The heads of babies born with microcephaly are small, but what’s striking, when you first see them, is that their faces look too big. Their facial features develop at a normal rate, so the face takes up much more of the head than in healthy children. Sometimes the cheeks will seem unusually high, or the noses unusually long. But for the most part their features tend to be average; they’re chubby and big-eyed, the faces of babies. What’s different is that they have no forehead. The face curves back abruptly above the eyebrows, with the crown sometimes forming a small pointed peak, like the top of a rubber eraser cap.
Microcephaly is a condition that begins in utero. Some patients develop it in the first few years of life, but for the most part it’s congenital. At a certain point in fetal development the brain stops growing, and the skull stops growing around it. For a minority of the very lucky, microcephaly’s effects are only cosmetic. For the rest, the failure of the brain to develop results in conditions such as limited speech and motor function, weakness and stunted growth, and hyperactivity. More than 40 percent of microcephaly patients will have epilepsy, but seizures are only part of the disorder. Intellectual disabilities are standard; independent adulthood is not feasible. Those who are severely afflicted need daily assistance for the rest of their lives, and their lives tend to be short. Many infants die within a year. Very few make it to 30.
Nowhere are the limits of the “women’s health” defense of abortion clearer than in the case of Zika.
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There are a number of causes of microcephaly. Exposure to large levels of radiation during pregnancy, for example, can cause microcephaly in a fetus (in Japan, a brief boom in the disorder followed the American bombings of Hiroshima and Nagasaki). Sometimes it can be the result of a case of rubella in the mother, or, rarely, the death of a fetal twin. More often, it’s a fluke: chromosomal defects cause the vast majority of cases. But recently, an increase in the reported prevalence of microcephaly in infants born in Brazil has made viral infection the new cause to fear. Zika, an otherwise anodyne, flu-like disease spread by mosquitos, was connected to microcephaly by medical researchers as early as 2014; in 2016 it reached the mainstream American press when microcephaly began occurring with alarming frequency in Brazil, and the country declared a state of emergency. Around the world, health ministries and the press warned women to be careful. Americans who were pregnant or hoping to be were instructed not to travel to any of the South and Central American countries where the virus was spreading. Brazilian women were advised to avoid pregnancy altogether for at least the next two years.
A government instruction not to get pregnant means something different in Brazil than it does in America, or perhaps anywhere else. A Catholic country, Brazil has one of the strictest abortion bans in the world; Saudi Arabia’s laws are more permissive. If a woman can prove that her pregnancy will kill her or that it was the result of rape, then an abortion may be performed; otherwise, women convicted of having abortions are sentenced to up to three years in prison. For doctors who perform the procedure, the sentence is up to four years. There is a legal exception for fetuses with anecephaly, a fatal condition in which the upper parts of the brain and skull fail to develop. The exception was instituted by the country’s supreme court after a legal battle that lasted over a decade; it does not extend to microcephaly or any other fetal malformations.
On the other hand, the country is, in many ways, more progressive than others when it comes to women’s health, namely the US. Healthcare has been a constitutional right in Brazil since the end of the dictatorship in the eighties, and the government isn’t so Catholic as to prohibit birth control. Their clinics subsidize women-controlled methods of contraception, like the pill, and a number of private organizations—notably the International Planned Parenthood Federation—have been providing contraception services to Brazilians since the 1960s. Sterilization is free for women over 25. The ease of access to family planning services and comprehensive sex education means that today the average number of children Brazilian women have is lower than that of Americans.
But if you’re pregnant in Brazil and you don’t want to be, there’s no legal way to end it. Over 1 million illegal abortions are performed every year there, and illegal abortions in Brazil proceed the way that illegal abortions everywhere do: without assurances of clean conditions or competent medical providers and under the pressure of secrecy and fear. Twenty percent of these procedures go badly enough that the patient has to be hospitalized.
You shouldn’t disregard people’s suffering when you evaluate the efficacy or cost of a public policy, but let’s do so for a moment. Because even if you don’t take into account the suffering these patients endure when illegal abortions go wrong, their high rate of hospitalization means that the Brazilian state may spend more money enforcing its abortion ban and taking care of the people that the ban makes sick than it would if it just legalized the procedure and paid for it under its public healthcare service. But as things stand, if you are Brazilian and pregnant with a microcephalic fetus, you are likely going to have no legal option other than to carry the pregnancy to term, and then devote yourself to caring for what may be a severely disabled child. At least you’ll have health coverage: the government’s clinics are notoriously overcrowded, but if you can get through them, the state will pick up much of the cost of the child’s care.
But what’s more confounding about the Zika crisis, and less commonly remarked upon, is that it’s a situation that the Brazilian government had every opportunity to avoid. Zika is spread by mosquitos, and mosquitos breed in standing water. Brazil’s Zika cases are occurring disproportionately among those who live in poor areas; one reason why these communities have more mosquitos, and hence more Zika, is that the state and local governments often aren’t able to pick up the trash. Due to a combination of factors including budget deficits and overcrowding, pick-up rates hover at around 80 percent even in cosmopolitan cities in cities like Sao Paulo and Rio. Sanitation services are carried out intermittently in working-class areas; in the large, illegal favelas where many of the poorest live, there often isn’t any trash pick-up at all. The country didn’t have a waste policy until last year, and when it finally got one, it didn’t have anything to do with citizens’ quality of life—it was implemented amid international pressure ahead of the Rio Olympics. It’s a situation that seems unlikely to change amidst the nation’s current political upheaval, where mass protests, bitter partisan divisions, and the impeachment of President Dilma Rousseff on corruption charges make it unlikely that many in government will keep their jobs. When trash goes uncollected for weeks or months or years, piles of tires and jugs and bits of plastic get rained on, and they collect water in pools. Guess what happens in pools of water that are left sitting outdoors in a tropical climate.
The government, of course, protests that this isn’t the case. When asked about the Zika outbreak, one public health official said, “The mosquitoes are very democratic. . . . It’s not just favelas where they breed. The swimming pools of the rich are also a problem.” Yet the majority of infants with microcephaly continue to be born to poor mothers. One theory is that Brazil’s upper class has access to safer, more expensive black market abortions. Maybe they just cover their pools.
So this is the double bind of the infected, pregnant Brazilian: your government will give you medical care, but it won’t pick up your trash; your state will forbid you from getting the abortion that you need, but its own negligence may be the reason you need it. You are at once an object of legislative concern and official neglect. The case of Zika in Brazil offers a decent lens into what public policy discussions get wrong about abortion rights, both in the US and internationally. The conversation continues to primarily be one about “women’s health,” and what it takes to keep women alive, rather than about ensuring that they are able to live the kinds of lives that most of us would recognize as happy.
Large-scale public health emergencies like Zika draw attention to circumstances in which most people would consider abortion to be rational and responsible. If you’re a Zika-infected person and discover you’re carrying a microcephalic fetus, abortion is a legitimate alternative to incurring the emotional and financial responsibilities of raising a severely disabled child. In the US, the Centers for Disease Control and Prevention announced in February that nine pregnant Americans had been diagnosed with Zika, and that two of them had had abortions (two others had miscarriages, and one gave birth to a disabled infant; the others were still pregnant). But the Zika crisis has not been seized by abortion rights advocates as a timely example of the humanity of abortion access. In fact, the conversation surrounding Zika hasn’t been about abortion at all—only about travel, mosquito nets, and DEET.
One reason why is because the debate over abortion and contraception access in the US over the past decade has been subsumed in the rhetoric of “women’s health,” the euphemistic yet not-untrue phrase that is meant to make abortion palatable as a civil right by obscuring its relationship to sex. It’s not that abortion doesn’t have anything to do with women’s health: abortion can be, among other things, a choice that is made with women’s physical and mental health in mind. In the days before Roe v. Wade, one of the most common exceptions that doctors made for Americans who went through legal routes to seek abortions was if a woman wasn’t physically fit to carry; another was if her mental health would be damaged by carrying a pregnancy to term. A lot of otherwise perfectly healthy women secured their exceptions in those years by testifying that they would kill themselves if they were forced to give birth.
But the limits of women’s health rhetoric have been made increasingly clear as a number of states, including Texas and Louisiana, have instituted laws aimed at shuttering abortion clinics under the guise of raising health standards. In March, the Supreme Court heard arguments over a Texas law that requires clinics that perform abortions to widen their hallways, to install piping used for flammable medical gases (which are not used in abortion procedures) and, weirdly, to remove all of their ceiling fans. Extensive other requirements for things like ventilation systems, off-street parking, water coolers in waiting rooms, and other irrelevant features also apply. If abortion advocates are only concerned with women’s health, the cynical reasoning of this law goes, then why wouldn’t they support drastically raising the standards for all abortion clinics?
What’s sinister about these laws is that they ignore the reality of what abortion access means to people by using the pro-choice movement’s own rhetoric against it. Under the logic of women’s health, prohibitively high standards for clinics are only meant to protect patients. In the end, of course, a lack of access to abortion causes the same health problems in the US as it does in Brazil. Women who have to wait longer to get abortions run higher risks, and in Texas, where half of the state’s abortion clinics have already shut down after the initial phase of the law went into effect, there has been a surge in Google searches for DIY abortions—posing the risk that scared women who don’t know what they’re doing will hurt themselves trying to get the abortions that their state has made inaccessible. Discussions about making abortions “safe for women” have always been complicated by ideology—many procedures, particularly early ones, are not especially complicated or invasive for professionals to perform, and both the pro-choice and anti-abortion sides of the debate have at times exaggerated the medical risks of abortion to their own ends. But the point is that even though illegal abortions frequently are unsafe, they shouldn’t have to be in order for people to deserve open, easy, and affordable access to the procedure.
Nowhere are the limits of the “women’s health” defense of abortion clearer than in the case of Zika. Here, the women’s health argument doesn’t apply because it aims to downplay the kinds of abortions that have little to do with a patient’s physical well-being. In the case of Zika, after all, the question of abortion is not about a woman’s health, at least not really. After all, the person who is pregnant with a microcephalic fetus isn’t in much danger. The Zika virus isn’t too hard on adults: a lot of people who have it don’t even realize that they’re sick. And as far as fetal abnormalities go, microcephaly presents relatively few risks to a mother, at least physically. What’s at stake isn’t the woman’s health, then, but her happiness—her risk of emotional suffering, and her chances of building the kind of life that she wants to lead. As in the case of a patient who finds out during an ultrasound that her fetus has downs syndrome, the question is at least in part about a parent’s quality of life. Whether a woman’s quality of life is a valid enough concern to justify an abortion isn’t something that is frequently discussed in our laws or in the mainstream press, but the reality of abortion for people who have them is that this concern is very important indeed.
For decades, abortion opponents have aimed to make the argument about abortion access into a moral opposition between bare life—i.e., a fetus’s right to exist—and the desire of women to live the lives they wish to—a desire that the pro-life camp casts as selfish, murderous, and frivolous in comparison to the fetus’ bare life claim. The unfortunate response from pro-abortion forces has been to accept the supremacy of bare life over happiness, and to claim that same narrow moral argument as their own. Hence, the pro-choice emphasis on “women’s health,” on cases of rape, incest, and the health of the mother, and on maternal mortality. What are not defended by this rhetoric are the abortions that have nothing to do with staying alive, and everything to do with staying happy: those abortions had by people who simply do not want to be mothers—perhaps not now, perhaps not ever. Until we have an abortion rights rhetoric that accepts happiness as its mantle and is willing to demand women’s right to happiness without apology, this rhetoric will continue to put women in the degrading position of asking for permission merely to be alive, rather than demanding to be acknowledged as full and complete citizens.
Abortion in a situation like fetal microcephaly is by no one’s estimation a joyous choice. But it’s a choice not to raise a disabled child, not to expend feeling, money, time, and ambition on raising a person who may never do what parents hope their children will do: grow up, become independent, and go on to lead their own lives. It is a choice not to risk doing all of this, expending all of that energy and love and time, only to see that child die before its mother does, as many microcephalic infants do. Even in cases where there is no disease and no malformation of the fetus, a complete, uncompromising, and unashamed demand for abortion would have to be a demand for women’s right to pursue happiness—the kind of happiness that includes more than merely avoiding physical harm. The well-intentioned pro-choice rhetoric of women’s health conceals the reality that many abortions are in fact about the right to adult autonomy, to try to build a life for oneself that contains as much joy and as little pain as one can reasonably hope for. It’s a right that women and their advocates have been reluctant to claim.
