Monday, 28 March 2016

Zika: Starting Over with Each New Public Health Emergency?

Every time there is a new public health emergency, it seems we have to re-learn the same old lessons. Zika is now forcing us to face some of the lessons we might have learned from Ebola. For example, Ebola showed us so clearly that outbreaks of disease have differential effects on different populations. An epidemic of any disease highlights, like a social x-ray, those who are vulnerable because of poverty, gender, race, age, and other aspects of identity. Individuals who live under any combination of these marginalizing conditions may be invisible in society much of the time, but when epidemics arise, their collective vulnerability to ill health, and the risk this poses to the rest of society, are illuminated in sharp relief.  The connections between poverty and gender discrimination could not be clearer in the aftermath of Zika. 
With Zika, public health advice across many of these countries has been to prevent mosquito bites, and to avoid getting pregnant, sometimes for up to two years. But these mosquitoes breed where there is stagnant water, and this is usually found where there are inadequate piped water and sanitation systems. That is, where people are trapped in poverty. And women in nearly all the countries where Zika is present have little control over their sexual and reproductive health. As Emma Saloranta wrote in her recent Huffington Post blog, advising these women to avoid pregnancy will have no real impact unless the advice is accompanied by access to contraception and reproductive health services, “as well as a drastic change in attitudes,” about (poor) women’s entitlements to control their own bodies, including sexuality education and having safe abortions. 
The speed with which chronic political and social failures have been translated into personal deficiencies in this Zika pandemic undoubtedly also relates to the fact that the population of greatest concern is women of reproductive age.  That is, women who may be having sex. When public health campaigns center around admonitions about these women and girls needing to keep themselves from getting pregnant, they sit all too cozily with the religious narratives of purity and sin that are prominent in many of the same countries affected by Zika. It is a slippery and misogynistic slope to casting Zika as a punishment for transgression on the parts of these women, because of course men are never blamed for wanting to have sex. 

Moreover, focusing on the short-term, often in practice means that what needs to be done in the long-term never happens. Focusing on behavior change within an accepted status quo precludes challenging the very institutional and social dynamics that systematically expose certain people—and certain women-- to diseases, and entrap these women and their communities in the kind of extreme poverty that robs them of basic life choices.   
But, if we recognized that the distribution of health and ill-health were the result of global and local power relations, of patterns of social (in)justice and questions of human rights, we would adopt a very different approach during times of emergency, and crucially before emergencies arise, in times of apparent social equilibrium that mask societal inequities based on gender and class, and fragmented systems.  

For example, the effects of laws and policies, such as the use of criminal law to regulate access to reproductive health services, would need to be considered.  A social justice/human rights approach also demands examining the size and allocation of budgets for public health infrastructure and health systems, as well as other important contributors to health, such as sexuality education, with a focus on vulnerable populations and redressing patterns of discrimination. And the health system, including public health measures, would not be treated as a technocratic delivery mechanism for goods and services but rather as a space for the construction of citizenship—from the macro-level of solidarity in financing to the most micro-level of interactions between health provider and patient.  

The alternative, if we do not learn these lessons, is that when Zika is eventually contained, those of us, in the global North and South, lucky enough to be able to exercise some control over the circumstances of our lives and health decisions, will once again be able to enjoy the Olympics unmarred, vacation wherever we wish, and at least until the next crisis, forget the long shadow that emanates from our privilege. But the poor and marginalized—and in particular women and children—will continue to experience their poverty and marginalization through contacts with indifferent or abusive health systems, not only in Latin America but around the world.   

Posted by: Alicia Ely Yamin
Lecturer on law and global health
Director of the JD MPH program
Policy Director of the Harvard FXB Center
Harvard T.H. Chan School of Public Health. 


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  2. Public health campaigns should conduct in healthcare need to be adapted to the type of meetings that we need and expect there. Otherwise, risk communication might be perceived as an unwarranted intrusion.
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