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.