Let's Talk about Sex: Why the Zika Outbreak is Really about Reproductive Rights for Latin American Women

~Written by Sarah Borg (Contact: sarahannborg@gmail.com; Twitter: @sarahannborg) 

Also published on PLOS Blogs 

Health Ministries of Latin American countries have recommended that women avoid pregnancy until 2018 due to the presumed prenatal consequences of Zika virus. This is despite a lack of sexual education in schools, limited contraceptive access, and strict abortion laws. Women attempting to adhere to this health policy are faced with cultural, religious, financial and legal barriers.

There are a growing number of Zika virus cases, currently estimated at around 1.5 million, with the majority concentrated in Brazil. Over the past twelve months, cases of microcephaly (a rare condition in which babies are born with abnormally small heads and underdeveloped brains) in Brazil have risen from less than 200 to over 4,000. It is postulated that this is a complication of Zika virus.

The issue is further exacerbated by social inequality. The poorest of women in Brazil live in regions where mosquito-borne diseases like Zika are more prone. Often these women spend much of their time working outdoors, exposed to mosquito bites. They often cannot afford to pay for safe abortions, and have less access to prenatal care where diseases may be identified in utero. These women will be the ones who end up having to care for disabled children without the level of adequate education and knowledge required to look after them.

The Zika outbreak has highlighted a dire need for comprehensive sexual and reproductive health care for all Latin Americans. The United Nations high commissioner for human rights has called for Latin America to allow contraceptive and abortion access in response to Zika. Unfortunately, cultural and religious opposition impedes the choice to prevent a pregnancy that could result in an infant with microcephaly or other neurological disorders. The Christian culture of Latin American countries has left women in a precarious position. Many women, especially of lower socioeconomic status, do not have the means to avoid accidental pregnancy or exposure to Zika, and if unwanted pregnancies occur, there are few safe options available.

Rates of abortion, including unsafe abortion, are predicted to rise in Latin America. An unsafe abortion is a procedure to terminate an unwanted pregnancy by persons lacking the necessary skills and/or in an environment which lacks the minimal medical standards. Ninety-five percent ofabortions in Latin America are currently unsafe. Unsafe abortions account for 13% of maternal mortality and result in the death of 47,000 women per year worldwide.

Abortion laws in most Latin American countries are strict. Currently, knowledge that a child will suffer from microcephaly or serious neurological disorders is not grounds for a legal abortion in Brazil. However, abortions are still common. One in five Brazilian women under 40 have had at least one abortion. El Salvador, one of the countries affected by Zika virus, has some of the most severe abortion laws in the world. Abortion can result in a 40-year prison sentence regardless of whether if it is for a victim of rape, foetal anomaly, or the woman’s life is in danger. There have even been cases of women being charged with homicide for having miscarriages or stillbirths. Thus, women in El Salvador face another worry in addition to the potential consequence of miscarriage or stillbirth from Zika virus – prosecution for intentional abortion or homicide.

Conditions where demand for modern contraception and abortion are not met, like in current day Latin America, can lead to high rates of unsafe abortion. Tactics of advising abstinence have been long proven to be ineffective, and dangerous, and evidence shows us that making abortion illegal is not the solution either. If we want to prevent unsafe abortion, couples need to be provided with effective, comprehensive, accessible, appropriate and affordable family planning and sexual and reproductive health education. It has been demonstrated in various countries thatwhen modern contraceptive methods become available and their use increases, abortion rates decrease. If women who were not using contraception but wanted to delay pregnancy were provided with effective contraception, 30% of maternal deaths could be avoided worldwide.

In a step towards the right direction, Pope Francis recently indicated that while abortion is an “absolute evil”, “avoiding pregnancy is not an absolute evil,” and may be the “lesser evil” in certain circumstances like exposure to Zika virus, indicating a potential nod towards contraceptive use.

If Latin American governments do not address the issue soon, they will be faced with increasing rates of maternal mortality resulting from unsafe abortion and a generation of disabled infants cared for by parents who lack adequate financial and educational capacity to care for them.

We Can End Rabies Together

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

Rabies is a neglected viral disease that is found on all continents except Antarctica and is endemic in 150 countries and territories. While rabies can be found almost everywhere, 95% of cases occur in Africa and Asia. Rabies is almost always fatal following the onset of symptoms. However, rabies is vaccine-preventable and can be eliminated. The World Health Organization (WHO) in conjunction with the Food and Agriculture Organization of the United Nations (FAO), the World Organization for Animal Health (OIE), and the Global Alliance for Rabies Control is raising awareness about rabies. September 28th is World Rabies Day and this year’s theme is “End Rabies Together”.

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Figure 1. Worldwide map of rabies indicating level of risk by country, 2011. Courtesy of the World Health Organization. http://www.who.int/rabies/Global_distribution_risk_humans_contracting_rabies_2011.png?ua=1

Rabies is usually transmitted to humans from the deep bite or scratch of an infected animal. Domestic dogs are responsible for more than 99% of human rabies cases throughout the world. According to the WHO, “while infected domestic dogs cause human rabies deaths in Africa and Asia; in the Americas, Australia and Europe, bats are the primary source of human rabies infections.” Children are disproportionately affected by rabies. Forty percent of people who are bitten by suspected rabid animals are children under 15 years of age.

No tests are available to determine if a person is infected with rabies before they show clinical symptoms. Once a person begins to show clinical symptoms of rabies, the disease is almost always fatal. There have been a few cases of people developing rabies symptoms and surviving, with the use of the Milwaukee Protocol. In 2004, a Wisconsin teenager was bitten by an infected bat. She did not seek medical treatment and did not receive PEP. Dr. Willoughby, an infectious disease specialist at the Children’s Hospital of Wisconsin near Milwaukee, tried an experimental treatment that included an induced coma and antiviral medication. The teen survived with few lasting complications. However, many experts caution that the Milwaukee Protocol is not the cure for rabies, at least not yet. The first 43 human rabies cases where doctors attempted to replicate the Milwaukee Protocol resulted in only five survivors. Admittedly, five survivors are pretty good for a nearly always fatal disease, but not enough to say that the Milwaukee Protocol is a cure for human rabies.

Vaccinating dogs is the most cost effective way to prevent human rabies deaths because it results in a decrease in the global deaths attributable to rabies and a decrease in the need for post-exposure prophylaxis (PEP). Post-exposure prophylaxis is the administration of rabies immunoglobulin and rabies vaccine to an exposed person immediately after exposure, in order to prevent infection. Timely PEP can prevent the onset of rabies symptoms and death. However, PEP is expensive and not widely available in many of the resource poor settings with high rabies burden. Eighty percent of dog-mediated rabies deaths occur in rural areas that lack awareness about, and access to, PEP.

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Figure 2. The 2015 World Rabies Day logo. Courtesy of the Global Alliance for Rabies Control. http://logos.rabiesalliance.org.s3-website-us-east-1.amazonaws.com/englishweb.jp

Rabies elimination is achievable for many of the countries with a high burden of dog-mediated rabies cases. Achieving a dog vaccination rate of at least 70% is accepted as the most effective way to prevent human rabies deaths. Rabies transmitted by dogs has been eliminated in many Latin American countries including Chile, Costa Rica, Panama, Uruguay, most of Argentina, the states of Sao Paulo and Rio de Janeiro in Brazil, and large parts of Mexico and Brazil. A Bill and Melinda Gates Foundation project, led by WHO, has made great strides against human rabies cases in the Philippines, South Africa and Tanzania. Furthermore, many countries in WHO South-East Asia Region have begun elimination campaigns with the goal of meeting the 2020 target for regional rabies elimination. Bangladesh, for example, launched an elimination program in 2010 and has seen human rabies deaths decrease by 50% during 2010-2013.

While there are still challenges in achieving a high vaccination rate in some areas of the world, such as vaccine availability and community support, some countries have been able to achieve rabies elimination. Events like World Rabies Day help draw attention to the high burden of rabies in resource poor settings and help to highlight the work being done to eliminate rabies.