Microsoft Word - Zika paper Corrections.docx 12 Oct 2017


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ZIKA Virus Disease as Public Health Emergency and Ethics 

 

Rhyddhi Chakraborty 1and Edmond Fernandes2 

1.Researcher (Bioethics, United Kingdom) and Visiting Faculty of Philosophy and Global Health 

(American University of Sovereign Nations, Arizona, USA), Email: rhyddhi_414@yahoo.co.in   

2. Founder and CEO, CHD Group, India and Adjunct Faculty, Dept. of Public Health, KSHEMA, Nitte 

University 

 

Abstract: This paper argues that Zika virus infection has its ethical implications beyond the 

reproductive health of women. It claims that Zika virus infection like public health emergency 

exposes the underlying health determinants and health status of women. Therefore, ethical 

mitigation of Zika like public health emergencies should consider these underlying health 

determinants and health status of women. For, undermining and overlooking these underlying 

determinants and health status of women, during the public health emergencies, enhance the 

health inequities. The recent Zika virus infection in Brazil has triggered different ethics 

consultation and has prompted to outline ethical recommendations. However, the 

recommendations have either focused on the reproductive health of women or on the core 

strategies of public health emergency. Considering this as a gap in perspective to prepare for 

Zika like public health emergencies, this paper argues that it is the underlying holistic health 

of women, precisely, health capability, which should be given due ethical consideration. 

Finally, the paper concludes highlighting the fact that focusing on the holistic health of the 

women during Zika like public health emergencies and beyond can bring in long-term benefits 

for global health equity.  

Key Words: Ethics, Health, Women, Zika  

Introduction: One of the remarkable incidences of 2016 is the hosting of Rio Olympics in 

Brazil, a Latin    American country which was trying to manage and control Zika virus outbreak. 

Gradually, as the disease continued to spread to other countries, the potential threat of this 

Aedes mosquito-borne disease, especially its possible association with microcephaly and other 

neurological disorders, has prompted World Health Organization (WHO) to declare it as public 

health emergency of international concern1. The incidences out of Zika virus disease in Brazil 

have also highlighted several novel and known ethical issues, which thereby, prompted 

international agencies to review ethical considerations and driven them to frame ethical 

guidance to prepare and act for Zika like public health emergencies2,3. Given the need of the 

situation in Brazil, ethics consultations have focused much more on the reproductive health of 

the women and on the strategic responses as any public health emergency demands. However, 

this paper argues, Zika virus-like diseases have the capacity to unveil the underlying health 

determinants, expose the existing poor health status of women, and have long-term health 

implications for the affected women. And, when these underlying determinants and health 

status of women are undermined, especially in ethics consultation, the disease mitigation 

strategies fall short of addressing health inequity. Consequently, the disease then contributes 

to and enhances health inequities4. Therefore, during Zika like outbreaks, the paper claims, the 



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ethical attention, should not just be restricted to strategic responses but should also be driven 

towards addressing the underlying health determinants and health conditions.  

The Seen and Unforeseen Impacts of Zika Virus Disease: Zika virus disease is an Aedes 

mosquitoes borne infection. Symptoms, usually, include mild fever, skin rash, conjunctivitis, 

muscle and joint pain, malaise, or headache, normally lasting for 2-7 days5. Since its first 

appearance in 1947 in the Uganda, Zika virus disease surprised the world by its re-emergence 

in 2015. Unlike its previous occurrences, the recent Zika virus infection came to be known as 

the first of its kind associated with human birth defects. It was found to be evidently co-

occurring with neurological complications such as Guillain-Barre Syndrome and 

microcephaly, for which there are no vaccines available6. In between 22 October 2015 and 16 

April 2016, Brazil reported a total of 7150 suspected cases of microcephaly and/or central 

nervous system malformations. Of these 1168 were suggestive of congenital infection and 246 

child deaths occurred after birth or during pregnancy 7 Children born with Zika congenital 

complications may reveal no symptoms at birth but later could develop epilepsy, convulsions, 

cerebral palsy, physical and learning disabilities, hearing loss, vision problems at different 

stages of their growth and development8. The rising incidences of the association of 

microcephaly and Zika virus disease provoked Brazil to declare Zika outbreak as a national 

public health emergency on 11 November 20159. From February 2016 onwards, Zika crossed 

the Brazilian border and was found in places such as Venezuela where already there were 

existing menaces of Aedes mosquito10. In February 2016, considering the severity of the 

situations in Brazil and other Latin American countries, World Health Organization (WHO) 

declared Zika virus disease as a public health emergency of international concern (PHEIC)11.  

Despite being mosquito-borne, Zika virus infection gradually turned out to transmit person-to-

person infection through the flow of the amniotic fluids of pregnant mothers to the child, the 

body fluids during sexual intercourse, blood transfusion, and laboratory and health-care setting 

exposure12. However, it is the mother to child infection that gained momentum, caused most 

of the transmissions recently, and incurred a huge loss to Latin American countries. The World 

Bank (WB) estimated $3·5 billion economic loss out of 2016 Zika-related effects in Latin 

America alone13. 

Besides its serious medical complications and economic loss, this recent incidence of Zika 

virus infection had its debilitating impacts on the certain section of women and on their born 

and unborn children. In Brazil especially, as it has been highlighted, thousands of women of 

child bearing age, who have already contracted or have the plausibility to contract Zika, live 

particularly in Northeast part of Brazil, the region which has already the heaviest share of the 

burden of poverty, poor infrastructure, lack of access to health services, and high penetration 

of Aedes Aegypti. As became noticeable, the women of the region are living with precarious 

sanitation and housing, irregular water supply, poor water storage system increasing mosquito 

breeding and contributing to the spread of Zika and frequent outbreaks of dengue, 

chikungunya14,15. Given this precarious condition, when women of the region were particularly 

affected by Zika, A.E.Yamin, a pioneer in Global Health and Human Rights, rightly reminds 

that in these Zika affected region, it is the “women who have experienced their poverty and 



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marginalization through their contact with indifferent health systems. It is women who again 

will pay the greatest consequences of the impacts of the lack of public health measures, 

inadequate social protection, and discriminatory laws and… may be blamed for getting 

themselves pregnant”16.  In sum, impact of Zika virus disease, from Brazil and other American 

countries, brings to notice that given the underlying conditions of health in the regions, given 

the situation of the places being less enabled and less interactive, Zika like public health 

emergencies, became opportunistic to affect these women, thereby, compromising their life 

and health expectations.  

Apart from the grave impacts on life and health expectations, the zika virus disease had its 

devastating impacts on reproductive health and opportunities of some women who continued 

to live in the Zika affected regions. Soon after the Zika outbreak, alarming calls by national 

governments were made to plead women to avoid and delay pregnancy. Consequently, voices 

were raised about the impairment of women’s reproductive rights, access to safe abortion 

services1718. Following this line of thought and showing a concern for the right of women, the 

United Nations High Commissioner for Human Rights released a statement criticizing advice 

to delay pregnancies and affirming that “laws and policies that restrict access to sexual and 

reproductive health services in contravention of international standards, must be repealed and 

concrete steps must be taken so that women have the information, support and services they 

require to exercise their rights to determine whether and when they become pregnant”19. 

Although the UN report stands against the local or national governmental 

injunctions, Zika Virus disease, however, once again unleashed the fact that it is 

not just the impoverished who are disproportionately disadvantaged in the face of public 

health disasters but Zika like public health emergencies can also push the rights and choices of 

the women at stake and in this case, it has been the reproductive rights of some groups of 

women which were compromised 

Realizing the interdependence of health and human rights amidst Zika outbreak, in early April 

2016, the Pan American Health Organization (PAHO) issued a guidance document on the key 

ethical issues raised by the epidemic that echo the demand of respecting women’s rights to 

reproduce and include the duty of all governments to provide adequate information, respect the 

right to choose, and provide access to comprehensive reproductive health care, social support 

to women and children affected by Zika 20. PAHO specified that the governmental allowances 

to these women should include allowing each woman to know how to assess whether she wants 

to continue the pregnancy and whether she is willing to bear a child with the risk of this 

syndrome, or whether she cannot submit to it, rather than being authoritative to sacrifice the 

reproductive choices21. Even though the PAHO guidance mentions about respecting the rights 

of the women, the drastic injunctions and governance principles have provoked some groups 

of women to comply with the governmental system and response to Zika virus disease at the 

midst of the emergency period. Consequently, the sudden reactions and preparedness have 

compromised these women’s life circumstances, and have shaken their abilities and 

confidences to continue the reproductive choices further in their lives. 



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With the severity of the Zika, in some places of Brazil and other countries, the government had 

put injunctions to pregnant women to abort the unborn child. With such injunction, the fear of 

unsafe abortions unleashed in the Zika affected regions and unfolded different facts about 

unsafe abortion and its ill- consequences on the health of the women. For instance, according 

to a 2015 Guttmacher Institute brief, as many as 67% of poor women in Guatemala and Mexico, 

as compared to 38% of well-off women, who have an abortion, experienced health 

complications leading to the requirement of the medical treatments afterwards22. Françoise 

Girard, president of the International Women's Health Coalition, in the context of injunctions 

of Zika related abortions, raised the point that rather than implementing the authoritative 

injunctions to Zika related abortions in Brazil and other Latin American countries, government 

could have focused on the fact of improving women’s health and human development by 

ensuring their reproductive rights, providing affordable reproductive health services (including 

contraception and safe abortions) and making comprehensive sexual education available to 

both girls and boys. As he emphasized, there is a need to assure reproductive rights in so-called 

normal times because next crisis cannot be predicted in advance23. The focus on improving the 

system and infrastructure for ensuring reproductive rights of women during normal times is 

reasonable. For, as some researchers pointed, failure of states to implement unrestricted 

abortion laws violates international human rights treaties, national constitutions protecting the 

right to health, privacy, human dignity, family planning, gender equality, lives free from 

discrimination, violence, physical and mental integrity, and free from torture, cruel, inhuman, 

or degrading treatment or punishment24. This paper supports Mr. Girard’s and others’ views on 

focusing on the improvement of the infrastructure of abortion and reproductive health during 

normal times. For, the paper claims that making ad hoc injunctions of abortions during 

emergency times, without securing the abortion measures in the concerned society, result in 

compelling the affected women to compromise their human health securities during the Zika 

virus disease like public health emergencies. 

With the gaining momentum of Zika virus disease, gradually it became noticeable that poor 

pregnant women being exposed to the Zika virus were further discovering themselves to be 

impoverished with the potential burden of born or unborn Zika affected child. For, being a 

mother of a neurologically disabled child meant they could not work. Many pregnant mothers, 

therefore, conformed to the existing abortion infrastructure. For, they could not bear the fear, 

anxiety, and stress of having the responsibility of a baby with special needs, as this would place 

a huge burden on her poor family25. Zika affected children, on one hand, while have their unfair 

burden of disabled childhood, the women, on the other hand, faced the unfair burden of life 

circumstances, uncertainty to achieve the lives they want to value. 

These foreseen and unforeseen impacts of Zika virus disease on babies, unborn children, and 

on women, especially in Brazil, have triggered different ethics consultation and have prompted 

outlining ethical recommendations. However, the recommendations have either focused on the 

reproductive health of women or on the ethics of Zika as a public health emergency, 

overlooking the need to focus on the health, both physical and mental, of the deprived women. 



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The Ethical Challenges and Guidance for Zika: The proliferation of cases of congenital 

neurological complications of children in Brazil raised the challenge to ensure women’s 

reproductive rights, including the rights to be pregnant and the right to interrupt the pregnancy. 

Therefore, PAHO came up with Zika ethics guidance highlighting the moral duty to give 

women of childbearing age up-to-date information, the capacity to choose between all relevant 

reproductive options, access to comprehensive reproductive health care, and social support. 

Supporting this view and categorizing the Zika affected women as the first generation and 

second generation affected persons, some researcher such as Diniz argue for strengthened 

social protection and policies for women and families with affected children, including 

immediate cash transfer benefits. She emphasized that women, being the main victims of this 

epidemic, need good science and good social policies to ensure their abilities, basic health 

needs, and rights as women26. For, women are more than a mother; her health comprises more 

than her reproductive health; she is a human, a person by herself who has a life of her own27. 

With the rising cases of Zika virus disease, an international panel on Zika consultation analysed 

the gaps in the countries’ health system and recommended increasing public health actions to 

reduce the risk of the effects of Zika virus infection in pregnancy, provide appropriate care and 

support (for women who have been exposed); reduce exposure to Zika virus infection for all 

people; provide appropriate clinical care and rehabilitation and continuing care for all those 

with long-term neurological conditions such as acute clinical services and rehabilitation; 

enhanced surveillance and research into diagnostics, vaccines, treatments and vector control28. 

In addition to the focus on these infrastructural developments, Nuffield Council proposes some 

general and specific ethical considerations. It focuses on ethics of data sharing, public 

engagement, and communication, mosquito control techniques, and maintaining a 

proportionate response. In short, this recent public health emergency of Zika virus prompted 

international agencies to delve into and discuss some old challenges for governments in 

controlling vectors, and dealing with issues of reliability, accessibility, diagnosis, vaccine 

production, and intensification of basic sanitation policies. However, these consultations 

overlooked the fact to reflect on why Zika like public health emergencies unleashed the old 

ethical issues of public health emergency preparedness and what have triggered the new issues 

to arise? Thinking along this line of thought, Saenz points out that ‘discussion should continue 

on the reasons why the lessons that could have been learned are still posing challenges, and 

how to ensure that the same situation does not occur in a future outbreak.’ And she suggests it 

is where there is a need of reinvigoration of the commitment to integrate ethics in health care29. 

Ethics in healthcare could be inculcated during the emergency on an ad hoc basis and even 

before and post-disaster phases, that is, during the normal times. Ethical actions implemented 

on an ad hoc basis might not be as sustainable as the ethical actions implemented and practiced 

during normal times and even carried over to the emergency situations. And to be sustainable, 

a health-care system needs a vision, precisely a vision of health. An underlying vision of health 

would not only help in the sustainable ethical actions during the emergency period but could 

also help to perform fairly, in an open and transparent manner during the normal times.  



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To point about the vision of healthcare, Luna points out that the definition of health by the 

World Health Organization, which includes mental health, is also to be remembered during 

Zika like public health emergencies30. However, given, the context of Zika like public health 

emergencies, this paper argues that Zika like public health emergencies need to consider about 

the women as affected agencies, their abilities and confidence to cope with these kind of 

situations, their enabling environment to ensure them of their health needs, and not the least, 

their underlying health performances which push them to be better-off and worst-off during 

the Zika like situations. And to consider these, the paper finds that health as capability could 

be the appropriate vision of health31. Under the paradigm of health capability, health is mainly 

considered as person’s ability to be healthy and has a special moral importance for it signifies 

more than the simple physiological health. JPRuger defines it as, “… the ability of the 

individuals to achieve certain health functionings as well as the freedom to achieve those 

functionings” (2010:81)32. For, health when considered as a capability, would consider holistic 

and comprehensive health of the individuals, would consider the underlying factors of health 

affecting women, would consider women as health agencies, would compare and check their 

health performances, both physical and mental during the emergency and normal times, and 

would also consider the health capabilities of individuals and groups to cope with the 

circumstances, thereby, making an attempt to address the health inequities. Health, when 

considered as a capability, would focus on the capability of the individuals and groups- their 

abilities to cope with the environments; their abilities and confidences to navigate the situations 

to look for the optimum health, their health values that they want to achieve. However, this 

also implies a shared governance to enable and ensure the environment to the individuals and 

groups to navigate through. Focusing on the health capabilities, during normal and Zika like 

emergency situations and by acting on the ground of such vision, would also enable the national 

healthcare system to aim to contribute to global health equity but to address the local health 

inequities. In the present case, Zika affected countries, grounding on the Health Capability 

Paradigm, could simultaneously address the inequities at the local level and can move forward 

to contribute to global health equity. And during the public health emergency situations, 

grounding on the Health Capability Paradigm, the healthcare systems of the affected countries 

could ensure its citizens, in this case the women, the highest available treatment and diagnostic 

regimes at the local levels; could assess their capability to meet the demands, their shortfall, 

and can attempt to contribute to sustainable healthcare systems. 

Conclusion: This paper mainly argues that Zika virus infection has its ethical implications to 

the health of women in general. Explaining certain seen and unforeseen impacts of Zika virus 

disease, especially in Brazil, the paper has analyzed the ethical situations and has attempted to 

point why there is a need of the ethical vision of health during Zika like public health 

emergency situations. Highlighting the lapses in the current Zika ethics consultations and 

recommendations, the paper claims that Zika like public health emergencies needs to focus on 

the ethical vision of health capability to act and promote sustainable healthcare during 

emergency times and normal period. Finally, highlighting the fact that during Zika like public 

health emergencies, healthcare systems should focus on the health capabilities of women, the 

paper concludes with the recommendation that the national healthcare systems should be 



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adequately capable to add infrastructures to be sustainable and to contribute to global health 

equity.  

 

Acknowledgement: The authors are grateful to the editorial team of the Bangladesh Journal 

of Bioethics and acknowledge their hard work behind the successful publication of the articles 

in the journal. 

Author Declaration: Rhyddhi Chakraborty conceived the idea, conducted literature review, 

and developed the manuscript. Edmond Fernandes had drafted the first version of the 

manuscript. 

Conflict of Interests: None. 

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