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02/23/2016

Zika: Time for the next wave of sensationalized worry

by Craig Klugman, Ph.D.

On the season (series?) finale of the X-Files (Season 10, episode 6) this week, all of humanity is being attacked by the Spartan virus, a disease that seems to turn off the human immune system and permits other diseases to kill us. This episode is built on our fears of an inevitable worldwide pandemic and, of course, the recent concerns over Zika virus.

Zika is a virus spread by the Aedes mosquito. An adult who is infected may experience a “mild fever, skin rashes, conjunctivitis, muscle and joint pain, malaise or headache.” Zika has been known since 1947 when the virus was found in a rhesus macaque being used for research on yellow fever in Uganda. The first case of an infected human was in Nigeria in 1954. Human infections were rare until 2007 when an epidemic hit Yap Island, Micronesia. In 2014, in French Polynesia, there was a cluster of microcephaly and Guillain-Barre syndrome (GBS). The current epidemic was declared a Public Health Emergency by the World Health Organization (WHO) in February 2016.

What’s important to know is that there are two things occurring: (1) An increase in people who have been or are infected with Zika virus. And (2) a cluster of microcephaly and GBS in Brazil, French Polynesia, El Salvador, Venezuela, Colombia, and Suriname. This type of evidence is called correlative—they both are happening in similar populations. Correlation does not necessarily mean causation. For example, the divorce rate in Maine correlates with per capita consumption of margarine. That does not mean margarine cause divorce. And the per capita consumption of mozzarella roughly follows the awarding of civil engineering doctorates. That does not mean more mozzarella means more engineers.

As stated by the WHO, “Evidence that neurological disorders, including microcephaly and GBS, are linked to Zika virus infection remains circumstantial, but a growing body of clinical and epidemiological data points towards a causal role for Zika virus.” In English, this means that there may be an association between the neurological conditions and Zika, but so far that has not been proven.

Like images from the X-Files where everyone is looting, trying to escape cities on congested roads, and people dying in hospitals, the discussion over Zika has led to some dramatized moments. Consider recent statements published in the New York Times from scientists who say that even if babies are not born with microcephaly, they may have mental disorders. Their evidence is that it’s been suspected that viruses in general can damage the brain and that Zika causes symptoms similar to other diseases believed to cause mental disorders.

More drama is found in statements that women should avoid traveling to areas with Zika. Some Olympic athletes have expressed concerns about attending the Olympics scheduled for Rio De Janeiro, Brazil this summer and that they may not attend. Others fear that a major international event like the Olympics could spread the disease dramatically as visitors come from all over the world and return home after being bitten by mosquitoes. Even bioethicists have suggested not allowing the public or athletes (many of whom are women in their reproductive years) to attend by cancelling the Olympics. Airlines and cruise lines are even offering cancellations for trips to areas with Zika.

From a medical ethics standpoint, Zika presents some interesting challenges. El Salvador has suggested that women do not get pregnant for two years until more is known. Colombia and Ecuador have joined this call. The challenge is that El Salvador does not permit abortion and accessing contraception is very difficult and expensive. As Human Rights Watch reports, women in that country have very little control over pregnancy with little family planning and “high rates of sexual violence.” These requests violate the idea of procreative liberty as well as placing all responsibility for microcephalic babies on women. It takes a man as well as a woman to make a baby. Any prohibition should also be on men.

Pope Paul VI in 1968 issued Humanae Vitae, an encyclical which confirmed the Church’s stance on the wrongness of contraception–“any action which, either in anticipation of the conjugal act [sexual intercourse], or in its accomplishment, or in the development of its natural consequences, proposes, whether as an end or as a means, to render procreation impossible” (Humanae Vitae 14). In a statement this week, the Pope said that “avoiding pregnancy is not an absolute evil” for a woman living in an area with Zika. This may be important since such statements were not forthcoming even in the height of AIDS. But it’s impact may be more on official policy than on everyday practice since 53% of women in El Salvador already use contraceptives. Though more openness might make access easier.

Preventing pregnancy is one approach, but what about a woman who is infected with Zika while already pregnant and/or has an embryo with microcephaly? In these very Catholic countries abortion is socially, religiously, and legally often not an option. She has no choice but to give birth to a child who may have microcephaly and likely developmental disabilities in a country that has few support services.

Perhaps most disturbing are reports that in the U.S., there may be 14 cases of Zika transmitted via sex. Before these reports there was no known human-to-human transmission. The WHO is now recommending that those who have traveled to Zika areas practice safe sex there and on return (and honestly, always).

This unfolding outbreak holds several lessons in public health ethics:

(1) Epidemiology is complicated and there is a difference between correlation and causation.

(2) It’s easy to make recommendations and jump to conclusions when you have inadequate data.

(3) We are seeing a growing number of new (or formerly rare) infectious diseases as a result of climate change and humans spreading into formerly rarely visited areas (i.e. cutting down rainforests).

(4). It’s reassuring to offer simple (but ridiculous) suggestions to prevent problems but often they only serve to increase stigmatization of already marginalized populations. Interventions such as saying women alone are responsible for pregnancy and should refrain from sex puts all responsibility for disease on women and stigmatizes any women who give birth to children with special needs. Also consider the damage being done to the economies of countries where tourists are frightened to go or the stigma that may accompany people who travel to the U.S. from a country with Zika (as happened with those from Haiti in the early days of HIV).

For those of us involved in bioethics, public health ethics, or crisis management planning, it’s important the communicate accurate information, to avoid increasing the hyperbole or sensationalizing the situation, and that we serve the public by offering appropriate and measured analyses.

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