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Carlos E. Rodríguez-Díaz, PhD, MPHE, MCHES,1,2 Adriana Garriga-López, PhD,3,4 Souhail M. Malavé-Rivera, PhD, MSc,1,2 and Ricardo L. Vargas-Molina, MA1

Carlos E. Rodríguez-Díaz

1Center because that Sociomedical Research and Evaluation, college of publicly Health, university of Puerto Rico-Medical scientific researches Campus

2Doctoral program in Public health with Specialty in Social components of Health, Social sciences Department, school of publicly Health, university of Puerto Rico-Medical sciences Campus


Adriana Garriga-López

3Anthropology Department, Columbia University

4Anthropology and also Sociology, Kalamazoo College


Souhail M. Malavé-Rivera

1Center because that Sociomedical Research and Evaluation, college of windy Health, college of Puerto Rico-Medical sciences Campus

2Doctoral routine in Public health with Specialty in Social components of Health, Social scientific researches Department, institution of publicly Health, college of Puerto Rico-Medical sciences Campus


Ricardo L. Vargas-Molina

1Center because that Sociomedical Research and Evaluation, institution of windy Health, university of Puerto Rico-Medical scientific researches Campus


1Center because that Sociomedical Research and Evaluation, school of publicly Health, college of Puerto Rico-Medical sciences Campus
2Doctoral regime in Public health with Specialty in Social components of Health, Social scientific researches Department, institution of windy Health, university of Puerto Rico-Medical scientific researches Campus

In 16 months end 35,400 instances of Zika virus infection have been confirmed in Puerto Rico. This to represent 85% of all situations reported top top the United states of America and also its territories. Zika epidemic is exposing the extensive failure that socioeconomic policies, and of the protection of sexual and also reproductive health rights in Puerto Rico. Considering high poor rates, high levels of sexuality-related stigma, bad quality sex education, restricted access to contraception, and limited participation in the allocation of sources for prevention; it is insignificant to emphasis public health efforts to prevent Zika virus epidemic to vector control. The allocation and equitable management of resources for research and intervention are compelled in order to understand and resolve barriers and facilitators for prevention at the individual, social, and also structural levels. Further, the affect of efforts to tackle the social factors of Zika virus epidemic in the island have to be assessed.

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On December 31, 2015, the an initial case of Zika epidemic was report in Puerto Rico - an organized but unincorporated territory of the United claims of America (US). Puerto Rico encompasses an archipelago in the Caribbean basin that became part of the us in 1898, complying with the Spanish-American War. Since at the very least 1917, Puerto Ricans space US citizens by birth. However, together an unincorporated region of the US, Puerto Rico lacks self-determination, and also Puerto Ricans ~ above the islands perform not have complete representation in Congress and also cannot poll for the president. Further, because of Puerto Rico’s territorial status, united state federal mandates take it precedence over regional legislation and policies in all areas of governance. Together of April 19, 2017; 41,807 instances of Zika virus infection have actually been report to the Centers for an illness Control and also Prevention (CDC) in the us (including 50 states, DC, and the regions of American Samoa, Puerto Rico, and also US Virgin Island). The these, 5,238 arisen in United says (excluding united state territories), and 35,418 (85% the all situations in the US and territories) in Puerto Rico alone. While many (94%) of the situations reported within the continental joined States have been travel related, the majority (99%) of cases reported in Puerto Rico have actually been gained through regional transmission. 1

Zika virus, one arthropod-borne flavivirus, generally causes mild infection in humans, yet is associated with major neurologic complications and adverse fetal outcomes.2 sex-related transmission that Zika indigenous both male and female partners deserve to occur.3,4,5 The virus have the right to remain viable in semen because that months6 and transmission via sweat or tears has actually been suggested.7 Puerto Rico has actually witnessed the most an adverse known outcomes that Zika virus infection through the very first birth of a child with Zika-related microcephaly reported in the US, v 29 situations of bear defects, 71 cases of Guillain–Barré syndrome, and at least 5 deaths concerned infection through Zika virus.8

Vector regulate has been a major area of fist for staying clear of Zika virus infections in Puerto Rico, together in most places influenced by the epidemic. These measures facility on mosquito reduction through resource elimination (removal and modification of reproduction sites) and also avoiding call with mosquitos. In stimulate to regulate the vector and prevent mosquito bites, the CDC recommends installing or repairing home window screens and also using mosquito nets, waiting conditioning, outdoor flying insect spray, using details insect repellents, and wearing certain kinds of clothing.9,10

The people Health Organization’s (WHO) reference to protect against sexual transmission of the virus develops that “all patients (male and also female) through Zika virus infection and their sex-related partners (particularly pregnant women) should receive information around sexual infection of the Zika virus, contraceptive measures and also safer sex-related practices, and should be listed with condoms when feasible”.11 accessibility to emergency contraceptive and also safe abortion services should likewise be accessible to women who have had actually unprotected sex and also do no wish to end up being pregnant because of concern over Zika virus infection. Similarly, free-of-charge or affordable care and support have to be noted to pregnant women and also their family members who have actually or will experience Zika infection. As most Zika virus infections room asymptomatic, the WHO also recommends the men and women life in locations where local transmission of Zika virus is known to occur should think about adopting more secure sexual practices or abstaining from sex-related activity.11

International, national, and also local organ have absolutely been responsive in regards to issuing public recommendations for vector control, avoiding the sexual transmission that the Zika virus, and postponing pregnancy. Notwithstanding, this recommendations must be thought about in context. In Puerto Rico, high levels of sexuality-related stigma,12,13,14 negative quality sex education,15 limited access come contraception,16,17 and limited participation in the assignment of resources for prevention18 make prevention of brand-new Zika infections in accordance v these recommendations challenging, if no downright onerous. Because that example, researcher in Puerto Rico have evidenced that there is bad quality sex education available,15,19 minimal access to contraception,16,17 short levels the reproductive planning,20 high level of gender-based violence,21 and low prices of condom use amongst women.17 Further, 2 thirds (65%) the pregnancies space unintended,22 sex-related abstinence is hardly ever practiced among sexually energetic adults,17 and also abstinence-based sexual education and learning (on i beg your pardon public plans are mostly focused) has actually proven to it is in ineffective and morally problematic together it threatens fundamental human rights to health, information, life, and reproductive freedom.23

Regarding accessibility to contraceptives, newly reported data from the CDC identify that in Puerto Rico, “access come contraception is constrained by minimal availability, especially of highly reliable long-acting reversible contraceptive, high-cost, incomplete insurance money coverage, and also lack of trained providers”.22 This is worsened by the big number the health professionals that have recently emigrated native the island.24 Lastly, abortion, together a constitutionally safeguarded right, demands to be considered within the extremely patriarchal social standards in Puerto Rico, wherein religious institutions have historically stigmatized sexuality and also condemned it.25 Such standards are imbricated transversally, indigenous the separation, personal, instance decision-making level, to the health and wellness services delivery arena, and all the way to the design and also enforcement that state policies. For instance, the local Catholic Church through their present Archbishop has actually condemned the usage of condoms, encouraging pendant to overlook the CDC’s reference to usage protection during sexual intercourse. Every these components are disproportionally affecting young adults (21–25 yr) who room the many sexually energetic group,17 among whom most of the unintentional pregnancies space reported,20,26 are recognized to have exacerbated economic constraints,27 and also are much more socially breakable in general.28

The political paper definition in Puerto Rico is more than likely the key constraint for local authorities and communities who look for to determine resources for comprehensive and culturally appropriate prevention programs. Puerto Rico is already in a state of political-economic emergency, while additionally burdened through a preexisting Chinkungunya epidemic, and endemic Dengue virus.29,30,31 The implications of a Zika virus epidemic are potentially severe for public health, since Puerto Rico is structurally under-resourced as result of the existing cap on conference spending for health services ~ above the island.18,32 This issue has been part of windy discussions and also congressional hearings on the fiscal crisis on the island and the establishment of the Puerto Rico Oversight, Management, and Economic security Act or PROMESA,33 but no activity has been taken to ameliorate the negative consequences of the situation with regards to public health care, which has actually rightfully been referred to as a humanitarian crisis.25 Implementation the austerity actions on Puerto Rico’s government budget, particularly related to funds allocated because that public services currently proposed by PROMESA’s board members, raises an ext concerns around the prospective ease of access of local resources to attend to the health treatment challenges do by the Zika epidemic.

Increasing prices of inequality and poverty are having a significant impact top top the island’s population. Data evince the the poverty level in Puerto Rico is 46.2% - nearly twin the poverty rate in Mississippi, the many impoverished the the 50 claims in the us (In Puerto Rico the typical salary is around $19,500 compared to $51,400 in the US).34 Similarly, the unemployment price is end 12%, and also high levels of bankruptcy and populace loss have actually been reported.35 Under these circumstances, that is insignificant to emphasis public health efforts to stop Zika virus infection at the separation, personal, instance level to manage the vector (e.g., purchase screens, air conditioners, clothes, or repellents). The visibility of structural barriers, as formerly discussed, highlights the urgent should conduct more research on regional conditions and also develop autonomous responses that assist communities in Puerto Rico reduce the impact of Zika. Accountancy for the structural inequalities in health treatment that exist on the island requires that we relocate confidently towards remediating not just the viral exposure, however crucially, the we deal with the extensive health vulnerabilities now present, because that Zika is neither the first, no one the critical epidemic Puerto Ricans will certainly experience.25

Thus, that is not surprising that Dr. Tom Frieden, former director that the director of the CDC, stated, “there is the potential for hundreds of thousands of Zika cases in Puerto Rico”.36 Moreover, he recently acknowledged that “effective activity in Puerto Rico has been complicated by lingering suspicions connected to historic activities, contending priorities, and also the speed necessary to lug integrated vector management to scale. Misinformation has clouded understanding of the finest ways to defend individuals and communities”.9 The opposition to the CDC’s response addressing the Zika outbreak by local ecological activists and some segment of the general public; including on the usage of organophosphate insecticides, particularly Naled (dimethyl 1,2-dibromo-2,2-dichloroethylphosphate), must be taken within a historic context, under i m sorry multiple health-related experiments have been carried out on neighborhood populations without informed consent, and many public health and wellness actions have actually been enforced with very limited community participation, questionable cultural adaptation, and also in notable cases, v detrimental outcomes. 37,38,39.40 Further, windy resistance has also been based on legitimate environmental concerns sustained by scientific data concerned aerial spraying through Naled. The main debates are focused on its potential toxicity because that humans, lethal results for endemic types of insects such together bees and also others that are necessary for the pollination the flora, and scarce scientific evidence of Naled spraying efficacy because that vector control.41,42 Moreover, too much reliance ~ above spraying insecticides together a mosquito control measure may do more harm than great by fostering viral resistance. The CDC’s own field tests present that most mosquitos in Puerto Rico are currently either resistant or partly resistant to insecticides.43 the is likewise important to cite that scientific cases made by the CDC officials supporting Naled spraying efficacy have been widely questioned by experts beyond the Puerto Rico jurisdiction.44

There is no doubt the the Zika epidemic is exposing the tragic fail of socioeconomic and health plans in Puerto Rico, and of the security of sexual and also reproductive wellness rights. The Zika epidemic supplies a belated opportunity for health and wellness scientists and professionals to resolve and reduce health and wellness inequities ~ above the island. The existing circumstances require instant attention to the social components of Zika epidemic in Puerto Rico. Indigenous this perspective, the is command to structure the response to the epidemic in ~ the paper definition of wellness inequalities in Puerto Rico and its political-economic relationship to the US. Given the intricacy of this panorama, the solution should be equally comprehensive.

We encourage public health leadership in Puerto Rico, in the US, and also globally to resolve structural barriers that produce and also reproduce wellness inequalities in Puerto Rico, quite than remain concentrated on individual avoidance efforts. To execute so, we recommend developing open networks of communication in between governmental agencies and the public sector commensurate to the immediate character that a public wellness emergency. Furthermore, it is vital to for sure transparency of details and energetic collaboration between sectors in initiatives to prevent and also manage the infection; avoiding replicating the very same top-down layouts fostered by the island’s” colonial status.

The assignment of resources for research study is required to understand barriers and facilitators at the individual, social, and also structural levels, and how these affect health promotion efforts to reduce health inequities and health disparities in the island. This is an important to occurring evidence-based, culturally ideal responses to ensure effective prevention and also mitigation practices. Similarly, us recommend the increase of neighborhood initiatives and existing great practices already in ar at the ar level.

Considering the present investments in vector control, more resources need to be allocated specifically for the prevention of Zika virus transmission through sexual intercourse. Accessible and affordable reproductive wellness services supplying multiple creates of contraception (i.e., including, yet not limited to condoms and other birth manage technology), prenatal diagnostics, prenatal reproductive health care, pediatric care, and also abortion solutions are mandatory and also a simple human right. Establishment of health policies and also implementation of ideal practices need to be based on respect because that reproductive rights, whilst coercive public policy, and also stigmatizing and also shaming discourses have to be avoided. Finally, permanent sustainability the these actions should be prioritized.

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The concern of how and also when to declare the epidemic over looms huge and uncertain. Recently, the Puerto Rico room of Health asserted the end of the Zika epidemic in Puerto Rico.45 Yet, the CDC maintains the the epidemic is not over, however is in reality ongoing46. Including to the uncertainty is lack of scientific agreement on the disparity in between the expected and actual number of cases of Zika syndrome among infected infants and the services listed to them.47

After much more than a year due to the fact that the start of the Zika epidemic later and decades too late, the instance points to colonial status and also poverty as the largest obstacles to wellness on the islands, and highlighting the must understand and also comprehensively resolve the social factors of health and wellness that produce and also reproduce wellness inequities in Puerto Rico.