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A health promoter teaches Vanessa del Carmen Velasquez how to clean the pila, the water storage basin to prevent Zika-carrying mosquitoes breeding.
A health promoter teaches Vanessa del Carmen Velasquez how to clean the pila, the water storage basin to prevent Zika-carrying mosquitoes breeding. Photograph: Nina Lakhani/The Guardian
A health promoter teaches Vanessa del Carmen Velasquez how to clean the pila, the water storage basin to prevent Zika-carrying mosquitoes breeding. Photograph: Nina Lakhani/The Guardian

El Salvador's Zika crisis compounded by failings of state, violence and machismo

This article is more than 8 years old

Virus-infected women in the Central American country face the world’s harshest abortion law, little sex education, and prevalent gang and sexual violence

Vanesa del Carmen Velásquez was 26 weeks pregnant when, just before Christmas, her joints started to ache. A day or so later came an itchy rash across her body and a fever of 39C (102F), swiftly followed by raw red conjunctivitis eyes.

Velásquez, 23, had been terrified by stories linking Zika to birth defects, so on Christmas Day she drove 25 miles south from the semi-rural canton of Aguilares to the nearest public hospital in the capital, San Salvador.

After a simple blood and urine test, the hospital said Velásquez was suffering an allergic reaction and sent her home with no follow-up.

“I thought it was Zika – three others in my family had the same symptoms – so I felt relieved when they said it was just an allergy. They didn’t give me an ultrasound, but said not to worry as I was past the first trimester,” said Velasquez, who is now 32 weeks pregnant.

But the all-clear was a mistake: the ache, the rash, the temperature were all symptoms of the Zika virus. Velásquez’s name appears on El Salvador’s national register of cases which should be closely monitored, yet until recently she had received no follow-up from healthcare workers.

Amid mounting concerns that Zika is linked to a spike in microcephaly, overstretched health authorities across the region have struggled to cope with the epidemic, and Velásquez is probably not the only Zika patient to have fallen through the net.

But in El Salvador the challenge is exacerbated by tottering public institutions, high rates of sexual violence, inadequate sex education and a backdrop of violence and gang warfare which are undermining efforts to control the outbreak.

The country has the highest rate of teenage pregnancies in Latin America and a total ban on abortion. In their initial response to the Zika outbreak, Salvadorian health authorities simply advised women to delay getting pregnant for two years.

But women’s rights activists said that the controversial advice failed to reflect the country’s entrenched culture of sexism which leaves many women – especially poor women – with little control over their bodies.

Mariela Hernandez, 27, a health adviser for pregnant teenagers and adolescent mothers in El Paisnal. Photograph: Nina Lakhani/The Guardian

Mariela Hernández, a health adviser for pregnant teenagers and adolescent mothers, said that most of the girls she works with have much older boyfriends; including one pregnant 15-year-old whose partner is 60.

“She is with this man out of necessity, because she needed to get out of her family home,” said Hernández. “This is a culture of machismo: many girls are dominated by their partners; contraception and pregnancy isn’t always their choice,” said Hernandez.

Hernández, 27 – who contracted Zika in September but was also told it was an allergy – is a devout Catholic and opposes abortion in any circumstance. But she is in favour of family planning and supports the government’s advice to delay pregnancy to avoid complications from Zika. For her, sex education is key. “There is none in schools, [but] with Zika it is urgent that this happens now.”

That lack of education has grave consequences: one in three pregnancies in El Salvador is to an adolescent. But legislation requiring schools to provide sex and diversity education has been stuck in congress for over two years. Technically, girls under 18 require adult consent to obtain contraceptives from health services.

Most contraceptives – the oral pill, condoms and injections – are available free at health clinics, but supplies can run short. In El Paisnal, a spike in pregnancies last year was likely linked to a shortage of contraceptive injections in 2014, according to Dr Nidia Mejía, director of El Paisnal’s health clinic.

The health ministry recently announced it was buying in more contraceptives. But the Guardian spoke to several doctors – in the public and private sector – who said there had been no increase in women seeking contraception or family planning advice since the government recommended delaying pregnancy.

Angie Rivas, from the Feminist Collective for Local Development, said the government’s advice to avoid pregnancy was dangerously simplistic as it failed to recognise the reality of many Salvadoran women’s lives. “It’s illogical to think that having a baby at 13 or 14, or getting pregnant by a sexually violent partner or gang member is part of anyone’s life plan. And why is the advice only directed at women? Men are responsible for reproduction too,” she said.

Activists say that the role of rape in this unfolding crisis should not be underestimated: according to the Ormusa observatory of violence against women, five sexual crimes against girls under the age of 18 were reported every day last year to the national police. The actual number is almost certainly much higher.

The UN has called on Latin American countries hit by the Zika epidemic to allow women access to abortion, in line with international standards. There are concerns that Zika may also cause miscarriages, which in El Salvador can lead to women being jailed for abortion or murder. Salvadorian authorities – and the Catholic church – have so far remained silent on the issue while public opinion remains divided.

One doctor at a nearby health clinic, who asked to remain anonymous, said: “If you allow abortions for Zika then soon you’ll have girls claiming they had it just so they can get an abortion, and how would we check?” The diagnostic test for Zika is not available in El Salvador, so diagnosis is based purely on clinical symptoms which last only a few days.

Dr Nidia Mejía talking to Vanesa del Carmen Velásquez, 23, who is 32 weeks pregnant, at her home in Las Pampas, Aguilares. Photograph: Nina Lakhani/The Guardian

Sara García, from the Citizens’ Groups for the Decriminalisation of Abortion, disagreed: “Allowing abortion in some circumstances is not promoting abortion, it’s about giving women the right to save their lives, or their health.”

The ministry of health claims Zika first appeared in El Salvador at the end of November. Since then, more than 7,000 people including 159 pregnant women have contracted the virus, according to official figures.

But several doctors told the Guardian that their clinics were full of patients who showed Zika symptoms between September and November. These cases do not appear on the official register. No one knows how many pregnant women could have been missed.

Velásquez only found out about her diagnosis when Dr Mejía, the director of the local clinic, fortuitously discovering her name on the national Zika register, and arranged a home visit.

Velásquez lives in a modest two-storey house on an unpaved road surrounded by sugar cane, fruit trees and maize, in a neighbourhood of 140 households. In front of the house are puddles of stagnant water – ideal breeding grounds for the Aedes aegypti mosquito which carries Zika, dengue and chikungunya.

In the shaded corners of the backyard, mosquito larvae can be seen wriggling freely in two deep concrete basins full of water from a nearby well. (Tap water here is supposedly drinkable, but it smells so foul that the family prefer to drink from the well.)

As her young nieces play noisily in the yard, Velásquez says many of her neighbours have suffered the same classic Zika symptoms – fever, rash and conjunctivitis. But few sought medical help as the symptoms are relatively mild, especially compared with dengue and chikungunya.

“Most of them think it’s an allergy too,” she said, stroking her belly as the baby stirs. “I’m going to buy larvae-eating fish for the tanks today, and I’ll go to the clinic, and talk to my neighbours.”

Sambo fish are being distributed for mosquito control as they are believed to eat mosquito larvae. Photograph: Marvin Recinos/AFP/Getty Images

But Mejía fears that the country’s Zika problems will not be solved so easily. “If what’s happening in Brazil with microcephaly happens here, it will be a catastrophe for this country,” she said. “We started seeing patients with Zika symptoms last September, and we told everyone it was an allergy until the end of November when the health ministry gave us the green light to diagnose Zika.”

In recent years, health reforms have refocused limited resources on prevention and primary care, so many neighbourhoods have health promoters who go door to door teaching families how to keep their homes mosquito-free.

But not in Aguilares: there’s not enough money to cover every neighbourhood, and security is a perennial concern – El Salvador’s street gangs are present in even the smallest communities. Not long ago Calle 18 members murdered a local woman for selling homemade lunches to the police.

The gangs have made it increasingly difficult and dangerous for health workers to do their jobs – some areas are essentially off-limits for government medical teams.

One local health worker – who asked not to be named for fear of retaliation from the gangs – described the case of a 14-year-old girl who told community health promoters that she was being sexually abused both by her father and local gang members.

“She’s asking for help to get out, but it’s a very delicate situation: if the gangs are involved, we need to consider our safety. The police aren’t totally trustworthy, but we have to get her out,” said the health worker.

And if the girl gets pregnant? “That would be complicated.”

And if she contracts Zika? “That would be very complicated indeed.”

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