Confronting a new epidemic: consequences of the Zika virus for public health and reproductive rights
************************ 15 february 2016
WHO predicts up to four million cases of the mosquito-borne Zika infection just this year.
In the past few weeks, there has been a storm of news articles and statements in the world press about the Zika virus. Among those written by abortion rights activists are calls for governments with restrictive abortion laws to legalise abortion, whether on all grounds, therapeutic grounds only, or just in relation to Zika infection. In El Salvador and Nicaragua abortion is illegal even to save the life of the woman, so why would they be moved regarding the effects of Zika?
Several articles recall that in the USA in the 1950s and 60s, fetal anomalies caused by rubella and thalidomide, as serious as those associated with Zika, contributed to the US Supreme Court decision in 1973 to declare abortion a matter between a woman and her doctor, but that decision was on its way anyway. And that is the point. Change is likely to follow only if the ground is already prepared. In the case of an epidemic as serious as the Zika virus is threatening to be, the meaning of “preparing the ground” is far wider than abortion, as important as safe abortion is.
A more appropriate example, in the search for precedents, is what happened when it was learned that HIV was transmitted during pregnancy and breastfeeding, causing serious illness, miscarriage, stillbirths and early death in millions of infants, as well as killing their mothers. Look how long it took, first to recognise and research the problem, then to develop treatment that would effectively prevent transmission ‒ and then to provide those treatments in public health care settings that reached a large proportion of the affected populations, especially in poor countries. Even today, more than 30 years into the HIV epidemic, this is unfinished work.
The epidemic of syphilis, a very old one compared to HIV, is another example. Syphilis is also transmitted vertically. For decades, it is supposed to have been a routine part of antenatal care to test and treat pregnant women for syphilis. Yet it was only in June 2015 that WHO announced that one country (Cuba) had eliminated mother-to-child transmission of both HIV and syphilis.
The same mosquito that transmits Dengue fever and several other tropical diseases transmits Zika. Microcephaly appears to be a consequence of Zika infection, but what else might this virus cause ‒ not only during pregnancy but also in adults and children?
Thus, it is important to see this problem through a wider public health lens, requiring a wide range of expertise and inputs, and to be cautious about what can be achieved and how soon, and therefore what to call for.
This statement summarises what experts on public health, pregnancy and reproductive rights are saying and recommending, based on current knowledge.
Key issues and recommendations being raised by experts Zika has exposed the weaknesses in public health systems’ responses to new epidemics, especially at the primary care level, in countries where the virus is already known to be widespread. It has also exposed the weaknesses in the provision of reproductive health services for women in those countries, both in relation to information and care during and after pregnancy, and in relation to the prevention and termination of pregnancy.
Five major areas for attention under these headings have been emphasised in relation to Zika:
1) Elimination of the mosquito that carries Zika, Dengue fever and other diseases, and possibly elimination of all mosquitoes A leading national voice on bioethics in Brazil, Volnei Garrafa, University of Brasilia and Unesco Cathedra of Bioethics, saidthat the Brazilian government wants to hold society responsible for fighting the mosquito, without assuming its own responsibility for the lack of adequate sanitation and the “garbage and stagnant water everywhere” which generate perfect breeding grounds for the mosquito.
Malaria eradication efforts offer pointers. Over 1 million people die from mosquito-borne diseases every year, and hundreds of millions more experience pain and suffering from illnesses transmitted by mosquitoes. According to biotechnological company Oxitec, malaria affects 350-500 million people each year and Dengue fever affects nearly 400 million, both at enormous cost in affected countries.
2) Policy, programme, and economic changes that will reduce climate change and its adverse effects on health and disease The rise in mosquito-borne diseases is interlinked with the adverse effects of climate change, such as rising temperatures and shifts in precipitation. Scientists say that long-term climate change will make it increasingly difficult to protect human beings from such diseases and the rapid spread of Zika over a few months is quite telling in this.
3) Critical improvements in the reporting of unusual conditions identified during pregnancy and delivery, so as to foster early recognition of new diseases affecting pregnancy, as noted by Sexuality Policy Watch.
4) Universal access to antenatal care, which provides diagnosis of diseases, now to include the Zika virus, and social support for women/families with a child affected by Zika, as, should be available for those with all children with serious disabilities. WHO’s guidance on antenatal care includes:
Preventive measures, including immunization (especially with tetanus toxoid) and screening for underlying conditions and diseases such as anaemia, malaria, sexually transmitted infections (especially syphilis and HIV), underlying mental health problems, and/or symptoms of stress or domestic violence.
Recognition and management of pregnancy-related complications.
Recognition and treatment of underlying or concurrent illness or disease.
As Débora Diniz, a law professor at Brasilia University and with the Anis Institute of Bioethics in Brasilia, said in aninterviewwith the BBC: “This is a public health battle against the mosquitoes and a women’s sexual and reproductive rights issue. The women most at risk of the Zika virus don’t even have access to antenatal care, so they cannot get an antenatal diagnosis of the Zika virus”.
5) Universal access to education, information and primary health care services, including those that will enable individuals and couples to make informed decisions about their bodies, about pregnancy and the regulation of their fertility, and access to the means to implement those decisions The Zika outbreak brings into sharp relief just how important primary health care systems are in identifying, preventing, treating, and managing infectious diseases. In relation to reproductive health care, in addition to comprehensive pregnancy care, this includes access to the full range of contraceptive methods that prevent both pregnancy and the sexual transmission of diseases, emergency contraception and safe abortion services.
Diniz and colleagues in Brazil, where thinking on the virus is most advanced, have shared the following statementof their plans:
“Abortion is a crime in Brazil with only three exceptions: in case of rape, when woman's life is at stake, and in case of anencephalic fetus. In 2004, I was one of the leading persons setting the litigation in a constitutional case, which led to a 2012 Brazilian Supreme Court decision allowing women pregnant with anencephalic fetuses the right to abortion.
Given the Zika virus epidemic, its association with fetal neurological syndromes, and the Public Health Emergency of International Concern declared recently by the WHO, we have been thinking of presenting a new case before the Brazilian Supreme Court.
Our current demand is not to allow abortion in case of microcephaly - which is otherwise an incorrect description of a possible association between Zika virus and fetus singularities. We feel it is more appropriate to speak accordingly to the WHO terms, congenital malformations and neurological complications. Our demands are as follows:
a) A comprehensive sexual and reproductive health care package to all women, with a special focus on women living in epidemic zones. These are poor, mostly black and brown vulnerable women with scarce access to social policies. We would demand the inclusion of the blood test (or any other test for Zika virus) as a routine at prenatal care in Brazil;
b) The right to proper information related to the epidemic, its risks and family planning possibilities (family planning is a constitutional right in Brazil - so for the case we will need to reframe our academic and political vocabulary of sexual and reproductive rights into "family planning");
c) The right to legal and safe abortion for pregnant women while the epidemics persists. We are not demanding the right to abortion in case of any specific diagnosis for the fetus. We are demanding the right to be freed of the psychological torture of living an imposed pregnancy in times of an epidemic caused by a decades-old negligence of Brazilian policies in not eliminating the mosquito;
d) Most women will not choose abortion, and for several reasons. For those women affected by the Zika virus and with newborn babies with disabilities, we will demand a social protection policy focused on maternity and childhood, with a immediate demand of cash transfer policies.”
The rapid spread of the Zika virus has prompted governments such as El Salvador’s to tell women not to get pregnant for the next two years. Access to contraceptives and reproductive health education in the country is very limited, however, and abortion is banned under all circumstances. Thus, the same governments that deny women control over their bodies are now asking those same women to control their bodies until 2018.
Débora Diniz also said in her BBC interview: “Anti-abortion activists protested the decriminalisation of abortion in cases of anencephalic fetuses in Brazil in 2012, arguing that life begins at conception. They are now arguing that abortion of microcephalic fetuses amounts to “eugenics” or selective breeding, and compare those who defend the right to abortion in these cases to Nazis. But eugenics occurs when the state intervenes in decision-making in an authoritarian manner, exercising control over women’s pregnancies, and not when the idea is for women to be free to make their own family planning decisions.”
It isn’t just El Salvador, however. The Zika epidemic has already spread to more than 25 countries in Latin America, a region where 97% of women of childbearing age live under highly restrictive abortion laws, according to the Guttmacher Institute.
On 5 February 2016, the UN High Commissioner for Human Rights, Zeid Ra’ad Al Hussein, issued a statement responding to the threats that women without access to reproductive health services face. Concrete steps must be taken, he said, so that women have the information, support and services they require to exercise their rights to determine “whether and when they become pregnant”. “Upholding human rights is essential to an effective public health response and this requires that governments ensure women, men and adolescents have access to comprehensive and affordable quality sexual and reproductive health services and information, without discrimination.”
In a letter to El Salvador’s Ministry of Health, which they are asking members of the public to sign, the Centre for Reproductive Rights and other signatories urge the Minister of Health to lift the total abortion ban in the face of this public health emergency. “Without providing women and families full access to the reproductive health services they need to prevent, plan and safely end pregnancies, your recommendation to postpone pregnancy for two years is meaningless. In fact, inaction at this critical time will only worsen the public health crisis, with more women seeking clandestine abortions that will put their lives and health at risk. To adequately protect themselves and their families, Salvadoran women are in need of access to the full range of reproductive health services, including safe and legal abortion. ”
These and other news summaries about Zika can be found in the following newsletters of the Campaign: