The White House's decision earlier this month to defund US aid to foreign health programs under the so-called “global gag rule” could put millions of lives in danger, Bill and Melinda Gates said today.

It could also reverse progress the Gates Foundation has made in improving health outcomes for the world’s poorest, the couple wrote in their annual letter to investor Warren Buffett, who provides the foundation with billions in funding.

The global gag rule prevents any group that promotes or performs abortion services from receiving US aid, even if abortion is legal in the country where the group operates.

Read More: Trump Targets Women’s Healthcare in One of His First Actions as President

The rule, also known as the “Mexico City policy,” has been imposed by Republican administrations dating back to Ronald Reagan in 1984, but the version signed into law by Donald Trump on his first day in office is farther-reaching than its predecessors. It affects any group receiving funding from US AID.

The Microsoft founder’s philanthropic efforts have been focused on improving global health, including that of women and children around the world. The letter to Buffet was to provide an update on the progress made in saving children’s lives, but included bad news on that progress.

“We’re concerned that this shift could impact millions of women and girls around the world,” Melinda Gates told the Guardian today. “It’s likely to have a negative effect on a broad range of health programs that provide lifesaving treatment and prevention options to those most in need.”

Bill Gates said that even though he met with Trump in December to talk about the foundation’s work, including the eradication of polio, Trump’s expansion of the global gag rule caught him by surprise.

Read more: The Netherlands Sets Up Abortion Fund in Challenge to Trump Policy

The rule will cut about $9 billion in funding from groups around the world that provide contraception, routine medical examines, maternal and child health care, and pregnancy and delivery services to some of the world’s poorest regions, according to the Planned Parenthood Federation of America.

The government of the Netherlands has set up a fund to try and make up for some of the lost US aid. The campaign, called She Decides, will ask other governments and individuals to contribute to making up the difference.

When women don’t have access to information about breastfeeding, or vaccinations for their children, their children’s lives often suffer consequences, Melinda said. The funding cut could also lead to unintended pregnancies and unsafe abortions, resulting in worse outcomes for children and women.

“So you have to look at the woman’s role and when you look at it you realize it can be an accelerator to every single thing you want to have happen in the world for global health and global development and social change.”

The funding also goes toward the prevention and treatment of HIV, tuberculosis, and malaria, diseases whose spread has been curbed in recent years with the aid of funding.

Read More: 8 Critical Numbers in Bill and Melinda Gates' Letter to Warren Buffett

The Gates Foundation won’t be able to make up the difference in funding, Bill Gates said.  

“The US is the No. 1 donor in the work that we do. Government aid can’t be replaced by philanthropy. When government leaves an area like that, it can’t be offset, there isn’t a real alternative. This expansion of this policy, depending on how it’s implemented, could create a void that even a foundation like ours can’t fill,” he said.

The letter ended on an optimistic note, with the couple telling Buffett they still believed that in their lifetimes polio would end and malaria would end, and that few people will get TB and no one will die from AIDS.

“We can’t put a date on these events, and we don’t know the sequence, but we’re confident of one thing: The future will surprise the pessimists,” they wrote.

Disclosure: The Bill and Melinda Gates Foundation is a funding partner of Global Citizen.

Editor's note: This piece has been updated to include a disclosure that the Bill and Melinda Gates Foundation is a funding partner of Global Citizen. We regret the oversight.


Demand Equity

Millions of Lives at Risk With Global Gag Rule, Bill and Melinda Gates Say

By Colleen Curry