The right(s) approach to Zika

The Zika virus epidemic is spreading: 63 countries are now reporting transmission, over 1500 cases of related microcephaly or CNS malformations have been confi rmed this year, and knowledge on the disease is advancing slowly. Adding to the tension around Zika, at the epicentre of the outbreak, Brazil is bracing for a large-scale mass gathering: the Olympic and Paralympic Games 2016 in Rio de Janeiro. Confl icting opinions on the need to postpone or cancel the Games have been expressed, but during the 69th World Health Assembly last month, the WHO issued clear public health advice on the matter: the Games will not signifi cantly change the international spread of the virus and travellers can reduce their risk of contracting the disease by following simple prevention measures such as avoiding mosquito bites with repellents and adequate clothing, practising safe sex, staying in air-conditioned housing, and avoiding areas with poor water and sanitation. These recommendations are sound and reasonable. They also highlight the true nature of Zika: it is a disease of the poor and disenfranchised. The face of Zika is not often seen in the airconditioned shopping malls of upscale Rio neighbourhoods or on the beaches of Ipanema. Rio has its fair share of cases, but so far the heaviest burden has been borne by the northeast region of Brazil, where poverty, poor infrastructure, and lack of access to health services are rampant, and the penetration of Aedes aegypti is high. A large proportion of the population in that region is of African descent—indeed, the face of Zika is often that of a darker-skinned person. And because most cases are asymptomatic, and the most dramatic signs of the disease appear through congenital Zika syndrome, the face of Zika is that of a woman or a small child. That is at least what we are able to outline, because in spite of the need for disaggregated epidemiological data to understand transmission patterns and evaluate interventions in vulnerable populations, there is no reliable count of Zika cases by sex and ethnicity. Last month, The Lancet Global Health published WHO’s interim guidance on pregnancy management in the context of Zika virus infection. The guidance includes recommendations for preventing and managing infection in pregnant women. Vector control is emphasised, as well as personal protection such as clothing, bednets, repellents, and safe sex. Again these are sound recommendations, duly relayed by health authorities, but they certainly don’t resonate in the poorest neighbourhoods of Brazil and other aff ected countries, where the availability, practicality, and aff ordability of protective items are doubtful and where safe sex is not always negotiable. When prevention fails, women of reproductive age or who are pregnant are faced with terrifying uncertainties, for lack of information, lack of access to basic services and diagnostic tests, and most importantly a blatant lack of choice. So in spite of the intensifying eff orts of civil society, UN agencies, and national authorities to address these issues—controlling vectors, launching communication campaigns, planning for long-term child services— this is where poor women in Brazil, Colombia, El Salvador, and elsewhere have been let down by their governments. They are at the centre of the epidemics, they are scrutinised and lectured, but lack of access to basic reproductive services and restrictive abortion laws have stripped them of a choice when faced with the dire consequences of the virus on their health and that of their children. This imbalance has been recognised and is being acted upon, in Brazil in particular where a group of lawyers, academics, and activists is bringing a case in front of the Supreme Court to request, among other things, access to information, to health services, and to safe abortions for victims of Zika. In early April, the Pan American Health Organization issued a guidance document on the key ethical issues raised by the epidemic that echo those demands and include the duty of all governments to provide information, respect the right to choose, and provide access to comprehensive reproductive health care and social support to women aff ected by Zika and their children. In many ways, Zika is the epitome of the interdependence of health and human rights. Controlling vectors is an essential step, but it will be ineff ectual without a rights-centred approach. ■ The Lancet Global Health


The right(s) approach to Zika
The Zika virus epidemic is spreading: 63 countries are now reporting transmission, over 1500 cases of related microcephaly or CNS malformations have been confi rmed this year, and knowledge on the disease is advancing slowly. Adding to the tension around Zika, at the epicentre of the outbreak, Brazil is bracing for a large-scale mass gathering: the Olympic and Paralympic Games 2016 in Rio de Janeiro. Confl icting opinions on the need to postpone or cancel the Games have been expressed, but during the 69th World Health Assembly last month, the WHO issued clear public health advice on the matter: the Games will not signifi cantly change the international spread of the virus and travellers can reduce their risk of contracting the disease by following simple prevention measures such as avoiding mosquito bites with repellents and adequate clothing, practising safe sex, staying in air-conditioned housing, and avoiding areas with poor water and sanitation. These recommendations are sound and reasonable. They also highlight the true nature of Zika: it is a disease of the poor and disenfranchised.
The face of Zika is not often seen in the airconditioned shopping malls of upscale Rio neighbourhoods or on the beaches of Ipanema. Rio has its fair share of cases, but so far the heaviest burden has been borne by the northeast region of Brazil, where poverty, poor infrastructure, and lack of access to health services are rampant, and the penetration of Aedes aegypti is high. A large proportion of the population in that region is of African descent-indeed, the face of Zika is often that of a darker-skinned person. And because most cases are asymptomatic, and the most dramatic signs of the disease appear through congenital Zika syndrome, the face of Zika is that of a woman or a small child. That is at least what we are able to outline, because in spite of the need for disaggregated epidemiological data to understand transmission patterns and evaluate interventions in vulnerable populations, there is no reliable count of Zika cases by sex and ethnicity.
Last month, The Lancet Global Health published WHO's interim guidance on pregnancy management in the context of Zika virus infection. The guidance includes recommendations for preventing and managing infection in pregnant women. Vector control is emphasised, as well as personal protection such as clothing, bednets, repellents, and safe sex. Again these are sound recommendations, duly relayed by health authorities, but they certainly don't resonate in the poorest neighbourhoods of Brazil and other aff ected countries, where the availability, practicality, and aff ordability of protective items are doubtful and where safe sex is not always negotiable. When prevention fails, women of reproductive age or who are pregnant are faced with terrifying uncertainties, for lack of information, lack of access to basic services and diagnostic tests, and most importantly a blatant lack of choice.
So in spite of the intensifying eff orts of civil society, UN agencies, and national authorities to address these issues-controlling vectors, launching communication campaigns, planning for long-term child servicesthis is where poor women in Brazil, Colombia, El Salvador, and elsewhere have been let down by their governments. They are at the centre of the epidemics, they are scrutinised and lectured, but lack of access to basic reproductive services and restrictive abortion laws have stripped them of a choice when faced with the dire consequences of the virus on their health and that of their children.
This imbalance has been recognised and is being acted upon, in Brazil in particular where a group of lawyers, academics, and activists is bringing a case in front of the Supreme Court to request, among other things, access to information, to health services, and to safe abortions for victims of Zika. In early April, the Pan American Health Organization issued a guidance document on the key ethical issues raised by the epidemic that echo those demands and include the duty of all governments to provide information, respect the right to choose, and provide access to comprehensive reproductive health care and social support to women aff ected by Zika and their children. In many ways, Zika is the epitome of the interdependence of health and human rights. Controlling vectors is an essential step, but it will be ineff ectual without a rights-centred approach. ■ The Lancet Global Health