The Paradigm of the Paradox: Women, Pregnant Women, and the Unequal Burdens of the Zika Virus Pandemic

Abstract

The inequalities of outcome are, by and large, biological reflections of social fault lines (Paul Farmer, 1999, 5) Three paradoxes characterize the Zika virus pandemic and clinical and policy responses to it:1. Zika virus has been shown to cause severe developmental anomalies in the fetuses of infected women. As a result, both women and men in endemic areas are asked to avoid or delay pregnancy. However, access to effective contraception and safe pregnancy termination is either not available (especially for those living below the poverty line) or a crime for many women in Zikaendemic regions. The Brazilian government is confiscating international shipments of pills for medical abortion and is reportedly aiming to increase sentencing minimums for women who obtain abortions for fetal anomalies linked to Zika infection. 2. Global approaches to pandemic planning and response, including those for the current Zika outbreak, are generally concerned with nominal fairness and the neutrality of procedural justice (i.e., response and allocation strategies equalize chances for those among the general population to receive benefits [or experience burdens]). Pandemic planners strive for systematic fairness by using (ostensibly) random processes (such as firstcome, first-served or a lottery) to allocate resources for those who are similarly prioritized. However, pandemics disproportionately affect the disadvantaged, meaning that neutral approaches to global Zika virus pandemic planning and resource allocation will perpetuate and in fact increase existing gender, social, and health disparities.3. Historically, concerns for the "vulnerability" of pregnant women and fetuses have resulted in the systematic exclusion of pregnant women from research. In addition, political opposition to abortion has made it increasingly difficult to conduct research using fetal tissue. However, research on Zika virus in fetal tissue collected at the time of pregnancy termination or loss could potentially help many pregnant women and their fetuses. Reluctance to engage in such research potentially exposes all pregnant women and their fetuses to unquantifiable risk.In this editorial, we examine and critique each of these paradoxes and reflect on the burdens that they inflict on women, especially pregnant women. International responses to the pandemic, and more specifically to the paradoxes embedded in these responses, have the potential to either advance reproductive justice or exacerbate existing reproductive injustice. BACKGROUND

A gendered human rights analysis of Ebola and Zika: locating gender in global health emergencies

“…68 As with other pandemics, there is the potential for the impact of the Zika virus to fall most heavily on the most disadvantaged members of society. 69 For women who do become pregnant, the WHO's interim guidance on 'pregnancy management in the context of Zika' includes that: 'Women who wish to discontinue their pregnancy should receive accurate information about their options to the full extent of the law, including harm reduction where the care desired is not readily available.' 70 However, restrictive abortion laws in many countries in Latin America leave women who may wish to discontinue their pregnancies with little access to safe, legal termination and leave women exposed to the risks of unsafe procedures.…”

Lessons From Zika Policies to Improve Gender Equity

“…As Harris et al stated, "While recommendations to avoid pregnancy make sense as a Zika infection management strategy, these recommendations become senseless and unjust in contexts where access to reliable contraception is not guaranteed. " 6 A welcome exception to this was women's groups in Brazil, which promoted a holistic policy towards Zika, including mosquito control, but also access to sexual education, contraceptives, prenatal care, and the option of safe and legal abortion. 7 Another recommendation is to have local public health agencies inform travelers at the port of entry of the risks and methods to minimize risks for locally acquired infectious diseases.…”

Zika Virus Public Health Crisis and the Perpetuation of Gender Inequality in Brazil

“…They also lack access to clean water and sanitation, which exposes them even more to the risks of getting infected by mosquito borne diseases. This fatal combination explain why the impact of the Zika virus reproduced existing inequality falling most heavily on the most disadvantaged members of society, leaving them unassisted to navigate mosquito control, contraception and pregnancy (5,8,9,16,(27)(28)(29)(30)(31)(32)(33).…”

“…When a public health crisis taps directly into reproductive health, typically a feminine realm, gender systems may reproduce traditionally and deeply-rooted gender norms, especially those linked to cultural beliefs and expectations playing out in different relational contexts. Despite its importance, most of the literature regarding the gender consequences of the Zika outbreak is theoretical (5,16,(27)(28)(29)(30)(31)(32)(33)(34)(35) with a dearth of empirical studies exploring how traditional gender stereotypes increase women´s vulnerability and how gender division of labor hinders arbovirus control. Exceptions have been able to explore gendered power and norms during the Zika outbreak in connection with sex and contraceptive use (24,28,36).…”