As of March 2, 2017, there have been 2,717 confirmed cases of Zika-related congenital syndromes reported in Latin America. This statistic collected by the Pan-American Health Organization paints a dismal picture for the region as Zika continues its spread. Infants born with microcephaly, the most well known of these conditions, have atypically small heads, and are subject to a number of developmental delays and intellectual disabilities. Declared an official global emergency by the World Health Organization in February 2016, the Zika epidemic has generated hysteria in Latin America. Many governments’ response? Don’t get pregnant.
In January of 2016, the El Salvadoran government released a statement urging women to avoid getting pregnant until 2018. Brazilian health officials offered similar advice in 2015. Even the World Health Organization urged men and women of reproductive age to be “correctly informed and oriented to consider delaying pregnancy” in their 2016 guidelines for preventing the sexual transmission of Zika.
The areas Zika has hit the hardest, however, also happen to have some of the most restrictive abortion laws in the world. El Salvador, the Dominican Republic and Nicaragua all have laws against abortion with no exceptions for violence or the health of the mother. In El Salvador, abortion is criminalized, punishable by two to eight years in prison. There are currently 17 Salvadoran women serving sentences for homicide after terminating their pregnancies. In Brazil, there are exceptions to this law in cases of rape or when the life of the mother or fetus is at risk. However, women who consent to an abortion or perform one themselves face one to three years in prison. Abortion providers face between one and four.
Abortion in Latin America: Government Policy Versus Cultural Factors
In a region with such unrelenting abortion laws, advising women not to get pregnant is at best a dubious attempt at combating the spread of microcephaly. These anti-abortion laws partially stem from the deeply Catholic governments of many Latin American countries. In Paraguay, 89% of adults identify as Catholic. Brazil and El Salvador do not boast as dramatic Catholic majorities, but still over 50% of adults identify as Catholic. Add to that poor sexual education and access to contraception—the WHO estimates that 22 percent of women across Latin America and the Caribbean would like to delay or prevent pregnancy but lack sufficient access to birth control—and the flaws with such logic become even more apparent. In a February 2016 statement, the UN Commissioner for Human Rights Zeid Ra’ad al Hussein urged countries to repeal restrictive abortion laws: “The advice of some governments to women to delay getting pregnant ignores the reality that many women and girls simply cannot exercise control over whether, when or under what circumstances they become pregnant, especially in an environment where sexual violence is so common.” Despite a statement from the pope in favor of contraceptives in the face of Zika -- an unusually progressive position -- Brazil has pushed forward a law that would restrict abortion even further. The law would increase jail times for women who abort fetuses with microcephaly.
Cultural factors are clearly at play here. ‘Top-down’ advocacy targeting the government policies that contribute to the sexual health climate in many Zika-affected areas is necessary and impactful. However, it misses the important social component that makes the intersection of Zika and women’s reproductive rights such a complicated issue. For one, the influence of religion in deeply Catholic Latin America makes the goal of loosening abortion restrictions at the government level very difficult. But even in the absence of such barriers, abortion laws do not operate in a vacuum. Targeting them is part of the issue, but expert recommendations and protest movements have suggested that it is crucial to look beyond the government level. Everything from the prevailing attitudes about women to the availability of high quality reproductive health care is closely related to the problem of Zika. Efforts from the international community urging governments to loosen their abortion laws are an important part of the solution. However, there must be a deeper focus on the psychological, cultural, and social problems brought to light by Zika.
The Burdens of Zika Fall Disproportionately Upon Women
The first of these problems is poverty; women living in poverty are at higher risk for Zika. On top of living in areas where mosquitos carrying Zika are endemic, their work is more likely to require them to be outside. Their neighborhoods are crowded, and diseases spread easily. Pools of stagnant water -- found more often in less affluent areas -- provide breeding grounds for these pests. Once infected, the financial stress only grows. In Brazil, the cost of a Zika test in private labs is close to 1000 reais, which amounts to over US$250, according to Brazilian activist Jacqueline Pitanguy. Pitanguy notes that this often causes men to abandon pregnant women infected with Zika, leaving them to parent their sometimes severely disabled children alone.
Poor women also have limited access to healthcare, both in quantity and in quality. The universal healthcare system in Brazil has been in place since 1988. However, inequality still persists according to Alicia Yamin, a lawyer and public health expert on health and human rights who has joined academic work with advocacy at the Harvard T.H. Chan School of Public Health, the FXB Center for Health and Human Rights, and Georgetown Law. Yamin notes, “There are enormous disparities in how far women have to go to get prenatal care, in what kind of delivery care and treatment there is, and in what information is being given to them to prevent Zika or to prevent pregnancy.”
These disparities hint at another social problem: what Yamin dubs a “vacuum of reliable, objective, scientific information” about sexual health in general. This issue is compounded by government policies exclusively targeting women. For example, many sexual health campaigns advise women not to get pregnant instead of promoting contraceptive practices among men. This focus is partially explainable through what Yamin calls a “macho culture” that pervades much of Latin America. Yamin explains how there exist “macho social norms… a sense of men not wanting to wear condoms, men being men and controlling when they have sex and the decision-making around sexuality.” In some ways a result of this “macho culture” embraced in many Latin American countries -- and in some ways exacerbated by it -- this focus on targeting women places the responsibility for preventing microcephaly on them alone.
Illegal abortion is the fifth leading cause of death for women in Brazil according to Brazil’s Ministry of Health. This statistic highlights not only structural disparities, but serious danger caused by strict anti-abortion stances. With the stakes of pregnancy heightened by the threat of Zika, many women are forced to work their way around restrictive abortion laws by putting their lives at risk.
Beyond Targeting Government Policies
A shift in how to address the Zika outbreak is crucial. Attempting to change restrictive abortion laws starting at international political pressure may be a well-motivated strategy, but it faces a number of barriers, mainly in the form of religious opposition. ‘Bottom-up’ efforts from in-country protesters, rather than distant international actors, have the potential to be better rooted in the cultural, social, and psychological factors that prevent women from having safe access to abortion. These efforts may better address the societal reasons for why women are paying the bulk of the price for the Zika epidemic.
Brazil is one of few countries in Latin America in which a successful protest movement has taken hold. In the wake of Zika, the Institute of Bioethics, founded by University of Brasilia law professor Debora Diniz, is preparing a petition to protest Brazil’s abortion policies. The petition seeks to make abortion legal not just in cases of anencephaly (which the Institute protested and achieved in 2012), but in all cases for women with Zika. Citing the disproportionate effects of Zika on poor women in an opinion piece for the New York Times, Diniz argues that government responses to this crisis must include providing women with equal access to information, education and care. Diniz adds that Brazil must start empowering and enabling women to have control over their pregnancy decisions, and providing sexual and reproductive education in public schools.
The government response thus far (mainly limited to advice against getting pregnant) has been inadequate and nonsensical. The Institute of Bioethics’ petition still targets Brazil’s government policies, but does so in a way that comes from below rather than above. Importantly, this strategy encompasses social aspects extending beyond the purely legal realm.
The negative psychological effects of this issue are often overlooked. Women suffer psychologically as a result of the unequal treatment they receive and the limited access to abortion and other contraceptives they have. As Alicia Yamin notes, the Zika crisis “illuminates some profound social problems, and what we see with the response is that those social problems, those political failures that are structural, are really quickly translated into personal failures of women.” Yamin describes how too often, the healthcare system seems to blame the very women it seeks to help. Yamin also explains that in Catholic and heavily religious Evangelical countries of the region, women often are negatively judged for not having considered the ramifications of engaging in sex. “[Health center staff] ask: ‘Now you feel guilty about this?’ That’s the sort of blaming that stigmatizes,” she says. According to Yamin, these negative psychological effects are further exacerbated by barred access to monitoring during pregnancy -- birth defects like microcephaly do not show up until very late in a pregnancy, between 30 and 32 weeks, at which point it becomes much more difficult to get an abortion. “If a woman knows she has Zika, it may be a kind of mental torture and stress thinking ‘what if this happens,’ and she may want an abortion without it being confirmed that there are congenital anomalies,” Yamin explains.
Some Latin American countries’ abortion laws do provide exceptions in certain circumstances. Yamin notes that in Brazil “there is an exception for the life or health of the mother… or in cases of congenital malformation. And that health exception needs to be interpreted in terms of psychological health as well, which has been a big barrier in Latin America.” This psychological burden falls mostly on poor women. In some countries, poor women are too often forced to go to health facilities where according to Yamin, “they’re expected to beg for services, where they’re made to wait in long lines, where they may be asked to pay under the table for this or that… they’re not really treated like they’re citizens entitled to services… they’re treated as though they are beggars.”
Looking to the Future: Potential Solutions and Shortcomings
There clearly exist many cultural, social, and psychological factors in countries like Brazil that complicate the task of targeting Zika and its disproportionate effects on women, especially poor women. While international pressure on Brazil’s and other countries’ governments to loosen their abortion laws may be effective, the deep-seeded religiosity of Latin American governments may render this route insufficient. Other strategies could help address the underlying social and political factors contributing to repressive sexual health laws that Zika highlights. Sexual and reproductive education and more gendered research could present potential strategies. These efforts would address the underlying factors by shifting the focus to women’s reproductive and sexual rights, but efforts to date have fallen short.
Sexual education in Brazil, for example, lacks the kind of focus on sexual and reproductive rights that would inform and empower women to advocate for their health and safety. A 2014 study on sex education in Brazilian schools collected interviews among teachers. It demonstrated that there are multiple barriers to sexual and reproductive rights becoming part of this sex education. These barriers include the clash with teachers’ staunchly-held religious beliefs, teachers’ desire for sex education to be more free-flowing and untargeted rather than planned curriculum, and teachers’ lack of adequate training on sex education. Additionally, the study showed that Brazilian sex education is mostly framed in “biomedical discourse” rather than cultural discourse, limiting the possibility of including sexual and reproductive rights. For example, the sex education curriculum seeks to teach students to avoid pregnancy, but it does so only through discussing the biological process of pregnancy. It does not thoroughly address the cultural issues of gender violence, relationships, abortion, rights, or many other important aspects of pregnancy. In 1994, a decision was made at the International Conference on Population and Development in Cairo to provide comprehensive sex education in Latin American and Caribbean schools. However, the execution was variable across Latin America and the Caribbean. Though sex education has come further in Brazil than in countries like El Salvador or Chile where the education still centers on the importance of abstinence and birth control methods, even the education in Brazil lacks a focus on women’s reproductive rights. Sex education in Brazil, too, mostly occurs in the main cities, not in the impoverished areas where it is needed most.
A 2016 study on gender, human rights, and global health outbreaks suggests that outbreaks like Zika require more gendered research. The Zika and Ebola outbreaks demonstrate how women are disproportionately affected by these diseases and their consequences, as compared with men. In responding to public health emergencies like Zika, efforts must account for the pervasive gender inequality that leads to women being unable to obtain sexual and reproductive rights. They must also account for the socioeconomic inequality that makes women unable to exercise those rights. Zika has not only underscored the importance of preventing microcephaly by loosening abortion laws, but also the importance of treating women’s rights and equality as integral to the issue. Women in Latin America need to see change that shifts the focus on combatting Zika to the importance of fighting for their reproductive rights.