Weaknesses in the public health system risk another Zika epidemic in Brazil, according to a report published two months after the government declared the mosquito-borne virus was no longer an emergency.

Blamed for the birth defect microcephaly, Zika exposed human rights deficiencies in areas such as sanitation, access to clean water, poverty and sexual health restrictions, the report released on Thursday by Human Rights Watch said.

“The underlying conditions that allowed the outbreak to be so damaging have not been addressed and there is a vulnerability for future outbreaks,” said Amanda Klasing, one of the report’s authors. She added that millions of people lack proper sanitation or fresh water, and women also need better information and access to contraception and safe abortion – which is illegal in most cases in Brazil.

Zika was first identified in Brazil in 2014 and spread rapidly through the country. There were 191,992 cases in 2016 and by May, 9,351 new cases this year. The ministry of health said Zika was responsible for the majority of the 2,753 cases of the devastating birth defect microcephaly – of which 322 were this year.

Microcephaly, which can also be caused by other infections such as herpes, rubella and syphilis, causes babies to be born with abnormally small heads and leads to cognitive and learning difficulties. Many of the babies come from low-income backgrounds, like Maria Eduarda, born 19 months ago, who is cared for by Cleane Serpa, 19, and Miriam Pereira, 42, who adopted the baby.



They live in a tiny house in a low-income community in Recife, the north-eastern city that was an epicentre for the Zika epidemic, and receive £225 in monthly benefits for the child and two women to live on. They also receive free bus travel to take her to occupational therapy, hearing, physiotherapy and other sessions – spending up to two hours each way on the journey.

“It is not enough. Her milk is expensive, and her medicine is expensive,” Serpa said. Caring for a microcephalic baby is intensive, full-time work. Maria Eduarda spent six months feeding through a tube that she has only just been weaned off. “She forgot how to swallow,” said Serpa.

Many women interviewed for the report said they lacked information on contraception and were unaware that Zika could be transmitted sexually. Almost half of those with microcephalic babies were single mothers.

Illegal abortions increased in Brazil in the face of the Zika crisis, according to a 2016 study by the New England Journal of Medicine. Requests from Brazil to Women on Web, a Dutch organisation that sends abortion medicines to women in countries where it is restricted, increased 108%. Since 2005, more than 900 women have died from unsafe abortion in Brazil.

The HRW report recommended that Brazil’s supreme court make abortion legal, a move the country’s conservative congress is unlikely to make in this deeply religious country.

“Politically, it is very difficult – but from a public health perspective, criminalising abortion is terrible policy,” Klasing said.

The microcephaly outbreak was concentrated last year in the north-east of Brazil – one its poorest and most arid regions – for reasons that scientists and researchers are still trying to understand. The report argues that a lack of proper sanitation and water supply contributed – a view many specialists share.

The Aedes aegypti mosquito, which transmits Zika and other arboviruses like Dengue and Chikungunya, lays eggs on damp surfaces near water. Poor sanitation and a lack of water supply, which means people leave their water sitting in buckets or containers, provide ideal conditions for it to spread.

“When you have more conditions for the Aedes aegypti mosquito to spread, you have more transmission possibilities,” said Jessé Alves, an infectious diseases specialist at the state-run Emilio Ribas hospital in São Paulo.

According to World Health Organisation statistics, 35 million people in Brazil do not have adequate sanitation and 3.8 million do not have access to safe drinking water. In the north-east, just 25% are connected to a wastewater system.

“There is a big deficit in the country,” said Alceu Galvão, a sanitation consultant in the north-eastern state of Ceará, following decades of low investment.

In 2013, left President Dilma Rousseff’s government launched a 20-year plan to improve sanitation across Brazil. The plan “was overtaken by the economic situation”, Galvão said as Brazil has sunk into a debilitating recession. Rousseff was impeached last year for breaking budget rules and her successor, Michel Temer, has introduced a 20-year ceiling on spending to reduce a spiralling £33 billion deficit he blamed on her overspending.

Other specialists agreed that Zika could return.



Danielle Cruz, an infectious diseases specialist in Recife who has treated many microcephalic babies, said Zika could be cyclical, like other arboviruses. While Dengue numbers fell sharply this year, Brazil had to mount an emergency vaccination operation to contain a sylvatic yellow fever outbreak.

“The lack of basic sanitation, the poverty, it all favours the mosquito,” Cruz said. “There is a big chance of Zika coming back.”