by Sonia Corrêa*
If things had gone well, 2014 would have been the perfect year to commemorate the positive developments of sexual and reproductive health and rights in Brazil. The year marked the 20th anniversary of the 1994 Cairo International Conference on Population and Development, when these policy concepts were given a stamp of approval at the global level, with clear and strong support from the Brazilian state. But also (and perhaps more significantly), 2014 would have been the right moment to assess and appraise the Comprehensive Women’s Health Program (PAISM), launched in 1984, a plan which moved beyond maternal and child health in responding to a wide range of women’s health needs. The PAISM, which would later be appraised as a groundbreaking policy for the global south, anticipating the Cairo Conference by ten years, has been a core topic in Brazilian feminist advocacy agendas since the 1980’s (see Corrêa 2006).
But unfortunately, things have gone wrong.
By 2014, the PAISM no longer existed, except in our fading feminist memories. During the 2010 electoral campaign, presidential candidate Dilma Rousseff was systematically accused of being in favor of abortion (Corrêa, 2010). To meet these accusations, one of her first measures as president was to abandon the PAISM framework, conceived in terms of women’s health rights, reactivating a conventional mother-and-child focused health policy known as the Stork Network.[i] At the same time, the forces set against women’s reproductive autonomy (which had been on the rise since the mid 1990’s) gained further space and power in both society and in government institutions. The number of regressive bills with regards to abortion and related matters in front of the Brazilian congress increased geometrically as the sectarian religious caucus in Congress expanded its pressure on the executive branch in relation to these matters. Since the mid 2000’s, the criminalization of both clandestine abortion services and women who abort has intensified (Galli, 2011). Further restrictions on abortion were imposed by the Health Ministry’s drug surveillance agency (ANVISA) with regards to access to MISOPROSTOL (Diniz, 2011). Consequently, access to relatively safe clandestine pregnancy termination has been drastically restricted.
Not surprisingly, in September 2014, the Brazilian and the international press reported that two women died as the result of unsafe abortion procedures provided by criminal networks in Rio de Janeiro. No public authority – at local, state or federal level – lamented these deaths or dared suggest policy measures to avoid further loss of life. On the one hand, this tragedy marked the 30th anniversary of PAISM the 20th anniversary of the Cairo Conference in Brazil. On the other, the deaths triggered indignation across diverse sectors of Brazilian society and re-infused energy into Brazilian reproductive rights debates and related activism.
This swell of political energy continued to expand in 2015, as sexual and reproductive politics worsened at institutional levels. One of the main feature of last years’ political climate was the election of Eduardo Cunha – an Evangelical Christian MP, whose positions against sexual and reproductive rights have been widely known since the 1990’s – as the new President of Brazil’s Chamber of Deputies. As soon as he took office, Cunha inaugurated a series of regressive propositions in relation to gender, families and sexual and reproductive matters, including a provision to criminalize HIV transmission (read more in Portuguese), a highly conservative “family law” and, in particular, PL5069: a law that, if approved, would drastically restricts access to abortion in the case of rape (a permission defined by Brazil’s 1940 Penal Code).
The high speed in which these propositions were processed by Congress was not accidental, being intimately linked to the wider and much more complex dynamics created by political efforts aimed at impeaching President Dilma Rousseff. This is a move that has been supported by a range of opposition forces, but which primarily counts upon the support of MP Cunha (even though he formally belongs the ruling government’s congressional base). Additionally, Cunha himself is under investigation for involvement in the Petrobras corruption scandal and, at present, is at risk of losing his post and mandate. His intense push regarding “moral issues” in the Chamber debates is evidently aimed at creating a smoke curtain around his own alleged wrongdoings. Significantly, in August, Rousseff promoted a wide-ranging ministerial reform in order to give executive power to MPs who could potentially join the impeachment bandwagon.[ii] In this shift, Dr. Marcelo Castro – a psychiatrist who is a congressman from the state of Piauí – was nominated as the new Minister of Health.
As these dynamics were playing out in the executive branch, the regressive nature of the legal provisions being processed by Congress gained social visibility, triggering public debates and propelling political mobilization. Public repudiation was particularly striking in reaction to PL 5069’s proposed restrictions on access to abortion in the case of rape. As 2015 wound down, feminist advocates were wrestling with legal regressions in Congress while feminist multitudes took to the streets, for the first time in a long time, to vibrantly claim women’s reproductive autonomy. Significantly, this was when the first reports were released to the press regarding the potential correlation between an uncontrolled epidemic of Zika Virus and a high incidence of microcephaly amongst babies born in the Brazilian northeast.
As this article was being prepared, in late January 2016, Zika Virus had already become a global public health scare. The epidemic affects many countries in Africa, the Pacific, South and Central America. It was in Brazil, however, that the correlation between the Zika infection and microcephaly was established for the first time. This is the aspect of the epidemic that is provoking a sort of global panic. In the third week of January, a case of microcephaly was discovered in Hawaii and the press was informed that the mother of the baby had been infected in Brazil. The CDC and the WHO have already issued formal alerts and behavior guidelines with regards to the reproductive risks of Zika.
In Brazil itself, the crisis is revealing poor sanitation conditions and the health system’s malfunctioning. It is also opening new inroads in the debates regarding the legal restrictions of women’s sexual and reproductive autonomy.
A Public Health System in disarray
Before examining the substantive debates triggered by the Zika crisis in relation to women’s reproductive capacity and autonomy, we must briefly provide a bird’s eye view of the conditions currently prevailing in the Brazilian public health system. As noted in the literature, the health reform of the 1980’s – which enshrined the right to health care in the Constitution and created a universal and unified public-funded free system (SUS) – was one of the major social right achievements of the Brazilian democratization process. The health system reform became the bedrock on which subsequent women’s health and HIV&AIDS policies would be anchored. But the establishment of SUS has not been simple nor easy. As late as 2006 (almost 20 years after the legal reform), SUS was still “under construction” and faced numerous challenges, beginning with its massive scale:
“SUS is a gigantic machine, delivering services to millions of people across an extremely diverse and unequal country… The extreme variation in technical capabilities, human resources and ideologies in a decentralized system implies that, not infrequently, excellent national policies translate poorly at local levels… This and other factors have compromised efficiency, access and quality of care…. As each new SUS “crisis” is made visible, more room opens up for the private sector to expand its reach. This implies a permanent tension between privatizing forces on the one hand (which use marketing strategies to sell “quality of care and access to technology”) and SUS’ fundamental principles of, universality, public funding and health as a right on the other (Corrêa, 2006, Pg. 56).”
Furthermore, the balance between public and private financing of health care has been skewed since the creation of SUS. This has not changed since the early 2000’s. Today, more than 50 percent of national health expenditures (roughly 9 percent of Brazil’s GDP) correspond to private financing. Just 28 percent of the population is covered by private health insurance, but public incentives to the private sector through tax breaks amounts to 20 percent of annual public health financing. Lavinas (2015) interprets this ongoing trend as a marked symptom that federal policies continue favoring the marketization of health in detriment of existing principles of universal and free coverage. [iii]
It should be said that, since 2006, fragmentation resulting from decentralization has enhanced the adoption of local legislation allowing private “social organizations” to be contracted as health care providers without ensuring, however, proper public oversight and regulation. These problems and distortions have predominantly affected the efficiency and quality of primary levels of health care, in which early detection, prevention and health education take place. The realm of reproductive health — pre-natal, obstetric and post-natal care – has been one of the main victims of this disarray.
These deteriorated conditions explain the high rates of congenital syphilis in Brazil, recently registered by Lancet in a report on fetal and neonatal mortality.[iv] It is also what explains the persistence of high maternal mortality ratios: 61 deaths/100,000 live births in 2012 (the most recent reliable data). In order to meet the global MDG target, Brazil needs to reduce this figure to 35 deaths/100,000 live births. The scale and effects of the Zika epidemics must be situated in relation to this wider, appalling backdrop.
To be fair in regard to the “still well functioning” parts of the public health system, it is important to mention that the potential connection between Zika and microcephaly was detected by a public health professional in a public clinic in Campina Grande, a town in the interior of Paraíba (and not by international health organizations, as was reported by the international press). The reaction of Brazil’s public health research institutions to the crisis has also been quick and effective.
More worrisome, however, is the fact that cases of Zika have skyrocketed since 2014, given that Brazil had 1,5 million cases of dengue fever last year. In fact, the new Minister of Health was honest enough to declare, on January 22nd (2016), that Brazil was “losing the battle against the mosquito”. Additionally, when the microcephaly crisis became evident in October 2015, thousands of babies had already been potentially disabled by the Zika virus, a striking indication that systems of early detection of maternal health crises are not working effectively in Brazil.
And then … we had to cope with deplorable acts of speech
The institutional response to the Zika scare was the first major task undertaken by the newly appointed Minister of Health. His first declaration on the matter was decidedly deplorable. In late November, the MoH released an initial report informing that 1,248 cases of microcephaly potentially attributable to the Zika virus had been already identified. Dr. Castro’s commented upon this saying, “Sex is for amateurs and reproduction is for professionals”. Consequently, in his view the Zika crisis required women to refrain from getting pregnant. SPW has collected the opinions (In Portuguese) of feminists and other experts and activists regarding this declaration. The view expressed by Veriano Terto, a HIV specialist who works at ABIA, deserves to be quoted:
This is another manifestation of conservative conceptions with regards to sexuality that have taken over the Brazilian state, in recent years. The Minister portrayed sex as a place of danger and as a less noble human function than others, in particular maternity. He expressed a moral vision that does not allow women the right to pleasure and reinforces gender stereotypes. The Minister has also considered women themselves responsible for having or not having babies with microcephaly. He more-or-less of accused them of “negligence and thoughtlessness”, rather than calling for an open and frank debate about the grave problems affecting our public health system today.
The Zika crisis, it should be said, is not the only front where there have been clashes between the new Minster and progressive public health actors. In December, Dr. Castro nominated Dr. Valencius Wurch for the post of Director of Mental Health a person. Wurch had previously been the manager of one of the most repressive psychiatric asylums in Brazil. In a context where the anti-asylum movement has been very strong and vocal since the 1970’s, this nomination triggered continuous waves of anger and contestation. Although protests are still underway nothing suggests that Dr. Wurch will be removed.
Furthermore, since November, Dr. Castro’s continued to demonstrate an apparent inability to keep his foot out of his mouth in his speeches regarding the Zika crisis. As mentioned above, he recently stated that the “war against the mosquito was being lost”, provoking much discomfort among federal authorities. A bit earlier, he also declared that it would be better if women got infected by Zika before their “fertile period”, so as to gain immunity against the virus, because a vaccine for the virus is not going to be immediately developed. A new spiral of criticism followed these declarations, particularly with regards to the minister’s grotesque confusion between ‘fertile periods” and “fertile age”.
As this new boutade was still being processed, the Ministry of Health then announced it would launch a national campaign to expand the use of (long term) contraceptive implants amongst teen-agers. Although it is not clear if there is a direct correlation between the two events, both have clearly reflected ideologies and policies aimed at controlling women’s sexual and reproductive behavior. In her sharp comments about the institutional response to the Zika crisis, feminist anthropologist Débora Denis insightfully underlined this glaring bias: “This is a perspective of birth control from 1950’s: it is a policy bypass typical of a country that has not been able to develop a serious discussion about women’s rights and reproductive rights”. [v]
Zika and the right to abortion: back to basics?
In the 75 years that have elapsed since the adoption of the 1940 Penal Code, abortion was reformed only once: in 2012, when the Supreme Court, after eight years of consideration, granted the right to abortion in the case of anencephalic fetuses. Since then, the judiciary has made recourse to the 2012 decision and, in a few instances, has granted access to abortion in cases of fetal abnormality other than anencephaly. The scale of the microcephaly crisis would inevitably increase pressures for existing legal restrictions on abortion to once again be contested. While many pregnant women infected with Zika virus were pondering how best to abort, a series of intense public debates (check here the articles published in Portuguese) began.
Claudia Colucci, in the paper Folha de São Paulo (January 10th, 2016), reported on experts’ views regarding whether microcephaly would or not be justifiable cause for abortion. Many of the experts polled declared that microcephaly can be very severe in some cases, and that abortion should be granted in these. Hélio Shwartzman, also in the Folha, correctly noted that, in face of the Zika crisis, it is highly regrettable to see the current Brazilian debate on abortion rights premised upon absolutist moral and religious arguments, which lag behind the legal arguments underpinning the reforms of the 1940 Penal Code. In her op-ed piece for the Estado de Minas, Black feminist Fátima de Oliveira expressed her indignation to see the Brazilian government pushing thousands of women into clandestine and unsafe abortions.
On January 18th, Le Monde’s French edition published a full report on the subject. Entitled “The Zika epidemic re-opens the abortion debate in Brazil”, the article begins with the testimony of a 12 week pregnant, middle class, 32 year old women who, infected by Zica, resorted to a clandestine abortion clinic in São Paulo in order to terminate her pregnancy. A shorter version of the article published in Portuguese captured the views of feminists and other experts regarding the potential positive impact of the Zika crisis on abortion politics. Some of these voices underlined the overall climate of morality and control as the one main barrier preventing a wider debate from happening; others, however, believed that the epidemics had definitely created new conditions for the debate on abortion to be re-assessed. Meanwhile, media reports continued pouring in, looking at the potential increase in clandestine abortions and the related risks and giving space to voices in favor of changing the law to allow pregnant women infected by Zika to abort. Even a judge from the state of Goiás went on record as favoring this change.
Brazilian abortion politics is definitely being transformed by the Zika crisis. If it is possible to reactivate the energies that were aroused against PL 5069 and connect these with the lively debate on Zika and abortion, the conditions presiding over the re-opening of Congressional discussions regarding PL5069 in February 2016 may be altered. Furthermore as note by Débora Diniz, the microcephaly scare is also rapidly creating favorable conditions for a new case to be presented to the Supreme Court requesting the right to abortion to be granted in the case of other fetal abnormalities. In an interview with the Global Post she said: “We have everything on hand – we an epidemic, we have the historical negligence of the Minister of Health and we have women’s need on the table” . Later in the day, in an interview with BBC Brazil she has expanded further this argument. Last but not least, it is crucial to acknowledge that what we are facing is not another Brazilian domestic challenge in relation to restrictive abortion laws. Brazil is now the epicenter of a global abortion politics storm. Although complex and risky, this crossroads is also a privileged opportunity to forge transnational connections and foster internal transformations.
While these glaring and intense dynamics are at play in the media and society at large, the public response of Brazil´s public executive authorities has been either appalling or almost nonexistent. The Minister of Health has issued a specific technical guideline for Zika, but at the ground level women, can not get proper information and the public health system does not seem to have the capacity to the respond to the crisis as it would be required.[vi] The Federal Government announced it will provide a “family grant”(Bolsa Família) for the mothers of babies born with microcephaly. This policy measure (although long overdue) is certainly to be applauded, but it is entirely insufficient. If things had not gone wrong and a solid, comprehensive sexual and reproductive health policy had been in place, the response to the Zika crisis would include extensive and well-designed prevention campaigns distribution of anti-mosquito nets and other measures against mosquito infestation, but also the effective intensification of pre-natal screening, as well as information on and facilitated access to emergency contraception. Most particularly as claimed by Jacqueline Pitanguy in an article published in O Globo (January 27th, 2016), it would have also contained legal norms and services to ensure that:
Women who today face the fear of being pregnant with a fetus affected by microcephaly [would be] able to freely decide to either carry to term or interrupt the pregnancy, as a fundamental right to reproductive autonomy and to the emotional integrity of herself and her family.
* I dearly thank Lena Lavinas and Sandra Valogueiro for sharing their analysis on SUS financing and maternal mortality rates and most principally Thaddeus Blanchette for the English revision
[i] The implementation of the PAISM has been marked since the 1980’s by sequential ups and downs. In 2010, the policy was not exactly passing through its best moment, it must be admitted. Furthermore, feminist political reaction to this regrettable shift was feeble, not to say almost absent. One factor explaining this debility is probably the continuous loss of financial resources experienced by feminist organizations since the late 1990’s. But other elements should be taken into consideration, such as (for example) a political dynamic – underway since the early 2000’s – which can be characterized as the cooptation of social movements by the state machinery through mechanisms of social participation and other means. Another contributing factor has been the glaring reluctance on the part of many sectors of the feminist movement to criticize the PT administration and, in particular, the first woman president of the country.
[ii] The reform also included the collapsing of the federal secretaries of the Human Rights, Women’s Policies and Racial Equality secretariats into one ministerial unit with a lower budget and much less political clout.
[iii]To learn more see : Lavinas, Lena (2015) Inovando no Setor Público Brasileiro – Desafios Institucionais e Políticas Públicas. Paper presented at the Seminar “Innovation for Inclusive Growth, Columbia University – Lemann Dialogue NYC, November, 2015
[iv] Joy e. Lawn et al (2016) Stillbirths: rates, risk factors, and acceleration towards 2030, available online since 19 January 2016
[v]In this analytical context, it is also very troubling to read international press reports that similar “reproductive control” approaches to the Zika crisis are being organized in other Latin American countries, such as El Salvador and Ecuador. It is as if neither the Cairo consensus on sexual and reproductive rights, nor its reaffirmation at the First ECLAC Regional Conference on Population and Development of 2013 had ever happened.
[vi] In O Globo (January 28th , 2016) Dr. Adriana Melo, who has detected the linkage between the Zika virus and microcephaly described the public health response in the following terms: “Women do not know where to go.… We do not know how long we will endure this situation… We have 300 pregnant women with suspected zika infections registered in our system but we can not do the serological test to make the diagnostics, because the Ministry of Health is not providing it.