safe reproductive care as well as 
restricting their access to quality health care more broadly.
    So, Dr. Kates, can you tell us more about the research and 
what it foreshadows for the impact of the expanded Global Gag 
Rule if it is not repealed?
    Ms. Kates. So the research has, and particularly the study 
that you were just citing from the Lancet does show a strong 
correlation between this policy being in place and increased 
abortion rates, increased pregnancy and reduction of 
contraceptive prevalence, and when the policy is not in place 
the opposite.
    One of the--and so that really suggests that there is a 
relationship here that really needs to be assessed, because 
that is not really what the goal of the policy seems to be. And 
as I mentioned earlier, there have been more recent--that is a 
retrospective analysis. There are current studies that have 
gone into the field to try to understand, is there a disruption 
in services, is there confusion, is there maybe 
overimplementation, and those have been documented.
    I think one challenge that I heard Ms. Bos speak to and I 
want to also echo is that we do not always have at our 
fingertips the data we need to understand the impact on women's 
lives right now, and that would be one area I would look to you 
all to potentially strengthen, which is having a better sense 
of what is happening in the field with U.S.-funded programs so 
we understand the impacts more in real time. This is something 
PEPFAR does quite well. It is not necessarily the case in some 
other global health programs.
    But just to come back to your question, there has been a 
lot of confusion about this policy, and the research as you 
said does suggest that there is a strong relationship here.
    Mr. Deutch. Thank you. And I have more questions on this 
that I will submit for the record. I just want to spend a 
moment to talk about the administration's repeated efforts to 
discontinue funds to UNFPA, the U.N. sexual and reproductive 
agency which provides essential women's health services around 
the world especially where there is otherwise little or no 
access to care.
    As chairman of the Middle East Subcommittee, I am 
especially concerned because of the agency's critical, 
irreplaceable, and lifesaving work that is done in Yemen and in 
Syria. As we know, the humanitarian crisis in Yemen remains the 
worst in the world, and in a country where rising food 
shortages have left more than a million pregnant and lactating 
women malnourished and where an estimated 114,000 women are 
likely to develop childbirth complications, UNFPA is the sole 
provider of lifesaving reproductive health supplies and 
medicines.
    And the importance of that work is also true at the Zaatari 
refugee camp in Jordan, the world's largest Syrian refugee 
camp. At Zaatari, the U.S. through this program was a major 
supporter of the camp's central maternity ward where UNFPA has 
facilitated over 12,000 births with zero maternal deaths. 
Thousands of babies have been born healthy, many with American 
flags on their bassinets, thanks to the important work of the 
agency and thanks to the United States financial support for 
their work. That is something that I think on both sides of the 
aisle we should be proud of, and I worry that by the continuing 
attacks by this administration on UNFPA funding that we will 
threaten those important and fragile global health gains.
    And I would like to just submit for the record the January 
2020 report called, ``Counting the Three Transformative 
Results,'' which identifies the specific interventions needed 
to achieve three transformative results in women's and girls' 
health by 2030.
    Mr. Levin. Without objection.
    [The information follows.]
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Deutch. Thank you, Mr. Chairman.
    I am so grateful for the witnesses for being here today to 
highlight a critical issue that this committee needs to 
address. And, Mr. Chairman, I appreciate the time. I yield 
back.
    Mr. Levin. Thank you, Mr. Deutch. I now recognize the 
gentleman from Tennessee, Mr. Burchett.
    Mr. Burchett. Thank you, Mr. Chairman. I will try not to 
run over and I will just get to my point here very fast.
    As one of the longest standing U.S. global health 
priorities, what have we learned from PEPFAR programs in terms 
of building health systems, accessing at-risk populations, and 
ensuring effective use of our taxpayer dollars? And I will just 
throw that out to the committee. Any of you all want to answer 
it and take a shot at it?
    Ms. Kates. I will start. Thank you for that question.
    Mr. Burchett. Yes, ma'am.
    Ms. Kates. We have learned a lot from PEPFAR and I cannot 
possibly highlight all the things we have learned, but some I 
want to focus on. First of all, there has been a bipartisan 
commitment to this program from the start and that is really 
important. It sends an important signal to the field so this 
program is seen as having lots of backing back home and that is 
important.
    The other thing that PEPFAR has done from the get-go is 
really focused on both delivering the lifesaving interventions 
that are needed, but figuring out how to do that in settings 
where there are no systems or were systems that weren't 
adequate. And that was a challenge, but there has been a lot 
that has been learned from that experience.
    PEPFAR has also done something fairly unique, which is it 
engages very regularly with civil society in both sharing 
information and getting feedback from civil society in how 
programming should be done. That has been an incredible effort 
that has led to better programming, and PEPFAR would probably 
be the first to say that.
    Something I mentioned earlier was data. We cannot always 
know that we are doing the best thing and reaching the people 
that need help the most unless we have the information as close 
to real time as possible. PEPFAR is probably the best model we 
have in the U.S. Government for doing that. There has been 
investments in that and that has been another lesson.
    And then, finally, I think PEPFAR has, through its 
leadership diplomatically as well as its programming, sent a 
strong message that you cannot leave anyone behind. That to 
truly have the impact on HIV incidents and on reaching more 
people with treatment you have to reach everybody. That is 
going to be hard and PEPFAR recognizes that, but the program 
has a lot of lessons in that regard.
    Mr. Burchett. Any of the others? Ms. Bos?
    Ms. Bos. I would mostly just ditto what Jen said. She said 
it very well. But just to add as well, I really do think 
because PEPFAR has focused so much on health work force and 
health systems, we owe PEPFAR a lot of gratitude. The Ebola 
outbreak in West Africa would have been much worse had it not 
been for PEPFAR being present and on the ground.
    It was noted earlier, you know, some programs, global 
health programs, are moving to localization. PEPFAR is one of 
them. How do we build the capacity of local partners, again, 
the journey to self-reliance that is a priority of the 
administration, we have to look at ways to buildup local 
structures and local institutions, and PEPFAR, really, I think, 
has prioritized that and we can learn lessons from that across 
other programs.
    Mr. Burchett. Thank you. I remember when the AIDS epidemic 
kind of came on and we had missionaries in our church come talk 
about it. And what impacted me as a young man was the fact that 
we lost entire, you know, they talk about losing entire 
villages. But, dadgum, they lost entire languages because of 
just the outbreak was just so widespread. So, thank you all.
    So, any others want to comment or out of you all's 
wheelhouse?
    Ms. Bos. No, I mean certainly the lifesaving benefit has 
tremendous impact. You know, PEPFAR, when we started doing HIV/
AIDS programming, you know, Pastor said, ``I just spend all my 
time going to funerals. That is my job. I do not actually 
preach, I go to funerals.'' And that was a tragedy.
    And I would say, you know, I have been able to travel a lot 
of places where PEPFAR has been investing resources. People 
know that that support is coming from the United States and 
their gratitude and appreciation is real. So, you know, thanks 
to the Congress for continuing to support that investment. 
People do appreciate it and they know where it comes from.
    Mr. Burchett. All right.
    Yes, ma'am?
    Ms. Kates. Oh, I just want to add, since the focus of the 
hearing is on women and girls and women's health, PEPFAR isn't 
thought of as a women's health program, but it actually serves 
millions of women each year and spends a significant amount of 
its resources on women. It has done many innovative things to 
reach women and address the many structural challenges that 
women have. So I think it is really important that we are 
talking about it today and recognizing its role in that regard.
    Mr. Burchett. I think also the fact that, you know, when I 
was a kid when the outbreak kind of happened, you know, Rock 
Hudson, and it just kind of swept the country, you know, folks 
died. I had friends that died, HIV and AIDS, and now that is 
just not necessary if we can get them the proper medication. So 
thank you all for what you all are doing for the least amongst 
us. We appreciate it so much. Thank you.
    Thank you, Mr. Chairman. Madam Chairman, excuse me. You 
slipped in on me. I yield back the remaining 14 seconds of my 
time. Please use it wisely.
    Ms. Titus [presiding]. We appreciate that.
    Ms. Spanberger, you are recognized now for 5 minutes.
    Ms. Spanberger. Thank you very much, Madam Chairwoman.
    And thank you to our witnesses today. Thank you for your 
testimony and thank you for your incredibly hard work on these 
issues that are so incredibly important to not just the United 
States or to Uganda, but to the larger world. I will be joining 
many of my colleagues for an Asia Subcommittee hearing on the 
coronavirus this afternoon, and experts agree that medical 
threats like SARS, Ebola, and now coronavirus, pose a risk to 
U.S. national security and global security. And I have a 
background in the intelligence community, so I do tend to think 
about public health issues in a broader context, particularly 
that of the national security consequences.
    So, it was discussed, the number, the disproportionate 
percentage of girls that were impacted by Ebola, by women, or 
the disproportionate number of women impacted by Ebola in the 
DRC, and so I was wondering, Ms. Crocker, could you expand a 
little bit more on how many of these outbreaks do uniquely 
impact women?
    Ms. Crocker. Thank you for the question. And just to, you 
know, to sort of start where we maybe ended is that for sure 
one of the lessons we learned from the Ebola outbreak in West 
Africa is the importance of making investments in primary 
health systems and infrastructure, and I think as Jen 
importantly took us back to why that is particularly important 
in the context of the subject of the hearing that we are having 
today.
    And women and girls face unique challenges in a number of 
different ways. We have discussed some of them: gender-based 
violence, and sexual and reproductive health access. And, in 
addition, they are uniquely challenged when it comes to being, 
you know, vulnerable to contagious and infectious disease, both 
because of sometimes social norms and the role that they play 
within their own communities and within their own families, and 
because of the role out sized that they play.
    In many countries around the world, it is estimated that at 
least 75 percent of the healthcare work force is women, which 
is on the one hand a positive; on the other hand, also means 
that they are the first line of defense, often. But what we 
also see is again due to social norms and access issues that we 
have also discussed, women are often the last to receive care 
in the communities and in their families. And so, it is sort of 
that twin, you know, it is both aspects. It is both they are 
more vulnerable, they are more exposed, and they are the least 
likely to be, you know, first in line to receive the assistance 
that is needed.
    So again, it speaks to the importance of having a focus 
from the outset of humanitarian emergencies all the way through 
development programming on the health needs and protection 
needs of women and girls in particular, but it also--anyway, 
sorry.
    Ms. Spanberger. Well, and so drawing on that point that 
they are oftentimes the first and/or more exposed, but then 
among the last to actually get treatment, what does that do for 
these sorts of outbreaks in terms of our ability to contain 
them and address them? It sounds to me that it would actually 
elongate that process because of the fact that women are overly 
exposed and perhaps last to receive treatment. Could you 
comment on that?
    Ms. Crocker. Well, I mean, I think again it just speaks to 
the importance of making sure that we have the right kind of 
assistance and support systems in place. And often we aren't 
thinking first and foremost about women's health needs when we 
think about responding to humanitarian emergencies, but we have 
certainly found that addressing the unique needs of women and 
girls, especially their health needs in the context of 
emergencies, is as important as things like food and water and 
access to shelter.
    And because they are often overlooked, I think, as you say 
it sometimes then prolongs or means more exposure and that 
women are even more vulnerable to things like contagious and 
infectious disease, when we know they are already facing 
significant and unique challenges in accessing health care and 
because of the unique needs of women and girls in the context 
of emergencies.
    Ms. Spanberger. And, Dr. Kates, would you add anything in 
terms of what we could be doing in our health systems more 
broadly to improve our preparedness and our resilience against 
communicable diseases?
    Ms. Kates. Yes, so the U.S. Government has played a leading 
role, clearly, in global health security around the world, 
strengthening other health systems, helping to set norms, 
leading the global health security agenda, but clearly there is 
going to be more outbreaks. That is a given. That is the one 
thing we know. There will be another outbreak after this 
outbreak.
    So, how do--what are the interventions that the U.S. can 
employ generally, and then I will get to women and girls 
specifically. Being able to work now to prepare for what we 
know is inevitable is really critical, it is very hard to do 
that. It is much easier to respond. But preparedness, we know, 
makes a huge difference. When the U.S. can help other health 
systems through the ministries of health in particular and this 
has worked, for example, CDC does, that can have long-lasting 
ramifications. That is what we want. We want a system that it 
can immediately respond to a potential outbreak. So that is 
critical work and I know that will be something you will 
discuss later today.
    Just to add to what Sheba said around what happen--we do 
not always think about women's needs in these contexts and for 
all the reasons she mentioned women are particularly 
vulnerable. The other thing that tends to happen is if a health 
system isn't robust, the very basic services that women need 
whether it is a skilled birth attendance, delivering in a 
hospital, getting basic maternal health needs met, family 
planning services get disrupted and resources and attention get 
diverted and that happens every single time. The more robust a 
system is in the beginning, the less likely that is going to 
happen. So it is a win-win, but one that definitely needs more 
attention.
    Ms. Spanberger. Thank you very much. I yield back.
    Ms. Titus. Thank you. Mr. Pence, you are now recognized.
    Mr. Pence. Thank you, Madam Chair. To all the witnesses for 
being here today, thank you very much on such important issues.
    Ms. Bos, I found your testimony to be particularly 
interesting. First, I would like to thank you for World 
Vision's work in promoting the sanctity of life in combating 
maternal and infant mortality in developing countries. I agree 
that abortion is not health care and that vulnerable women 
seeking true, comprehensive care around the world deserve 
better than abortion-centric facilities.
    In my home State of Indiana, working toward lowering the 
infant mortality rate is a priority for Hoosiers. In fact, in 
2018, Indiana's infant mortality rate showed the biggest 
decrease in 6 years. While this is encouraging progress, we 
must remain vigilant. Similar to World Vision's Time and 
Targeted Counseling home visiting program, Indiana recently 
launched OB Navigator in 20 of the 92 counties to support women 
in high-risk communities, six of which are in my communities. 
The goal of this program is to improve prenatal and pregnancy 
care for vulnerable Hoosiers.
    Ms. Bos, as we continue to expand this program, what advice 
would you give to new home visiting programs and are there key 
challenges to new home visiting programs that must be overcome 
to reach the most vulnerable populations in Indiana?
    Ms. Bos. Well, kudos to Indiana for their leadership in 
this space and I say that carefully as a native Michigander. I 
do think there are challenges in doing home visits. Our 
programs, we work with volunteers. As others have noted these 
volunteers are mostly women, these health workers, so they are 
taking time away from their own homes, their own families, 
potentially businesses, livelihoods. I think that is one of the 
biggest barriers.
    I do not know how Indiana is addressing that issue, but, 
you know, as we look at how we do programs, you know, how do 
you start to integrate those health volunteers into the formal 
health system, maybe get them a stipend is something we are 
starting to look at. There needs to be some incentive at times 
for these health volunteers to continue doing this work.
    I would say the other barrier, oftentimes, is just having 
the right information at the right time, and really that is 
where we are trying to use mobile phones more often. Our Timed 
and Targeted Counseling messages are often now coming to women 
and to the health volunteers just right through a mobile phone. 
You have all probably heard about, you know, women might not 
have access to a health facility that is nearby, but they will 
have access to a mobile phone.
    So using technology is increasingly critical. And I know in 
the domestic sphere, you know, that has been something that the 
U.S. Government has been looking at as well, how do we better 
leverage technology.
    Mr. Pence. Thank you. Thanks again for all that all of you 
do. Madam Chair, I yield back.
    Ms. Titus. Mr. Cicilline, you are now recognized for 5 
minutes.
    Mr. Cicilline. Thank you, Madam Chair, and thank you to our 
witnesses for your important testimony.
    Dr. Kates, I want to start with you. There was some 
suggestion made by some of my friends on the other side of the 
dais that access to abortion services cannot be part of a 
woman's health care. Would you like to respond to that 
assertion?
    Ms. Kates. Well, I am here as an expert on what the U.S. 
Government does and the policies and so I am not going to take 
a position either way. But I will, just to reiterate what I 
said before that the services that the U.S. Government does 
support--voluntary family planning, HIV treatment and 
prevention, a range of reproductive health services and many 
more--to the extent that these may be disrupted by a policy, I 
do not think the intention of the policy is to disrupt them, 
but when there is evidence that that could be happening it is 
cause for concern.
    Mr. Cicilline. Thank you. And despite the expansion of 
access to prevention and treatment for HIV, TB, and malaria, 
these epidemics continue to threaten the health of women and 
girls worldwide. Maternal health services have been identified 
as a point of entry for improving access to prevention and 
treatment of HIV, TB, and malaria in women.
    And again, Dr. Kates, in what ways are we tailoring 
interventions, if we are, to protect women, particularly those 
of reproductive age?
    Ms. Kates. So I think that is a fundamental thing. We have 
to understand where women are going to get their health care, 
what kinds of services they need. I am a parent. You want to do 
what is best for your kid always, and so reaching women where 
they are going for their health care and for their kids is a 
critical approach.
    PEPFAR is doing that more and more. I know that the USAID's 
MCH, Maternal and Child Health, and family planning programs 
over the last few years have really started to integrate much 
more their work so that they are trying to meet women together, 
but there is a lot more that could be done. So there is real 
opportunity for the U.S. to do, to step back and understand 
where it is working, which countries in terms of overlap with 
the programs, and where they could meet women most in need, 
what sites is the U.S. Government working in.
    Mr. Cicilline. Thank you. And we know that LGBTI persons 
face higher levels of stigma and discrimination in their 
communities including when seeking healthcare options. However, 
when--LGBTI persons also require a unique set of services 
including HIV prevention and treatment, comprehensive sexual 
education and family planning. And we know that as a result of 
this, their clinics have developed programs specifically 
designed for the LGBTI population and they are seen as trusted 
sites for other medical providers to refer LGBTI patients.
    And my question is, given the Global Gag Rules expansion to 
all of U.S. global health assistance including PEPFAR, these 
same clinics may have been forced to close or have gagged, have 
had to scale back their integrated and comprehensive healthcare 
services, and so, Dr. Kates, what has been your assessment of 
the impact of the Global Gag Rule on the LGBTI populations who 
require this kind of integrated and comprehensive range of 
services?
    Ms. Kates. So as you mentioned, there has been a lot of 
effort by the U.S. Government through PEPFAR, through USAID to 
enhance services for LGBTI populations because those 
populations are often criminalized, face violence, face stigma 
in their countries, and not reaching them has tremendous 
impacts on their health. And, in fact, in the context of HIV, 
key populations including men who have sex with men and 
transgender women, make up more than half of new HIV 
infections. So ending the epidemic--ending AIDS is not going to 
happen unless key populations are reached.
    I think in the context of this expanded Mexico City policy, 
the studies that have been done so far suggest that there have 
been service disruptions and clinics have closed in some 
places. Many times, with the populations like the LGBTI 
community, there are very few providers to begin with and the 
U.S. has often worked with them to bring them on and help build 
their capacity.
    To the extent that those providers choose not to be a 
partner with the U.S. Government, choose to stop offering some 
services that may be legal in their country because they do not 
understand a policy, that could really affect the availability 
of services to the most vulnerable and I think that is 
something the U.S. Government should pay very close attention 
to.
    Mr. Cicilline. Thank you. In my view, reproductive rights 
are human rights and without full access to reproductive health 
care including information about comprehensive sexuality 
education, contraception, and access to abortion, women and 
girls are undermined in their ability to make decisions about 
their bodies and health.
    Mr. Mulumba, is there value in the United States reporting 
on reproductive rights in countries? We have lost that 
reporting and really understanding what the condition has been 
and the impact for the last two to 3 years. By cutting these 
sections out of the State Department reports, are we losing the 
ability to kind of understand the full impact of these 
decisions?
    Mr. Mulumba. Thank you so much for the great question. I 
think, historically, human rights have been divided and much of 
the time we focus on civil political rights and forget about 
socioeconomic rights. And the nature of reproductive rights is 
that they are cross-cutting and, unfortunately, we only look at 
them as socioeconomic rights.
    At the national level, there is a lot of focus on civil 
political rights and not socioeconomic rights, so it would 
really help if United States focuses on comprehensive reporting 
on human rights because other countries where sometimes do not 
appear to respect human rights, the human rights reporting is 
used as a tool, as mobilization of shame for the countries and 
compliance, and it would therefore be a missed opportunity if 
the United States does not require the reporting on sexual 
reproductive health rights.
    Mr. Cicilline. Thank you very much. I yield back, Madam 
Chair.
    Mr. Engel. Thank you.
    Mr. Guest.
    Mr. Guest. Thank you, Mr. Chairman. Members of our panel, 
as we meet today to discuss challenges and global health, I 
believe it is important that we address the challenges faced by 
the most vulnerable of our society, by our children both born 
and unborn. The World Health Organization reported in their 
last report that between 2010 and 2014 that over 55 million 
abortions were performed each year across our globe. That 
equates to over 150,000 abortions each day, a hundred abortions 
each minute. During the 5-minutes that I have to address this 
panel, over 400 children will lose their lives because of 
abortion.
    I believe that all life is precious. I believe that it is a 
gift from our Heavenly Father, and I believe that our founding 
fathers held that same belief. We find that in our earliest 
documents, the Declaration of Independence, where our founding 
fathers held that we hold these truths to be self-evident, that 
all men are created equal, that they are endowed by their 
Creator with certain unalienable rights, that among these are 
life, liberty and the pursuit of happiness.
    We have seen great medical advances and medical treatments. 
Last night that was on display when President Trump recognized 
a young lady who was born after 21 weeks and 6 days. To our 
friends at World Vision, I want to thank them and their 220,000 
community health workers and volunteers, and I want to thank 
you for your belief that life begins at inception. World Vision 
along with the other organizations and USAID have helped save 
the lives of more than nine million children and over 340,000 
women over the last 10 years. Ms. Bos, I agree with the 
statement that you gave and the conclusion of your written 
statement. ``Improving health for the world's most vulnerable 
people is not only a moral imperative, but also a pragmatic 
investment for peace, security, and worldwide economic 
growth.''
    Ms. Bos, my question to you is, what role do you see 
telemedicine playing in improving the health of women and 
children across our globe?
    Ms. Bos. Thank you for the question, Congressman. As I 
mentioned to Congressman Pence as well, I do think technology 
presents some great opportunities for how we do health care in 
the developing world. Having done domestic health work when I 
was here working as a staff member in the House, you know, we 
saw the opportunities that telemedicine presented in rural 
areas in bringing resources to people.
    I do think there are some challenges with that in the 
developing world, but challenges we are trying to overcome. If 
there is not electricity, if you cannot, you know, purchase the 
right kind of equipment that does present some barriers. That 
is why we tend to lean right now more toward kind of mobile 
phone technology.
    But I do think there are unique opportunities for new 
partnerships in how we better use telemedicine, especially 
because there is such a lack of physicians and really high-
quality trained professionals, we need to start looking at 
those other new innovations.
    Mr. Guest. Thank you.
    And thank you, Mr. Chairman. I yield back.
    Mr. Engel. Thank you very much.
    Ms. Titus.
    Ms. Titus. Thank you, Mr. Chairman. We have heard a lot 
today about how the Global Gag Rule has a negative impact on 
women, generally. We have heard a lot of pontificating about 
the sanctity of life from those who often vote to cut critical 
services for children in vulnerable communities. We also heard 
a little bit about some the specifically more vulnerable 
populations among women including LGBTI. I would like to now 
look at two other groups that we haven't talked about as much 
and that would be female sex workers who are certainly 
vulnerable, and also women with disabilities.
    Sex workers are a population that faces a significant 
amount of stigma in their communities. This often extends to 
healthcare settings, discrimination in interaction with 
healthcare providers. In particular, they have unique family 
planning, contraceptive, maternal health, and abortion needs 
that are related to their work and they often report limited 
access to information about these services. Data also show that 
female sex workers face a disproportionately high risk of 
acquiring HIV, 21 times higher than the general population.
    Given this clear need for services, treatment among female 
sex workers, some healthcare services have created specific 
outreach programs to build entrusted relationships and provide 
stigma-free care. Unfortunately, we hear that these programs 
are being forced to scale back or even shut down due to the 
Global Gag Rule.
    Also, we know the other vulnerable population I would ask 
you to address is women and girls with disabilities. They too 
are at a higher risk of HIV infection as well as stigma and 
discrimination, and also difficulty in just getting access to 
the healthcare services that they need.
    Starting with you, Dr. Kates, would you address some of the 
problems and how we can do better serving those two 
communities?
    Ms. Kates. Certainly. I will focus on the first that you 
mentioned, female sex workers, because as you mentioned they 
are at much higher risk of HIV and other health challenges, are 
often overlooked, criminalized, not given access to services. 
Within the U.S. Government's purview, PEPFAR is the program 
that has probably moved the furthest on this and makes female 
sex workers and male sex workers a priority key population that 
it focuses on.
    One of the challenges though is working in environments 
where they are not able to get services at all. So in some 
cases, PEPFAR has helped to create those services, but others 
it is working with challenging local laws and cultural beliefs. 
One thing PEPFAR is doing now and is planning to scale up is 
PrEP, pre-exposure prophylaxis, which is antiretroviral 
medication one takes before exposure to HIV that prevents HIV 
acquisition by close to 99 percent. This is a tremendous 
intervention and PEPFAR is going to be scaling that up, but 
that still the uptake is very, very low.
    So, I would just think looking at PEPFAR's ability to do 
more in the countries in which it works, as well as USAID's 
other programs that haven't had as much of an emphasis on 
reaching female sex workers.
    Ms. Crocker. Thank you for the question. And, I think, you 
know, one thing that it highlights is that there are unique 
challenges that are faced by marginalized parts of the 
population. So just to sort of bring it up to a level of 
generalization and to note that, you know, the importance of 
protection activities in the context of humanitarian 
emergencies, sometimes those may be specific to women and 
girls, generally; sometimes those may be specific to 
particularly discriminated against groups within society.
    I think your question also raises again the importance of 
ensuring that women and girls and, in fact, all members of the 
population have access to the tools and education they need to 
make informed decisions and voluntary decisions about their own 
family planning needs. In certain cases, there is enormous 
stigma due to social norms in certain communities around things 
like even reporting. So we have talked a bit today about the 
statistics around gender-based violence as an example, but 
because of stigma we actually think that those statistics are 
probably underreported, right. So as high as they sound, they 
are probably actually worse than what we know.
    And I think in terms of female sex workers, you know, the 
stigma is only heightened and, certainly, I think in terms of 
having, you know, enabling access by disabled people, whether 
girls or otherwise, in humanitarian emergencies is only more 
challenged. We have talked a lot about the degraded health 
systems, generally, in the context of humanitarian emergencies 
and the difficulty around access issues that again especially 
marginalized members of societies face.
    [Audio malfunction in hearing room.]
    Mr. Mulumba. Thank you. Very quickly, I think one of the 
immediate impacts when programs are cut to special groups like 
sex workers and women with disabilities the argument has been 
that you will find alternatives in other areas. But these 
groups receive treatment as a result of trust, so trust is 
created with providers over some time. So once you have 
immediate cuts they may not be able to receive services because 
of the lost relationships that they have had with the 
institutions that have lost funds, and it is a really a serious 
problem with the Global Gag Rule.
    Ms. Bos. Just really quickly, recognizing the time, 
disability inclusion is a huge priority for us in our programs. 
It is something we factor in to all of our programming, making 
sure, you know, identifying the barriers, you know, and really 
focusing on that, so it is definitely a priority in our work.
    Ms. Titus. If you have some specific information on that 
could you send it to me, or any of the Federal programs?
    Ms. Kates.
    Ms. Kates. Yes, I just want to add one thing. While clearly 
there are NGO's that do that work, it has not been something--
it is a gap in USG programs and policies. There is not an 
emphasis on this in the global health programs that are 
supported.
    Ms. Titus. That is what I feared.
    Thank you, Mr. Chairman.
    Mr. Engel. Thank you, Ms. Titus.
    Mr. Keating.
    Mr. Keating. Thank you, Mr. Chairman.
    First of all, I just want to reaffirm my support as 
original cosponsor for Representative Lowey's bill, the Global 
HER Act, as well as, you know, work as cosponsoring the 
International Violence Against Women Act and the recent 
resolution we had showing our concern as a Congress with 
treatment of children and violence in that regard. You know, 
the way women are treated, the way children are treated, I am 
reminded when you are on a plane sometimes and they warn you, 
the flight attendant will warn you if the pressure goes, ``The 
mask will come down. Put your mask on first before helping 
others.'' And I think as we talk about protecting children, it 
is just inextricably connected to protecting women and mothers 
and their family members in that regard. So this has been an 
important hearing in bringing that together and it is a 
terribly important issue.
    I want to hit something that probably has not been 
discussed as something that could interrupt your program, 
besides the fact that our policy is an on-again/off-again 
policy, which really hurts, I think, the ability of you to do 
your jobs, but I want to touch base on how climate change can 
affect and disrupt your programs as well. You know, you have 
areas of Africa, Sub-Sahara, where there is really this problem 
with children is the greatest, and I do not think it is 
coincidental that that is an area struck by climate change and 
the challenges that is around that.
    So if you can talk about how sometimes climate change, not 
just in the long-term effects of this, the result in famine, 
drought, water supply, other things, but also what happens when 
there are natural disasters that occur and how that disrupts 
the program and how that leaves women and children more 
vulnerable. I guess, Ms. Crocker, that is something that you 
could speak to.
    Ms. Crocker. Thank you. And I mean, for sure the impact of 
climate change and the climate crisis is having, is impacting 
our own programming. But I think, more importantly, and as your 
question alludes to, really impacting countries and communities 
around the world including those that aren't necessarily used 
to dealing with those kinds of disasters. And so we saw, for 
example, last spring with the double cyclones in Mozambique, 
hitting a country that had just not seen that type of disaster 
before and, you know, the implications that that has in terms 
of the ability of the local communities and local governments 
to muster the right kind of response and also the resilience of 
those communities.
    CARE sees in our work all over the world the impacts of 
climate change, the things you mentioned--drought, famine, 
other things--and we work with communities both to help them 
respond in times of crisis when sometimes you might be in a 
longer-term development posture but then there is a rapid onset 
crisis of some kind, but also, importantly, to help build and 
create the conditions under which communities themselves can 
build their own resilience.
    But of course, when countries, including here and 
communities here in the United States are facing disasters of 
types that they have never seen before, that is more 
challenging. You know, the confluence of impacts of the climate 
crisis and the protracted conflicts and crises we are seeing 
around the globe are also not something to forget, right. So we 
both are seeing an enormous wave of displacement due to 
conflict around the world, but we are also increasingly seeing 
displacement due to climate. And I think what we will all need 
to be watching for is how also those two things come together.
    Mr. Keating. Yes. And I honestly believe that, tying my two 
comments together, that it is so important whether it is a 
short-run emergency or whether it is a longer run climate 
change effect that women have to be more a party to dealing 
with the programs around that. There shouldn't be this divide--
well, we are going to take care of this here, but then you are 
doing all your work where it is there.
    So I hope there is more of an integration into that in the 
future. I think it is necessary. And I do not know if anyone 
else wanted to briefly comment.
    Ms. Crocker. If I could just add, briefly----
    Mr. Keating. Yes.
    Ms. Crocker [continuing]. Just to note that in all of our 
responses as CARE, we do a rapid gender assessment to 
understand the gendered implications of a disaster whether it 
is manmade or natural disaster. And I think you are exactly 
right, and it alludes to some of the things we have been 
discussing earlier around the importance of addressing the 
particular needs of women and girls, protection needs and 
health-related needs----
    Mr. Keating. Yes.
    Ms. Crocker [continuing]. From the outset of a disaster all 
the way through.
    Mr. Keating. And if women and those mothers aren't involved 
in that planning, it could get left out. In fact, it does. So, 
I yield back, and thank you for all the work you are doing.
    Mr. Engel. Okay, thank you.
    I understand that Mr. Smith would like a second opportunity 
to ask questions.
    Mr. Smith. Thank you, Mr. Chairman.
    Mr. Engel. So, Mr. Smith, you are recognized for 5 minutes.
    Mr. Smith. Mr. Chairman, thank you very much for that 
courtesy. Let me just--I learned of the forced abortion policy 
in the PRC, in China, in 1983. In 1984, offered an amendment 
saying that any organization that supports it should no longer 
receive U.S. funding. Jack Kemp and Senator Kasten added to the 
appropriations bill and we have had Kemp-Kasten ever since. 
Kemp-Kasten says voluntary yes, involuntary no. China is the 
most brutal example of coercion.
    I have chaired many hearings with women who have been 
forcibly aborted who told their stories, and the degradation, 
the impact on their bodies and especially on their minds as the 
government coerced them to kill their babies. Unwed mothers in 
China have to abort. I mean in this country, thankfully, we put 
our arms around unwed mothers and try to protect them and help 
them through. All of UNFPA that is denied by the U.S. 
Government goes to family planning and maternal health, so it 
is a one-for-one, dollar-for-dollar. We do support that.
    I had a number of hearings on the missing girls both in 
China and in India, and I had one woman, an expert, Mara 
Hvistendahl, who wrote a book called, and I read it and I 
encourage all to read it, ``Unnatural Selection: Choosing Boys 
Over Girls, and the Consequences of a World Full of Men.'' She 
said, and quote from the book, ``By August 1969, when the 
National Institute of Child Health and Human Development and 
the Population Council convened another workshop on population 
control, sex selection had become a pet scheme.''
    She goes on to say, ``Sex selection, moreover, had the 
added advantage of reducing the number of potential mothers.'' 
Kill the girl child in the womb and she will never be a mother 
perhaps in her 20's or 30's or even before. If reliable sex 
determination technology could be made available to a mass 
market, there was a rough consensus that sex selection abortion 
would be an effective, uncontroversial and ethical way of 
reducing the global population. Fewer women, fewer mothers, 
fewer future children. At the conference, she goes on to say, 
one abortion zealot, Christopher Tietzi, co-presented sex 
selection abortion as one of the 12 new strategies representing 
the future of global birth control.
    We are missing, and my good friend Mrs. Wagner mentioned in 
her comments, well over a hundred million women who should be 
here, but for the reason of their gender, the fact that they 
were a girl child in utero, was killed by abortion. My question 
is, do any of you support sex selection abortion? Have you seen 
the impact it has had on India? And in China, it has had an 
impact on human trafficking.
    For years, I tried to get the TIP Office, Trafficking in 
Persons Office, to recognize that when women are killed in 
utero because they are girls, the girl child, that creates a 
huge space for the human traffickers to fill a void because men 
cannot find women to marry, and that is a huge problem in the 
People's Republic of China as a direct result of the missing 
daughters.
    There is also the suicide issue. China is one of the 
countries, I think it is the only one where the rate among 
suicide among females far outnumbers the rate of men. The 
coercion clearly has something to do with it. The UNFPA has 
supported the Chinese program. We have asked them to leave, and 
yet you know as well as I that they have to comport with all of 
the China's laws and policies and regulations to do business 
there.
    Marie Stopes had to do that when they were there. They 
probably are still there. I am not sure of that. But they were 
denied money under Kemp-Kasten, and certainly the UNFPA has to 
comport with those laws, which makes them part of that coercive 
machinery. Remember, no unwed mothers. One child, now two-child 
per couple policy. For a long time, all brothers and sisters 
were illegal.
    So I would ask you, do you support sex selection abortion 
and are you concerned about this huge, you know, and we have 
two girls, two boys in my family, my wife and I. When we found 
it was a baby girl, we celebrated. Couldn't have been happier. 
``It is a girl.'' That phrase is one of the most dangerous 
phrases in some parts of the world, and 20 countries like I 
said have these disparities of male to female.
    On that question, and do you believe that China's program 
is coercive? Ms. Crocker?
    Ms. Crocker. Well, I would say to start off that CARE is, 
of course, is vehemently opposed to sex-selective abortion as 
well as any form of systemic gender discrimination, and sex-
selective abortion as you know is usually premised on harmful 
gender norms and stereotypes that stem from a belief that a 
male has greater value than a female, a belief, actually, that 
CARE seeks to address in our programming.
    We believe that the most effective way to address harmful 
gender norms that devalue women and girls is to address the 
root causes of gender inequality. CARE works with local 
partners and communities around the world to engage not only 
women and girls, but also men and boys as well to improve 
education, to improve health, to improve economic opportunities 
for women, and to create lasting change that benefits everyone 
in a community.
    Ms. Kates. My organization is not an implementer and we do 
not take positions. But I would just echo what Sheba said that 
the overall gender discrimination and conditions that create 
such hardship for women and girls in societies is something 
that the U.S. does work to combat and address, but clearly 
there are significant challenges and it is a very serious 
issue.
    Mr. Engel. I am going to have to cut it now because your 
time has lapsed, Mr. Smith.
    Ms. Omar.
    Ms. Omar. Thank you, Chairman, for having this important 
conversation. Thank you all for being here. My apologies if my 
line of questioning has already been dealt with in committee.
    I really think that there is a pressing global challenge of 
child marriage. Currently, we have 650 million women who are 
alive who have been married before their 18th birthday and 12 
million girls who are at risk of becoming child brides each 
year. We know that issues are compounded, that issue is 
compounded by poverty, safety, and security.
    Many countries have implemented laws to outlaw child 
marriage, but there are countries like the United States that 
allow, with consent, for some States to have young girls get 
married before they are 18. And so, I am wondering if, 
Jennifer, if you have any thoughts to how we can create a 
societal shift in recognizing how harmful this practice is and 
what would it take beyond the implementation of laws for us to 
be able to outlaw this global crisis?
    Ms. Kates. Thank you for the question. Clearly, a really 
critical global issue. One of the biggest ramifications of 
child marriage is the physical and emotional harm for young 
girls and that in and of itself goes against what the U.S. 
Government is trying to do just to enhance the lives and 
livelihoods of young people and women in countries in which it 
works.
    I think what the U.S. has done and probably would continue 
to have the biggest impact is addressing the root causes of the 
structural challenges that create the conditions that would 
lead to young women, against their will or without any say, 
being married at young ages and ultimately giving birth at very 
young ages and that is more access to education, more access to 
income-generating opportunities, things that will keep them 
healthy and also allow them to not--to have more voice and 
opportunity. The U.S. Government does work in this area, but 
clearly there is a lot more to do. Thanks.
    Ms. Omar. Do any of you want to chime in?
    Ms. Bos. I am happy to just add briefly from World Vision's 
perspective, you know, preventing child marriage is a complex 
issue. We need to work with parents. We need to work with 
schools. We need to work with faith leaders or traditional 
leaders who are performing the marriages. You are correct in 
that the enforcement piece is critical. In so many of these 
countries laws are on the books, but we still see girls getting 
married ages 12, 13, 14, so it is a critical issue.
    I agree with Jen, you know, the U.S. Government is doing 
some work in this space. I really have appreciated especially 
PEPFAR through the DREAMS program focused on adolescent girls, 
really helping girls feel empowered and feel like they can say 
no to early marriage.
    Ms. Omar. Yes.
    Ms. Crocker. Sorry. If I could just add, I mean, to bring 
it back to the context of humanitarian emergency also, which we 
have been discussing a lot, and just to know that child early 
enforced marriage also often increases during emergencies. It 
is a negative coping mechanism sometimes that families need to 
resort to or feel that they need to resort to in the context of 
emergencies.
    And I have flagged several times today the Safe from the 
Start Act, which is a bipartisan bill before Congress, and one 
of the things that the Safe from the Start Act would seek to 
address is child early enforced marriage in the context of 
emergencies.
    Mr. Mulumba. So on that point, I think in Uganda where I 
come from it is one of the biggest problems with children 
having children. It is such a huge problem, but it moves beyond 
the law to changing the societal norms. And one of the big 
challenges we have seen is that these are not arranged as 
marriages, but, you know, a young girl comes when she is 
pregnant and she is still in the same society, and the side of 
the offenders, you know, begin to negotiate with the other 
side.
    So, we have systems where even safe spaces are not 
provided. We are challenging the Government of Uganda for 
having no single safe space for girls that have been offended 
in situations like this. So it will take laws, but it will also 
take engagement within the communities but also challenging the 
governments.
    Ms. Omar. And the children having children is a huge 
problem. I have found it be quite alarming in the number of 
countries that have policies on the books that have increased 
the age, the legal age for a young woman to get married, but 
still have this problem persist because it is such a societal 
norm. I was even shocked as someone who comes from the same 
part of the world as you come from, to find that even in my own 
State of Minnesota that you do not legally have to be 18 to be 
able to get married.
    And it is such a tragedy that there are so many young 
women's opportunities for education, for a stable life that 
does not get to be advanced because they are sometimes forced 
to become mothers and care for others. So I appreciate you all 
for the work that your organizations do and to many of my 
colleagues who deeply care about ending this crisis. Thank you.
    Mr. Engel. Well, thank you. Thank you, Ms. Omar.
    I also want to thank our witnesses and the members who 
participated in this very important and interesting hearing. I 
want to thank the audience for being here today and showing 
their support, and with that the hearing is adjourned.
    [Whereupon, at 12:45 p.m., the committee was adjourned.]

                                APPENDIX
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                   PLANNED PARENTHOOD AYERS STATEMENT
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         COALITION STATEMENT OPPOSING THE GLOBAL GAG RULE 2019
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                            RESPONSES DEUTCH
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                            RESPONSES WAGNER
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                           RESPONSES PHILIPS
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                         ENGEL LETTER TO POMPEO
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                         ENGEL LETTER TO ESPER
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             INTERNATIONAL WOMEN'S HEALTH COALITION DOORLEY
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                        TASNIM LETTER IN ARABIC
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                            STANFORD LETTER
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                             CHANGE LETTER
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                     SAVE THE CHILDREN LETTER BORSH
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                           HUMAN RIGHTS WATCH
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             CHAMPIONS OF GLOBAL REPRODUCTIVE RIGHTS LETTER
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                            COLUMBIA LETTER
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                                 [all]