Collateral damage from Trump’s family planning aid ban? What it means in fight against thalassemia blood diseases

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Donald Trump’s reinstatement of a Regan-era policy that opposes abortion abroad will have widespread public health implications in dozens of countries that receive health aid through the United States Agency for International Development (USAID). Known as the Mexico City policy, and called “the global gag rule” by its critics, it prohibits aid to nongovernmental organizations (NGOs) abroad that perform or discuss abortion as a family-planning option.

The order originated with President Ronald Reagan and has alternately been instituted or repealed, depending on which party controls the White House. During the Reagan and both Bush administrations it prevented about $575 million in US funds from being distributed outside the US. So it was not a surprise when Trump reinstated the policy through executive order. But he did take things a step further, according to the New York Times:

Mr. Trump’s order takes the prohibition further: It freezes funding to nongovernmental organizations in poor countries if they offer abortion counseling or if they advocate the right to seek abortion in their countries. The freeze applies even if the organizations use other sources of funding for these services.

The freeze stands to affect more than $9 billion in funding to NGOs that support reproductive health efforts in other countries. The US is the biggest global funder of family-planning services. To better understand the wide-ranging impact, we look at how this order could have collateral impact on other health conditions, focusing specifically on one disorder that could see a resurgence.

Hemoglobinopathies, USAID and abortion

Thalassemia is an inherited blood disorder common in the Mediterranean, Middle East, Africa and South Asia. It is passed down through families in which the body makes an abnormal form of hemoglobin, the protein in red blood cells that carries oxygen. The disorder results in excessive destruction of red blood cells, which leads to anemia. The more severe form of the disease is thalassemia major. The sometimes-fatal condition has been on the decline in recent years as a result of genetic screening, counseling and elective abortion. The new executive order could put things into reverse.

What do Mediterranean regions, the Middle East, Africa, and South Asia have in common that would make this class of diseases common? The answer is malaria. They all harbor climates where mosquitoes thrive. People who live in these regions have been subjected to evolutionary pressure from the disease.Evolutionary geneticists think it has imparted a survival advantage against malaria for people harboring genes encoding abnormal versions of the globin chains that comprise hemoglobin.

Abnormal genes can produce a defective globin, as happens with the sickle cell gene, which produces an abnormal version of the hemoglobin beta chain. Or, genetic defects can cause simply insufficient quantities of normal alpha- or beta-globin. The latter scenario is thalassemia — either alpha- or beta thalassemia, depending on which globin chain type is under-produced. Alpha thalasssmia is common in Asia and Africa. Beta thalassemia is common in Mediterranean regions (including the northern coast of Africa), though there’s a lot of overlap as people have moved around a lot in modern times.

Because these conditions are so common, USAID has programs in place to fight disorders such as thalassemia. These initiatives include premarital and preconception genetic counseling. Abortion is inevitably worked into the equation, because any couple knowing that it carries a fetus that will develop thalassemia major — a severe form of the disease —  is going to consider it. Many governments use preconception counseling to discourage marriage when genetic screening shows that both people are carriers of the thalassemia trait. According to a review published in the journal Public Health Genomics in 2015, counseling generally results in an increased rate of elective abortions.

During the time in which genetic counseling has been available, there has been a decrease in the number of cases of thalassemia major. The reason for this has to do with the genetics underlying thalassemia, which is complex compared with something like sickle cell disease, which results from just a single abnormal gene copy. Thalassemia is different because it involves multiple copies (alleles) of the involved genes.

Islam and abortion

Why is it that fetal screening for thalassemia is done through chorionic villus sampling (CVS), instead of amniocentesis, the prenatal sampling procedure familiar to most Americans? The answer is that CVS can be performed a little bit earlier in an environment where timing is a major factor. Because of the 1973 Roe v. Wade Supreme Court ruling, the comfort zone for elective abortion in the US ends somewhere in the range of 20 to 24 weeks gestation. And so the paradigm here is between Roe v. Wade and Christian fundamentalism. The latter calls for no abortion at all and that’s what drove the recent executive order on the Mexico City Policy.

In many countries with high thalassemia rates, the paradigm is different. Greece does not restrict elective abortion during the first 12 weeks gestation, whereas in Israel both the legal structure and society is completely pro-choice. Many Muslim countries also allow abortion, because Islam does not prohibit the procedure up to 120 days (about 17 weeks) gestation. This makes for a situation that’s intermediate between anti-abortion Christian fundamentalist and those with a fully pro-choice view.

Thus, the expanded Mexico City policy will be denying health aid, including genetic counseling and screening, to NGOs in a wide range of nations in Africa, Asia and the Middle East. So, either by losing funds, or by deciding to prohibit abortion, these nations can expect to see a reversal of the current trend toward lower incidence thalassemia.

The only thing that can prevent this from happening now would be an influx of funding from other nations to compensate for the loss from the United States. Recently, the Dutch government announced that it would step in to help by establishing an abortion fund.

David Warmflash is an astrobiologist, physician and science writer. Follow @CosmicEvolution to read what he is saying on Twitter