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Zika Virus and El Salvador: Why Abstinence May Not Be an Answer

For women in El Salvador, the prescription for abstinence either before or during marriage is an impractical one, perhaps a naïve wish.
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Co-written by Douglas Morgan, director of Latin America sites in the Vanderbilt University Institute for Global Health

"Where you live shouldn't determine whether you live," is a quotation often heard in global health circles, often espoused by the Irish rock star, Bono and his ONE Campaign. But the mantra is especially poignant in countries such as El Salvador.

The Central America Four (CA-4) region (El Salvador, Honduras, Guatemala, Nicaragua), with a population of 37 million, and additional 5 million immigrants in the U.S., is one of the principal low/middle income regions in the western hemisphere. El Salvador is representative, as one of the most difficult countries to live in worldwide, suffering from the violence of poverty, gang warfare, and the recent civil wars. In fact, for adolescents, reminiscent of the civil war years, there are stark choices: join a gang, face daily intimidation and violence, or emigrate.

Over 30 percent of the population lives in extreme poverty, living on less than $1.25 per day. These conditions have serious consequences including a lack of access to sufficient nutrition, water, and sanitation services. Alongside the endemic poverty, the homicide rate is among the highest in the world, with astronomical murder rates, over 18 per day. Although most of this is "gang on gang" violence, the entire population is trapped in the daily crossfire. Nelson Mandela commented, "Freedom would be meaningless without security in the home and in the streets."

To add to these challenges, El Salvador is now grappling with the epidemic of the Zika virus. To date, the Zika virus has been associated with over 4,000 cases of microcephaly in Brazil and Latin America. Over 4 million people are expected to contract the virus within the next year.

The Centers for Disease Control and Prevention and others have issued advisories for the Americas calling for postponing travel to the region, mosquito bite avoidance, and safe sex practices. In El Salvador and other countries, the Ministries of Health have advised women to consider delaying pregnancy for the next two years, in anticipation of mosquito control programs and potential population immunity.

In El Salvador, how can women take an active role in safe sex practices and delaying a pregnancy over the next two years? Currently, over half the pregnancies in El Salvador are unintended. Because of the high rates of sexual violence, in February, El Salvador created a specialized court system for violence against women. Moreover, there is limited access to contraceptives due to "gatekeepers" limiting access to contraceptives to women, and documented "stock outs" where modern methods of contraceptives are simply unavailable.

For young girls who bear the brunt of much of this poverty and violence, the need for education and assistance with access to contraceptives is critical, timely, and compassionate. One out of every 12 girls in El Salvador is a mother by the time she is 15, and in the rural areas, the number is one in five. By age 18, over 30 percent of girls have had at least one pregnancy, which accounts for nearly a third of the pregnancies in the country, one of the highest rates of teenage pregnancy in Latin America.

In recent years, suicide rates have skyrocketed for young, pregnant women in El Salvador. Over 57 percent of the deaths of pregnant females aged 10 to 19 in El Salvador are attributed to suicide and likely subject to under-reporting.

One response would be to facilitate access to counseling and contraception to prevent an unwanted, unintended pregnancy in the face of violence, shame, and now, the effects of the Zika virus epidemic. Women in El Salvador currently have great difficulty accessing contraceptives, including birth control pills and condoms. Although legal in El Salvador, birth control can only be given to women with a prescription and the pills themselves are only sold in some pharmacies. There is a limited availability of condoms, which are expensive. Recent evidence suggests that Zika can be transmitted through sex, such that condoms may be the most important contraceptive for consideration.

Having access to contraception for all girls, women, and partners in El Salvador would be life-saving and compassionate. Women who postpone the debut of her first pregnancy until she is 20 years of age are exponentially more likely to survive the complications and birth, as is the newborn child. And if she can time her children just three years apart, her child is twice as likely to survive, especially in settings of extreme poverty.

For women in El Salvador, the prescription for abstinence either before or during marriage is an impractical one, perhaps a naïve wish. The possibility for education on natural family planning, or fertility awareness is a viable component, but the access to modern contraceptives, as supported by Pope Francis as a means to prevent the devastation of the Zika virus, would be a compassionate step forward to uplift this extremely vulnerable population of young women.

Currently, our U.S. government does not fund international, voluntary family planning efforts in El Salvador. We can urge our members of Congress to reconsider funding in El Salvador, exclusive of abortion prohibited by the Helms Amendment, to save the lives of women and children across the nation. We ask you to join us in this effort.

For many, the El Salvadoran martyr, Monseñor Oscar Romero embodied the visions of Mother Teresa and Martin Luther King in the Latin America context during the civil wars in El Salvador. He commented, "There are not two categories of people. There are not some who were born to have everything and leave others with nothing ... God wants a Christian society, one in which we share the good things that God has given for all of us."

(The opinions expressed herein are the authors' and not of their respective institutions).