The recent announcement the World Health Organisation (WHO) has declared Zika no longer a “public health emergency of international concern” is sad news. Rather than signalling a victory over this high profile global health threat, it is more a recognition the virus is here to stay.

The announcement downgrades Zika to just another of the chronic, complex public health issues countries have to deal with. However, this one has a clear gender dimension. The losers will be women; poor, marginalised women who already have enormous threats to their reproductive health and the health of their babies.

Zika reached prominence in the past year as a rapidly spreading outbreak affecting Brazil and other parts of South America but now with active transmission in more than 60 countries and territories. The particular features of Zika create a reproductive health nightmare that we now know is unlikely to end.

Women will be disproportionately affected

Zika in pregnancy has been linked to microcephaly – a condition caused by the virus attacking brain cells and leading to small heads and brain damage in babies.

Zika infection often has no symptoms, so pregnant women may be silently infected, with potentially catastrophic outcomes for their child. Testing for mosquito-borne infections can be complex, making it difficult to be certain of infection on blood test alone.

This leaves pregnant women in an affected area unsure of their infection status and the impact on their baby. The only option is to monitor the baby by ultrasound and provide the choice of termination if the condition is detected early enough. An additional complexity for reproductive health is the fact that Zika has been transmitted sexually.

Nearly 3000 babies have been born with microcephaly since the outbreak began. Although scientific investigations are still continuing, researchers conclude there is a link with Zika infection. Although most microcephaly cases are in Brazil, there have been cases in other countries and the full extent of the problem is far from clear.

As a recent article highlighted, the gender dimensions of global health emergencies such as Zika and Ebola have not received enough attention. In both cases women of reproductive age have been particularly vulnerable to the effects of the outbreaks and tend to come from poor, marginalised communities where their access to reproductive health care is already limited.

In Sierra Leone, a country that already had one of the highest rates of maternal death, maternal and newborn deaths rose by a third in the height of the Ebola outbreak. In Brazil, the areas most affected by Zika were those where women were least likely to have access to contraception and medical care.

Implications of the status downgrade

When downgrading Zika’s emergency status WHO said its response would remain robust. However, this downgrade is a move from emergency response to long term development issue.

The decision is based on WHO’s assessment that the situation no longer meets criteria for a public health emergency of international concern. A WHO expert committee can declare such a public health emergency under legal structures set up to govern pandemics called the International Health Regulations.

There have only been three previous declarations since the regulations began in 2007 (for swine flu, polio and Ebola). A declaration is a political tool that WHO uses to focus attention and expertise on “extraordinary” global health threats and can allow for trade and travel restriction.

The uncertainty around Zika and explosion of microcephaly cases in Brazil triggered the declaration to mobilise increased surveillance and global awareness. In removing the emergency status WHO has accepted this is not an acute situation that can be limited, that Zika is not going away, and that emergency structures are not the most appropriate framework for this now chronic situation.

WHO acknowledged Zika remains a “significant and enduring public health challenge”, one that should not be underestimated.

Concerned about the announcement

Public health experts have reacted with concern to the announcement. Global health expert Lawrence Gostin called the move “quite worrying” due to the possibility the international response could become “lethargic”.

The high-level attention, associated mobilisation of funds, and pressure for vaccine development, risk losing momentum if Zika is no longer seen as a crisis.

In the absence of a vaccine, which could be years away, women in affected areas face a devastating reproductive health crisis. Preventative measures to avoid mosquito bites have been unable to eliminate transmission in other mosquito-borne infections.

The advice to consider delaying pregnancy is not feasible long-term. Potential public health responses – sex education, access to contraception, access to ultrasound and antenatal care, access (and legal frameworks for) safe and accessible abortion – are already lacking or severely compromised in many areas affected.

The recent WHO announcement takes us into a new phase, one that is unknown and complex. Zika is now a reproductive health threat that is here to stay, another shadow of uncertainty hanging over thousands of women worldwide as they go through the vulnerable journey of pregnancy and childbirth.