Zika and the political battle of rights

By Pia Riggirozzi, Associate Professor in Global Politics at the University of Southampton (@PRiggirozziAcademia.edu). You can find more posts by Pia here.


 

In recent years there has been growing global awareness of the interplay between rights and social development. In 1997, in an attempt to mainstream human rights as a central feature of all UN programmes, the UN Secretary-General Kofi Annan, called for a reorientation of the UN’s mission to reflect the realisation of human rights as the ultimate goal of the UN (UNDP 2005). Within this approach, the UNDP declared that human rights should not be regarded as the outcome of development but should rather be seen as the critical means to achieving it. With the signature of the Millennium Declaration and more recently the Sustainable Development Goals (SDG) there has been a renewed focus on the links between global poverty and human rights in development. As a consequence, protecting and promoting rights, and creating opportunities for individuals and groups to access, enjoy and reproduce those rights have increasingly been furthered in transnational campaigns promoting broader civil liberties, the ‘right to development’ (Grugel and Piper 2009) and ‘human right to health’ (Oslo Declaration).

However, as Easterly (2009) argues ‘which rights are realised is a political battle’ contingent on a political and economic reality often determined by what is considered (national and internationally) visible and urgent. The response to the outbreak of the Zika in South and Central America is manifestation of that battle.

Zika and systemic injustices

In February 2016, South America became, for the first time, the epicentre of a Public Health Emergency of International Importance when the World Health Organisation (WHO) declared that the Zika virus and its link to neurological disorders deserved global attention. After nine months Zika dropped from the international radar as the WHO declared it was no longer an international emergency. But the crisis is not over. The Zika outbreak that began in 2015 and has now spread across much of Central and South America has implications over the medium and long term on equity, health, education, gender and community relations. The challenges of managing the medium/long-term impact of outbreaks, as previously seen in the case of Ebola, are still poorly understood, and so are the prospects of safeguarding the right to health and the right to development in policies advanced by international and national health agencies addressing those amongst the most vulnerable.

The Zika virus, as with other insect-borne diseases such as Dengue and Chikungunya, is part and parcel of troubling inequities, amongst which health inequality is key, based on deprived living conditions. What raised international alarm in 2015 was the number of cases of microcephaly detected in countries affected by the Zika virus, particularly in Brazil. Microcephaly is a condition where babies are born with unusually small skulls. It is a developmental defect and is usually also associated with serious nervous system disorders – including deficiencies in mental functions and muscular weaknesses of varying degrees (WHO 2016). More than 1.5 million people in Brazil have been stricken with the mosquito-borne Zika virus, and since the outbreak began in 2015, the country has logged around 4,000 confirmed and suspected cases of microcephaly. This is alarming, particularly compared to 2014 when there were 147 cases.

Economically disadvantaged segments of the population are at higher risk of exposure to Zika, of being infected, and of their children of being born with microcephaly or other genetic conditions that require special care in the long term. The Zika crisis has also reinforced the socio-cultural expectations about the role of child-raising/caring that disproportionately fall on women, limiting even more opportunities to engage in education programmes or seek/obtain formal employment. Finally, promiscuity, lack of education and the simple fact that poor women might spend more time at home and thus are more exposed to dirty water, sewage, and mosquito breeding grounds than men, also means that women bear the burden of the prospect of infection. This drama typically unfolds in conditions where infrastructural deficiencies and lack of quality medical care and social services are the norm.

Consequently, poor women and their families are likely to be stigmatised as poor, as women, as sexually irresponsible, as families marked by disability. The Zika crisis is, in effect, a window that exposes systemic injustices related to poverty and marginalisation of poor women and children. It also a constitutive dimension of the ‘structural violence’ as global, regional and national responses to the Zika outbreak have disproportionately concentrated on prevention of infection and transmission which although necessary and urgent do not change the structural and related socio-cultural conditions that perpetuate injustice and inequality in these societies.

Which rights are right? 

The Zika crisis is not gender neutral and a focus on women is needed. Take Brazil, where there is a large proportion of single parent families, the majority of which are headed by women. These households are more likely to experience perpetual cycles of poverty as a result of the economic shock of disease. In addition, where children are born with potentially disabling impairments, they are often further isolated by limited support or social protection. The significant increase in the number of infants with microcephaly in the Northeast of Brazil which triggered of the WHO declaration of international emergency, highlights the centrality of the social determinants of health in the transmission chain, as well as issues such as the social division of care and debates on sexual and reproductive health.

During 2016, a roll out of official declarations put women at the centre: the High Commissioner for Human Rights and the WHO reinforced the importance of women’s human rights being central in the response to the Zika outbreak in many states (Gostin and Phelan 2016), while the US Center for Disease Control and Prevention advised pregnant women to refrain from travelling to countries affected by the Zika virus. Most dramatically, health officials in El Salvador urged women not to get pregnant until 2018; Colombia called on women to delay pregnancy for six to eight months.

This particular response focusing on behaviour is problematic for at least three reasons. First, implementing vector control programmes in the poorest areas is particularly challenged by more structural issues of lacking infrastructure, running water and access to healthcare. And even if such operations are conducted, mosquitoes have previously shown their capacity to quickly resurface whenever there is inadequate funding or surveillance. Second, shifting responsibility to women’s behaviour delinks the disease from its social determinants and their rights; not least because most pregnancies amongst poor and vulnerable women in the region are unplanned. As Davies and Bennett (2016: 1046) note, responses tend to focus on the ‘immediate’ health-care problem, while the status of gendered inequality that underpins the prevailing unhealthy conditions is considered ‘beyond’ the capacity of public health interventions. Add to this prevailing high rates of sexual violence, elusive contraception, teen pregnancies and the lack of sexual education prevalent in Zika-affected countries. According to a study published by the Guttmacher Institute in 2014, as many as 56 per cent of pregnancies in Latin American and the Caribbean are unintended, either because of lack of access to contraceptives or because of associated forms of gender violence.

Third, reducing the problem in this way to a few modifiable behaviours ignores factors of social determinants of health and poverty. Responses to communicable diseases such as Zika, and before Ebola, have so far tended to focus overwhelmingly on short-term-vector control and surveillance (Gostin and Hodge 2016; Davies and Bennet 2016). Such responses may be effective in terms of disease containment, effectively masking the precarious social conditions in which they live, in which many rights remain merely notional.

A final issue raised by the Zika crisis is that of reproductive rights. In a region where birth control is limited and sexual violence is widespread, the debate on legalising abortion has gained prominence. Last February, the Obama administration put under Congressional consideration $1.8 billion in emergency funding to help prepare for and respond to the threat posed by the Zika virus. But abortion politics sterilised these discussions as Republican lawmakers leading a congressional hearing on the Zika outbreak made funding conditional on anti-abortion policies in recipient countries. And while Pope Francis hinted at softening the rigid stance of the Catholic Church on contraception because of the threat posed by the Zika virus, it is the region’s restrictive abortion laws that remain a critical problem. In most Latin American countries affected by Zika, abortion is illegal or can only take place in exceptional situations. In El Salvador, for instance, where more than 7,000 cases of Zika were reported between December 2015 and January 2016, abortions are illegal under any circumstances and miscarriages could even lead to homicide convictions if proven to be self-induced.

Advocacy groups in Brazil are increasingly presenting legal cases to the Supreme Court to legalise abortion and secure reproductive rights for women under the principles of the 1988 National Constitution that guarantees the right to health. But the challenges ahead are many, not least in what a human rights-based approach to health may mean in addressing the long-term consequences of Zika (and other such health crises).

To be clear, vector control actions are imperative, but policies and recommendations based on behaviour, control and prevention are not only not enough to address women’s marginalisation in society and the effect this has on their health, they may further exacerbate this problem in addressing the immediate health risk. More academic and policy debate is needed on the scale and nature of future needs (health, social, economic, educational, welfare) of vulnerable communities particularly women and children, and how to calculate them. Government awareness of this issue is still low in Central/South America and although regional, global and expert/practitioner networks might be able to provide support in the future (Riggirozzi 2015; Riggirozzi and Yeates 2015) both in defining the scale of need and in providing support to governments in developing policies to address them, their roles over the medium/long term require greater definition.

Governments in South and Central America are in urgent need of a multi-policy approach – and funding- if they are to put in place effective responses to mitigate long-term effects and not derail progress in terms of meeting the SDGs targets on gender, childhood, disability and inclusive growth. Vector control and compliance could be seen as first step. The right to health needs to be delivered with a view that development in general and the delivery of health in particular should be anchored in an understanding of the inequalities, discriminations and power relations that prevent many people having access to good healthcare systems, care provisions and education and a view that states have legal and ethical obligations under international law to ensure the best possible provision of services for all.

 

Pia is currently involved in a funded project on regional organisations and access to medicines in South America.

 

Responsibility for Refugees

By David Owen, Professor of Social and Political Philosophy at University of Southampton (@rdavidowen, Academia.edu). You can find more posts by David here.


 

How should responsibilities for refugees be distributed? According to the UNHCR, at the end of 2014 there were 19.5 million refugees among a total of 59.5 million forcibly displaced persons worldwide. 1 Developing countries hosted 86 % of this refugee population (up from 70 % ten years previously.) 2 Lebanon (26 %) and Jordan (9.8 %) have the highest per capita ratios of refugees worldwide. 3 Is this a fair distribution of responsibilities?

Considerations of fairness have been much to the fore in the political rhetoric of debates concerning current flows of Syrian refugees into the European Union (although to put this into perspective, from the beginning of the crisis up to the end of 2015, the total number of asylum applications from Syrians in the European Union reached 681,713, 4 while in the same period the number of Syrian refugees in Turkey amounted to 2.18 million 5). But at least one of the difficulties in this debate is that there is no agreement among states, globally or within the EU, concerning what would count as criteria of a fair distribution of responsibility for refugees.

The current EU crisis also illustrates a further question that is urgent in the contemporary context: what are the limits on state’s obligations to refugees? Is it, for example, sufficient to have done one’s fair share or, in the absence of established criteria, to have done what a good faith effort to work out one’s fair share required? Or do states that have done their fair share have an obligation to take up the slack consequent on others failing to do their fair share?

In ‘Refugees, Fairness and Taking up the Slack’ – available open access here – I argue that in circumstances where not all states do their fair share, human rights protecting states are morally obliged to do more than their fair share, i.e., that refugee protection takes priority over fair distribution of responsibility for refugee protection. However I also draw attention to the prudential point that effective refugee protection is likely to depend on states being willing to do their fair share. Combining these claims, I argue that states have a duty to come to arrangements that, as far as plausible, aim at ensuring a fair distribution of responsibilities.

If the political task is thus that of establishing effective mechanisms for determining fair shares and generating reasonable compliance among states, what are prospects for the fulfillment of this duty? The article provides some reasons for thinking that any general rule for directly determining fair shares is both open to reasonable disagreement and is liable to be skewed by states’ perception of their own interests. It further argues that we have little reason to be confident that states will support the establishment of effective compliance measures – a point sadly illustrated by the failure of EU cooperation in the current refugee crisis.

Refugee crises as political crises are always a combination of a crisis of production and a crisis of response. As things stand, there is little reason to think that both types of crisis will not continue to recur. What this suggests is that we need both to recognize that the existing refugee regime – for all its limitations – is a considerable political achievement – and to acknowledge the extent of the hard political work that will be needed to address current and future refugee crises.

 

Health for All on Human Rights Day: A Pro-Poor Approach

By Pia Riggirozzi and Erica Penfold. Pia Riggirozzi is Senior Lecturer in Global Politics at University of Southampton (@PRiggirozziAcademia.edu) and Erica Penfold is Research Officer at the South African Institute of International Affairs. Both are partners at the ESRC-DFID funded project ‘Poverty Reduction and Regional Integration: SADC and Unasur Health Policies’ (@PRARIRepir). You can find more posts by Pia here.


In recent years there has been growing global awareness of the interplay between rights and the development process and a generalised recognition of social determinants of health connecting poverty, equality and health. Yet, for millions of people throughout the world, the full enjoyment of the right to health still remains a distant goal. Poverty remains one of the driving forces behind ill health, a lack of access to healthcare and medicines and consistent underdevelopment. The World Bank shows that 700 million fewer people live in conditions of extreme poverty in 2010 than in 1990 across developing regions. However, the Global South is still struggling, everyday thousands of children, women and men die silently from preventable diseases associated with poverty.

The United Nations acknowledges these issues as it continues to produce a stream of further guidance in the form of General Comments, such as the General Comment 14, while sponsoring global Declarations and Commissions on Social Determinants of Health. Human Rights Day observed by the international community on 10th December since 1950 acts as a reminder of the importance of recognition and advancement of rights and the human right to health. But the current high-level focus on health by the international community while recognising the strong relationship between poverty and health, in practice, has been quite conservative in turning the rhetoric into practice. Translating normative principles into politics of compliance and practices for policy implementation remains uneven across the wide spectrum of human rights issues, acknowledging and affecting bearers of rights in different ways. For William Easterly this is clear, ‘which rights to health are realised is a political battle’ contingent on a political and economic reality that profits on the margins of (poor) health. He is right, we can’t downplay politics. Think of a funder – whether the Gates Foundation, Welcome Trust, private charity or government programme – their agenda may well spend a great deal of resources (financial and human) on dealing with one disease. Or programmes advanced by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, or the Gates Foundation; despite having the best intentions, they may be guided by their own views, agendas and objectives. Undoubtedly, diseases like HIV, malaria and tuberculosis account for over 90 per cent of the global disease burden, yet the millions of dollars poured into programmes to tackle these diseases have done little to tackle weak healthcare systems which are in many cases unreachable or distrusted by the people they are designed to help. Equally critical, other peoples’ rights could be neglacted if diseases like dengue, leishmaniasis, Chagas and Chikungunya that also add to the increasing toll of human life and to the poverty-disease burden receive little attention. The risk is that what is visible and urgent leads over what is marginal and that actions targeted to the poor, yet ignoring the social factors that cause poverty and exclusion, discriminate positively, normalising and even reproducing inequities. The Ebola outbreak in West Africa is another reminder of these risks.

The realisation of people’s rights, entitlements, and obligations, is largely determined by the nature of the state and its capacity to respond to internal public demands, interests, and pressures. Philanthropists in rich countries and the global aid community more generally can mainstream and support national strategies. But we believe there is a role to pay by the neglected partners in development: regional organisations. Regional organisations can be key engines in the development of progressive social policies and advocacy of rights. For example, the Economic Community of West African States (ECOWAS) has established a regional court of justice adjudicating on national labour rights, while the Union of South American Nations (UNASUR) is now driving initiatives to expand entitlements to health care and social security within member states and it is shaping policies around disability all over the world, negotiating with one voice at the World Health Organisation. This makes sense because some social harms and epidemics are inherently cross-border, and are exacerbated or facilitated by regional developments.

Regional organisations that were built for other reasons are now becoming much more important for health and will be particularly important if we look at the Post-2015 Agenda. Organisations such as UNASUR and ECOWAS can provide donors and partners with a single point of contact for discussions and implementation of poverty reduction programmes in member countries. They are close to their populations and can develop technical cooperation, building infrastructure and strengthening capacity between the member states, rescaling practices to reduce socio-economic disparities.

Renewed focus on health, as a basic human right, is a poverty issue. It demands thinking about the deep determinants of (under)development and social exclusion and national, regional and global commitments to enhance access to health care, to medicines, to opportunities. Neglecting this will be a tragedy of aid assistance and possibly of the Sustainable Development Goals.