Eliminating Obstetric Fistula: A Comprehensive Approach to a Long-Ignored Problem

Sneha Barot

Obstetric fistula is a source of shame, stigma, and despair for millions of women. But US politics will inevitably play a role in whether it can be effectively addressed.

This article is part of a series by Rewire with contributions from  EngenderHealth, Guttmacher Institute, the International Women’s Health Coalition, the Fistula Foundation, the United Nations Population Fund (UNFPA), and the Campaign to End Fistula.  All articles in this series represent the views of individual authors and their organizations and can be found at this link.

The series is being published in conjunction with renewed efforts by advocates and the public health community to increase U.S. international support for efforts to address obstetric fistula, a wholly preventable but debilitating condition caused most immediately by obstructed labor and too early or too frequent childbearing, but generally rooted in lack of access to health care and discrimination against women.  Fistula affects the lives of individual women, their children and families, and also grossly undermines women’s economic productivity and participation in society. The global public health community has called for comprehensive strategies both to prevent new cases and treat existing cases of fistula.  Congresswoman Carolyn Maloney (D-NY) will soon introduce legislation intended to support a comprehensive U.S. approach to fistula as part of a broader commitment to reducing maternal mortality and morbidity worldwide.

After decades of taking a backseat to other more visible global health problems, the issue of maternal health has finally captured the attention of the world’s policymakers.  In 2000, 189 countries adopted eight Millennium Development Goals (MDGs) designed to reduce global poverty and support development. MDG 5 called for improving maternal health, and includes the specific targets of reducing the maternal mortality ratio by three-fourths and achieving universal access to reproductive health by 2015.  At the 2010 G-8 Summit in Canada, leaders of the richest countries promised to prioritize investments in maternal, newborn and child health, pledging $5 billion over the next five years to these efforts, while private foundations and non-G-8 countries pledged another $2.3 billion. The United Nations (UN) Secretary-General highlighted his desire to raise the profile of MDG 5, by launching a global strategy to accelerate progress on maternal and child health. And the Obama administration has included maternal and child health as a key pillar in its Global Health Initiative.

Although increased international attention as well as recent data showing some progress in lowering rates of maternal mortality are both welcomed by those concerned with public health and human rights, rates of pregnancy-related deaths remain unacceptably high and the world remains far behind in meeting the MDG 5 targets. To achieve this goal, governments must not only keep their funding promises, but ensure that funds are spent in the most effective ways possible to both prevent the causes of maternal illness and death and to offer accessible and effective care and treatment when complications do arise.

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Federesi’s story of surviving fistula in Uganda. Video courtesy of Engender Health and USAID.

Within the field of maternal health, moreover, there are specific pregnancy-related disabilities that themselves have been particularly neglected.  Prominent among these is obstetric fistula, a-long ignored problem now finally garnering some well-deserved awareness. Obstetric fistula is caused by prolonged, obstructed labor without access to emergency obstetric care, leaving a hole, otherwise known as a fistula, between a woman’s vagina and her bladder or rectum, or both. Without surgical intervention, women with fistula live with urinary or fecal incontinence, and invariably face shame, stigma and despair.

Understanding the Problem

Although there is widespread agreement that the existing data are incomplete and likely underestimate the problem, according to the World Health Organization (WHO), there are at least two million women worldwide who have obstetric fistula. Another estimated 50,000 to 100,000 new cases of fistula occur each year, though some say the incidence is higher.

There may be no more heart-wrenching portrait than a girl or a woman enduring obstetric fistula. She is typically young, often as young as 13. She is usually from a poor family in a poor community in a poor country, probably in Sub-Saharan Africa or South Asia, because obstetric fistula has almost disappeared from the developed world. She may have a weak, stunted or undeveloped pelvis, due perhaps to malnutrition, childhood illness or just being too young to bear children. Often married while barely in her teens, she does not or is not allowed to practice contraception and becomes pregnant, perhaps frequently. During prolonged, obstructed labor, her fetus is too large to pass through the birth canal, and pushes against the tissues of her vagina, bladder and rectum for days, which leads to a fistula. Access to emergency obstetric intervention, in particular a cesarean section, could prevent a fistula from occurring, but is generally unavailable.

Most of the time, such a woman delivers a stillborn baby. If she herself survives the labor, which can last up to a week, fistula causes an involuntary leaking of urine or feces, which is horrifying to her and those around her. The physical effects can include a strong stench, bladder or kidney infection, infertility, painful ulcerations, and nerve damage and paralysis in the legs. The overpowering smell and her physical condition often lead to divorce, abandonment by her family and ostracism from her community. A woman with fistula may have little or no access to resources to get appropriate physical and mental health care or to economic opportunities to earn a livelihood, pushing her further into poverty and depression, and sometimes suicide. A woman may live with this condition for the rest of her life, if unable to access treatment. The physical, psychological, social and economic consequences are utterly debilitating.

Fatoumata’s Story

Today I am 30 years old. I was 14 when everything turned upside down: my father arranged my marriage, and less than one year later, I was struck down by this terrible and humiliating sickness: urine leakage.

This happened after one week of prolonged and difficult labor. Yes, I spent seven days laboring in the hands of my poor mother and the village women, battling for my life and battling to give birth. But I could not.

On the seventh day, my husband took me from the village to the nearest health center, located 40 km away, where an unqualified health provider pulled the baby out by force. He was dead. The following day, my ordeal started: I could not control my bladder any more.

Read the rest of Fatoumata’s story…

Courtesy of Engender Health and USAID

The Three Prongs

 There is widespread consensus among fistula experts that a comprehensive approach to addressing the problem encompasses three prongs: prevention, treatment and rehabilitation. As with many other global health issues, however, prevention may be key to solving the problem, but it is often the most difficult area in which to make progress and demonstrate success.

In the case of obstetric fistula, prevention means providing universal access to adequate reproductive and maternal health care, as well as addressing the underlying systemic conditions that lead to the condition. At the most proximate—or direct–level, prevention measures include the availability of skilled birth attendants and emergency obstetric care, including access to a cesarean section. Another essential prevention strategy, however, is access to family planning services that enable women to avoid too-early pregnancies, have only as many pregnancies as they want, and space them to maximize their own health during pregnancy and the health of their babies.

Equally important to fistula prevention are interventions to combat the other, often interlocking, social and economic inequities that contribute to this problem: the low status of women, lack of education for girls, early marriage and pregnancy, malnutrition, poverty, inadequate health and transportation infrastructure and harmful traditional practices such as female genital mutilation. Failure to aggressively take on these persistent, root causes of fistula—and indeed of most other poor maternal health outcomes—will only ensure that the problem endures.

Treatment for obstetric fistula usually consists of surgical repair. There are many different forms of fistula, from the simple to the complex. Some 90 percent of uncomplicated cases can be successfully repaired; the average cost of fistula treatment, however, is about $300. For complex cases, repair may not be possible at all, but if it is, incontinence may continue regardless. Some fistulas can be extremely complicated, involving damage to other bodily systems and requiring multiple, expensive surgeries to treat. A holistic model of treatment also requires attention to infrastructure and local capacity, including the training of indigenous health professionals, provision of postoperative care, and equipping and upgrading health facilities.

Moreover, surgical repair of fistula is often only the first step for women to heal from this condition. Years and sometimes decades of living with fistula leave many women socially, psychologically and financially unable to function in their communities. Accordingly, the last prong of a comprehensive approach to fistula includes services that help fistula patients reintegrate into society through the provision of counseling, skills training, literacy classes and other support, to restore their dignity, self-confidence and self-sufficiency.

A variety of contingencies can arise even after a repair, including later complications, subsequent pregnancies (if possible) that require cesarean section, or recurrent fistulas (which can reoccur even with prior uncomplicated cases). Because of these factors and the devastation to women affected and those around them, it is crucial that prevention efforts be strengthened and emphasized in tandem with those around treatment and repair. Moreover, because obstetric fistula shares the same underlying causes that lead to other types of maternal morbidity, and to maternal and newborn deaths, it is not surprising that WHO and other leading global health professionals recommend that fistula prevention and treatment programs be integrated into a country’s overall plan to lower maternal and infant deaths. By pursuing a coordinated approach, fistula programs themselves will be stronger, more effective and more sustainable, along with the broader safe motherhood initiatives in which they are located.

Ongoing Fistula Initiatives

International aid efforts to tackle fistula have gained steam over the last few years. The global development agency that has led the charge against obstetric fistula is the United Nations Population Fund (UNFPA), which founded the first global campaign around fistula in 2003. The Campaign to End Fistula has embraced a comprehensive framework to eliminate fistula and assists countries in conducting assessment surveys, developing national plans and implementing those plans through interventions to prevent and treat fistula, and to provide reintegration services. It is working in 49 countries, and UNFPA has raised $37 million to support the campaign (see map). Additionally, UNFPA acts as Secretariat for the International Obstetric Fistula Working Group, which coordinates activities to eliminate fistula and whose membership includes leading individuals and organizations dedicated to fistula prevention, treatment and recovery.

The UNFPA-led campaign is active primarily in Africa and South Asia.

The UNFPA-led campaign is active primarily in Africa and South Asia.

The U.S. government’s financial and technical contribution to international fistula efforts is carried out through the U.S. Agency for International Development’s (USAID) maternal health program as well as its population and reproductive health program. USAID’s FY 2010 allocation for fistula is more than $11 million, and the agency has programmed $59 million since it began implementation in 2005. It currently provides assistance to 34 fistula repair centers in 11 countries, as well as an additional 39 facilities for prevention services such as family planning and maternity care. The bulk of USAID fistula funding is funneled through the Fistula Care Project, a five-year cooperative agreement with EngenderHealth, a nongovernmental organization working on reproductive health. The project implements the majority of USAID’s prevention and repair programs, and manages the data for all of USAID’s fistula programs. In addition, USAID is a member of the Campaign to End Fistula, as well as of the International Obstetric Fistula Working Group.

New Directions

Because fistula generates such deep sympathy, a diversity of actors in the advocacy, media and policy communities—including those who sit at opposite poles of the political spectrum—have taken an interest in it.  One consequence of this broad-based acknowledgment of the problem, however, is the ideological divide that often forms over how to address a problem so intricately linked to sex and reproduction.

As happened with HIV in the context of the President’s Emergency Plan for AIDS Relief (PEPFAR), fault lines have already developed over the level of emphasis that should be placed on efforts to prevent fistula, which would include family planning, versus less ideologically-fraught treatment efforts. Experts in the field overwhelmingly agree that as advocates and policymakers consider efforts to develop new initiatives on obstetric fistula, it is imperative that such policies be grounded in an evidence-based, which is to say comprehensive, approach.

In Congress, interest in fistula spans the ideological spectrum. Congresswoman Carolyn Maloney (D-NY), a staunch ally of reproductive rights who has a long record of supporting fistula programs, is expected to reintroduce a bill this spring that emphasizes both prevention—including access to sexual and reproductive health services—and treatment, along with activities that build country capacity, such as promoting “south-to-south” training from one developing country to another.

Socially conservative legislators also have taken action on this issue. Rep. Chris Smith (R-NJ), a vehement opponent of comprehensive sexual and reproductive health services, has long promoted obstetric fistula programs. His philosophical approach was apparent during consideration of the FY 2006–2007 State Department reauthorization bill, to which he added funding for fistula repair activities, yet also successfully introduced an amendment that weakened language on fistula prevention and removed reference to contraceptive services.

Given the current political climate, the new Republican majority in the House, and the anti–family planning stance of many socially conservative lawmakers, advocates for eliminating obstetric fistula worry that a strong commitment to fistula prevention, particularly with regard to family planning, could be dropped in any legislative effort that seeks to attract broad bipartisan support and conservative evangelical participation.

Their concerns stem from the experiences of advocates during the original PEPFAR authorization process in 2003, as well as the reauthorization process in 2008, in which the price paid for holding together a coalition that included religious and social conservatives was steep. Both times, evidence-based prevention policies were sacrificed in favor of abstinence promotion, devaluation of prevention efforts generally, and a failure to recognize the value of better integration between contraceptive services programs and HIV prevention and treatment programs.

With respect to maternal health policies, the MDG framework clearly sets forth the importance of universal access to reproductive health care to the achievement of better maternal health. This interrelationship has been repeatedly affirmed by evidence, and supported by key implementers and donors alike. As the recent G-8 declaration stated, many pregnancy-related deaths and injuries could be prevented with “better access to strengthened health systems, and sexual and reproductive health care and services, including voluntary family planning.” With specific regard to fistula, the 2008 report of the UN Secretary-General on “Supporting Efforts to End Obstetric Fistula” states that “optimal maternal health, including elimination of obstetric fistula, will ultimately be achieved through universal access to reproductive health.”

Policies and programs to eradicate obstetric fistula cannot succeed without a robust family planning component. Sexual and reproductive health advocates working on fistula are therefore anxiously monitoring the development of fistula legislation and policy in this Congress. As the process moves forward, they are determined to ensure that, this time, comprehensive and evidence-based policies are not sacrificed to accommodate an ideologically diverse constituency. Even as advocates continue, years later, an uphill battle to repair some of the shortcomings of PEPFAR, the lesson and their message to policymakers has become clear: Do it right the first time, so you don’t have to fix it later.

Analysis Abortion

Legislators Have Introduced 445 Provisions to Restrict Abortion So Far This Year

Elizabeth Nash & Rachel Benson Gold

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. Of these, 35 percent (445 provisions) sought to restrict access to abortion services. By midyear, 17 states had passed 46 new abortion restrictions.

Including these new restrictions, states have adopted 334 abortion restrictions since 2010, constituting 30 percent of all abortion restrictions enacted by states since the U.S. Supreme Court decision in Roe v. Wade in 1973. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

Mid year state restrictions

 

Signs of Progress

The first half of the year ended on a high note, with the U.S. Supreme Court handing down the most significant abortion decision in a generation. The Court’s ruling in Whole Woman’s Health v. Hellerstedt struck down abortion restrictions in Texas requiring abortion facilities in the state to convert to the equivalent of ambulatory surgical centers and mandating that abortion providers have admitting privileges at a local hospital; these two restrictions had greatly diminished access to services throughout the state (see Lessons from Texas: Widespread Consequences of Assaults on Abortion Access). Five other states (Michigan, Missouri, Pennsylvania, Tennessee, and Virginia) have similar facility requirements, and the Texas decision makes it less likely that these laws would be able to withstand judicial scrutiny (see Targeted Regulation of Abortion Providers). Nineteen other states have abortion facility requirements that are less onerous than the ones in Texas; the fate of these laws in the wake of the Court’s decision remains unclear. 

Ten states in addition to Texas had adopted hospital admitting privileges requirements. The day after handing down the Texas decision, the Court declined to review lower court decisions that have kept such requirements in Mississippi and Wisconsin from going into effect, and Alabama Gov. Robert Bentley (R) announced that he would not enforce the state’s law. As a result of separate litigation, enforcement of admitting privileges requirements in Kansas, Louisiana, and Oklahoma is currently blocked. That leaves admitting privileges in effect in Missouri, North Dakota, Tennessee and Utah; as with facility requirements, the Texas decision will clearly make it harder for these laws to survive if challenged.

More broadly, the Court’s decision clarified the legal standard for evaluating abortion restrictions. In its 1992 decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, the Court had said that abortion restrictions could not impose an undue burden on a woman seeking to terminate her pregnancy. In Whole Woman’s Health, the Court stressed the importance of using evidence to evaluate the extent to which an abortion restriction imposes a burden on women, and made clear that a restriction’s burdens cannot outweigh its benefits, an analysis that will give the Texas decision a reach well beyond the specific restrictions at issue in the case.

As important as the Whole Woman’s Health decision is and will be going forward, it is far from the only good news so far this year. Legislators in 19 states introduced a bevy of measures aimed at expanding insurance coverage for contraceptive services. In 13 of these states, the proposed measures seek to bolster the existing federal contraceptive coverage requirement by, for example, requiring coverage of all U.S. Food and Drug Administration approved methods and banning the use of techniques such as medical management and prior authorization, through which insurers may limit coverage. But some proposals go further and plow new ground by mandating coverage of sterilization (generally for both men and women), allowing a woman to obtain an extended supply of her contraceptive method (generally up to 12 months), and/or requiring that insurance cover over-the-counter contraceptive methods. By July 1, both Maryland and Vermont had enacted comprehensive measures, and similar legislation was pending before Illinois Gov. Bruce Rauner (R). And, in early July, Hawaii Gov. David Ige (D) signed a measure into law allowing women to obtain a year’s supply of their contraceptive method.

071midyearstatecoveragetable

But the Assault Continues

Even as these positive developments unfolded, the long-standing assault on sexual and reproductive health and rights continued apace. Much of this attention focused on the release a year ago of a string of deceptively edited videos designed to discredit Planned Parenthood. The campaign these videos spawned initially focused on defunding Planned Parenthood and has grown into an effort to defund family planning providers more broadly, especially those who have any connection to abortion services. Since last July, 24 states have moved to restrict eligibility for funding in several ways:

  • Seventeen states have moved to limit family planning providers’ eligibility for reimbursement under Medicaid, the program that accounts for about three-fourths of all public dollars spent on family planning. In some cases, states have tried to exclude Planned Parenthood entirely from such funding. These attacks have come via both administrative and legislative means. For instance, the Florida legislature included a defunding provision in an omnibus abortion bill passed in March. As the controversy grew, the Centers for Medicare and Medicaid Services, the federal agency that administers Medicaid, sent a letter to state officials reiterating that federal law prohibits them from discriminating against family planning providers because they either offer abortion services or are affiliated with an abortion provider (see CMS Provides New Clarity For Family Planning Under Medicaid). Most of these state attempts have been blocked through legal challenges. However, a funding ban went into effect in Mississippi on July 1, and similar measures are awaiting implementation in three other states.
  • Fourteen states have moved to restrict family planning funds controlled by the state, with laws enacted in four states. The law in Kansas limits funding to publicly run programs, while the law in Louisiana bars funding to providers who are associated with abortion services. A law enacted in Wisconsin directs the state to apply for federal Title X funding and specifies that if this funding is obtained, it may not be distributed to family planning providers affiliated with abortion services. (In 2015, New Hampshire moved to deny Title X funds to Planned Parenthood affiliates; the state reversed the decision in 2016.) Finally, the budget adopted in Michigan reenacts a provision that bars the allocation of family planning funds to organizations associated with abortion. Notably, however, Virginia Gov. Terry McAuliffe (D) vetoed a similar measure.
  • Ten states have attempted to bar family planning providers’ eligibility for related funding, including monies for sexually transmitted infection testing and treatment, prevention of interpersonal violence, and prevention of breast and cervical cancer. In three of these states, the bans are the result of legislative action; in Utah, the ban resulted from action by the governor. Such a ban is in effect in North Carolina; the Louisiana measure is set to go into effect in August. Implementation of bans in Ohio and Utah has been blocked as a result of legal action.

071midyearstateeligibilitytable

The first half of 2016 was also noteworthy for a raft of attempts to ban some or all abortions. These measures fell into four distinct categories:

  • By the end of June, four states enacted legislation to ban the most common method used to perform abortions during the second trimester. The Mississippi and West Virginia laws are in effect; the other two have been challenged in court. (Similar provisions enacted last year in Kansas and Oklahoma are also blocked pending legal action.)
  • South Carolina and North Dakota both enacted measures banning abortion at or beyond 20 weeks post-fertilization, which is equivalent to 22 weeks after the woman’s last menstrual period. This brings to 16 the number of states with these laws in effect (see State Policies on Later Abortions).
  • Indiana and Louisiana adopted provisions banning abortions under specific circumstances. The Louisiana law banned abortions at or after 20 weeks post-fertilization in cases of diagnosed genetic anomaly; the law is slated to go into effect on August 1. Indiana adopted a groundbreaking measure to ban abortion for purposes of race or sex selection, in cases of a genetic anomaly, or because of the fetus’ “color, national origin, or ancestry”; enforcement of the measure is blocked pending the outcome of a legal challenge.
  • Oklahoma Gov. Mary Fallin (R) vetoed a sweeping measure that would have banned all abortions except those necessary to protect the woman’s life.

071midyearstateabortionstable

In addition, 14 states (Alaska, Arizona, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Maryland, South Carolina, South Dakota, Tennessee and Utah) enacted other types of abortion restrictions during the first half of the year, including measures to impose or extend waiting periods, restrict access to medication abortion, and establish regulations on abortion clinics.

Zohra Ansari-Thomas, Olivia Cappello, and Lizamarie Mohammed all contributed to this analysis.

Commentary Politics

In Mike Pence, Trump Would Find a Fellow Huckster

Jodi Jacobson

If Donald Trump is looking for someone who, like himself, has problems with the truth, isn't inclined to rely on facts, has little to no concern for the health and welfare of the poorest, doesn't understand health care, and bases his decisions on discriminatory beliefs, then Pence is his guy.

This week, GOP presumptive presidential nominee Donald Trump is considering Mike Pence, among other possible contenders, to join his ticket as a vice presidential candidate.

In doing so, Trump would pick the “pro-life” governor of a state with one of the slowest rates of economic growth in the nation, and one of the most egregious records on public health, infant and child survival, and poverty in the country. He also would be choosing one of the GOP governors who has spent more time focused on policies to discriminate against women and girls, LGBTQ communities, and the poor than on addressing economic and health challenges in his state. Meanwhile, despite the evidence, Pence is a governor who seems to be perpetually in denial about the effects of his policies.

Let’s take the economy. From 2014 to 2015, Indiana’s economic growth lagged behind all but seven other states in the nation. During that period, according to the U.S. Department of Commerce, Indiana’s economy grew by just 0.4 percent, one-third the rate of growth in Illinois and slower than the economies of 43 other states. Per capita gross domestic product in the state ranked 37th among all states.

Income inequality has been a growing problem in the state. As the Indy Star reported, a 2014 report by the United States Conference of Mayors titled “Income and Wage Gaps Across the US” stated that “wage inequality grew twice as rapidly in the Indianapolis metro area as in the rest of the nation since the recession,” largely due to the fact “that jobs recovered in the U.S. since 2008 pay $14,000 less on average than the 8.7 million jobs lost since then.” In a letter to the editor of the Indy Star, Derek Thomas, senior policy analyst for the Indiana Institute for Working Families, cited findings from the Work and Poverty in Marion County report, which found that four out of five of the fastest-growing industries in the county pay at or below a self-sufficient wage for a family of three, and weekly wages had actually declined. “Each year that poverty increases, economic mobility—already a real challenge in Indy—becomes more of a statistical oddity for the affected families and future generations.”

In his letter, Thomas also pointed out:

[T]he minimum wage is less than half of what it takes for a single-mother with an infant to be economically self-sufficient; 47 percent of workers do not have access to a paid sick day from work; and 32 percent are at or below 150 percent of the federal poverty guidelines ($29,685 for a family of three).

Despite the data and the struggles faced by real people across the state, Pence has consistently claimed the economy of the state is “booming,” and that the state “is strong and growing stronger,” according to the Northwest Indiana Times. When presented with data from various agencies, his spokespeople have dismissed them as “erroneous.” Not exactly a compelling rebuttal.

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As a “pro-life” governor, Pence presides over a state with one of the worst infant mortality rates in the nation. Data from the Indiana State Department of Health reveals a “significant disparity” between white and Black infant mortality rates, with Black infants 1.8 times more likely to die than their white counterparts. The 2013 Infant Mortality Summit also revealed that “[a]lmost one-third of pregnant women in Indiana don’t receive prenatal care in their first trimester; almost 17% of pregnant women are smokers, compared to the national rate of 9%; and the state ranks 8th in the number of obese citizens.”

Yet even while he bemoaned the situation, Pence presided over budget cuts to programs that support the health and well-being of pregnant women and infants. Under Pence, 65,000 people have been threatened with the loss of  food stamp benefits which, meager as they already are, are necessary to sustain the caloric and nutritional intake of families and children.

While he does not appear to be effectively managing the economy, Pence has shown a great proclivity to distract from real issues by focusing on passing laws and policies that discriminate against women and LGBTQ persons.

He has, for example, eagerly signed laws aimed at criminalizing abortion, forcing women to undergo unnecessary ultrasounds, banning coverage for abortion care in private insurance plans, and forcing doctors performing abortions to seek admitting privileges at hospitals (a requirement the Supreme Court recently struck down as medically unnecessary in the Whole Woman’s Health v. Hellerstedt case). He signed a “religious freedom” law that would have legalized discrimination against LGBTQ persons and only “amended” it after a national outcry. Because Pence has guided public health policy based on his “conservative values,” rather than on evidence and best practices in public health, he presided over one of the fastest growing outbreaks of HIV infection in rural areas in the United States.

These facts are no surprise given that, as a U.S. Congressman, Pence “waged war” on Planned Parenthood. In 2000, he stated that Congress should oppose any effort to recognize homosexuals and advocated that funding for HIV prevention should be directed toward conversion therapy programs.

He also appears to share Trump’s hatred of and willingness to scapegoat immigrants and refugees. Pence was the first governor to refuse to allow Syrian refugees to relocate in his state. On November 16th 2015, he directed “all state agencies to suspend the resettlement of additional Syrian refugees in the state of Indiana,” sending a young family that had waited four years in refugee limbo to be resettled in the United States scrambling for another state to call home. That’s a pro-life position for you. To top it all off, Pence is a creationist, and is a climate change denier.

So if Donald Trump is looking for someone who, like himself, has problems with the truth, isn’t inclined to rely on facts, has little to no concern for the health and welfare of the poorest, doesn’t understand health care, and bases his decisions on discriminatory beliefs, then Pence is his guy.