(New York) – The latest revisions to China’s Criminal Law impose up to seven years in prison for “spreading rumors” about disasters, Human Rights Watch said today. The revised law, which took effect November 1, 2015, does not clarify what constitutes a “rumor,” heightening concerns that the provision will be used to curtail freedom of speech, particularly on the Internet.

“The revised Criminal Law adds a potent weapon to the Chinese government’s arsenal of punishments against netizens, including those who simply share information that departs from the official version of events,” said Sophie Richardson, China director at Human Rights Watch. “The authorities are once again criminalizing free speech on the Internet, which has been the Chinese people’s only relatively free avenue for expressing themselves.”

The National People’s Congress Standing Committee approved the addition of a provision to article 291(1) of the Criminal Law (Criminal Law Amendment Act (9)), which states that whoever “fabricates or deliberately spreads on media, including on the Internet, false information regarding dangerous situations, the spread of diseases, disasters and police information, and who seriously disturb social order” would face prison sentences – with a maximum of seven years for those whose rumors result in “serious consequences.” The vagueness of the provision means that individuals doing nothing more than asking questions or reposting information online about reported local disasters could be subject to prosecution.

In the past, the Chinese government has detained netizens who questioned official casualty figures or who had published alternative information about disasters ranging from SARS in 2003 to the Tianjin chemical blast in 2015, under the guise of preventing “rumors.”

The revision was made in the context of a wider effort to rein in online freedom since President Xi Jinping came to power in 2013:

  • In August 2013, the authorities waged a campaign against “online rumors” that included warning Internet users against breaching “seven bottom lines” in their Internet postings, taking into custody the well-known online commentator Charles Xue, and closing popular “public accounts” on the social media platform “WeChat” that report and comment on current affairs;
  • In September 2013, the Supreme People’s Court and the Supreme People’s Procuratorate (the state prosecution) issued a judicial interpretation making the crimes of defamation, creating disturbances, illegal business operations, and extortion applicable to expressions in cyberspace. The first netizen who was criminally prosecuted after this took effect was well-known blogger Qin Huohuo, who was sentenced to three years in prison in April 2014 for allegedly defaming the government and celebrities by questioning whether they were corrupt or engaged in other dishonest behavior;
  • In July and August 2014, authorities suspended popular foreign instant messaging services, including KakaoTalk, claiming the service was being used for “distributing terrorism-related information”;
  • In 2015, government agencies such as the State Internet Information Office issued multiple new directives, including tightening restrictions over the use of usernames and avatars, and requiring writers of online literature in particular to register with their real names;
  • In 2015, the government has also shut down or restricted access to Virtual Private Networks (VPNs), which many users depend on to access content blocked to users inside the country and also help shield user privacy;
  • In March 2015, authorities also deployed a new cyber weapon, the “Great Cannon,” to disrupt the services of GreatFire.org, an organization that works to document China’s censorship and facilitate access to information;
  • In July 2015, the government published a draft cybersecurity law that will requires domestic and foreign Internet companies to increase censorship on the government’s behalf, register users’ real names, localize data, and aid government surveillance; and
  • In August 2015, the government announced that it would station police in major Internet companies to more effectively prevent “spreading rumors” online.
     

Activists in China are regularly prosecuted for speech-related “crimes,” Human Rights Watch said. The best known of these crimes is “inciting subversion,” which carries a maximum of 15 years in prison. But authorities have also used other crimes such as “inciting ethnic hatred,” as in the case of human rights lawyer Pu Zhiqiang, who has been detained since May 2014 for a number of social media posts questioning the government’s policies towards Uighurs and Tibetans.

While providing the public with accurate information during disasters is important, the best way to counter inaccurate information would be to ensure that official information is reliable and transparent, Human Rights Watch said.

Above all, journalists should have unimpeded access to investigate and inform the public about these events, and the wider public should have the freedom to debate and discuss disaster response.

“The casualties of China’s new provision would not be limited to journalists, activists and netizens, but the right of ordinary people and the world to know about crucial developments in China,” Richardson said. “The best way to dispel false rumors would be to allow, not curtail, free expression.”

Posted: January 1, 1970, 12:00 am

Clara is a community health worker’s dream client—she has absorbed all the training offered on preventing mosquito breeding in her home and implements it to perfection. I spoke to her last October in a favela in downtown Recife. She described how she diligently washes and covers her stored water tanks and told me that environmental officers even recognized her great efforts. “Congratulations,” they told her during the last inspection.

But, Clara is frustrated.  Her efforts to keep things clean at home seem futile when she looks at what’s happening outside her front door. “I have a flush toilet in the house, and it goes directly into the river. We don’t have any standing water here in the house, but the river is directly behind us.”

The marshy area behind her house is a breeding ground for mosquitos. 

O Brasil não solucionou os já antigos problemas de direitos humanos que permitiram que a epidemia de Zika se intensificasse, deixando sua população vulnerável a futuros surtos e a outros graves riscos de saúde pública. Em maio de 2017, o governo declarou o fim da emergência para o vírus Zika – mas sua ameaça no Brasil permanece.

For the past 10 months, we have been researching the impact of the Zika epidemic on women, girls, and families in northeastern Brazil. We interviewed 183 people, including 98 women and girls, for a new Human Rights Watch report.

The outbreak in Brazil exposed longstanding human rights problems that in turn exacerbated its impact. The Zika virus is most often transmitted through the bite of an infected Aedes aegypti mosquito. The warm, humid climate of northeast Brazil, with climate change in the backdrop, is a place where the mosquito thrives. By late 2015 and early 2016, authorities had linked babies born with microcephaly to an outbreak of the virus.

Brazilian authorities faced a reckoning. Decades of underinvestment in public water and wastewater services in this poorest region of the country exacerbated the proliferation of this mosquito. Efforts to control its breeding at the household level—a responsibility that often fell to women and girls—were burdensome and very insufficient.

As the virus raged, women and girls struggled to avoid unplanned pregnancies. Once pregnant, many didn’t get adequate information on how to prevent Zika transmission during pregnancy—causing anxiety and stress.

Criminal penalties for abortion force women and girls who wish to terminate a pregnancy to turn to clandestine, and often unsafe, procedures. Some doctors told us about patients who had used caustic acid or other unsafe methods in the last year to try to induce abortion.

Pregnant women and girls we talked to were scared about contracting Zika. Many, especially from poor communities, said that they couldn’t always afford to use mosquito repellent. And, it’s women from poor communities who typically endure the worst water and wastewater systems and are therefore exposed to more mosquitoes.

Inevitably, then, it’s some of Brazil’s poorest families who are struggling to raise children with Zika syndrome without the support they need. One father told us he had to spend almost his entire monthly salary on medications for his child. Many mothers we spoke with needed to give up their jobs so they could ensure their children had access to services and care—traveling long distances, sometimes daily, to health facilities.

Brazilian health authorities recently declared the Zika emergency over.  But for these communities suffering from inadequate water and sanitation infrastructure, the public health crisis remains.

When governments neglect peoples’ rights—to water, to sanitation, and to health—Zika and other diseases thrive.

The end of an emergency is not a time to relax. Now comes the hard work of preventing the next one.

This article was written by Amanda Klasing, Senior Researcher at Human Rights Watch, and João Bieber, consultant at Human Rights Watch

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Teenage girls are the forgotten victims of Brazil’s Zika outbreak. The virus, transmitted by mosquitos, leaves many babies of mothers infected during pregnancy with lifelong disabilities that require constant care. Because teenage girls in Brazil don’t always get the information they need to prevent pregnancy and have very limited access to abortion in the case of unplanned pregnancy, many of the mothers of children affected by Zika are very young.

One muggy October evening last fall in Paraíba State, Brazil, a round-faced 17-year-old girl—let’s call her Thaís—handed off her 8-month-old daughter to her mother, and turned to talk to me. Thaís gave birth to a baby with Zika syndrome in January 2016, just two months after authorities in Brazil started tracking an unprecedented increase in the number of infants born with microcephaly, a condition in which the baby’s head is smaller than expected, often accompanied by problems with brain development.

Wastewater and garbage are dumped directly into the river in a slum in the Coelhos neighborhood of Recife, Pernambuco state.

© 2016 César Muñoz Acebes/Human Rights Watch

As we sat in the living room of the modest home she shares with her partner, she told me her pregnancy was not planned. Like many people infected with Zika, Thaís never had symptoms of the virus during her pregnancy. However, she lives in a community with longstanding water and sanitation problems. Thaís and her partner only have access to tap water three days a week, so they store water in huge containers.

Mosquitos can breed in stored water if it is not properly covered and maintained. Thaís was careful to cover her water containers, but she lived near an open sewage channel full of dirty, standing water—ideal conditions for mosquito breeding.

Brazil has not addressed longstanding human rights problems that allowed the Zika outbreak to escalate, leaving the population vulnerable to future outbreaks and other serious public health risks. 

“We have a lot of mosquitos,” she told me. “The sewage is not covered, and at night it’s full of mosquitos.” She did not know she had been infected with Zika until after the baby was born. Children born with Zika syndrome, like Thaís’s daughter, often have seizures, difficulty eating, problems with vision and hearing, and other complications.

Zika has already spread to the United States. Mosquitos in parts of Florida and Texas carry the virus and can transmit it to humans. It can also be transmitted sexually, in the US often by people returning from trips to Zika-affected countries. Brazil’s Zika crisis showed just how quickly the virus can spread in the right conditions. The outbreak in Brazil is linked to the birthof thousands of children with Zika syndrome.

Thaís stopped going to school when her daughter was born, though she hopes to go back one day. Now she spends her days battling municipal authorities to get transportation so that she can take her daughter to a specialized rehabilitation center. For teenage mothers like Thaís, getting the services their babies need can be especially difficult.

The Brazilian newspaper Estadão reported that roughly one-quarter of the women and girls who gave birth to babies with microcephaly between November 2015 and September 2016 were under age 20. That’s more than 760 adolescent girls and young women—including 35 girls between 10 and 14—now raising children with Zika syndrome.

Thaís was just one of nearly 100 women and girls my colleagues and I interviewed in northeastern Brazil, the center of the Zika outbreak, for a new report. Many of them had similar stories, but what really moved me were the experiences of girls, still children themselves, trying to prevent pregnancy and protect themselves from Zika. Now some of them are raising children affected by the virus.

More than one-third of Brazil’s population lacks access to a continuous water supply, and nearly half is not connected to a wastewater system, according to the latest data—this means raw sewage is going directly into the environment, often close to homes or open waterways. It’s hopeless for anyone, let alone a teenage mother raising a child, to try to battle mosquitos at home when they also have to deal with these pervasive water and sanitation problems in their communities.

Unplanned pregnancies were common among the young mothers we interviewed. Health services often didn’t give them the clear and accessible basic information about reproductive health that they needed. But nearly 20% of births in Brazil are to girls and young women ages 10 to 19—more than 560,000 births per year. A national survey involving nearly 1,000 young women and girls ages 15 to 19 found that 21% were not using any method of contraception, and only 17% had visited a public health clinic to discuss family planning in the 12 months before the survey.

Women and girls told us they felt “disturbed,” “shocked,” or “desperate,” when they found out they were pregnant. Unfortunately, their choices are limited. Abortion is a punishable crime in Brazil, except in cases of rape, when the life of the woman is at risk, or the fetus has anencephaly—a fatal congenital disorder where the brain doesn’t develop. Women are discouraged from even speaking about abortion. Over and over, the women and girls we interviewed told us they felt that they didn’t have any options except continuing their pregnancies—even when they didn’t want to.

Because of this situation, studies show that hundreds of thousands of women and girls in Brazil risk their health and lives to get clandestine—often unsafe—abortions each year. Doctors told us they had treated women and girls in the last year who had turned to unsafe methods to try to induce abortion. Some of them tried to induce abortion by placing water purification chemicals in their vaginas, causing bleeding ulcerative sores.

More than 900 women have died from unsafe abortion in Brazil since 2005, according to Ministry of Health data. One out of every six of those deaths between 2011 and 2015 was a girl, as young as 10, or a teenager.

One young woman told me she was raped when she was 13, and took pills she bought at a pharmacy to terminate the pregnancy. At the time, she didn’t know that because she was raped she probably could have had a legal abortion. “I didn’t have a lot of information,” she said. “I didn’t know what I could do. I didn’t even tell my mother.” After taking the pills, she experienced heavy bleeding to the point that her clothing was soaked with blood, she told me, shifting in her chair as she spoke. She managed to terminate the pregnancy, but as she described what happened, I kept thinking that she was only 13. Imagine how scared she must have felt; bleeding excessively, not knowing what to do, and afraid to tell anyone.

Being a teenage girl is hard, anywhere. Being a teenage girl without reproductive choices is even harder. Being a teenage mother of a child with Zika syndrome, without adequate support from the government—that’s inexplicably tough. That’s what Thaís and other girls confronting the impacts of the Zika virus outbreak are: warriors, “guerreiras,” as one father called them.

The families raising children with Zika syndrome in Brazil are fighting for the support and services their families need. They struggle to pay for expensive medicines, get to urban centers for services for their children, and continue work or school. One mother told us, “If we don’t go after things, fight for them, there is nothing.” But no one, especially children like Thaís, should have to fight so hard to live or to raise a child safely and with dignity.

The authorities in Brazil should make long overdue investments in water and sanitation infrastructure, provide women and girls with comprehensive reproductive health information and services, decriminalize abortion, and ensure children with Zika syndrome have long-term access to services.

Additionally, the U.S. and other countries should look at what went wrong in Brazil to stop the next Zika crisis from happening.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Raquel, 25, holds her daughter Heloisa in Areia, Paraíba state, Brazil. Raquel gave birth to twin daughters with Zika syndrome in April 2016. “I want to give my best to my daughters,” she said in an interview with Human Rights Watch.
 

© 2017 Ueslei Marcelino/Reuters

(São Paulo) – Brazil has not addressed longstanding human rights problems that allowed the Zika outbreak to escalate, leaving the population vulnerable to future outbreaks and other serious public health risks, Human Rights Watch said in a report released today. The government declared an end to the national public health emergency related to the Zika virus in May 2017, but the Zika threat in Brazil remains.

The 103-page report, “Neglected and Unprotected: The Impact of the Zika Outbreak on Women and Girls in Northeastern Brazil,” documents gaps in the Brazilian authorities’ response that have a harmful impact on women and girls and leave the general population vulnerable to continued outbreaks of serious mosquito-borne illnesses. The outbreak hit as the country faced its worst economic recession in decades, forcing authorities to make difficult decisions about allocating resources. But even in earlier times of economic growth, government investments in water and sanitation infrastructure were inadequate. Years of neglect contributed to the water and wastewater conditions that allowed the proliferation of the Aedes mosquito and the rapid spread of the virus, Human Rights Watch found.

Brazil has not addressed longstanding human rights problems that allowed the Zika outbreak to escalate, leaving the population vulnerable to future outbreaks and other serious public health risks. 

“Brazilians may see the Health Ministry’s declaration of the end of the Zika emergency as a victory, but significant risks remain as do the underlying rights issues it exposed,” said Amanda Klasing, senior women’s rights researcher at Human Rights Watch and a co-author of the report. “Brazilians’ basic rights are at risk if the government doesn’t reduce mosquito infestation over the long term, secure access to reproductive rights, and support families raising children affected by Zika.”

The announcement came 18 months after the government declared Zika a national emergency, as increasing numbers of infants were born with microcephaly – a condition in which the infant’s head is smaller than expected – and other potential health problems, together now known as Zika syndrome. But Aedes mosquitos are still present in Brazil, and still carry Zika and other serious viruses. A recent outbreak of yellow fever, which can be spread by the same mosquito, has killed at least 240 people in Brazil since December 2016. Climatic phenomena, like the 2015 El Niño, with the backdrop of climate change and steadily rising temperatures, may contribute to the more rapid spread of mosquito-borne illnesses.

Brazilian authorities should make long overdue investments in water and sanitation infrastructure to control mosquito breeding and improve public health, Human Rights Watch said. Authorities should also provide comprehensive reproductive health information and services for women and girls, decriminalize abortion, and ensure children with Zika syndrome have long-term access to services to give them the best possible quality of life.

Human Rights Watch interviewed 183 people in Pernambuco and Paraíba, two of the northeastern states hardest hit by the virus, including 98 women and girls ages 15 to 63. Forty-four of these women were pregnant or had recently given birth, and 30 were raising children with Zika syndrome. Human Rights Watch also spoke to men and boys in affected communities, service providers and other experts, and government authorities, and analyzed government and other data on health surveillance, water and wastewater assets, and budgets.

In response to the Zika outbreak, Brazilian authorities have encouraged household-level efforts such as cleaning water storage containers and eliminating standing water in homes. Women and girls are often the ones responsible for these tasks, but their efforts are burdensome and cannot fill the considerable gap left by inadequate government action. The authorities have failed to make necessary investments in water and sanitation infrastructure for long-term control of mosquito breeding and to improve public health.

More than one-third of Brazil’s population lacks access to a continuous water supply. That leaves people with no choice but to fill tanks and other containers with water for household use, which can unintentionally become potential mosquito breeding grounds if left uncovered and untreated. Poor wastewater infrastructure creates standing water in communities. More than 35 million people in Brazil lack adequate facilities and services for the safe disposal of human waste. Only an estimated 50 percent of the population was connected to a wastewater system in 2015, and less than 43 percent of the country’s total volume of wastewater was treated. In Brazil’s northeast in 2015, less than 25 percent of the population was connected to a wastewater system, and only 32 percent of wastewater was treated.

Human Rights Watch saw untreated sewage flowing into open, uncovered channels, storm drains, roads, or waterways near communities that are often obstructed with debris, creating dirty, standing water – ideal conditions for mosquito breeding.

In the areas studied, some women and girls did not have access to comprehensive reproductive health information and services through the public health system. Many cannot avoid unplanned pregnancies or make informed decisions about their pregnancies.

Criminal penalties for abortion force pregnant women and girls to turn to clandestine, and often unsafe, procedures to terminate unwanted pregnancies. Some doctors said they had treated women and girls in the last year who had turned to caustic acid or other unsafe methods to try to induce abortion. One 23-year-old woman who was raped as an adolescent and had heavy bleeding after a clandestine abortion said, “I didn’t have a lot of information… I bled a lot.”

Unsafe abortion remains the fourth-leading cause of maternal mortality in Brazil. Since 2005, more than 900 women have died from unsafe abortion in Brazil – largely preventable maternal deaths. The risk of Zika infection during pregnancy will likely lead even more women to seek unsafe and clandestine abortions. A July 2016 study published in the New England Journal of Medicine found a 108 percent increase in abortion requests from Brazil received by Women on Web – a nonprofit organization providing abortion medication in countries where safe abortion services are highly restricted – following a November 2015 Pan American Health Organization announcement related to Zika virus risks.

Many pregnant women and girls interviewed said that during their prenatal appointments, public health workers did not provide comprehensive information about preventing Zika transmission. Many said health workers didn’t inform them that Zika could be transmitted sexually, partially due to conflicting or inconsistent information from authorities. As a result, few were consistently using condoms to protect themselves and their fetus from Zika transmission.

Pregnant women from low-income households that typically have the worst water and wastewater systems and high exposure to mosquitos said they did not have the means to purchase mosquito repellent for everyday use.

More than 2,600 children in Brazil born with microcephaly and other conditions from the Zika virus will need long-term support. Their primary caregivers often don’t receive the full support they need from the government and society to raise their children with disabilities, including financial and logistical support to make care accessible. Mothers raising children with Zika syndrome said they found it hard to get information and support both at the time of delivery, and as their children grew and developed. Health providers and parents of children with Zika syndrome said that fathers needed additional support to actively participate in caregiving.

One father told Human Rights Watch he had to spend almost his entire monthly salary on medications for his child with Zika syndrome.

In 2017, the number of Zika cases, and the number of infants born with disabilities linked to the virus, dropped dramatically as compared to the same period in 2016, but authorities cannot identify the cause of the reduction in cases.

“As mosquito season amps up in parts of the Americas and the United States, other Zika-affected countries should recognize that human rights problems can contribute to the rapid escalation and impact of the Zika epidemic,” Klasing said. “Countries hoping to avoid the crisis Brazil continues to face should address human rights issues at the outset of their planning and response.”

Posted: January 1, 1970, 12:00 am

Raquel bathes her daughter Heloisa, a girl with Zika syndrome born in April 2016. Raquel says she cannot afford the medicines her twin daughters need for convulsions. 

© 2017 Ueslei Marcelino/Reuters
In May, the Brazilian government declared that the national public health emergency caused by the Zika virus had ended. Yet the underlying conditions that led to the outbreak’s escalation, such as poor water and sanitation conditions that result in fertile breeding grounds for mosquitos, remain unaddressed. While visiting two of the states hardest hit by the virus, researchers Amanda Klasing and Margaret Wurth interviewed more than 180 people – many of them women of reproductive age – to see how the epidemic affected their lives. Nazish Dholakia spoke to the researchers about what they saw, and what the government should do to prevent a resurgence of Zika.

Raquel, 25, holds her daughter Heloisa in Areia, Paraíba state, Brazil. Raquel gave birth to twin daughters with Zika syndrome in April 2016. “I want to give my best to my daughters,” she said in an interview with Human Rights Watch. 

© 2017 Ueslei Marcelino/Reuters
What is it like in Recife and Campina Grande, the cities in northeastern Brazil that you visited?

AK: What was shocking to me was the vast inequality. There are these beautiful high-rises and a beautiful beach in Recife, and then there are communities that are really suffering. And Zika is just one way that they are suffering. You have very poor water and sanitation conditions right next to shiny malls. It’s the type of inequality you can see around the world, but you never get used to it.

MW: I was interviewing a pregnant woman, and she was walking me around her community, pointing out how untreated sewage was pooling on the uneven roads right in front and behind her house, and she couldn’t afford to buy insect repellant and protect herself. Her only defense against the mosquitos that were swarming around her community was a fan in her house. Her vulnerability and her inability to protect herself during her pregnancy was really stark.

Did the women and girls you spoke with have information about how to protect themselves?

MW: We interviewed a lot of pregnant women and girls to try to assess what types of information and services they were getting during the outbreak. The one thing that emerged so clearly was that the women and girls we interviewed had very limited information about the sexual transmission of Zika. Even though Zika is transmitted primarily by infected Aedes mosquitos, the virus can also be transmitted sexually, and pregnant women should use condoms with their partners if they’re living in an area with Zika. The women we interviewed had all heard about Zika on the news, and their healthcare providers were talking to them about wearing insect repellant and cleaning up standing water. But very few women knew the virus could be transmitted sexually, so they didn’t know to use condoms with their partners. I told this to one 16-year-old girl, and her jaw dropped because she had never heard of this and had no idea.

AK: It was such a contrast to me how easily we could find information about Zika in preparation for our trip, and how pregnant women living there weren’t given that information or that opportunity to protect themselves.

Brazil has not addressed longstanding human rights problems that allowed the Zika outbreak to escalate, leaving the population vulnerable to future outbreaks and other serious public health risks. 

Why weren’t women – and particularly pregnant women – given this information by their healthcare providers?

AK: At the federal level, there was conflicting information about the possibility of sexual transmission. And that was early on, and sometimes that sets the tone of how much importance to put on it. The possibility of sexual transmission wasn’t being communicated to the clinics or providers in at least one state, and it wasn’t communicated down in a consistent way across the system.

The government said the public health emergency had ended. What does this mean, and what changed so they could make that claim?

MW: The Ministry of Health declared that Zika was no longer a public health emergency of national concern, which doesn’t mean that the virus is gone or that the threat is gone. It basically means that the outbreak of Zika is no longer unusual or unexpected. It no longer meets the World Health Organization’s criteria for a public health crisis. The argument that the Ministry of Health made was that that they have sufficient plans in place to say that this is no longer a national emergency.

Lindasselva lives in a shack in a slum in Olinda, Pernambuco state. There are no sanitation services and she has access to water from only one tap. Mosquitos can breed and proliferate in stored water, if it is not properly covered and maintained. 

© 2016 César Muñoz Acebes/Human Rights Watch
Our fear is that people will hear the announcement and think, “Zika’s over, the risk is gone, I don’t need to worry about this anymore.” When, in fact, the underlying conditions that allowed the virus to spread so rapidly have not been addressed. In 2017, the number of cases of the virus and of children born with Zika syndrome are dramatically lower than they were in the same months in 2016, so that’s encouraging. That shows us something is happening that’s allowing the virus to be better controlled. But the conditions that made the epidemic so severe in the first place have not been fixed.

Why have the numbers dropped dramatically?

AK: It’s hard to determine why. It could be that the use of mosquito-killing pesticides had an effect, that there’s increasing immunity, or that it was a drier season, so the mosquitos haven’t bred. But those are not indicators of long-term success. You only have to look at how other mosquito-borne viruses like dengue and chikungunya have ebbed and then peaked over the years to see that the danger of another Zika epidemic is still there. The underlying conditions that exacerbated the Zika outbreak – failing water and wastewater systems – haven’t been fixed.  The mosquito that carries these viruses is still present in Brazil. For us, the concern is that people will assume the crisis has passed.

A flyer posted at a women’s community group in Passarinhos, a neighborhood in Recife, states, “In the time of Zika, protection and care begin by informing the woman about her reproductive rights.” Paula Viana, executive secretary of Grupo Curumim, a feminist organization in Pernambuco that was involved in designing the flyer, told Human Rights Watch, “There are no government campaigns talking about women’s rights on the Zika issue. It’s all about the mosquito. The message to women is you have to clean your house or don’t get pregnant.”

© 2016 Amanda Klasing/Human Rights Watch
What steps has the government taken to address the virus?

MW: They put a lot of resources and efforts into trying to control the mosquito population. But this was largely focused on the household level, and visits by environmental agents to check water storage containers. The missing piece, and our main argument in the report, is that this response did not include making sure people have consistent access to running water, so they don’t have to store water in ways that lead to mosquito breeding, and facilities to treat human waste. And it’s tough, because Brazil is facing one of the worst economic recessions that it’s seen in decades. But even in times of economic growth, the investments in the water and sanitation infrastructure were inadequate.

What concrete steps can the government take to help parents raising children with Zika?

MW: In families raising children with Zika syndrome, the caregivers are overwhelmingly the mothers. The lives of these women and girls are profoundly affected by raising children without the support they need. They are juggling lots of appointments and battling local municipal authorities to get the types of tests and consultations that their children need. Their lives are extremely chaotic. Also, families living in rural areas sometimes have to leave their houses at 3 or 4 in the morning to take their children to doctor’s appointments in cities, a demanding and exhausting routine for them. For some families, it’s waiting for public transportation that never comes and scrambling to find another way to get to the appointment.

The government should make it easier for these families to get the services their children need. The Brazilian public health system can decentralize services so that rural families can find them – or, at least, the services that their children need most often – closer to home.

AK: For example, the government can make some services – like physical therapy and occupational therapy – more accessible, even with the current fiscal restrictions, by reorganizing the services geographically.

MW: I think there was a real fear among some of the parents we interviewed that, as the news of Zika faded from the headlines, their children would be forgotten. As time goes on, their children are still going to need services. A lot of families were worried that they won’t have the long-term support they need.

 

Posted: January 1, 1970, 12:00 am

Brazil has not addressed longstanding human rights problems that allowed the Zika outbreak to escalate, leaving the population vulnerable to future outbreaks and other serious public health risks. The government declared an end to the national public health emergency related to the Zika virus in May 2017, but the Zika threat in Brazil remains. The outbreak hit as the country faced its worst economic recession in decades, forcing authorities to make difficult decisions about allocating resources. But even in earlier times of economic growth, government investments in water and sanitation infrastructure were inadequate. Years of neglect contributed to the water and wastewater conditions that allowed the proliferation of the Aedes mosquito and the rapid spread of the virus, Human Rights Watch found.

Posted: January 1, 1970, 12:00 am

Summary

On a Friday afternoon in October 2015, Luciana Caroline Albuquerque Bezerra, the executive secretary of health surveillance for the state of Pernambuco, Brazil, received a call from her boss, the secretary of health for the state. Two pediatric neurologists serving at separate hospitals had come to report a strange phenomenon: they each had seen an increase in the number of infants born with microcephaly—significantly smaller than average head circumference associated with incomplete brain development. By the following Monday, it was clear something was seriously wrong. The state health secretariat instituted a compulsory notification to the surveillance system of any new cases of babies born with microcephaly. Albuquerque was stunned as institutions around the state reported 600 new cases before the end of November, when in a typical year they might see only a dozen. She realized they were on the precipice of a new epidemic—but they had yet to discover its origin.

A few hundred kilometers away in the state of Paraíba, Adriana Melo, a physician specializing in high-risk pregnancies, was following the news from Pernambuco. She had seen two pregnant women in a short period of time whose sonograms showed unusual fetal brain development—microcephaly and other complications. She collected samples of amniotic fluid from both patients and sent them to Fundação Oswaldo Cruz (Fiocruz), a scientific institution in Rio de Janeiro, for analysis. Both samples tested positive for the Zika virus, establishing the first concrete link between microcephaly and the mosquito-borne illness.

Brazil has not addressed longstanding human rights problems that allowed the Zika outbreak to escalate, leaving the population vulnerable to future outbreaks and other serious public health risks. 

No one is sure exactly when or how the Zika virus was introduced into northeastern Brazil, but the conditions for its rapid spread are ideal. Zika is transmitted predominantly through the bite of an infected Aedes aegypti mosquito, which has bred rampantly in the warm, humid climate of the states in the northeast. Research suggests that the 2015 El Niño climate phenomenon, occurring against the backdrop of climate change and steadily rising temperatures, was conducive for the transmission of Zika. The poorest region in the country, decades of underinvestment in public water and wastewater services exacerbated the proliferation of this mosquito, which can also carry other serious viruses, including dengue, chikungunya, and yellow fever. The outbreak hit as the country faced its worst economic recession in decades, forcing authorities to make difficult decisions about allocating resources in response.

Dengue has been present in Brazil for decades, so when hundreds of thousands of people with cases of what was thought to be a milder case of dengue began arriving in health clinics in late 2014, it was worrying but not a surprise—until the wave of children born with microcephaly. State governments in the region tried to respond quickly, and in November 2015, the Brazilian government declared a national health emergency as cases of microcephaly increased. By February 2016, the World Health Organization had declared a global public health emergency in response to the spread of Zika. As of May 2017, the virus had been detected in 85 countries and territories around the world.

Nearly a year after the physicians first raised the alarm, Human Rights Watch began research in Pernambuco and Paraíba, two of the states hardest hit by the virus, to understand the human rights impacts of the Zika outbreak on women and girls, and on children with Zika syndrome. We spoke with more than 180 people, including more than two dozen mothers raising children with Zika syndrome and 44 women and girls who were pregnant or had given birth during the epidemic.

Raquel bathes her daughter Heloisa, a girl with Zika syndrome born in April 2016. Raquel says she cannot afford the medicines her twin daughters need for convulsions. 

© 2017 Ueslei Marcelino/Reuters

We found that the Zika virus outbreak in Brazil disproportionately impacted women and girls and aggravated longstanding human rights problems, including inadequate access to water and sanitation, racial and socioeconomic health disparities, and restrictions on sexual and reproductive rights. These problems existed long before the government confirmed local transmission of the Zika virus. However, the outbreak, and the national and international response to it, brought renewed attention to ongoing, unaddressed challenges to public health and human rights in Brazil. Human Rights Watch analyzed these human rights problems through the lens of the Zika outbreak. Our research found gaps in the Brazilian authorities’ response that have particularly harmful impacts on women and girls, and leave the general population vulnerable to continued outbreaks of serious mosquito-borne illnesses in the future.

The Brazilian authorities’ response to the Zika epidemic has centered on the fight against the mosquito, or vector control; access to services for affected populations; and technological development, education, and research. However, Brazilian authorities at all levels have not addressed systemic problems with public water and sanitation systems that exacerbated the Zika crisis by contributing to ideal conditions for mosquito breeding. Years of dengue outbreaks should have made it abundantly clear that water and sanitation conditions are dangerous and require attention and investment, even among competing priorities. More than one-third of Brazil’s population lacks access to a continuous water supply. This intermittent access to water leaves people with no choice but to fill tanks and other containers with water for household use, which can unintentionally become potential mosquito breeding grounds if left uncovered and untreated. Poor wastewater infrastructure creates standing water in communities. On site visits in Pernambuco and Paraíba states, Human Rights Watch saw untreated sewage flowing into open, uncovered channels, storm drains, roads, or waterways near communities that are often obstructed with debris, creating dirty, standing water—ideal conditions for mosquito breeding, contrary to a false but popular belief that mosquitos only breed in clean water.

Since 2015, Brazil’s economy has suffered a deep recession, with high rates of unemployment and inflation. But long before the recent economic crisis, including in times of economic growth, government investments in water and sanitation infrastructure were inadequate. Years of neglect contributed to the water and wastewater conditions that allowed the proliferation of the Aedes mosquito and the rapid spread of the virus.

In 2007, after more than two decades of limited investments in sanitation, the National Congress enacted a new public law addressing sanitation, with implementing regulations adopted in 2010, boosting investments in the sector. Total investments grew from R$4,238 million in 2007 to R$12,175 million in 2015. Still, the expansion in the provision of sanitation services has been painfully slow. Management and institutional problems—including a simple lack of qualified projects—created bottlenecks in pushing funding out, a foreseeable risk after decades of underinvestment. In the context of the current economic recession, it will be difficult for Brazilian authorities to overcome the deficit in water and wastewater investments and to allocate the resources necessary to sustainably address failing systems.

Rather than planning additional investments in water and sanitation infrastructure to control mosquito breeding, the government’s national and state response to the Zika outbreak has focused quite narrowly on encouraging household-level efforts—namely cleaning water storage containers and eliminating standing water in homes—and spraying for mosquito eradication. Women and girls are often the ones responsible for these types of vector-control tasks in the home. In an emergency phase, vector control focused on the household is key, but it is unsustainable in the long-term. Women’s and girls’ household efforts to control mosquito breeding are burdensome and often futile without state attention to structural water and sanitation failures.

In March 2016, the United Nations special rapporteur on the human rights to safe drinking water and sanitation stated, “There is a strong link between weak sanitation systems and the current outbreak of the mosquito-borne Zika virus, as well as dengue, yellow fever and chikungunya,” and added further that, “the most effective way to tackle this problem is to improve the failing services.”

Our research also looked into the nexus between the Zika outbreak and reproductive health. Many women and girls, frightened by the news of the epidemic, sought to avoid or delay pregnancy. However, many of those we spoke to said they found it difficult to avoid unplanned pregnancy—either because they lacked clear and accessible basic information about reproductive health, or because they encountered barriers in accessing contraceptive methods, especially long-term ones. Our findings indicate that the Brazilian public health system may not be consistently providing comprehensive reproductive health information and services to some women and girls. In addition, the criminalization of abortion in Brazil forces many women to turn to clandestine, and often unsafe, procedures to terminate unwanted pregnancies—endangering their health and even their lives. In 2015, an estimated half a million women in Brazil had abortions, the vast majority performed clandestinely. Some doctors we interviewed had treated women and girls in the last year who had turned to caustic acid or other unsafe methods to try to induce abortion. A few women interviewed by Human Rights Watch had experienced or witnessed complications from unsafe abortion. Unsafe abortion remains the fourth-leading cause of maternal mortality in Brazil. Since 2005, at least 911 women have died from unsafe abortion in Brazil—largely preventable maternal deaths. Approximately 17 percent of the abortion-related deaths between 2011 and 2015 were adolescent girls and young women 10 to 19 years old.

The risk of Zika infection during pregnancy and the resulting consequences will likely lead even more women to seek unsafe and clandestine abortions. A July 2016 study published in The New England Journal of Medicine found a 108 percent increase in abortion requests from Brazil received by Women on Web—a nonprofit organization providing abortion medication in countries where safe abortion services are highly restricted—following a November 2015 Pan American Health Organization (PAHO) announcement related to Zika virus risks. The study concluded, “Ensuring reproductive autonomy through access to a full range of reproductive choices is currently a missing piece of the public health response to Zika.”

Pregnant women and girls interviewed for this report said that they often suffered anxiety and uncertainty related to the possibility of getting Zika during their pregnancies, and said that in their experience, the Brazilian public health system did not provide the information and support they needed to protect themselves from the virus. Many women and girls said that at their prenatal appointments they did not receive comprehensive information about how to prevent Zika transmission during pregnancy. Many interviewees did not know that Zika could be transmitted sexually, and therefore few of the pregnant women we spoke with were consistently using condoms to protect themselves and their fetus from Zika transmission during pregnancy.

In addition, some pregnant women and girls who believed, or feared, they had been exposed to Zika told Human Rights Watch they had difficulty accessing diagnostic tests or sonograms they needed to find out if they indeed had Zika or if their pregnancies could be impacted by the virus. Pregnant women from low-income households said they did not have the means to purchase mosquito repellent for everyday use.

Even as their stories fade from the headlines, the more than 2,600 children in Brazil born with microcephaly and other complications from the Zika virus—together now known as Zika syndrome—will need long-term support and care. Their primary caregivers are very often women whose lives are profoundly changed by having children with disabilities without receiving the full support they need from the government and society. Mothers raising children with Zika syndrome told Human Rights Watch they faced obstacles in accessing adequate information and support both at the time of delivery, and as their children grew and developed. They face difficulties buying expensive medicine, traveling to urban centers for appointments, and continuing paid work. Many mothers we interviewed expressed fears and doubts about what the future would hold for their children with Zika syndrome, particularly around access to state-supported services. Their fears and concerns are particularly relevant as Brazilian authorities enact fiscal austerity measures that may decrease funding for public health, education, and other services that could help children with Zika syndrome, and their caregivers, have the best possible quality of life in the long-term.

In December 2016, the National Congress approved a constitutional amendment freezing public spending for a period of 20 years, adjusting only for inflation. Before the amendment was passed by Congress, the Oswaldo Cruz Foundation (Fiocruz), a public research and health technology institution, published a letter to the federal government and National Congress warning that the proposed amendment, if approved, “would result in significant harm to people's health and life.” Fiocruz raised particular concerns regarding how the amendment could affect Brazil’s capacity to respond to Zika and other epidemics: “The question is: how to ensure control of epidemics such as Zika, dengue and chikungunya, including research, assistance, vector control, medicines, and necessary vaccines, with a freeze on resources? In particular, the impact on research, fundamental to new products and new solutions that are already underfunded in our country, will be incalculable, compromising in the long term the capacity for response and national autonomy.”

The United Nations special rapporteur on extreme poverty and human rights, Philip Alston, called the bill “a radical measure, lacking in all nuance and compassion.” He added, “It will hit the poorest and most vulnerable Brazilians the hardest, will increase inequality levels in an already unequal society, and definitively signals that social rights are a very low priority for Brazil for the next 20 years.” The constitutional amendment took effect in early 2017, and further austerity measure remain under discussion by the government and National Congress.

The national, state, and local response to the Zika outbreak should not overlook men and boys or reinforce gender stereotypes about health and caregiving. When health authorities fail to communicate clear information about the sexual transmission of the virus, many people perceive the prevention of Zika transmission during pregnancy as the sole responsibility of pregnant women.

Women interviewed for this report and some of their male partners spoke of the need for the authorities to support fathers as well as mothers in their efforts to prevent Zika transmission and to address the economic and psychosocial burdens of rearing children affected by the Zika virus. Providers told Human Rights Watch that fathers needed additional support to actively participate in caregiving. One father of a child with Zika syndrome in Pernambuco state described the need for more outreach by service providers and support organizations to fathers raising children impacted by the virus, to facilitate their role in supporting their partners and addressing their children’s needs. “The mothers are warriors,” he said, using the Portuguese word “guerreiras.” “I think the fathers sometimes are absent, but the mothers are always here.” But, he said that he does not believe it has to—or should—be this way. Authorities should avoid reinforcing negative gender stereotypes in policies or messaging around the prevention of Zika and in the provision of services to families affected by it.

In February 2017, the director-general of the World Health Organization declared the Zika epidemic was no longer a public health emergency of international concern, and stated, “WHO and affected countries need to manage Zika not on an emergency footing, but in the same sustained way we respond to other established epidemic-prone pathogens, like dengue and chikungunya, that ebb and flow in recurring waves of infection.” She added, “Zika revealed fault lines in the world’s collective preparedness. Poor access to family planning services was one. The dismantling of national programmes for mosquito control was another.” The juxtaposition of these statements is not an accident.

In May 2017, the Brazilian government declared that the national public health emergency related to the Zika virus had ended, 18 months after physicians in the northeast first identified a link between Zika and microcephaly. The number of Zika virus cases, and the number of infants born with disabilities linked to the virus, were dramatically lower during the first few months of 2017, as compared to same period in 2016. Still, the underlying conditions that allowed the outbreak to escalate in Brazil remain largely unaddressed, leaving the population vulnerable to future outbreaks.

As Brazil moves to confront the long-term implications of the Zika outbreak, authorities should take additional steps to address the underlying contexts that made its initial impacts so severe. Without government investments in water and sanitation infrastructure, outbreaks of serious, and potentially fatal, mosquito-borne viruses could continue to threaten public health in Brazil. In order to ensure the fundamental human rights of women and girls, the government should guarantee they have access to comprehensive reproductive health information and services, including full autonomy to voluntarily terminate pregnancies. The government should also ensure that children with Zika syndrome, and their caregivers, have long-term access to a range of services to have the best possible quality of life. Mothers and providers interviewed for this report feared that the state would forget children affected by the virus as the rate of new cases decreased, and media and public attention to the outbreak dwindled.

Under international human rights law, Brazil‘s population has the right to sufficient, safe, and affordable water and sanitation. Persons with disabilities and their families have the right to an adequate standard of living. The government has an obligation to ensure access to reproductive health information and services. It is also obligated to eliminate excessive restrictions on access to safe and legal abortion. This report examines the Brazilian government’s human rights obligations as they relate to its response to the Zika epidemic, including its failure to meet its obligations related to women’s reproductive rights.

These human rights guarantees should guide Brazil’s efforts moving forward. A human rights-based approach to the Zika outbreak should address, in particular, gaps in fulfilling the rights to water and sanitation, women’s and girls’ reproductive rights, and the rights of persons with disabilities and their caregivers. To better respect and protect human rights, national, state, and local authorities should work collaboratively to:

  • Address pervasive problems affecting the rights to water and sanitation to stem the spread of mosquito-borne illnesses. A household approach to vector control will fail in the long-term if systemic problems are not also addressed.
  • Take concerted action to reduce unplanned pregnancies by providing women and girls with comprehensive reproductive health information and services, including long-term contraceptive options, and identify and resolve any gaps in distribution or challenges in access.
  • Provide pregnant women and their partners full and accurate information and services to prevent Zika virus transmission during pregnancy, including related to the sexual transmission of Zika.
  • Provide sustained support for the short and long-term services to families raising children with Zika syndrome that will allow children affected by the virus, and their family members, to live with dignity.
  • Engage men and boys in preventing unplanned pregnancy, combatting the spread of Zika virus, and ensuring that children with Zika syndrome have support.

As a matter of urgency, the National Congress should enact legislation to decriminalize abortion to ensure that women and girls do not have to resort to life-threatening clandestine procedures to terminate pregnancies they do not want to continue.

As one woman whose child has Zika syndrome told Human Rights Watch, “there’s a big opportunity to pay attention and prevent other cases in the future.” If the Brazilian authorities at federal, state, and local levels do not act, the risk that women and girls will continue to be impacted by the Zika outbreak, or future epidemics, will remain.

Recommendations

To National, State, and Municipal Health Authorities

Improve Zika Virus Prevention, Detection, and Response

  • Ensure integrated efforts across all levels of government to combat Aedes mosquitos and prevent transmission of Zika and other mosquito-borne viruses.
  • Establish inter-ministerial or inter-agency working groups at the national, state, and municipal levels to ensure close collaboration among water, sanitation, and environmental authorities in addressing vector control in the short, medium, and long-term.
  • Strengthen epidemiological surveillance systems to identify all cases of Zika virus and congenital Zika syndrome, including monitoring past early infancy.
  • As part of a comprehensive response to combat the transmission of the Zika virus, ensure that national, state, and municipal prenatal care protocols include the following:
    • Comprehensive counseling on Zika virus prevention as a mandatory component of all initial prenatal clinical visits. Ensure counseling includes evidence-based information on the sexual transmission of Zika, and the importance of condom use during pregnancy;
    • Full access to Zika diagnostic testing and sonograms, including voluntary fetal anomaly scans, for pregnant women and girls who believe they have been exposed to the Zika virus and wish to perform the scan. Ensure results of tests are explained fully and shared in a timely fashion; and
    • Access to high-quality and regular psychological support services for women and girls whose pregnancies are impacted by the Zika virus, and for their partners. Offer psychological support at the first indication of an anomaly in the pregnancy, and continue throughout the pregnancy, and during and after delivery.
  • Make insect repellent accessible to all pregnant women free of charge in the public health care system.
  • Revise national, state, and local public education and awareness-raising campaigns and communications related to the Zika virus to ensure that they include the best scientific evidence on Zika prevention, including sexual transmission, and the consequences of the virus, particularly when pregnant women are exposed. Review materials to ensure they do not disproportionately, or unfairly, suggest that women and girls should bear the burdens of Zika prevention. Include the roles of responsibilities of men and boys in Zika virus prevention.
  • Ensure national, state, and, local health protocols are regularly reviewed and updated to reflect new developments in the scientific literature related to the Zika virus and the evolving needs of children born with Zika syndrome.
  • Ensure that national, state, and local public education efforts and individual counseling engage couples and men, and do not single out pregnant women alone to bear the burden of preventing Zika transmission during pregnancy. Efforts should ensure men understand their risk of transmitting Zika to their partners and are encouraged to get tested before trying to conceive. If a woman is already pregnant, her partner should receive counseling on the benefits of condom use during the pregnancy to prevent Zika and other sexually transmitted infections.

Provide Comprehensive Sexual and Reproductive Health Care

  • Expand access to long-acting reversible contraceptives and voluntary sterilization through the public health system to reduce unplanned pregnancies.
  • Update relevant national, state, and local health protocols to ensure men and boys receive counseling and information about contraceptive and family planning methods, and access to condoms and voluntary sterilization.
  • Ensure that all relevant national, state, and local reproductive healthcare protocols include the following:
    • A screening process to determine whether pregnant women and girls planned and wanted their pregnancies, and what options may be available to those with unplanned pregnancies, including legal abortion;
    • Harm reduction counseling and information on post-abortion care for women and girls who indicate that they may terminate pregnancies clandestinely; and
    • Routine post-delivery contraceptive counseling to ensure all women and girls who give birth have comprehensive and accurate information about how to prevent pregnancy.
  • Develop and implement an extensive training program to ensure all health care providers can competently and consistently implement sexual and reproductive health protocols, including the provisions listed above.

To the Ministry of Health

  • Establish a task force to address gaps in Brazil’s reproductive health services and to identify barriers in accessing family planning information and services, particularly for traditionally underserved or vulnerable populations, including adolescent girls, older women, people of color, and those from low-income communities.
  • Conduct a national study leading to the adoption of measures to ensure that women and girls can access legal abortion services as provided under the law and the 2011 technical norm, without geographic or institutional obstacles. Based on the outcome, update the technical norm to address any undue obstacles identified.
  • Ensure universal access to abortion services, when legal, within the national health system and in all Brazilian states.
  • Develop an extensive training program to ensure all providers can competently and consistently implement all Zika-related and sexual and reproductive health protocols, including the provisions listed above. Work with state and local health authorities to implement the training.

To National, State, and Municipal Authorities Across Sectors

Support Families Raising Children with Zika Syndrome

  • Compile data on confirmed cases of children with Zika syndrome and availability of service providers with the training and capacity to treat them. Map out areas where additional services are needed consistent with the evolving needs of children born with Zika syndrome. To the extent possible, channel resources to areas where additional coverage is needed.
  • Ensure both male and female caregivers, and family members of children with Zika syndrome, have full access to ongoing psychological support as needed.
  • Examine bureaucratic processes required for families with Zika syndrome to access specialized services in facilities outside of the municipalities where they live. Streamline and simplify these processes to ensure families raising children with Zika syndrome are not forced to delay treatment due to procedural hurdles.
  • Expand access to safe, reliable, state-funded transportation services for families to bring their children with Zika syndrome to appointments and consultations as well as to other fundamental services as appropriate, like education, health, and rehabilitation.
  • Elicit feedback from families raising children with Zika syndrome about their long-term needs.

Support Children with Zika Syndrome

  • Develop and carry out an educational policy to include children with Zika syndrome in the educational system. Develop and conduct an extensive training program to ensure all early childhood caregivers and educators can serve the children and address their needs competently and consistently.
  • Develop initiatives to include children with Zika syndrome in alternative care programs, such as foster families or extended families, in case their own families are temporarily unable to provide adequate support.
  • Develop specific programs to ensure children with Zika syndrome and other disabilities are not placed in residential institutions, and have appropriate long-term alternative care.
  • Develop early intervention programs, beginning at the earliest possible stage, to adequately stimulate and habilitate children with Zika syndrome, based on multidisciplinary assessments, particularly in the areas of health, education, and social services. Establish and maintain services for children with Zika syndrome as close as possible to their own communities, in both urban and rural areas.

To National, State, and Municipal Authorities engaged on Environmental, Water, and Wastewater Infrastructure and Investments

  • Establish inter-ministerial or inter-agency working groups at the national, state, and municipal levels to ensure close collaboration with health, water and sanitation, and environmental authorities engaged in short-term vector control to ensure that medium and long-term efforts are adopted and implemented by non-health agencies or authorities.
  • Audit water, sanitation, and wastewater assets to determine whether they are contributing to mosquito breeding and implement a plan to address vector control at the site of assets.
  • Adjust capital investments and planning in water, sanitation, and wastewater services to be targeted to communities most affected by mosquito-borne outbreaks.
  • Ensure capital investments and planning in water, sanitation, and wastewater services reflect a whole of government approach to mosquito eradication and vector control.
  • Revise climate change policies to include strategies to address increased risks of vector-borne diseases like Zika and their impact on women’s human rights. Ensure that the National Adaptation Plan and other climate change adaptation policies include strategies to address the increased risks women face from vector-borne illnesses.

To the National Congress

  • Amend Law No. 13,301 of 2016 to ensure all families raising children with Zika syndrome have access to the financial benefit (Benefício de Prestação Continuada) provided to individuals with disabilities in Brazil. Ensure that all children with long-term health complications related to Zika transmission, not just those with microcephaly, are eligible for consideration.
  • Repeal criminal code provisions that criminalize abortion, especially those that punish women for inducing abortion or doctors for providing safe abortion services.
  • Enact laws to provide women and girls with access to voluntary and safe abortion services.
  • Amend the Family Planning Law No. 9,263 of 1996 to ensure access to family planning services and respect women’s reproductive autonomy. Exclude requirements of age and number of children to access permanent contraceptive options.

To the Supreme Court of Brazil

  • To the extent permitted under domestic law, consider the relevance and applicability of Brazil’s international human rights obligations in relation to constitutional petitions related to women’s reproductive rights, as detailed in the amici curiae submitted to the court by Human Rights Watch in April 2017.

UNFPA, UNICEF, WHO, Other UN Agencies and Donors

  • Provide support for ongoing monitoring and surveillance of Zika and other mosquito-borne viruses, including across geographic borders.
  • Provide guidance as well as technical and other support to Zika-affected countries for eradication efforts, reproductive health services, and research.
  • Support and help implement long-term programs to support children with Zika syndrome and help their families achieve the best possible quality of life.
  • Support continued research on the long-term impacts of Zika and ensure knowledge sharing.
  • Facilitate development and sharing of best practices for Zika testing, diagnosis, and eradication efforts.
  • Eliminate all restrictions to foreign assistance that limit the exercise of fundamental human rights, including sexual and reproductive rights.

Methodology

Human Rights Watch conducted research for this report in late 2016 and early 2017 in two states in the northeast region of Brazil, Pernambuco and Paraíba. Most interviews were carried out in two cities: Recife, in Pernambuco state, and Campina Grande, in Paraíba state. Many interviewees resided in other parts of the two states but regularly traveled to one of these two cities to access health services or services for children with Zika syndrome.

We interviewed 98 women and girls ages 15 to 63, including 44 who were pregnant or had recently given birth, and 30 who were raising children with Zika syndrome; nine men, ages 19 to 62, who lived in communities affected by the Zika outbreak, four of whom were the partners of women and girls interviewed for the report; 25 service providers; and 27 other experts, such as prosecutors, public defenders, academic researchers, and representatives of nongovernmental organizations (NGOs). Human Rights Watch also interviewed health and sanitation authorities from national, state, and local government entities, including the Ministry of Health, Ministry of Cities, the Pernambuco and Paraíba Secretariats of Health, the Recife Secretariats of Health and Sanitation, and others. In total, Human Rights Watch interviewed 183 people for this report.

Human Rights Watch identified interviewees through outreach at medical facilities and in communities affected by the Zika virus, with the assistance of advocates, researchers, service providers, and NGOs.

Most interviews were conducted in Portuguese, at times through interpreters. When possible, Human Rights Watch held interviews individually and in private, though in some cases, interviewees preferred to have another person present. Interviews were primarily held in homes, community spaces, and medical facilities.

Human Rights Watch informed all interviewees of the purpose of the interview, its voluntary nature, and the ways in which the information would be collected and used. Interviewers assured participants that they could end the interview at any time or decline to answer any questions, without any negative consequences. All interviewees provided verbal informed consent to participate.

Interviews were semi-structured and covered topics related to reproductive health, access to information and services, and environmental conditions in the context of the Zika virus epidemic. Most interviews lasted 30 to 60 minutes, and all interviews took place in person. Care was taken with victims of trauma to minimize the risk that recounting their experiences could further traumatize them. Where appropriate, Human Rights Watch provided contact information for organizations offering legal, counseling, health, or social services. Human Rights Watch did not provide anyone with compensation or other incentives for participating.

Human Rights Watch also analyzed relevant laws and policies and conducted a review of secondary sources, including epidemiological data, public health studies, reports from the World Health Organization and the Brazilian national, state, and local health entities, and other sources.

The names of women, girls, and men interviewed have been changed to protect their privacy and safety, unless they requested their real name be used. Names of service providers, officials, and experts have not been changed. A few requested anonymity, which is noted in the relevant footnotes.

In this report, the word “child” refers to anyone under the age of 18, with “girl” referring to a female child.

Human Rights Watch did not use a random sampling method to identify interviewees. The experiences of the individuals we interviewed may not be representative of the broader population of the northeast region, nor of the country as a whole. However, Human Rights Watch found patterns and similarities in the experiences of interviewees from a range of cities and towns across two states. Our research strongly suggests many other women and girls in Brazil face similar challenges related to their sexual and reproductive rights, and access to information and services in the context of the Zika outbreak.

I. Background

In 2015, the first confirmed cases of Zika virus infection in Brazil put the country at the epicenter of a new epidemic. The public health crisis that followed exacerbated the difficult living conditions of many marginalized communities, and at the same time, was itself exacerbated and amplified by inadequate access to water and sanitation, racial and socioeconomic health disparities, and restrictions on sexual and reproductive rights. Though these problems existed long before the government confirmed local transmission of the Zika virus, the outbreak, and the national and international response to it, brought renewed attention to longstanding challenges to public health and human rights in Brazil, including the rights to water and sanitation and sexual and reproductive rights.

The Zika Virus Outbreak in Brazil

Though scientists first identified the Zika virus in humans in Africa in 1952, the first large outbreak occurred decades later, in Micronesia in 2007. In 2013 and 2014, outbreaks occurred in four other groups of Pacific islands.[1]

In late 2014, health officials in the northeast of Brazil began reporting cases of an illness characterized by skin rashes and fever. By May 2015, health authorities confirmed local transmission of the Zika virus in Brazil. At the time, complications related to pregnancy were unknown. In 2016, Brazil’s Ministry of Health reported 214,193 probable cases and 128,266 confirmed cases of Zika virus,[2] though many more cases were likely unreported. The government estimated there were somewhere between 500,000 and 1.5 million cases from 2015 through early 2016.[3] Since the emergence of Zika in Brazil, the virus has spread to many countries. As of May 2017, 85 countries and territories have reported documented instances of Zika virus transmission.[4]

The Zika virus is transmitted predominantly through the bite of an infected Aedes aegypti mosquito. The virus can also be transmitted during pregnancy from a woman to her fetus, and through unprotected sexual activity.[5] Individuals infected with Zika virus are often asymptomatic, or present mild symptoms, such as fever, muscle and joint pain, conjunctivitis, and rash.[6] Blood and urine tests can confirm Zika infection.[7]

Zika is associated with serious neurological complications, particularly when a pregnant woman becomes infected and her fetus is exposed to the virus in utero. Confirmed infection in the first trimester poses the highest risk, with 15 percent of babies born with disabilities.[8] The outbreak in Brazil has been linked to the birth of thousands of babies with atypical brain development and other complications including seizures, problems with hearing and sight, musculoskeletal differences, and microcephaly, when the brain and head are underdeveloped. Together, the range of complications observed in infants that were exposed to Zika virus in utero are referred to as congenital Zika syndrome.[9] Research suggests that infants who were exposed to Zika prenatally and born without microcephaly may develop microcephaly and other problems with brain development after birth.[10]

The virus has also been identified as a trigger for Guillain-Barré syndrome, a rare neurological disorder that can lead to paralysis and death in severe cases, with most people recovering fully in the course of weeks or months.[11] According to the World Health Organization, “There is scientific consensus that Zika virus is a cause of microcephaly and Guillain-Barré syndrome.”[12]

Brazil accounts for the overwhelming majority of cases of congenital Zika syndrome worldwide.[13] The Ministry of Health began tracking an unprecedented increase in cases of babies born with microcephaly in October 2015.[14] Between 2015 and April 2017, there were 2,698 confirmed cases of Zika syndrome in infants in Brazil, and more than 3,000 remain under investigation.[15] Media reports suggest that not all state and municipal health authorities are accurately notifying cases, so this may be an undercounting.[16] In the state of Rio Grande do Norte, an audit carried out by the Ministry of Transparency reported cases of mayors failing to report suspected cases of Zika syndrome so that they do not reflect badly on the municipality.[17]

According to Ministry of Health data, the number of Zika virus cases, and the number of infants born with disabilities linked to the virus, were dramatically lower during the first few months of 2017, as compared to 2016.[18]

Climatic, Water, and Wastewater Context

Brazil’s humid, tropical climate—particularly in the rainy season—have contributed to the proliferation of mosquitos and the rapid spread of Zika and other mosquito-borne diseases. The Zika epidemic in Brazil may have been fueled by unusual climatic conditions during the time of its outbreak. A recent study suggests that exceptionally high temperatures related to the 2015 El Niño climate phenomenon, occurring against the backdrop of steadily rising temperatures because of climate change, were conducive to the transmission of Zika in South America.[19] With rising temperatures, the reproductive cycle of the mosquitos accelerates: the higher the air temperature, the faster the virus reproduces in the mosquito for transmission to another person. Higher temperatures can also cause the mosquitos to mature faster. Droughts, exacerbated by climate change, can also be a cause for disease spread if households store more water in containers that provide suitable mosquito breeding sites.[20]

Over the coming decades, climate change is likely to increase the spread of mosquitos carrying vector-borne diseases.[21] While the relationship between Zika and climate change still needs further research, a recent study suggests that the potential worldwide habitat range for Aedes mosquitos carrying Zika and other diseases could increase by more than 10 percent by 2061-2080, as a result of high greenhouse gas emissions and population growth.[22]

The Brazilian national government has developed several policies to address the effects of climate change, including a National Plan on Climate Change (2008), a Sector Health Plan for Mitigation and Adapting to Climate Change (2013) and a National Adaptation Plan to Climate Change (2016). The National Adaptation Plan to Climate Change (NAP) recognizes that “issues of race and gender” are “contributing factors” to social vulnerability and that certain socioeconomic groups are disproportionately impacted by climate change.[23] The NAP also acknowledges the importance of utilizing “gender-sensitive” criteria to develop adaptation measures.[24]

While cognizance of issues of race and gender in these policies is encouraging, the NAP does not include a gendered analysis in its Strategy for Vulnerable Populations. When discussing steps to mitigate the impacts of climate change, the NAP considered how several socioeconomic groups, including Indigenous peoples, family farmers, and fishermen, were particularly vulnerable to these impacts. The NAP, however, fails to consider how women were affected by climate change.

The NAP also acknowledged that climate pattern changes “impact the vectors of some diseases” and that effects of climate change, such as “change in rainfall patterns and increased frequency of extreme climate events, associated with factors such as poor sanitation” reduce the availability of drinking water, which, in turn, exposes populations to vector-borne diseases.[25] The NAP fails to recognize that women face increased risks from vector-borne diseases, such as Zika.

Poor water and wastewater conditions also contribute to mosquito population growth. In a joint statement released in March 2016, several UN experts explained how poor access to public water and sanitation services contribute to the spread of Zika and other viruses. Leilani Farha, the UN special rapporteur on adequate housing, said, “When people have inadequate living and housing conditions, where they do not have access to safely managed water services, they tend to store water in unsafe ways that attract mosquitos. In addition, poor sanitation systems where wastewater flows through open channels and is disposed of in unsafe pits leads to stagnant water and unfit housing—a perfect habitat for breeding mosquitos.”[26]

More than one-third of Brazil’s 208 million people do not have access to a continuous water supply, while 3.8 million lack any access to safe drinking water.[27] Residents who lack continuous access to water must store water in tanks, buckets, and other containers. If left uncovered and untreated, stored water can be a breeding ground for mosquitos. Aedes mosquitos—which carry Zika as well as other serious mosquito-borne viruses, including dengue, chikungunya, and yellow fever—lay eggs in containers filled with standing water, including those used for domestic water storage. They also lay eggs in objects where water can collect like used tires and discarded food and beverage containers filled with rain.[28]

Poor garbage collection services could also contribute to the proliferation of mosquitos. In 2014, approximately 55.7 percent of the population had access to adequate garbage collection services, while 32.7 percent were covered by a precarious service and 11.6 percent did not have access to any kind of service.[29]

More than 35 million people in Brazil lack adequate sanitation services—provision of facilities and services for the safe disposal of human urine and feces.[30] Millions more do not have adequate wastewater or fecal sludge management for their homes or communities, as a result of which untreated sewage is dumped into storm canals and waterways, which along with other solid waste obstructs the flow of water and creates standing and stagnant water. Only an estimated 50 percent of the population was connected to a wastewater system in 2015, and less than 43 percent of the country’s total volume of wastewater was treated. In the northeast region of the country, the situation is even worse: in 2015 less than 25 percent of the population was connected to a wastewater system, and only 32 percent of wastewater was treated.[31]

In Brazil, federal, state, and municipal governments share the responsibility for developing and implementing sanitation policies. The three have jurisdiction to regulate it under the guidelines set by the federal government which is also the main financier.[32] While municipalities bear the original jurisdiction over the provision of water and sanitation services, states, through public companies, have often assumed the provision of these services, as in the cases of Pernambuco and Paraíba.[33] Thus, a response to improving the conditions requires the cooperation of all levels of government.

Responding to climatic changes and the poor water and wastewater conditions will be key to the long-term reduction of Zika transmission, but is also urgent due to other serious, and potentially fatal, mosquito-borne viruses threatening public health in Brazil. The largest outbreak of dengue virus in recent history took place in 2013, but there were still more than 1.5 million cases of dengue, and more than 640 confirmed deaths, registered in Brazil last year.[34] The incidence of chikungunya in Brazil has increased dramatically in recent years. From 2015 to 2016, the number of cases of chikungunya increased nearly sevenfold, from approximately 38,000 in 2015 to more than 265,000 in 2016, overwhelmingly in the northeast region of the country.[35]

Since December 2016, Brazil has also had a surge in yellow fever, with hundreds of confirmed cases and at least 240 deaths.[36] The yellow fever outbreak is the largest in Brazil since health officials began tracking the virus in 1980.[37] As of May 31, 2017 health authorities had reported more than 3,200 suspected cases in 17 states, transmitted by Haemagogus and Sabethes mosquitos found in rural areas, and 792 confirmed cases in nine states (Minas Gerais, Espírito Santo, São Paulo, Rio de Janeiro, Pará, Tocantins, Mato Grosso, Goiás and Distrito Federal).[38] Reports also suggest a high number of epizootic transmission in non-human primates.[39] If the virus reaches urban areas, and Aedes mosquitos begin transmitting it, the number of cases could increase dramatically.[40]

Marginalized Populations Vulnerable to the Zika Outbreak

The long-term impacts of the Zika outbreak have fallen disproportionately on young, single women and girls of color. The northeast region of Brazil, one of the poorest in the country,[41] accounts for more than three-quarters of the confirmed cases of babies born with Zika syndrome since the start of the epidemic.[42]

Unpublished Ministry of Health data obtained through an information request by the Brazilian publication Estadão, suggests that roughly one-quarter of the women and girls who gave birth to babies with microcephaly between November 2015 and September 2016 were under the age of 20 (by comparison only 18 percent of pregnancies occur among adolescents under 20).[43] More than 760 adolescent girls and young women ages 10 to 19 gave birth to babies with microcephaly during that period,[44] including 35 girls ages 10 to 14.[45] It should be noted that girls under 14 in Brazil are considered below the age of the sexual consent, regardless of the age of their partners.[46]

Nearly half—48 percent—of women and girls who gave birth to babies with microcephaly are single (as compared to 40 percent in the general population) and more than three-quarters identify as “black” (preta) or “brown” (parda) (as compared to 59 percent in the general population).[47]

Sexual and Reproductive Health and Rights in Brazil

In January 2016, amid scientific uncertainty around the long-term impacts of Zika virus, authorities from several countries in Latin America recommended that women delay pregnancy.[48] Their recommendations sparked new public discussions about access to sexual and reproductive health information and services in countries affected by the epidemic.[49] Brazil, as the epicenter of the epidemic, issued a protocol that highlighted women’s access to contraception as a key pillar of the response to the epidemic, but failed both to recognize the significant barriers women face to access contraception or what to do in case of contraceptive failure.[50] Recently, the Ministry of Health developed a new integrated plan against the Zika epidemic, which included a focus on sexual and reproductive health, for municipalities in six states—Maranhão, Ceará, Rio Grande do Norte, Alagoas, Sergipe and Bahia.[51] The most recent protocol on public health emergencies, released in December 2016, increased the list of actions related to sexual and reproductive health and rights, including a recommendation on the use of condoms during pregnancy.[52]

Women and girls in Brazil have constitutional and statutory guaranteed rights to access contraception for free in many forms at local health centers run by the national health system (Sistema Único de Saúde, or SUS).[53] Despite this, a national demographic and health study published in 2008 found that nearly half of pregnancies in Brazil are unplanned or unwanted, indicating unmet contraceptive need.[54] Likewise, a more recent study published in 2016 involving nearly 24,000 Brazilian women who had recently given birth found that 55 percent reported that their most recent pregnancies were unintended.[55] Younger, single, women and girls of color without paid employment and with fewer years of schooling were more likely to report their pregnancy was unintended.[56] Consistent with these findings, the UN estimates more than 2.3 million Brazilian women and girls ages 15 to 49 who are married or in unions have an unmet need for family planning.[57] These estimates reflect the need prior to the outbreak, and do not include women and girls who are not married or in unions.

Adolescents may have greater unmet need for contraception than other segments of the population. Nearly 20 percent of live births in Brazil are to adolescent women and girls ages 10 to 19, accounting for more than 560,000 births per year.[58] A national survey involving nearly 1,000 sexually active young women and girls ages 15 to 19 in 2013 found that 21 percent were not using any method of contraception, and only 17 percent had visited a public health agent to discuss family planning in the 12 months prior to the survey.[59]

Women and girls in Brazil who become pregnant and wish to terminate unplanned pregnancies have few legal options for accessing abortion. Abortion is legal in Brazil only in cases of rape, when necessary to save a woman’s life, or when the fetus suffers anencephaly, a fatal congenital brain disorder.[60] According to the criminal code, women and girls who terminate pregnancies under any other circumstances are subject to criminal punishment of up to three years in prison, while people who perform abortions face up to four years, if convicted.[61] According to some media reports, in 2014 alone at least 33 women were arrested for abortion, and seven of them were denounced by doctors after having come to hospitals in need of post-abortion care. One of them spent three days handcuffed to a bed.[62]

National and International Response to the Epidemic

In November 2015, as cases of microcephaly increased, the Brazilian government declared a public health emergency of national concern and created a system for the immediate notification of all suspected cases.[63] Less than a week later, the World Health Organization (WHO) through its regional counterpart, the Pan American Health Organization (PAHO), issued an epidemiological alert asking countries to report cases of microcephaly and other neurological complications.[64] On January 22, 2016, the US Centers for Disease Control and Prevention activated its Emergency Operations Center, followed on February 1, 2016, by a WHO declaration that the cluster of neurological disorders and microcephaly was a “public health emergency of international concern.”[65] PAHO Brazil established a “Situation Room” to coordinate information about the Zika virus and its consequences to the country and the world, focusing on international and interagency cooperation, communication and knowledge management, logistical support, and epidemiological analysis.[66]

In late 2015, the Brazilian government launched the National Plan to Combat Aedes and Microcephaly with three areas of focus: 1) mobilization and fight against the mosquito; 2) attending the population; and 3) technological development, education, and research.[67]

WHO has a Zika Strategic Response Plan, developed in February 2016 and revised in June, which established the basis for coordination and collaboration among WHO and its partners until December 2017.[68] The plan calls for four areas of intervention: 1) development of integrated surveillance systems at all levels; 2) prevention of adverse health outcomes; 3) strengthening of health and social systems to provide support to the population affected; and 4) research. WHO also combined efforts with United Nations Population Fund (UNFPA) and UN Women. Within the Situation Room, WHO, UN Women, and UNFPA met with civil society organizations to lead coordination, monitoring, and advocacy for the rights and empowerment of women in the context of Zika.[69] As part of this joint effort, UNFPA launched the campaign “Mais direitos, menos Zika” (“More rights, less Zika”), engaging youth and women from Bahia—one of the other states hardest hit by Zika—and Pernambuco to mobilize the community in health surveillance actions and provide access to information about the Zika outbreak in order to minimize its impact on rights.[70]

In 2016, UNFPA, UN Women, WHO, together with the Brazilian government, organized communication campaigns, including radio programs, reports on television, and flyers and posters addressing women’s rights in the context of Zika.[71]

Ten months after calling it an emergency, WHO declared the Zika epidemic was no longer a “public health emergency of international concern.”[72] In explaining the decision, Dr. Margaret Chan, then director-general of WHO, said, “In large parts of the world, the virus is now firmly entrenched. WHO and affected countries need to manage Zika not on an emergency footing, but in the same sustained way we respond to other established epidemic-prone pathogens, like dengue and chikungunya, that ebb and flow in recurring waves of infection.”[73] Some specialists criticized the decision, arguing that governments and donors would slow down their responses, while the general public might misunderstand it as a sign that the outbreak is over.[74]

In May 2017, the Brazilian government announced that the national public health emergency related to the Zika virus had ended, 18 months after first declaring Zika a public health emergency “of national concern.” One of the World Health Organization’s requirements for maintaining a state of emergency is that the event is unusual or unexpected. This no longer is the case in Brazil, as there is now sufficient scientific evidence connecting the Zika virus with congenital neurological impacts. Health officials said that monitoring, surveillance, and efforts to combat mosquito-borne viruses would continue.[75]

State Response to the Zika Epidemic in Pernambuco and Paraíba

The management of the epidemic is a tripartite system between the federal, state, and municipal governments. However, the initial actions to identify and respond to reports of increased cases of microcephaly occurred at the state level. On October 27, 2015, Pernambuco’s Secretariat of Health required the immediate notification of all suspected cases of microcephaly in newborns.[76] Two weeks later, after a high volume of notifications, the secretariat developed the first clinical and epidemiological protocol on microcephaly, which served as a reference for the national one.[77] The Pernambuco state protocol set the criteria for identifying microcephaly in newborns in the state, and defined the diagnostic, surveillance, prenatal care, and newborn follow-up services flow. An updated version, released one month later, extended the focus to pregnant women whose fetus is suspected of having microcephaly and pregnant women who have had a rash during pregnancy.[78] In November 2015, Paraíba’s government also released its own protocol with the same purpose.[79]

Both protocols present general recommendations for individual action, for example, measures to protect against mosquito bites. Neither state protocol made explicit recommendations to avoid or delay pregnancy, nor provided women with counseling or information about family planning and contraceptive methods.[80] The most recent versions of the protocols in both states, from December 2015, do not address the risk of sexual transmission of Zika, and present outdated information. As of May 2017, Paraíba’s protocol incorrectly states that the Zika virus is not transmitted through sexual relations.[81]

In late 2015, the Pernambuco and Paraíba state governments declared a situation of emergency and released their own state plans to fight the diseases transmitted by Aedes mosquitos. Both plans had similar measures, encompassing health assistance, epidemiological and health surveillance, communication, management and monitoring of the actions implemented, and research.[82] One year later, the government of Pernambuco state renewed for the second time the emergency status and launched a new plan.[83]

Financing for Response to Zika Epidemic

The response to the Zika epidemic required effort at the international, national, state, and municipal level and engaged experts and authorities from various sectors, including health, education, and research. Most of the funding targeted the key pillars of Brazil’s national plan, which focused on mobilization and fighting against the mosquito, providing services to affected populations, and promoting technological development, education, and research.

In March 2016, the federal government announced plans to invest R$649 million (US$203 million) in mosquito eradication efforts, vector control, diagnostic testing, and research.[84] The Ministry of Health also transferred R$2.7 billion (US$840 million) to states and municipalities in 2016 to fund state and municipal health surveillance programs and measures to control Aedes mosquitos, together representing an approximated R$800 million (US$250 million) increase in federal disbursements for health surveillance from the prior year.[85]

The federal government also invested significant resources in ensuring services for affected populations, including commodity acquisition of more Zika and pregnancy tests and repellent for pregnant women enrolled in Bolsa Família, a cash-transfer program for poor families, as well as capital investments in the construction and updating of specialized rehabilitation centers for persons with disabilities.[86] As of March 2017, 52 new centers were operating, at an estimated cost of R$114 million (US$35.7 million) per year.[87] According to the Ministry of Health, between December 2015 and January 2017, it expanded the public health system to include 63 new specialized rehabilitation centers, at an annual operating cost of R$128 million.[88] In 2017 Pernambuco’s Secretariat of Health will expand the rehabilitation services specialized for children with Zika syndrome to its 12 health regions. Currently such services exist in only 10 regions.[89]

In the area of technological development, education, and research, Brazil’s government announced investments of more than R$250 million (US$78.1 million) in the development of vaccines against Zika and dengue, innovative vector control technologies, and in the research on the prevention, diagnosis, and treatment of Zika.[90]

Although the national Zika plan does not highlight investment in water or wastewater infrastructure to combat mosquitos, the National Plan on Sanitation, launched in 2013, sets the goals of universal access to water and garbage collection systems in urban areas, and expanding access to wastewater systems to 93 percent of residences in urban areas by 2033.[91] The plan estimated the need for a total of R$508.4 billion (US$158.9 billion) to achieve these objectives.[92] In 2014 and 2015, total investments in water systems and wastewater collection amounted to approximately R$12.2 billion (US$3.8 billion) each year.[93] A recent study published by the National Confederation of Industry (Confederação Nacional da Indústria) found that if the current trend of investments continues, the entire Brazilian population would be fully connected to a wastewater system by 2054.[94] Inadequate water and wastewater infrastructure presents a significant threat to the federal government’s broader efforts to combat Aedes mosquitos and the diseases they spread.

States have also invested in eradication efforts. Pernambuco budgeted R$25 million (US$7.8 million) in 2016 to fund a plan to combat all diseases transmitted by Aedes mosquitos.[95] Of this, R$5 million (US$1.6 million) was allocated for vector control and materials and personal protective equipment, and another R$5 million (US$1.6 million) was dedicated to awareness campaigns. The remaining R$15 million (US$4.7 million) went to construction of regional centers to attend infants with Zika syndrome.[96] In 2017, Pernambuco’s state government announced investments of R$78 million (US$24.4 million) to combat mosquitos, assist patients with dengue, chikungunya, and Zika, and for research.[97]

To address the very deficient sanitation coverage, Pernambuco entered the largest public-private partnership in Brazil in 2013. With planned total investments of R$4.5 billion (US$1.4 billion) over 35 years, the project aims for universal access to sanitation in 14 municipalities of the metropolitan region of Recife, and Goiana. Within 12 years the wastewater collection rate was expected to increase from 30 percent to 90 percent, benefiting 3.7 million people.[98] Three years after the agreement, the rate of wastewater collection has risen to only 32.17 percent, while the companies responsible for the investments face financial problems and construction is behind schedule.[99] Moreover, total investments in water and wastewater services across the whole state decreased from 2013 to 2015, from R$746 million (US$233 million) to R$550.3 million (US$172 million).[100] Paraíba witnessed a similar decrease in investments in water and wastewater services, dropping from R$148.4 million (US$46.4 million) in 2013 to R$56 million (US$17.5 million) during the same period.[101]

II. Findings

In February 2017, the director general of the World Health Organization stated that “Zika revealed fault lines in the world’s collective preparedness. Poor access to family planning services was one. The dismantling of national programmes for mosquito control was another.”[102] Human Rights Watch found that Brazilian authorities need to take additional steps to address many of these fault lines that existed prior to the Zika outbreak. Our research found gaps in the Brazilian authorities’ response that have distinct harmful impacts on women and girls, and leave the general population vulnerable to continued outbreaks of serious mosquito-borne illnesses in the future.

Instead of planning needed investments in water and sanitation infrastructure to control mosquito breeding, Brazilian authorities have encouraged household-level efforts: namely cleaning water storage containers and eliminating standing water in homes. Women and girls are often the ones responsible for these tasks, but their efforts are burdensome and often futile without attention to structural water and sanitation failures.

Traditional gender roles within society often assign women and girls the primary responsibility for preventing unplanned pregnancy, yet we found that some women and girls did not have access to comprehensive reproductive health information and services through the public health system. Criminal penalties for abortion force pregnant women and girls to turn to clandestine, and often unsafe, procedures to terminate unwanted pregnancies. Pregnant women bear the burden of preventing Zika infection and transmission to the fetus during pregnancy, but we found they often suffer anxiety and uncertainty when they cannot access the information or services they need to protect themselves from the virus. In families raising children affected by the virus, women overwhelmingly take on primary caregiving for babies with Zika syndrome, often without the support that would provide their families the best possible outcomes.

Human rights should guide Brazil’s efforts moving forward. A human rights-based approach to the Zika outbreak should address gaps in fulfilling the rights to water and sanitation, women’s and girls’ reproductive rights, and the rights of persons with disabilities.

Mosquito Eradication Requires System-Wide and Household Efforts

A rights-respecting and sustainable approach to fighting the transmission of the Zika virus would address pervasive problems with the rights to water and sanitation that stymie short-term mosquito eradication efforts. In an emergency phase, vector control focused on the household is key, but it will fail in the long term if systemic problems are not also addressed.

In the emergency phase of a mosquito-borne epidemic, emergency vector control is crucial to a multi-sector response, which includes integrating chemical, mechanical, and biological vector control and individual prevention efforts—essentially backpack, truck, or aerial spraying to kill mosquitos and larvae and household efforts to eliminate standing water breeding grounds.[103] In the long-term, addressing poor water and sanitation infrastructure is needed to achieve lasting vector control.[104] To date, this long-term investment in lasting vector control has not been a government priority in response to the Zika epidemic, likely setting Brazil up for years of repeat outbreaks of mosquito-borne illnesses.[105] Even medium-term efforts, such as removing aquatic weeds, trimming river and lake vegetation to change sunlight and shade conditions, and maintaining the lining of canals, are not set as a pillar of the response.[106]

The World Health Organization, in its guidance on managing pregnancy in the context of Zika virus infection, states, “It is essential to correct the social determinants of viral illnesses that are transmitted by Aedes aegypti mosquitos at the population level. Strategies to considerably reduce the potential threat of Zika virus infection should therefore include concerted efforts to provide sustainable and equitable access to safe and clean water; consistent application of sanitation and hygiene practices; and appropriate waste management at the community level.”[107]

The Brazilian government has worked to engage households and communities in vector control interventions. Through campaigns and public announcements, the Ministry of Health urged residents to destroy mosquito breeding sites by cleaning and covering water storage containers and eliminating standing water. The federal government combined efforts with state and municipal authorities to intensify eradication efforts.[108] Due to these investments, the share of buildings with mosquito breeding grounds decreased from 3.37 percent in the first cycle of 2016 to 1.91 percent in the last one.[109] Despite progress, the number still exceeds the goal of one percent set by the National Plan to be achieved in June 2016.[110] In addition, initiatives and campaigns involving public schools and civil society organizations raised awareness and mobilized the population to eradicate mosquito breeding sites.[111] UNICEF has also provided assistance to engage municipalities in combatting Aedes mosquitos, and trained 2,383 social mobilizers in 707 municipalities, including 771 teenagers.[112]

Municipalities have also taken steps to eradicate mosquitos.[113] In late 2015, Recife declared an emergency situation and released an emergency plan to combat the Aedes aegypti.[114] Among other measures, the plan included the hiring of additional 300 environmental health and endemic control agents.[115] In November 2016, Recife authorities announced the 2017 plan to combat the diseases transmitted by the Aedes with several initiatives.[116] However, investments in sanitation are not part of the plan to eradicate dengue, Zika, and chikungunya, even when there are some investments being made at the local level related to sanitation.[117] One official in the Pernambuco Secretariat of Health recognized this is not sufficient, saying, “health alone cannot address this issue. So, education, housing, sanitation departments play a role as well.”[118]

Municipal and state governments have also employed the use of insecticides and larvicides to address mosquito breeding, however a government audit conducted state-by-state over a period between 2014 and 2016 found that more than half of the states and one-fifth of the municipalities investigated did not apply the funds in a timely manner. Auditors also observed expired boxes of insecticides and inadequate conditions of the warehouses in several states. Furthermore, poor management practices, such as inefficient use of the vehicles to spray insecticides, overbilling, lack of planning and inventory control, and failures to distribute insecticides to the municipalities hindered the effort. [119]

The bulk of the daily effort on mosquito eradication, however, has fallen to individual households to address. The “Cleaning Saturday—do not give a break to the dengue mosquito” campaign, launched in late 2015, called on the population to clean their houses once a week.[120] One year later, the Ministry of Health released a new campaign with the same approach and different cleaning day (Friday).[121]

Missing from plans for mosquito eradication was addressing the dismal state of water and wastewater services in many communities. Governments at all levels have not sufficiently addressed longstanding structural failures in water and wastewater systems—limiting the effectiveness of individual household and neighborhood efforts to eradicate mosquitos, particularly in underserved communities.

The national plan to combat Zika does not address systemic wastewater and sanitation failures contributing to mosquito breeding, which means there are no directed investments in lasting efforts at vector control through the lens of eliminating the risk of Zika and other arboviruses. In October 2016, during the first meeting of a national network of Zika experts, the minister of health affirmed, “Treated water, treated wastewater and garbage collected and treated are fundamental to prevent the dissemination of diseases. We do need to do strong investments in sanitation.”[122]

Instead a focus on the household shifts the responsibility to make up for poor water and wastewater systems and puts the burden of mosquito eradication efforts on households. Household efforts—namely the elimination of standing water around homes through emptying and scrubbing out containers and covering them, turning them over, or throwing them out—are fundamental to an emergency vector control effort and authorities were correct in emphasizing these efforts immediately. However, household efforts are futile and burdensome in the medium and long-term without national and local investments in lasting vector control through improved water and sanitation. Talita Rodrigues, an advocate in Recife, explained:

State and national health authorities started telling people they had to clean their houses, clean their neighborhoods, don’t leave standing water, but at the same time, there is open water, dirty water, sewage, rainwater, muddy water [in their communities]. So it was really confusing because the state was not looking at its own responsibility [to address problems with water and sanitation], it was transferring responsibility to people to clean their houses.[123]

Personal responsibility for cleaning households cannot stop mosquito breeding if the water and wastewater infrastructure is insufficient. People who have difficulty accessing water and wastewater services, like many residents of the two cities where Human Rights Watch conducted research for this report—Recife, in Pernambuco state and Campina Grande, in Paraíba state—may be especially vulnerable to mosquito-borne illnesses.[124] Indeed, most of the people interviewed for this report told Human Rights Watch that they or another member of their household had been infected with Zika, dengue, or chikungunya in recent years.

Since 2015, Brazil’s economy has suffered a deep recession, with high rates of unemployment and inflation. But long before the recent economic crisis, including in times of economic growth, government investments in water and sanitation infrastructure were inadequate.

In 2007, after more than two decades of limited investments in sanitation, congress enacted a new public law addressing sanitation, with implementing regulations adopted in 2010, boosting the sector.[125] An officer at the Ministry of Cities explained that until then ,“the legislation was diffuse, which reflects the fact that over decades sanitation was not part of the government’s agenda.”[126] Some states with more resources did invest in the sector, but states in the poorer regions, such as the northeast, worked hard in the period without federal investments to prevent regression in coverage rates. Since 2007, the federal government has increased investment in sanitation. Total investments grew from R$4,238 million in 2007 to R$12,175 million in 2015.[127] Still, the expansion in the provision of sanitation services has been painfully slow. Management and institutional problems—including a simple lack of qualified projects—created bottlenecks in pushing funding out, a foreseeable risk after decades of neglect.

Nevertheless, there has been a small uptick in coverage rates since 2007. The Brazilian population with access to water and wastewater systems increased from 80.9 percent and 42.0 percent in 2007 to 83.3 percent and 50.3 percent in 2015, respectively.[128] In Recife, the share of the population accessing water and wastewater services grew from 72.3 percent and 15.1 percent in 2007 to 76.3 percent and 17.3 percent in 2015.[129] An officer at Paraíba’s sanitation company summarized the context: “Since 2007, they started investing again, making projects, but not at the necessary speed, and now it has become complicated again because of the Brazilian [economic] situation.”[130] In the context of the recession, it will be difficult for Brazilian authorities to overcome the deficit in water and wastewater investments and to allocate the resources necessary to sustainably address failing systems.

Water Storage to Manage Inconsistent Water Supply

Many households do not have continual access to water without storing water in the home. This is particularly true in communities that rely on clandestine water connections, or in areas that have a problem with supply. In Paraíba state, Campina Grande and neighboring cities have been affected by a serious drought in recent years. The city’s main water source has dropped to dangerously low levels, and intermittent water supply causes many residents to store water in excess of their daily needs in large containers in their homes.[131] Parts of Pernambuco state have been equally impacted by the drought. According to officials at the state public water company, 30 municipalities’ water systems are in total collapse due to the drought and receive water by truck only.[132] Even one day of water in a month means that the service level does not qualify for trucked water. For example, in Santa Cruz do Capibaribe, access to water is restricted to two days with water and 28 without, but the state water company does not distribute additional water by trucks. “These are used only in cases of total collapse,” according to an official.[133] Informal neighborhoods in and around Recife often do the same, because they receive intermittent water supply due to clandestine or unreliable connections to the water system. Stored water, if not properly covered and maintained, can create areas for mosquito breeding.

Lindasselva lives in a shack in a slum in Olinda, Pernambuco state. There are no sanitation services and she has access to water from only one tap. Mosquitos can breed and proliferate in stored water, if it is not properly covered and maintained. 

© 2016 César Muñoz Acebes/Human Rights Watch

For this report, Human Rights Watch asked 60 people visiting health facilities in Pernambuco and Paraíba states and in poor neighborhoods around Recife and Campina Grande about their access to water in the diverse communities where they reside. Only about one-third of them said they had continuous access to water in their homes. The rest said that their water only flowed through the taps two or three days per week, or sometimes less frequently. One official in Recife’s Secretariat of Sanitation confirmed that Passarinhos, one of the communities Human Rights Watch visited, has intermittent access to water. She said, “they say it is one day with water and five without, but we observe that it can be more than five days [without water].”[134] While not a representative sample, our research suggests there are significant barriers to continuous availability of water in homes. A report by the WHO and UN Water confirmed more than one-third of Brazil’s population does not have access to a continuous water supply.[135]

As a result, most people have no choice but to fill tanks and other containers with water for household use. If not properly covered, those containers become potential mosquito breeding grounds. Clara, a 28-year-old mother of three children living in a poor neighborhood in Recife, explained in detail how a health outreach worker told her to maintain her water storage containers free of larvae. She has a large water tank that collects water when it is running, and then has two large buckets of water that she stores water in for the household to use during the week, “Every Saturday, I empty the water and clean out the buckets, and then I fill it with new water.”[136]

Where water is scarce or expensive, this type of cleaning regime is not possible. Alícia, a 36-year-old woman in Paraíba who was four months pregnant when she spoke with Human Rights Watch, said she had intermittent access to water at home. “We are afraid of running out of water all at once,” she explained, “[So when the water comes] then we fill up everything. Where I live, there are neighbors with many containers, and it’s full of little [mosquito] larvae, right? One fills up everything one can, so it is complicated because we don’t use all the water and keep it for the following week and, thus, it got worse.”[137]

Some interviewees in Paraíba said their access to water had decreased since the start of the Zika epidemic, due to the drought and water rationing.[138] Mirella, 48, told Human Rights Watch, “It’s been a year or more that we have water only three days a week because it’s not raining enough, and the water is not reaching the reservoir.” Mirella said it was difficult for her to care for her four children and elderly mother with an inconsistent water supply: “I have kids at home. They are always getting dirty, and their clothes get dirty. We need water to wash and shower. My mother lives with me as well, and I need water for her too.”[139]

Natália, a 30-year-old woman in Paraíba who was 34 weeks pregnant when she spoke to Human Rights Watch, said she had access to water every three days. “Due to the rationing, we have to store water, and many don’t store it properly,” she said. She described how her family was affected by a dengue outbreak in her community in early 2016: “In my community, there were many, many cases of dengue…. In my mom’s house, out of four people, my mother, father, and sister all had dengue. Only my niece didn’t have it…. It was an epidemic there.”[140]

Poor Wastewater Management Systems in Underserved Communities

Inadequate wastewater management systems, particularly in underserved communities, make household efforts to control the mosquito population futile in the long-term. Many of the marginalized communities Human Rights Watch visited in Recife backed up to open canals or marshes, where garbage and debris led to areas of standing water and stagnation. For many of the communities, their sewage and wastewater flowed directly into these open water sources. According to state public water company officials, today approximately 35 percent of the population in the metropolitan region around Recife has access to wastewater system.[141]

Almost all interviewees said they covered their water storage containers in their homes, but many said there were other sources of standing water in their communities that they could not control.[142] Many of the households living in the highest concentrations of poverty that we visited bordered open water channels or ravines that served to collect untreated wastewater. Mosquitos and their larvae were visible to Human Rights Watch researchers.[143] A 2016 study found that storm drains, among other types of standing water, served as larval development and adult resting sites for mosquitos that can carry Zika and other viruses, and yet these are often not the focus of eradication efforts.[144]

Wastewater and garbage are dumped directly into the river in a slum in the Coelhos neighborhood of Recife, Pernambuco state.

© 2016 César Muñoz Acebes/Human Rights Watch

In several low-income communities, Human Rights Watch saw untreated sewage flowing into open, uncovered channels, roads, or waterways near communities, creating dirty, standing water—ideal conditions for mosquito breeding. Some interviewees said their flushed toilets went directly into open channels nearby.[145] A community health worker in a Recife favela with 12,000 residents explained, “All wastewater goes untreated into the river… There is open-air wastewater in the streets.”[146] Clara, who described how she diligently washes and covers her stored water tanks, recognized the limited utility of her efforts because the marsh directly behind the house serves as a mosquito-breeding ground. “I have a flush toilet in the house, and it goes directly into the river. We don’t have any standing water here in the house, but the river is directly behind us.”[147] This is frustrating for her. An environmental health officer recently inspected her water tank and told her “congratulations, keep going!” yet the sewage and solid-waste filled marsh and polluted river behind her remains.[148]

A 19-year-old woman from one underserved community, who sat outside her home with her three-week-old baby while she spoke with Human Rights Watch, said there was often standing water in the street and there were “many, many mosquitos” in her home. She got chikungunya during her pregnancy, but her baby was born healthy.[149]

In another community in Recife, Human Rights Watch researchers walked along uneven, unpaved roads with Rebeca, a 25-year-old woman who was pregnant with twins. She pointed out how sewage flowed directly into the streets in her neighborhood, and dirty, standing water accumulated in areas near her home. “People don’t care how we’re living here,” she said. She had Zika prior to her pregnancy.[150]

Thaís, a 17-year-old girl who gave birth to a baby with Zika syndrome in January 2016, showed Human Rights Watch an open sewage channel near her home in Paraíba state. “We have a lot of mosquitos. The sewage is not covered, and at night it’s full of mosquitos,” she said. When her baby was five months old, Thaís and her whole family, including the baby, got dengue and chikungunya. “No one escaped,” she said. “We could barely walk. Our legs hurt a lot. [We had] fever, rash. I had dengue first and then chikungunya.”[151] Júlia, 23, lived in the same community and had chikungunya during her most recent pregnancy. She said there was “a lot” of standing water in her community:

“The streets have sewage and the channel is open. It’s sewage in the channel.” She explained that health officials visited her home to check her water storage containers for signs of mosquito breeding. “But no one comes to deal with the sewage,” she said.[152]

Household Environment Officer Visits Important Line of Defense

While long-term efforts are needed to address sustainable vector control, even the household efforts of Brazilian authorities have not been sufficient in some places to address vector-control in the home. Many people interviewed by Human Rights Watch did report that health officials visited their homes periodically to check water storage vessels for signs of mosquito breeding, and treat affected water with chemicals to destroy mosquito larvae (larvicides). However, many of them said there was very little, if any, information provided during these visits, suggesting a missed opportunity for educating the public about Zika prevention. Jessica, a 24-year-old woman in Pernambuco state who was eight months pregnant, said, “There’s a sanitation agent who comes to check water in the houses. It’s not to give information, it’s to treat the water…. They put a chemical in the water, but they don’t educate us.”[153]

Ana Sophia, a 17-year-old girl in Pernambuco state who was five months pregnant when she spoke to Human Rights Watch, had a similar experience: “They just come, look at the water, and if needed, put medicine in the water.” She believed additional education might lead members of her community to cooperate more fully with the government’s mosquito eradication efforts at the household level. “I think they should inform people,” she said, “because some [of my] neighbors don’t like that they put something in the water because it gets dirty at the bottom of the container. People don’t allow it [the health officials to apply a larvicide] because they don’t like it, but if they knew why it’s important, they might allow it.”[154]

Some women did report speaking to health agents about vector control, but most said the agents told them only about dengue or chikungunya, not Zika, and told them nothing about the need to control mosquito breeding generally. “Health agents came to speak about chikungunya and [told us] don’t keep standing water or anything dirty. That’s it, but it was a long time ago,” said Helena, a 34-year-old woman in Recife.[155] She thought it might have been in February 2016, eight months before our interview, and shortly after five people in her household contracted chikungunya. Consistent outreach is needed, and the necessity of vector-control to combat multiple threats should be better communicated.

The success of these efforts also relies on a consistent supply of the larvicide and sufficient environmental officers to distribute it to the household level. One municipal environmental surveillance officer in Paraíba told Human Rights Watch that in the months leading up to the epidemic, between May and November 2015, her municipality experienced a shortage in the supply of the larvicide used for vector control due to lack of federal funding. “On average we use 40kg of larvicide per month. There were moments we received only 10kg per month, and moments [between May and November 2015] we didn’t have anything. This shortage happened during a water crisis in the region.”[156] She indicated this was consistent in municipalities across the state. A state health surveillance director told Human Rights Watch that employment of environmental officers in some municipalities ended after recent local elections, leaving a temporary gap in services.[157]

Of most concern is that some people, particularly those living in underserved communities, told Human Rights Watch no one had visited their homes or communities to try to eradicate the mosquito population.[158]

Impact on Women and Girls

Some women’s rights advocates told Human Rights Watch that the government’s focus on household interventions to limit mosquito breeding had a harmful or stigmatizing effect on women and girls because it creates the impression that they are at fault if they are unable to control the mosquito population. This approach seems to ignore systemic issues related to the eradication effort and water and wastewater systems that might undermine household efforts. Traditional gender norms place the burden of household mosquito eradication efforts—cleaning water storage containers and eliminating standing water in homes—on women and girls, who already often take primary responsibility for preventing pregnancy. Paula Viana, executive secretary of Grupo Curumim, a feminist organization in Pernambuco, explained, “There are no government campaigns talking about women’s rights on the Zika issue. It’s all about the mosquito. The message to women is you have to clean your house or don’t get pregnant.”[159]

A flyer posted at a women’s community group in Passarinhos, a neighborhood in Recife, states, “In the time of Zika, protection and care begin by informing the woman about her reproductive rights.” Paula Viana, executive secretary of Grupo Curumim, a feminist organization in Pernambuco that was involved in designing the flyer, told Human Rights Watch, “There are no government campaigns talking about women’s rights on the Zika issue. It’s all about the mosquito. The message to women is you have to clean your house or don’t get pregnant.”

© 2016 Amanda Klasing/Human Rights Watch

Leaders of a women’s rights group working in an underserved community in Pernambuco state told Human Rights Watch they did research on the impacts of the Zika virus epidemic in their community. They found government communications around the Zika epidemic problematic for women and girls:

What’s being put out [to the public] is that people are responsible for what’s happening. Obviously, we are responsible for disposing of our garbage, but of course the causes of the epidemic are much bigger.[160]

Vera Barone, a leader of a Uiala Mukaji, a Black women’s organization in Pernambuco, concurs.

Women are being blamed for this crisis. [Women are being told] that they are responsible for not cleaning well enough, not dealing with standing water…. The majority don’t have access to water, so they have to store water, and they are blamed for how they store water. The government doesn’t recognize that the lack of investment in water and sanitation is what leads women to store water. ... In addition, the garbage is not collected properly. The government doesn’t recognize its mistakes. It just blames women.[161]

One pregnant woman interviewed by Human Rights Watch in Pernambuco state described how she had to be constantly vigilant about standing water and the use of repellent, while coping with the constant anxiety of getting Zika. “I’m being pressured all the time to take all kinds of care with the pregnancy, care for the baby,” she said. “It affects me a lot. Now, since I’m still at the beginning of the pregnancy and the baby is still developing, I get really frightened.”[162]

Reduce Unplanned Pregnancy, Ensure Reproductive Choice

Human Rights Watch found that some women and girls continue to face challenges in accessing basic information and services that would allow them to prevent pregnancy during the outbreak. Further, restrictions on reproductive health services, particularly abortion, can drive women and girls unable to prevent pregnancy but worried about the impact of the virus to seek clandestine and often dangerous methods to terminate pregnancy. Despite the difficulties in preventing unplanned pregnancies, many women and girls interviewed by Human Rights Watch reported struggling to access long-acting or permanent family planning options.

The national protocol on the necessary and appropriate response to the Zika virus included guidance on pre- and post-natal care, and emphasized access to contraception. However, the protocol did not address access to abortion in circumstances in which it would be legal nor did it identify how to overcome barriers in access to contraception among traditionally underserved populations.[163]

Brazil should take concerted action to reduce unplanned pregnancies by providing women and girls with comprehensive reproductive health information and services, including long-term contraceptive options, and identify and resolve any gaps in distribution or challenges in access. It should also ensure women and girls have reproductive autonomy and access to safe, legal abortion, so they do not have to resort to life-threatening clandestine procedures to terminate unplanned pregnancies they do not want to continue. Excessive legal restrictions on access to abortion hamper a rights-respecting response effort.

Unplanned Pregnancies

A Ministry of Health public advisory on Zika encouraged women and girls to go to their Basic Health Unit to receive an orientation on family planning and contraceptives and to choose a contraceptive method to prevent an unplanned pregnancy.[164] It also recommended that women who would like to become pregnant should speak with a health professional before doing so.[165] Yet, the government response did not scale up family planning services, particularly access to long-term contraceptive methods. Due to reports of sexual transmission of the Zika virus, the United Nations Population Fund (UNFPA) executive director, Dr. Babatunde Osotimehin, urged “governments and all other partners to provide information and access to voluntary family planning, including condoms.”[166] Yet, in practice, this does not seem to have been universally part of the response effort encountered by the women and girls interviewed by Human Rights Watch.

One hospital administrator expressed his frustration that this was not a greater priority. “Most pregnancies are unplanned… They have said ‘you shouldn’t get pregnant,’ but didn’t do anything different.”[167] Even when authorities did make family planning a priority, it was after great delay. In November 2016, nearly a year after the start of the public health emergency, Recife authorities did announce strengthening family planning services as part of its 2017 plan to combat the diseases transmitted by Aedes mosquitos.[168]

A study published in 2017 found that 66 percent of women of child-bearing age in the northeast of Brazil were trying to avoid pregnancy in 2016.[169] But less than one-third of the women and girls Human Rights Watch spoke to about family planning—most of whom we interviewed in health facilities or in communities near Recife and Campina Grande—said their most recent pregnancy was planned. The remainder reported a variety of reasons for an unplanned pregnancy, many hinging on lack of clear and accessible basic information about reproductive health. Although not a representative sample, many of the women who had unplanned pregnancies experienced similar contraceptive failures, often related to lack of information on correct usage.

While most forms of modern contraception have a high success rate under perfect use, many can have increased failure rates when human error is introduced.[170] At least two of the people we spoke to, women ages 34 and 47, reported accidently skipping a pill prior to becoming pregnant.[171] Others reported becoming pregnant while switching to new contraceptive pills or taking antibiotics that interacted with the efficacy of the pill.[172] Several women, including one who has a child with Zika syndrome, reported becoming pregnant while on a low dose contraceptive pill taken while breastfeeding.[173] Some of the women, and one girl, told Human Rights Watch that inconsistencies in the supply of contraceptives to the health centers would cause them to miss doses—either they would be out of pills or injections or the center closed due to strikes.[174]

Several women in their late 30s and early 40s reported being shocked by their pregnancies, some believing themselves to be entering menopause and unable to become pregnant.[175] Veronica, 42 and mother of a child with Zika syndrome, told Human Rights Watch that she thought she was too old to get pregnant. “When I found out, my life collapsed, because he was not planned,” she said.[176]

Overwhelmingly, the women and girls who spoke to Human Rights Watch about unplanned pregnancies described their first reactions as negative—everything from “a bomb going off in life” to being “disturbed,” “shocked,” “desperate,” or “scared.”[177] Most women who had continued their unplanned pregnancies did not want to discuss details about other options they considered in response to their unplanned pregnancy—including abortion or adoption. Yet, a few told Human Rights Watch that they had considered these other options. One woman, 21, had her first child when she was 16 years old. Pregnant again, unplanned, she told Human Rights Watch, “I knew I had other options, but I never chose them.”[178] Another woman who had an unplanned pregnancy told Human Rights Watch that she “felt broken and sad” after she found out she was pregnant. She considered seeking an abortion, but instead decided to continue the pregnancy and have a tubal ligation performed concurrent to delivery, to prevent any future unwanted pregnancies.[179]

Of particular concern is that many mothers who have children with Zika syndrome said they received no post-delivery contraceptive counseling, leaving them without comprehensive information about their options for preventing future pregnancy.[180] A few have since had unplanned pregnancies.

Clandestine and Unsafe Abortions

While the women we spoke with were reluctant to discuss abortion in the context of their current pregnancies, studies show that despite criminalization many women and girls in Brazil risk their health and lives to access clandestine abortions. For example, according to a 2015 study, there were as many as 865,000 abortions in 2013 among women and girls ages 15 to 49 in Brazil.[181] More recent research estimates that, by the age of 40, approximately one in five Brazilian women has terminated a pregnancy in her lifetime, and in 2015, approximately 500,000 women had abortions.[182]

Very few facilities provide legal abortions. One study estimated only 37 health facilities actively perform legal abortion services in all of Brazil, and that seven states do not have any institutions that offer this service.[183] Additionally, a very small number of abortions in Brazil occur under legal circumstances. According to one academic study, the 37 active abortion services in Brazil attended 5,075 women seeking legal abortion and performed 2,442 terminations of pregnancy between 2013 and 2015. The study analyzed 1,283 abortions that occurred in five of these services, one from each region in Brazil.[184] Ninety-four percent of those legal abortions were in cases of rape; 15 percent were provided to girls ages 11 to 14, and five were provided to girls younger than 10.[185] According to Ministry of Health data provided to Human Rights Watch, 1,667 and 1,678 legal abortions were administered in 2015 and 2016, respectively.[186] A total of 11,318 legal abortions were conducted between 2010 and 2016.[187]

The unavailability of and restricted access to legal abortion means the vast majority of abortions that take place are clandestine, and often unsafe, even when they fall within the exceptions provided by law. Human Rights Watch spoke with obstetricians who have provided emergency care for patients who have undergone illegal abortions. One coordinator of an obstetric intensive care unit in Recife recounted extreme cases, including cases where the patient died due to an unsafe abortion. The illegal nature of the abortion makes attending women in crisis difficult:

They are desperate and try anything, and so they use an unsafe method… We receive many severely sick patients, but it’s not so common to treat them for post-abortion care because people don’t tell the truth. They come with complications but they don’t say what happened… If we knew something was attempted we could start antibiotics earlier, because the risk of infection is higher.[188]

According to official data, unsafe abortion is the fourth leading cause of maternal mortality in Brazil. Since 2005, 911 women have died from unsafe abortion, including 69 in 2015, and 48 in 2016.[189] Approximately 17 percent of the abortion-related deaths between 2011 and 2015 were of adolescent girls and young women between 10 and 19 years old.[190]

Complications related to unsafe abortion lead to an estimated quarter million emergency room visits each year.[191] These figures likely vastly under-represent the consequences of unsafe abortion. Since abortion is largely illegal, it is likely that patients who have induced abortion and face complications are afraid to tell medical providers what brought about the complications. This makes data collection on the issue difficult.[192]

A few women interviewed by Human Rights Watch had experienced or witnessed complications from unsafe abortion. One 23-year-old woman told Human Rights Watch she had taken pills she bought at a pharmacy to terminate a pregnancy when she was raped at age 13. At the time, she did not know that she likely could have accessed abortion legally: “I didn’t have a lot of information. I didn’t know what I could do,” she said. After taking the pills, she experienced heavy bleeding, to the point that her clothing was soaked with blood. “I bled a lot,” she said, describing how scared and unprepared she felt.[193] Another woman, also 23, said she brought a friend to the hospital with post-abortion complications after she took an abortive substance she had acquired clandestinely. Describing the experience, she said, “She was bleeding a lot, and she fainted. I was with her. I was desperate. I was worried she wouldn’t survive.”[194]

Those who suffer most from legal restrictions on access to abortion are poor and marginalized women and girls, who may not be able to afford safer procedures, and instead resort to unsafe methods of abortion or feel compelled to carry unwanted pregnancies to term.[195] One doctor explained, “The truth is in Brazil abortions are done … Rich people can do it safely. Poor people have to appeal to unsafe methods and they die because of it.”[196] In the context of criminalization, abusive clandestine providers may take advantage of or even harm the most marginalized women, as illustrated by the tragic case of Jandira dos Santos, which gained international attention. Police suspect dos Santos died from a botched illegal abortion in 2014 and her body was mutilated to obscure her identity.[197]

The criminalization of abortion also makes women more likely to undergo coerced or unsafe abortion since they cannot freely seek professional medical advice or counselling about their options. One woman told Human Rights Watch about the pressure her partner put on her to seek an abortion, even though it would not be safe. “He forced me to call places to look for pills. It was horrible. It wasn’t what I wanted.”[198] She was unsuccessful in locating the pills, and continued the pregnancy, which she said was “a relief.”[199] Not all women are so lucky. An emergency obstetrician told Human Rights Watch that she attended a 26-year-old woman whose boyfriend forced her to undergo an abortion. He took her to a clandestine location, and they put something caustic in her vagina and her uterus ruptured. She lost her uterus and her ovaries, triggering early menopause, and her colon was damaged.[200]

Legal restrictions on abortion leave women and girls unable to speak openly about their options when they experience unplanned pregnancies. One doctor explained how decriminalizing abortion could create opportunities for providers to give the comprehensive counseling women and girls need when facing unplanned pregnancies:

The way I see it, the government should legalize and support it [abortion]. That way women can come to the health care system, where there is psychological and medical support. Sometimes all these women need is support. They are alone. If they knew they had other options, like adoption, they might not abort.[201]

Anxiety and uncertainty around the Zika virus outbreak may have increased demand for illegal abortion in Brazil. A July 2016 study published in The New England Journal of Medicine analyzed requests for abortion in 19 Latin American countries received by Women on Web—a nonprofit organization providing abortion medication in countries where safe abortion services are highly restricted—before and after a November 2015 PAHO announcement related to Zika virus risks. The study found a 108 percent increase in abortion requests from Brazil following the PAHO Zika announcement, as compared to a model based on statistical data from prior years.[202]

The study concluded that with the Zika epidemic in Latin America,

[T]here is both a need for clear information and an increase in requests for abortion that is not currently met by their own healthcare systems. While the WHO response to the Zika epidemic focuses on enhanced surveillance, vector control, communication and guidance, our results show that issuing to women advice that they cannot implement merely precipitates fear and anxiety. Ensuring reproductive autonomy through access to a full range of reproductive choices is currently a missing piece of the public health response to Zika.[203]

The newspaper Estadão reported an increase in the number of abortions in Pernambuco state since the emergence of the Zika virus, illustrating its findings with testimonies. A social worker attending pregnant women identified as having complications related to Zika or mosquito-borne viruses told Estadão that some of her patients who received an early diagnosis of fetal complications discontinued prenatal care and sought abortions outside the health system. One 28-year-old woman initially happy about her pregnancy, told Estadão that she terminated her pregnancy after learning that the fetus had serious neurological problems related to a mosquito-borne virus: “I didn’t mention to anyone [at the prenatal clinic] my intention to abort. I was afraid they would denounce me. I left and disappeared. I looked for a friend and she brought me to a clandestine clinic where she had undergone an abortion last year. My boyfriend gave me the money. Of course I got sad, but I knew this was what I had to do.”[204]

In February 2016, a representative from Pernambuco state introduced a bill in the Chamber of Deputies—the lower house of Brazil’s National Congress—that would increase sentences for women who have abortions due to microcephaly or other fetal anomalies.[205] As of May 2017, the bill had not been brought for a vote.

As a response to the challenges posed by the Zika virus epidemic, in August 2016, the National Association of Public Defenders, with support from the NGO Anis-Institute of Bioethics, filed a petition before the Brazilian Supreme Court to allow pregnant women infected with Zika virus the right to terminate the pregnancy.[206] The petition also called on the Brazilian authorities to provide the full range of benefits to women impacted by the virus, including early and regular screening during pregnancy; a full range of contraceptive methods, particularly long-acting reversible contraceptives; and state benefits if they have children affected by the virus.[207] In March, the Socialism and Liberty Party (Partido Socialismo e Liberdade, or PSOL) filed a case calling for the full decriminalization of abortion up to 12 weeks of pregnancy. Human Rights Watch submitted expert briefs in support of both cases in April 2017. As of May 2017, the Supreme Court had not ruled on the petitions.

Problems Accessing Long-Term Family Planning Options

One of the most effective ways to avoid unplanned pregnancies and abortions is to ensure women and girls have access to long-acting reversible contraceptives, such as implants or intrauterine devices (IUDs), or to voluntary sterilization (tubal ligation). Many of the women who spoke to Human Rights Watch expressed a desire to pursue these family planning options, but many of them encountered difficulties. A Secretariat of Health official in Pernambuco state recognized the challenges in accessing IUDs in particular: “We have been working to encourage the use of IUD. … We have a sufficient amount of IUDs available in Pernambuco. … The problem lies in the lack of health professionals willing to provide and insert it. Prescribing contraceptive pills is faster and easier. … Our goal is to provide training encouraging [physicians to provide IUDs].”[208]

One obstetrician-gynecologist providing prenatal care and family planning services to women in Campina Grande explained that she had to refer her patients to the maternity hospital to get IUDs. “We train those who want to get an IUD to go to the maternity hospital,” she said. She said that access to some long-acting contraceptive methods were limited based on municipal residency.[209]

Some women told Human Rights Watch they had never been provided with information about long-acting reversible contraceptive options. For example, Larissa, 28, was four months into a high-risk, unplanned pregnancy when she spoke with Human Rights Watch in October 2016. She had developed thrombosis, a serious blood clot, while taking oral contraceptive pills. When she tried hormonal injections, she said she felt nauseated and lost hair. “I didn’t adapt well,” she said. Though she had struggled to find a form of contraception that worked for her, no one had ever informed her about longer-term options, like an IUD.[210]

Others said they could not access longer-acting methods. Júlia, a 23-year-old woman with four children under age 6, said she requested an IUD from the public health system, but was denied. “I tried, but I didn’t get it. The public health system didn’t offer it to me because of my age. The health unit said it’s only allowed to women over 25 years.”[211] This is incorrect information, as the minimum age requirement is 20 years of age.[212]

A hospital administrator told Human Rights Watch that promoting access to longer-acting methods was not a government priority. “Women continue using the same flawed methods … which are … less safe than long-term methods like the IUD or implants.”[213] He also noted that some government-supported hospitals in more remote municipalities are run by religious institutions that will not provide IUDs to women, further decreasing access to these methods for women far from main urban centers.[214]

In addition, one official from the Pernambuco Secretariat of Health told Human Rights Watch that aside from the copper IUD, other long-acting reversible contraceptives are not available through the public health system.[215] In April 2016, the Ministry of Health decided not to include implants as a choice of contraceptive methods available in the public health system to adolescents between age 15 and 19, citing both the lack of scientific evidence of the effectiveness of this method compared to other available methods and the greater financial impact.[216]

Maria Carolina, a 21-year-old woman in Paraíba state, was prescribed a low-dose contraceptive pill to use while she was breastfeeding her first child, but her provider did not inform her that the pill would not be effective if she stopped breastfeeding, and she became pregnant. When her second child, a girl with Zika syndrome, was born in early 2016, she requested an IUD in the city where she lives, but she was told it would take four months to obtain one. “In my city, they have condoms, sometimes injections, but not the IUD,” she said. “No one speaks about it.”[217] Several women who were raising children with Zika syndrome told Human Rights Watch they were on waitlists to access IUDs through the public health system.[218]

Some women also faced obstacles when trying to access voluntary sterilization. Luna, a 25-year-old woman in Pernambuco, told Human Rights Watch that she “went crazy” and “was desperate” when she became pregnant after her hormonal birth control failed, but she adjusted to the pregnancy.[219] Luna said she requested a tubal ligation after delivering her son, a boy with Zika syndrome, but she faced bureaucratic hurdles. She was told she would need to visit the social assistance office at a specific time to request permission to have a tubal ligation. As a single mother caring for a child with a disability, these additional steps created undue obstacles to accessing the procedure. Her baby was 9 months old when she spoke to Human Rights Watch, but she still had not been able to get the procedure.[220]

Aline, 33, had three children, including a boy with Zika syndrome. When her youngest was one month old, she requested a tubal ligation, but she remained on a waiting list 11 months later. She said she experienced difficult side effects from hormonal contraception, and she was frustrated with having to wait for the procedure. “The moms who have babies with Zika syndrome should have access to get their tubes tied because we can’t have more kids,” she said, explaining that she had to be with her baby 24 hours a day. “I don’t have time to take care of another baby. The moms can’t do it.”[221]

Access to Full and Accurate Information and Services for Pregnant Women

More than a year into the epidemic, Human Rights Watch interviewed many pregnant women and girls who did not have access to the information and support they needed to protect themselves from Zika during pregnancy. Brazil’s government should ensure pregnant women and their partners have full and accurate information and services to prevent Zika virus transmission during pregnancy, including related to the sexual transmission of Zika.

Insufficient Information on Zika during Prenatal Clinical Visits

Almost all the women and girls we interviewed who were pregnant or had recently given birth had access to prenatal care, most often through the public health system. During their pregnancies, most of them had regular appointments with medical providers, but most interviewees were not receiving comprehensive information about Zika transmission and prevention during their prenatal visits.

A few women told Human Rights Watch they did not receive any information about the Zika virus during their prenatal care. Most of these women had heard about Zika through media reports and had access to other sources of information, but they described feeling uneasy that they had not received reliable information from medical professionals. For example, Karina, a 34-year-old woman who was 37 weeks pregnant when she spoke with Human Rights Watch in Paraíba state, said no one had given her any information about Zika at all during her prenatal appointments at a hospital serving high-risk patients. “They should have informed us. There are so many doctors and students here. They could take time to give information. I was using repellent because I knew [about Zika], but I didn’t have information on how often to use it.” Karina said she had stopped using repellent near the end of her pregnancy because she stopped hearing about Zika in the news, so she believed the epidemic was over.[222] Jessica, a 24-year-old woman in Pernambuco state who was eight months pregnant when she spoke to Human Rights Watch, said there were signs about Zika posted at the local health center where she had prenatal visits, but she had not been given any information by providers. “There should be a conversation,” she said. “I know about Zika, but not everyone knows about it.”[223]

Jessica, a 24-year-old woman who was eight months pregnant when she spoke to Human Rights Watch, points to standing water in her community outside Recife, Pernambuco state. She said there were signs about Zika posted at the local health center where she had prenatal visits, but providers did not give her any information. “There should be a conversation,” she said. “I know about Zika, but not everyone knows about it.”

© 2016 Margaret Wurth/Human Rights Watch

A 2016 survey of more than 3,000 pregnant women in Brazil conducted by the Patrícia Galvão Institute found one-third of respondents had not received any training on Zika virus prevention during their prenatal care.[224]

There have been efforts to address this gap through the federal and state government protocols. And in July 2016, UNICEF launched the program “Networks of Inclusion” in partnership with governments at the three levels, civil society organizations, PAHO/WHO, the private sector, and other institutions. Taking place in Campina Grande and Recife, the project supports pregnant women, families, and caregivers; trains health, education, and social workers; and promotes integral and integrated care.[225]

Most pregnant women and girls said their providers gave them basic information about the Zika epidemic and encouraged them to wear repellent, but very few received basic information about the sexual transmission of Zika. Though Zika is transmitted primarily through the bite of an infected mosquito, the virus can also be transmitted through sex.[226] Evidence suggests that Zika remains in semen for many months, but public information provided by the Ministry of Health in Brazil does not provide comprehensive information to couples who are pregnant, or wanting to become pregnant, about the risk of sexual transmission. In a list of frequently asked questions about the Zika virus, the Ministry of Health provides contradictory information about the sexual transmission of the virus, stating at one point, “the virus cannot be classified as sexually transmissible,” and stating later, “there is growing evidence that the virus can be sexually transmitted.”[227] The first two national protocols developed in response to the epidemic recommend women of reproductive age and pregnant women, along with their family members, take protective measures against mosquito bites, but they did not mention the risk of sexual transmission or recommend pregnant women and their partners use condoms to prevent the sexual transmission of Zika.[228] However, the most recent version of the protocol includes a recommendation on the use of condoms during pregnancy.[229]

Roughly one-third of the women and girls we interviewed who were pregnant or had recently given birth did not know that Zika could be transmitted sexually, and therefore were not taking steps to prevent the sexual transmission of the virus during pregnancy. When Human Rights Watch spoke with 16-year-old Clarice, who was eight months pregnant with her first child, in Paraíba state, she said she had never heard that Zika could be transmitted sexually. “This is the first time I heard about it,” she said, shaking her head in disbelief.[230]

Others that Human Rights Watch interviewed had learned about the sexual transmission of Zika on the internet or on television, but without comprehensive information, very few were consistently using condoms with their sexual partners to protect themselves.[231] According to guidance from the World Health Organization, “To prevent potential sexual transmission of Zika virus, sexual partners of pregnant women, living in or returning from areas of ongoing Zika virus transmission, should correctly and consistently use latex condoms for sexual activity for the duration of the pregnancy.”[232]

Long Waits and Problems Accessing Sonograms and Zika Diagnostic Tests

Some pregnant women and girls interviewed by Human Rights Watch believed, or feared, they had been exposed to Zika, but had difficulty accessing the sonograms and diagnostic tests they needed to find out if their pregnancies could be impacted by the virus.

Many women said there were long waits for sonograms through the public health system, and this contributed to their fear and anxiety around Zika, particularly for those who were unable to go to private providers. For example, Júlia, 23, gave birth to her youngest child in July 2016. She said she was very concerned about Zika during her pregnancy. “I was worried and I felt I couldn’t do anything to prevent something from happening to my baby. I wore pants, long sleeves, repellent. I stayed at home, indoors,” she said, but she lived in a community with standing water and open sewage, where her neighbors had gotten Zika and other mosquito-borne illnesses.

Though she started prenatal care when she was three months pregnant, she was told she could not get a sonogram through the public health system for several months. “I started my prenatal care at three months, but since then, the health unit was not scheduling sonograms. It was booked, so they weren’t scheduling more sonograms, and I didn’t have the means to pay for a private one … I was very angry and worried for the baby.” When she was four months pregnant, she started to feel pain and went to the emergency room, where they did a sonogram and identified a complication with the fetus. Seven months into the pregnancy, she got chikungunya. But she was not able to get another sonogram through the public health system until the end of her pregnancy. “I had the [second] sonogram at nine months—the week I gave birth.”[233] Thankfully, her baby was born healthy.

In addition, some women and girls told Human Rights Watch they were unable to access specialized second-trimester sonograms that detect differences in fetal development, including microcephaly (fetal anomaly scans, or in Portuguese, ultrassom morfológico), through the public health system. Alana, a 26-year-old woman in Pernambuco state who was six months pregnant with her first child in October 2016, told Human Rights Watch she lived in a neighborhood with poor sanitation and standing water, and that there were many mosquitos in her home. She said she was “enormously” concerned about Zika, but could not get a detailed fetal anomaly scan through the public health system, and had to pay to get one done at a private provider. “It caused a lot of worry,” she said. “We really wanted a more detailed ultrasound to see if the baby had any disability, if there was any problem with the baby.”[234]

The World Health Organization’s guidance on pregnancy management in the context of the Zika epidemic recommends, “Regardless of a history of illness consistent with Zika virus infection, all women in areas of ongoing Zika virus transmission should be requested to have a fetal anomaly scan between 18 and 20 weeks or at the earliest possible time if the first visit occurs after 20 weeks.”[235]

Other women had difficulty obtaining Zika tests or test results when they went to medical facilities presenting symptoms of the virus during their pregnancies. Human Rights Watch interviewed Lorena, 22, when she was six months pregnant with her first child. During her first trimester, she got a rash, fever, joint pain, and other symptoms, but when she went to the hospital in her town in Paraíba state, she was told there were no diagnostic tests for Zika available, even though she informed the providers that she was pregnant. “I don’t know which [virus I had] because I didn’t do a blood test,” she said. Up to that point, her sonograms had not shown any anomalies, but Lorena lacked clarity about whether she had been exposed to Zika or another virus.[236]

Vitória, who had just given birth to a healthy baby girl when Human Rights Watch interviewed her in Paraíba state in October 2016, said she went to a hospital with a fever, rash, and other symptoms in the first trimester of her pregnancy. “They did a blood test,” she said, “but they didn’t give us the results.” Vitória said it would have cost R$1,000 for her to pay for a Zika test, so she continued the pregnancy uncertain about what virus she had. “It wasn’t a very easy pregnancy because I didn’t know how the baby would be born. Even the ultrasound doesn’t show real problems that can be there when the baby is born. I cried all throughout the pregnancy. … It’s torture. You have all the doubt and it can only be resolved when the baby is born,” she said.[237]

A recent survey of more than 3,000 pregnant women in Brazil conducted by the Patrícia Galvão Institute suggests many would like to have greater access to testing and sonograms during their pregnancies. The survey found 90 percent of respondents would like to be tested for Zika during pregnancy if they had access to the exam. In addition, 70 percent of respondents accessing prenatal care through the public health system said they would like to have more ultrasounds.[238]

The World Health Organization recommends testing for Zika virus infection for “pregnant women presenting with a history of Zika virus disease symptoms or signs.”[239] The Ministry of Health has allocated resources to state and municipal secretaries for rapid pregnancy tests and to allow women access to second sonograms in the seventh month of pregnancy.[240] It allocated enough for 2.1 million sonograms to be carried out around the 30th week of pregnancy, claiming this is sufficient to meet demand but not providing a time frame.[241] Municipal and state authorities confirmed that they had either hired or trained sonographers or gynecologists to perform diagnostic sonograms between 32 and 35 weeks (or at approximately 33 weeks) of pregnancy.[242]

Zika notification is made based on clinical diagnosis. Health professionals do not have to wait for laboratory results; however, that can mean Zika cases may be diagnosed as dengue or chikungunya.[243] Laboratory tests can confirm the diagnosis, but during epidemics only about 10 percent of suspected cases sent to the labs can be processed, due to resource constraints. Pregnant women are prioritized, according to one Pernambuco Secretariat of Health official.[244]

Difficulty following Recommendations for Pregnant Women

The World Health Organization recommends that pregnant women take several measures to protect themselves from Zika, including “wearing clothes that cover as much of the body as possible,” using mosquito bed nets and screens in homes, and using insect repellents consistently. Few pregnant women who spoke with Human Rights Watch could implement these measures fully, due to both financial and practical constraints. As mosquito repellant is a significant element in Brazil’s response to preventing transmission of Zika during pregnancy, the authorities should provide repellent to women in the public health system to eliminate barriers that prevent pregnant women from using repellant consistently throughout their pregnancy.

Many women told Human Rights Watch they tried to cover up with long pants and long-sleeved shirts, but found it difficult in the high heat of the summer, when Aedes mosquitos are most abundant.[245] Only a few women said they had mosquito nets or screens in their homes.

Many pregnant women, particularly those from low-income households, said they did not have the means to purchase mosquito repellent for everyday use during their pregnancy. Interviewees told Human Rights Watch that a bottle of repellent cost around 20 reais (approximately US$6.50) and typically lasted about two weeks. Very few interviewees said health facilities or governments distributed repellent free of charge. As a result, most pregnant women and girls used repellent inconsistently during their pregnancies, and some did not use it at all.

For example, Rebeca, 25, who was four months pregnant with twins when she spoke to Human Rights Watch, cleaned windshields at a stoplight in Recife for work and earned between 10 and 30 reais per day—the only income she had to support herself and her 2-year-old son. She lived in a run-down neighborhood with open sewage and standing water, but she was unable to wear repellent. “I don’t use it because I can’t afford it,” she said, explaining that she used a fan to try to keep mosquitos out of the house.[246]

A 25-year-old pregnant woman stands near uncovered water storage containers in her home in a run-down neighborhood in Recife, Pernambuco state. She showed Human Rights Watch how sewage flowed directly into the streets in her neighborhood and how dirty, standing water accumulated in areas near her home. “People don’t care how we’re living here,” she said. She said she could not afford to purchase mosquito repellent to protect herself from the Zika virus during her pregnancy.

© 2016 Margaret Wurth/ Human Rights Watch

Other women said they were only able to purchase repellent some of the time. Débora, 19, had given birth to a baby boy three weeks before she spoke with Human Rights Watch in her community in Recife. She had chikungunya when she was two months pregnant, and her providers told her to wear repellent to protect herself from Zika, but she said she could not get as much as she needed: “Sometimes I didn’t have the money, especially when I wasn’t working. … I was scared he [the baby] might be born with microcephaly.”[247]

In late 2016, the Ministry of Health announced plans to provide repellent free of charge to nearly 500,000 pregnant women enrolled in the Bolsa Familia cash transfer program,[248] a step that could help expand access to the most vulnerable populations.

Mothers of Children with Zika Syndrome Need Comprehensive Support

Mothers raising children with Zika syndrome told Human Rights Watch they faced obstacles in accessing adequate information and support, both at the time of delivery and as their children grew and developed. The thousands of children born with Zika syndrome in Brazil will need long-term support and care. Their primary caregivers are often women whose lives are profoundly affected by having children with disabilities. Brazil’s government should provide sustained support for the short- and long-term services that will allow children affected by the virus, and their family members, to live with dignity.

Barriers in Accessing Services for Children with Zika Syndrome

The Ministry of Health recommends that children with Zika syndrome from birth to the age of 3 be referred for early stimulation programs offered through the public health system, and receive auditory, visual, motor, cognitive, communicative, and manual stimulation services.[249]

In some instances, cities such as Recife in Pernambuco and Campina Grande in Paraíba have also provided additional resources to ensure services for children born with Zika syndrome. Recife inaugurated a child development unit in late 2015 focused on children with microcephaly—with pediatricians, pediatric neurologists, occupational and speech therapists, psychologists, and social assistants.[250] Campina Grande, in Paraíba, took the lead in the state by creating a health service specialized in microcephaly, comprising prenatal care, psychological support, and rehabilitation services. It is one of the three cities in Paraíba—the others are João Pessoa and Patos—providing services to children with microcephaly and supporting their families.[251] The municipality also trained the staff of the public day care centers to provide care to these children.[252]

Many children suspected of having Zika syndrome remain without a confirmed diagnosis. In April 2017, there remained 3,236 cases under investigation in Brazil.[253] Without a diagnosis, some children affected by Zika may not have access to early stimulation and specialized rehabilitation services. In March 2016, the federal government grew concerned that confirmation of diagnosis did not quickly follow after suspected cases were first reported, and transferred R$10.9 million (US$3.4 million) to states and municipalities to expedite confirmation of diagnosis in children with suspected Zika syndrome.[254] Some suspected cases seem to have fallen through the cracks. An official in the Secretariat of Health explained the situation in Pernambuco:

[W]e have 238 babies [under investigation] that need to be found … and diagnosed. Some of them are waiting for [test] results, but the majority are babies that we could not locate. … The largest municipalities face the most difficulties locating the babies…[255]

Even a confirmed diagnosis does not guarantee a child is receiving services. As of April 2017, out of the 2,653 confirmed cases, 41.8 percent were receiving early stimulation and 57.4 percent specialized rehabilitation services.[256] A Ministry of Health official told Human Rights Watch that the same child may access both types of services, depending on the degree of severity of the syndrome as manifested. Also, only 51.6 percent of the children with Zika syndrome are accessing standard primary pediatric care, including vaccines.[257]

Most of the mothers interviewed by Human Rights Watch said their children received some, or most, of the services they needed, including physical and occupational therapy and consultations with various specialists.[258] However, some mothers of children affected by the virus said they struggled to access the services their children needed due to the centralization of providers in urban areas, unreliable transportation, and government bureaucracy. Some mothers also struggled to access financial benefits from the government to help cover their children’s needs.

Mothers in both Paraíba and Pernambuco who lived in rural areas or small towns said services for their children were limited outside of urban centers. State health authorities and providers acknowledged that the specialized services for children with Zika syndrome are concentrated in referral centers in big cities. Luciana Albuquerque, executive secretary of health surveillance for the state of Pernambuco, said that initially there were only two institutions, both in Recife, attending children with congenital Zika syndrome. Since then, although the list of institutions has increased to 27 in the whole state, two health regions out of the 12 into which Pernambuco’s territory is divided remain uncovered and still do not offer Zika diagnostic and rehabilitation services.[259] Pernambuco’s plan for 2017 is to expand these services to both regions.[260] Dr. Danielle Cruz, a pediatrician in Recife caring for babies with Zika syndrome, described the “lack of professionals available in the countryside of Pernambuco and in the small cities. … We are trying to provide the best services we can, to use our resources efficiently. Even before the [Zika] crisis, we had a deficit in the provision of pediatric services. We didn’t have enough physical therapists, occupational therapists, and speech therapists specializing in children even before the crisis. Can you imagine how it is now?”[261]

As a result, many mothers said they regularly made long commutes to referral centers in larger cities to access services for their babies. The process was onerous for many of them. Rafaela, 35, lives three hours from the city in Paraíba where her youngest child, a boy with Zika syndrome born in November 2014, receives services. “Here in the center [in Campina Grande] we have all the infrastructure required. But in my town, we don’t have anything,” she told Human Rights Watch. To make it to her son’s appointments, she said she woke up at 3 a.m. and left the house at 4 a.m.[262] Even services that should be available in local health centers may not be consistently administered to children with Zika syndrome—namely standard pediatric care, such as vaccines. Municipal health officials told Human Rights Watch, “Primary care staff are still scared, unsure about how to proceed, they are afraid of vaccinating the babies. Sometimes we observe the vaccination schedule is behind...”[263] As a result, mothers are bringing children from other municipalities to be treated for even basic pediatric care at specialized facilities, or they are having to make multiple trips when one is all that is warranted. One mother explained that her son receives his vaccinations in a local health unit in her community, “However, they don’t vaccinate him as they should. He should get four vaccines in one day, but he didn’t. He had to visit the unit four times, once a week.”[264]

For many mothers, the challenge of traveling long distances to access services for their children was compounded by unreliable and disorganized transportation provided by local governments. Many women interviewed by Human Rights Watch said the transportation services they were entitled to were not always available, and accessing them required time and persistence with local bureaucracy, an extra burden many mothers struggled to manage. Rafaela explained, “Last week, I couldn’t come because there was no transportation available. To be here today, I had to fight for two days at the municipal secretariat. Otherwise, we wouldn’t be here.”[265]

Fernanda, a 23-year-old woman with two children, including a boy with Zika syndrome born in December 2015, lives an hour from the city where her son receives treatment. She said she often waited hours for transportation to her son’s appointments, even though she always notified local authorities well in advance. “Two times we arrived here, but late, so we didn’t get the appointment.” She also said she often waited hours to be picked up after her son’s therapy sessions.[266]

“I missed some appointments because we didn’t have transportation,” said Stephanie, 26, who lives an hour outside of the city in Paraíba where her daughter receives services. “There were situations where we waited a long time and the car didn’t come.” Stephanie’s daughter was on a waiting list for a special respiratory therapy offered at a state university. When the university had an appointment available, she was unable to take it because the municipal authority could not provide transportation at the designated time. She was still waiting for the treatment at the time she spoke with Human Rights Watch. Stephanie also said she often waited hours for a ride home after her daughter’s appointments. “I could get home at 3 [p.m.] but I get home at 7 p.m. because they are so disorganized with the transportation.”[267]

When local governments were unable to provide transportation, mothers said they had to scramble to raise funds and organize other transportation.[268] Small municipalities may face many demands in ensuring all people needing specialized services reach referral facilities in urban centers. However, the frequency with which children with Zika syndrome must attend appointments means that resource constraints are more than a minor inconvenience—they can be a weekly or even daily problem. Municipalities should work with mothers of children with Zika syndrome to make even limited transportation services more responsive to their needs.

Some women interviewed by Human Rights Watch also faced challenges getting needed authorizations from local officials to access exams and services that were only available in institutions in larger cities. For example, Antonella, a 34-year-old grandmother and caregiver of a baby with Zika syndrome born in March 2016 in Pernambuco, lives an hour from Recife, where the baby receives specialized service. To schedule appointments at the reference centers in Recife, Antonella or her daughter have to request authorization from the health secretariat in their town. “It’s difficult to schedule appointments because the doctor prescribes it, and we have to go to the health secretariat in [our town],” she said. “We wait months for a free spot.” An ophthalmologist had requested to see Antonella’s granddaughter when she was six months old, but due to the bureaucratic process, the baby could not get an appointment until she was almost one year old.[269] Stephanie, a mother in Paraíba, told Human Rights Watch she had a similar experience. “We should have access to these services in our own town,” she said. “Accessing the exams is a lot of bureaucracy.”[270]

Providers confirmed that many families from rural areas encountered difficulties accessing transportation and authorizations from local officials, at times causing their babies with Zika syndrome to delay treatment or miss appointments.[271]

Some mothers also had difficulty accessing federal financial benefits for their children with Zika syndrome. Under federal law, any family with an elderly person or a person with a disability is entitled to a monthly salary, equivalent to the federal monthly minimum wage (R$937 or US$297), if total household income is less than one-quarter of the minimum salary per person, per month.[272] There can be only one such benefit payment per family, even if there are multiple family members meeting the criteria. Under a federal law approved in 2016, all children with microcephaly resulting “from diseases transmitted by the Aedes aegypti mosquito” are entitled to access the financial benefit (BPC or Benefício de Prestação Continuada) for a period of three years, if their families meet the criteria.[273]

Many families receiving the financial benefit said it was not sufficient to cover the costs associated with caring for their children with Zika syndrome. Olívia has a baby with microcephaly born in June 2015, and a 6-year-old with autism, but her family receives only one minimum salary. “The minimum wage is nothing,” she said. “It doesn’t meet our needs. Special children need special foods, and even if the government provides us with transportation and health care, the mothers can’t work, can’t study. We don’t have possibilities or normal life.”[274] A father of a child with Zika syndrome, Lucas, said, “I think [the minimum wage salary] is low for him [my son], for his needs, because it is one minimum wage for everything that happens in his life and there is still the family. … My wife had to quit her job to take care of him.”[275]

A pediatrician caring for 150 children with Zika syndrome in Pernambuco explained that some of her patients have to pay out of pocket for special medications that the public health system does not yet cover. She described how one medication she prescribes to children with Zika syndrome for reflux cost R$100 (US$31) and lasted one month. “The minimum wage is not enough to cover their needs,” she said.

“It’s not enough, but it’s what we have,” said Aline, a 33-year-old mother of three, including a baby with Zika syndrome born in Paraíba in September 2015. “We have to manage somehow.”[276]

Impact on Women’s Lives

Among the families interviewed by Human Rights Watch, the primary caregivers of children with Zika syndrome were overwhelmingly the mothers, and the demands of caregiving affected their lives profoundly. Many women and girls said they were unable to continue going to work or school while caring for their babies. Of the 26 mothers of babies with Zika syndrome interviewed for this report, only four said they were able to continue paid work or study after their children were born.[277] While some women may have chosen to discontinue paid work after their children were born anyway, some took parental leave from work with the intent to return after the extent of leave was exhausted. Others were self-employed and had intended to continue with this form of employment, but said they were unable to. Many of the women said it put a financial strain on the family that they could not continue paid work.

Lídia, a 34-year-old mother with five children, calls her youngest son—a boy with Zika syndrome born in Paraíba in December 2015—her “prince.” She explained that she had to stop working after the boy was born: “I was a daily maid at four houses, cleaning the houses, but to take care of his treatment, it’s a lot of things to do. I couldn’t take care of him if I was working.”[278]

Human Rights Watch interviewed Luna, 25, while she sat with her two children waiting for an appointment with a pediatrician. She told Human Right Watch it was “impossible to reconcile” work and taking care of her son with Zika syndrome, who was born in Pernambuco in December 2015. “He has four to five physical therapy sessions a week,” she said. “No company will grant me that much time off.”[279]

Similarly, Evelyn, 18, said there was no way for her to return to school after her second daughter, a baby with microcephaly, was born in Pernambuco in March 2016. “There are no classes at night,” she said. “I can’t go [to school] during the day because I have to take care of her.”[280]

Another mother told Human Rights Watch she worked as a receptionist at a lab until her daughter was born in Pernambuco in October 2015: “When I got back from maternity leave, I worked for one month, but I had so many appointments for [my daughter]. After one month, I was fired.”[281]

The few mothers who were able to work while raising children with Zika syndrome said they negotiated with their employers to get the flexibility they needed, but they struggled to balance work and caregiving. “The routine is very demanding,” said Ines, a 33-year-old elementary school teacher and mother of two, including a baby with Zika syndrome born in March 2016. “There are nights without sleep.”[282]

Some women told Human Rights Watch that caring for their children with Zika syndrome affected their relationships with their partners and other children. Monica, who often travels six hours round-trip to appointments with her daughter, worries that she never has a time to see her 6-year-old daughter. “My aunts care for her. In the beginning it was really hard.”[283] Jusikelly, a 32-year-old mother of five children, said the birth of her baby with Zika syndrome in November 2015 made it difficult for her to care for her older children. “My 3-year-old was potty-trained before the baby,” she said. “Now she isn’t.”[284]

In addition, almost all the mothers of children with Zika syndrome interviewed for this report had experienced what they felt was a form of prejudice or social stigmatization. Many felt they were not provided with sufficient information or psychological support after delivery of babies with Zika syndrome to navigate the early weeks of their infants’ lives.

Jusikelly, 32, holds her daughter, a girl with Zika syndrome born in November 2015, in their home in Pernambuco state. She told Human Rights Watch she was unable to continue working when her daughter was born, and her family struggles financially. “I used to work. We had hard times, but not like today.” Jusikelly said the family receives a financial benefit equivalent to the federal monthly minimum wage (R$937 or US$297), but her daughter’s medications cost nearly double the benefit (R$2000). “Where do I find the rest? We pay rent. I have other kids… It is a very big impact."

© 2016 César Muñoz Acebes/Human Rights Watch

Some of the women and girls interviewed by Human Rights Watch first received the news of an anomaly in their child’s development at the time of delivery, and the experience with how doctors and nurses treated them then had a profound psychosocial impact on many of them.[285] These mothers said the hours and days following the birth of their babies were

characterized by tremendous anxiety, uncertainty, and doubt, but many of them were not given full information about their child’s diagnosis or psychological support or counseling to help them cope with difficult news.

Rafaela, a 35-year-old mother of four in Paraíba, said that shortly after she delivered her youngest son in November 2014, the doctor informed her that her baby had microcephaly, but did not tell her what the diagnosis meant. “It’s like they throw you a bomb, and you don’t know how to deactivate it,” she said. “I asked the doctor, ‘What’s going to happen? What will the consequences be?’ The doctor said, ‘if it’s microcephaly he won’t be able to walk, maybe he’ll be blind. He’ll be useless. He won’t be able to do anything.’ I felt rejected, like the worst person in the world. But I also felt very angry. … I started looking [for information] on the internet with my phone. I read that he wouldn’t be useless. … I didn’t receive any support or information.”[286]

Most mothers regularly faced insensitive and uninformed questions and comments about their babies from members of the public. The cumulative effect of many small incidents weighed on the mothers. Jacqueline Ioureiro, a psychologist working with mothers of children with Zika syndrome in Paraíba, explained, “At the moment, the mothers and the babies are really close—they are almost inseparable—so it’s hard to say if the prejudice is directed to the baby or to the women, but it is the women who suffer from that prejudice the most. It makes them angry, and tired.”[287]

Fears about the Future

Many mothers we interviewed expressed fears and doubts about what the future would hold for their children with Zika syndrome. They articulated anxiety about how their babies would grow and develop and what they would need, particularly given the scientific uncertainty about the long-term effects of Zika syndrome. Others expressed concerns around access to services, education, and the state’s ongoing commitment to support families raising children affected by the epidemic.

For example, Mayara, who gave birth to a boy with Zika syndrome in January 2016, said her hope for the future was, “That it will be more inclusive and welcome for babies and kids that will grow up with special needs—the schools, the health system. These issues have been around for a long time.”[288] Other mothers explained that they did not know whether their babies would ever be able to walk or talk, so they did not know what kind of long-term care they would need.[289]

Some mothers expressed concern that the financial benefit for their children would only be provided for three years. “The disability will not disappear when she’s three,” said one mother of a child with Zika syndrome in Paraíba.[290]

Several mothers said they worried about access to education for their children in the future. Crislene, a 27-year-old mother of a baby with Zika syndrome in Pernambuco, said, “I’m afraid because nowadays we see that they do not have schools prepared to receive special children, not only with microcephaly but with other needs.”[291] Luna said she hoped there would be kindergarten classes to accommodate her son when he was ready to begin school. She said she and other mothers needed a place “where we can leave them and be sure that they’ll be well-treated, so we can also continue our lives.”[292] It was beyond the scope of this report to evaluate whether Brazil’s public education system was prepared to provide inclusive education to children with Zika syndrome as they reach school-going age.

Some providers expressed concerns about their institutions’ long-term financial and operational capacity to serve the needs of children with Zika syndrome. Providers told Human Rights Watch there were too few institutions providing services to children with disabilities, particularly in rural areas, and existing institutions lacked financial resources and personnel to serve all the families in need, resulting in long waiting lists and centralization of services in urban areas. One therapist told Human Rights Watch that these problems “existed prior to the Zika epidemic, but they have become worse due to the increasing demand.”[293]

Some providers also worried about the mothers’ ability to maintain the demands of caregiving over the long-term. Providers in Pernambuco told Human Rights Watch how the “hectic routine of sessions and medical appointments” strained both mothers and children, particularly those traveling long distances to access services.[294] Susana, a mother of a boy with Zika syndrome, raised concerns about how she will continue to be able to carry him on the bus, around her neighborhood, and to appointments as he grows.[295] A physical therapist serving children with Zika syndrome in Paraíba said she already observed many mothers exhibiting signs of fatigue: “It makes me worried. If they [the mothers] are tired and exhausted after three months or four months, how will they feel after three years or four years?”[296]

Their fears and concerns are particularly relevant as Brazilian authorities enact fiscal austerity measures that may decrease funding for public health, education, and other services that could help children with Zika syndrome, and their caregivers, have the best possible quality of life in the long-term.

In December 2016, the National Congress approved a constitutional amendment freezing public spending for a period of 20 years, adjusting only for inflation. Before the amendment was passed by Congress, the Oswaldo Cruz Foundation (Fiocruz), a public research and health technology institution, published a letter to the federal government and National Congress warning that the proposed amendment, if approved, “would result in significant harm to people's health and life.” Fiocruz raised particular concerns regarding how the amendment could affect Brazil’s capacity to respond to Zika and other epidemics: “The question is: how to ensure control of epidemics such as Zika, dengue and chikungunya, including research, assistance, vector control, medicines, and necessary vaccines, with a freeze on resources? In particular, the impact on research, fundamental to new products and new solutions that are already underfunded in our country, will be incalculable, compromising in the long-term the capacity for response and national autonomy.”[297]

The United Nations special rapporteur on extreme poverty and human rights, Philip Alston, called the bill “a radical measure, lacking in all nuance and compassion.” He added, “It will hit the poorest and most vulnerable Brazilians the hardest, will increase inequality levels in an already unequal society, and definitively signals that social rights are a very low priority for Brazil for the next 20 years.”[298] The constitutional amendment took effect in early 2017, and further austerity measure remain under discussion by the government and National Congress.

Engaging Men and Boys in Prevention and Parenting

Much of the public response to the Zika virus epidemic has focused on women, particularly pregnant women and mothers of children with Zika syndrome. A doctor we interviewed in Pernambuco provided a critical analysis of the problem: “It is a patriarchal culture for which the woman is responsible for getting pregnant, and [responsible] if there is a complication.”[299]

Men and boys have an important role in both combatting the spread of the disease and ensuring that children with Zika syndrome have the best access to services and high quality of life. Brazilian authorities at all levels should take steps to ensure that policies aimed at preventing unplanned pregnancy, preventing Zika and other sexually transmitted infections, and caring for children with Zika syndrome do not reinforce harmful, gendered notions about men’s and women’s responsibilities within intimate relationships, families, and households.

Role of Men and Boys in Preventing Zika Transmission and Unplanned Pregnancy

As described above, Zika can be transmitted sexually, both through vaginal and anal sex.[300] Although it is still uncertain how long the risk of sexual transmission remains after infection, scientists detected Zika virus RNA in men’s semen up to six months after the onset of symptoms, and with a higher viral load than what was found in urine, saliva and plasma samples.[301]

Both men and women interviewed by Human Rights Watch did not know that Zika could be transmitted sexually. “I do not think it is transmitted like that,” said one 40-year-old man interviewed in Pernambuco. “You can get AIDS, syphilis, and gonorrhea, but not Zika.”[302] A 27-year-old man in Pernambuco whose partner was pregnant with their fourth child, said, “I don’t know how Zika is transmitted because people never explained it to us here.”[303] Without comprehensive information on the risks, many interviewees said they or their partners were not consistently using condoms during pregnancy.[304]

Sueli Valongueiro with Grupo Curumim, a nongovernmental organization that does education and awareness-raising initiatives around Zika and human rights in northeastern Brazil, told Human Rights Watch she was not aware of any initiatives focused on men and preventing the transmission of Zika and other sexually transmitted infections. She said, “We have been working on raising awareness about sexual and reproductive health and rights and the Zika virus with nurses in the primary care network and in hospitals in two municipalities, as well as with women, adolescents, and young people. The testimonies given during our meetings evidence the need for a state intervention that improves the quality of the information [provided] in the [health] services and for the population related to the transmission of the Zika virus through bodily fluids.”[305]

The absence of information and guidance on the role of men in Zika prevention reinforces the idea that women are solely, or primarily, responsible for preventing Zika transmission during pregnancy. As one academic told Human Rights Watch, the narrative around the mothers with children with Zika syndrome has been to focus on their sacrifice, forcing them to maintain this image of saintly women, instead of talking about their rights.[306] In this narrative, fathers are not discussed, or worse, a narrative that men are abandoning their partners and children born with Zika syndrome is perpetuated as absolute.

Brazilian authorities should ensure that public education and individual counseling engage couples and men, and do not single out pregnant women alone to bear the burden of preventing transmission during pregnancy.

Brazilian authorities should also take steps to ensure that men and boys have access to the information and services needed to make fully informed decisions with their partners about family planning options. This was a challenge for some families Human Rights Watch interviewed. One family with a child with Zika syndrome discussed the need for the government to help fathers access vasectomies as a permanent family planning option. Susana, 25-year-old mother of two, was breastfeeding her first child and on a low-dose contraceptive when she became pregnant with her son, who was born with Zika syndrome. At the hospital in Pernambuco, she did not receive counseling on family planning, so she and her husband went on the internet to research options. The couple decided that a vasectomy was the best option for them, but when he asked for the procedure at the hospital, he was told it had been suspended for budget reasons. Tubal ligations had not been. “My husband wanted to do this, for us. But they said the procedure was suspended. I will get a tubal ligation now, but it would be much easier for him. We don’t have that option, so now I worry a bit. I will have to stay in the hospital overnight, and it might be a tough recovery.” For now, the couple is relying on condoms as their only method of contraception.[307]

Another mother of a child with Zika syndrome told Human Rights Watch that her husband was unable to access a vasectomy through the public health system in the town in Paraíba where they lived. Through a private provider, they would have had to pay R$3,000 (US$920) for her husband to get the procedure, which was more than the family’s entire monthly income.[308] While these experiences do not constitute a pattern of neglect, they do demonstrate that at least in some cases, partners may face difficulties pursuing family planning options that focus on men—namely vasectomies.

Fathers of Children with Zika Syndrome Need Support for Fuller Participation in Childcare

Women interviewed for this report and some of their male partners, spoke of the need for the authorities to support fathers as well as mothers in their efforts of rearing children affected by the Zika virus. Providers told Human Rights Watch that fathers needed additional support to actively participate in caregiving. It is challenging for authorities to ensure the provision of services to children with Zika syndrome and to address the logistical challenges faced by caregivers. To the greatest extent possible, however, they should take into consideration how to avoid reinforcing negative gender stereotypes in policies and programs that shift significant burdens for caregiving to women alone.

The few fathers we interviewed who have children with Zika syndrome expressed their desire to support their partners and be involved in caregiving for their children—but logistic and economic challenges made it difficult for them accompany their children to the near daily appointments they had at multiple health facilities. Mothers also consistently reported that they wanted more support from their partners, but similarly that logistics and the caregiving challenges related to the children with Zika syndrome made this difficult. Providers told Human Rights Watch that overwhelmingly women and girls brought their babies with Zika syndrome to appointments without the babies’ fathers. “It’s rare, the presence of the fathers,” said Jeime Leal, a physical therapist serving babies with Zika syndrome at a hospital in Campina Grande, Paraíba. She said that of the 115 patients she was treating, only four of them were regularly accompanied by their fathers.[309]

Yet, when we spoke to some fathers, they expressed a desire to help their partners and a need for greater support so they can participate more in caregiving. One father, Lucas, who was with his wife and child at a physical therapy appointment at a hospital in Recife expressed the need for more outreach to fathers with children with Zika syndrome, “The mothers are warriors. I think the fathers sometimes are absent, but the mothers are always here.”[310] Still, Lucas tries to accompany his wife and child to physical therapy sessions “When I am not working, I come with her.… Whenever I can, I am by her side, because I know how difficult it is.”[311] But, it is difficult for him to play an active role in helping his son access services, “The demand is high, there are a lot children, it always takes a lot of time … we arrive but we don’t know when we will be ready to go home.”[312] With this uncertainty, fathers who are employed have to take the whole day off from work or not go to the physical therapy sessions at all. Lucas is currently able to go because he is unemployed, but he does not feel like he should have to choose between being employed and helping his wife and son.

Human Rights Watch found that for the few fathers we spoke to many factors influence their lower participation in caregiving, some of which could be addressed with more inclusive policies and practices by the Brazilian authorities.

As discussed above, Human Rights Watch found that most mothers were unable to work or study while raising children with Zika syndrome. For some families, this meant that fathers were responsible for earning the sole source of income, making it complicated for men to try to negotiate with their workplaces to get the flexibility they would need to participate more fully in their children’s care. Human Rights Watch interviewed 27-year-old Gustavo, the father of baby with Zika syndrome born in early 2016 in Pernambuco, while he and his wife waited with their baby for an appointment with a doctor. “I am losing a day of work by being here,” he said. He operates machinery for a living, and his family survives solely on his income: “My wife worked before as a waitress, and the plan was for her to come back to work, but she cannot anymore,” he explained. Gustavo came to an agreement with his employer that if he provided documentation from the hospital of the baby’s visit, he could miss work without losing pay.[313] But other fathers did not have this option. Brazil’s labor laws do not protect employees whose children face health problems and require continuous care.[314]

Fathers of Children with Zika Syndrome Need Psychosocial Support

The mothers and fathers of children with Zika syndrome interviewed for this report said they often struggled emotionally and psychologically. Most of the mothers we interviewed had access to some kind of psychological or social support, through a trained professional, a support group, or informal social networks. Some did not think it was sufficient, but for the most part it was available. Some women said they felt their partners did not have adequate access to psychosocial support. The few fathers we interviewed expressed a need for greater support.

Rosalyn, 29, was 36 weeks pregnant when she spoke with Human Rights Watch in Paraíba. She had the Zika virus early in her pregnancy, and her providers had identified several complications in fetal development that they suspected were linked to the virus. The news had been distressing for Rosalyn and her husband. She had been offered psychological support at the institution where she was receiving specialized prenatal care, but she thought her partner needed additional support: “I would like it [psychological support] more for my husband. I have more information. I know more, but I’d also like to have it for him.”[315]

Fathers described fear and uncertainty when they learned their babies had atypical development. Gustavo, the 27-year-old father of baby with Zika syndrome born in early 2016, said, “It was very difficult at the beginning because I was going to have a special child and had no preparation whatsoever.”[316] Lucas expressed a similar feeling. “From the moment [we received the diagnosis] we started to analyze everything that will happen to us…. Since we visited the doctor and did the first tests, our struggle started and we continue struggling, every day more.”[317]

While many of the mothers raising children with Zika syndrome participate in support groups or are in good contact with other mothers, fathers have not connected with each other in the same way. Yet, some seemed interested in a more structured way to speak with other fathers. “Yes, I would be interested” in speaking with other fathers, Lucas told Human Rights Watch. “Sometimes I talk to other fathers while we are waiting at the hospitals, but it is not common. As I am shy, I don’t talk a lot.”[318]

Some fathers also said they struggled emotionally with the ongoing challenges of raising children with disabilities.[319] Men interviewed by Human Rights Watch seemed particularly concerned about providing the economic support their families needed, especially when their partners were unable to continue working.

“We are fighting to survive,” said Paulo, a 44-year-old father of six children, including a baby with Zika syndrome born in November 2015. The family had a bakery before their baby was born, but they sold it because Paulo was unable to manage it without his wife’s participation, and she was unable to continue working when the baby was born. “I feel insecure about our lives. If I die, I will leave nothing to my children. I need a psychiatrist. I cry a lot. I feel depressed. It’s related to our financial and psychological situation, to the family.”[320]

Gustavo said he had to spend almost his entire monthly salary on medications for his baby with Zika syndrome. “We rely on our family’s help to pay for food, water, and rent… It’s very stressful. At the end of the month I do not know how I am going to find the money to pay for his medicines.” Gustavo said the stress affected his relationship with his partner. “When there are 10 reais left at the end of the month, I cannot spend it to have an ice cream with my wife. We used to go out on weekends. Now we basically only take care of him [their baby with Zika syndrome].”[321]

III. The Brazilian Government’s Human Rights Obligations

Brazil is party to international treaties addressing access to reproductive health services, including safe and legal abortion, the rights to water and sanitation, and other social, economic and cultural rights, and the rights of children and adolescents—including the International Covenant on Economic, Social and Cultural Rights (ICESCR), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), the Convention on the Rights of Persons with Disabilities (CRPD), the Convention on the Rights of the Child (CRC), and the Protocol of San Salvador.[322] This section examines the Brazilian government’s human rights obligations as they relate to its response to the Zika epidemic, including its failure to meet its obligations related to women’s reproductive rights.

Access to Reproductive Health Services

Sexual and reproductive health and rights and government obligations are addressed in a number of international treaties and other authoritative sources.[323] Article 12 of CEDAW provides that “[s]tates parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning.”[324] The CEDAW Committee in its General Recommendation 24 affirmed states’ obligation to respect women’s access to reproductive health services and to “refrain from obstructing action taken by women in pursuit of their health goals.”[325]

The Zika epidemic has put sexual and reproductive health and rights at the epicenter of the crisis. The UN High Commissioner for Human Rights stated that “Upholding human rights is essential to an effective public health response and this requires that governments ensure women, men and adolescents have access to comprehensive and affordable sexual and reproductive health services and information, without discrimination.”[326]

Right to Information

The right to information is set forth in numerous human rights treaties.[327] CEDAW provides that states should provide women “[t]he same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights.”[328] The right to information requires the state to provide complete and accurate information necessary for the protection and promotion of rights, including the right to health.[329] Furthermore, the CESCR Committee in its General Comment 14 has stated that the right to health includes the right to health-related education and information, including on sexual and reproductive health.[330] It also noted that “[t]he realization of women’s right to health requires the removal of all barriers interfering with access to health services, education and information, including in the area of sexual and reproductive health.”[331] In its General Comment No. 22, the Committee notes that, “Information accessibility includes the right to seek, receive and disseminate information and ideas concerning sexual and reproductive health issues…. All individuals and groups, including adolescents and youth, have the right to evidence-based information on all aspects of sexual and reproductive health…”[332]

The CEDAW committee has also noted that, under article 10(h) of CEDAW, women must have access to information about contraceptive measures, sex education and family-planning services in order to make informed decisions.[333] It has said that specific attention is needed to ensure that adolescent girls “have access to accurate information about their sexual and reproductive health and rights.”[334] In the same vein, the Committee on the Rights of the Child has also called on states to ensure that children have access to reproductive and sexual education and information, including in schools.[335] In its General Comment No. 20, the CRC urged states to “adopt or integrate a comprehensive gender-sensitive sexual and reproductive health policy for adolescents, emphasising that unequal access by adolescents to such information and services amounts to discrimination.”[336]

Access to Safe and Legal Abortion

Authoritative interpretations of international law recognize that access to safe and legal abortion services is crucial to women’s exercise of their human rights, in particular rights to equality, life, health, physical integrity, the right to decide on the number and spacing of children, and to be free from cruel, inhuman and degrading treatment.[337]

Since the mid-1990s, the UN treaty bodies that monitor the implementation of the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights, the Convention on the Elimination of All Forms of Discrimination against Women, the Convention against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment, and the Convention of the Rights of the Child have produced a significant body of jurisprudence regarding abortion in concluding observations concerning close to 100 countries.[338] These treaty bodies have also issued general comments addressing reproductive rights and abortion.[339]

In their commentaries, these bodies have frequently expressed concern about the relationship between restrictive abortion laws, clandestine abortions, and threats to women’s lives, health and well-being. They have repeatedly recommended the review or amendment of punitive and restrictive abortion laws and have urged states parties on multiple occasions to legalize abortion, in particular when a pregnancy is life or health threatening or the result of rape, including incest.

Treaty bodies have made specific recommendations to Brazil in relation to its restrictive abortion laws. The Committee on the Rights of the Child recommended in 2015 that Brazil “[d]ecriminalize abortions in all circumstances and review its legislation with a view to ensuring access to safe abortion and post-abortion care services.”[340] The CEDAW Committee urged Brazil to “[e]xpedite the review of its legislation criminalizing abortion in order to remove punitive provisions imposed on women.”[341] It also recommended that Brazil “[e]nsure women’s right to safe motherhood and affordable access for all women to adequate emergency obstetric care.”[342]

Rights to Water and to Sanitation

The right to water entitles everyone, without discrimination, “to have access to sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic use.”[343] Various resolutions from the United Nations General Assembly and Human Rights Council affirm that the right to safe drinking water is derived from the right to an adequate standard of living.[344] Brazil has ratified numerous treaties, such as the ICESCR, CEDAW, CRPD, and the CRC, in which the right to an adequate standard of living is enshrined.

The CESCR, in its General Comment 15 on the right to water, stated that “The water supply for each person must be sufficient and continuous for personal and domestic uses.”[345] The Committee also noted that, “States parties should monitor and combat situations where aquatic ecosystems serve as a habitat for vectors of diseases wherever they pose a risk to human living environments.”[346]

For its part, the right to sanitation entitles everyone, without discrimination, to “have physical and affordable access to sanitation, in all spheres of life, that is safe, hygienic, secure, and socially and culturally acceptable and that provides privacy and ensures dignity.”[347] As with the right to water, the right to sanitation is derived from the right to an adequate standard of living.[348]

The United Nations special rapporteur on the rights to water and sanitation has stated that states should “ensure that the management of human excreta does not negatively impact on human rights.”[349]

In March 2016, the UN special rapporteur on the human rights to safe drinking water and sanitation stated that “There is a strong link between weak sanitation systems and the current outbreak of the mosquito borne Zika virus, as well as dengue, yellow fever and chikungunya,” and added further that “the most effective way to tackle this problem is to improve the failing services.”[350]

Rights of Persons with Disabilities, Including Support for Their Families and Caregivers

International human rights law addresses the rights of persons with disabilities, including children, and their caregivers. The CRPD recognizes that children with disabilities should have full enjoyment of all human rights and fundamental freedoms on equal basis with other children. [351] This includes the right, when possible, to be cared by their parents,[352] as well as the right of children with disabilities not to be separated from their families. [353] Health services for children with disabilities need to be disability-specific, including early identification and intervention as appropriate and services need to be designed to minimize and prevent further disabilities. Furthermore, children with disabilities should be provided with appropriate habilitation and rehabilitation services “as close as possible to people's own communities, including in rural areas.”[354] The CRPD also recognizes the right to an adequate standard of living for persons with disabilities and their families, as well as the right to social protection. It says that states parties should “ensure access by persons with disabilities and their families living in situations of poverty to assistance from the State with disability-related expenses, including adequate training, counseling, financial assistance and respite care.”[355]

The UN Committee on the Rights of the Child has noted that support to caregivers of children with disabilities should include “[t]he education of parent/s and siblings, not only on the disability and its causes but also on each child’s unique physical and mental requirements; psychological support that is sensitive to the stress and difficulties imposed on families of children with disabilities … material support in the form of special allowances as well as consumable supplies and necessary equipment … deemed necessary for the child with a disability to live a dignified, self-reliant lifestyle, and be fully included in the family and community.”[356]

The Committee on Economic, Social and Cultural Rights has also interpreted the right to social security for persons with disabilities in its General Comments No. 20 and No. 5. It has emphasized the importance of providing adequate income support to persons with disabilities, including permanent disabilities. It has said, “Such support should be provided in a dignified manner and reflect the special needs for assistance and other expenses often associated with disability. The support provided should cover family members and other informal carers.”[357]

Acknowledgments

This report was researched and written by Margaret Wurth, researcher in the Children’s Rights Division, João Bieber, consultant in the Women’s Rights Division, and Amanda Klasing, senior researcher in the Women’s Rights Division at Human Rights Watch. César Muñoz, senior researcher in the Americas Division, and Andrea Carvalho, consultant in the Americas Division, provided research support.

Janet Walsh, deputy director in the Women’s Rights Division, edited the report. Michael Garcia Bochenek, senior counsel in the Children’s Rights Division; Maria Laura Canineu, Brazil director; Diederik Lohman, acting director of the Health and Human Rights Division; César Muñoz, senior Brazil researcher; Katharina Rall, researcher in the Environment and Human Rights Program; Shantha Rau Barriga, director of the Disability Rights Division; Carlos Rios-Espinosa, researcher in the Disability Rights Division; and Daniel Wilkinson, managing director of the Americas Division reviewed and commented on the report. Chris Albin-Lackey, senior legal advisor, provided legal review. Tom Porteous, deputy program director, provided program review.

Production assistance was provided by Kate Segal, senior associate in the Americas Division; Adelaida Tamayo, associate in the Women’s Rights Division; Olivia Hunter, photo and publications coordinator; Fitzroy Hepkins, administrative manager; and Jose Martinez, senior administration coordinator. Di Pinheiro translated this report into Portuguese. João Bieber and Andrea Carvalho vetted the Portuguese version.

Human Rights Watch would like to thank the groups and individuals who provided invaluable guidance and support with our project design, research, and advocacy. In particular, thank you to Debora Diniz and Shena Cavallo for comments on an earlier draft of this report.

Most importantly, we are deeply grateful to all those we interviewed, who so generously shared their stories with us. We are especially grateful to Brazil’s “guerreiras,” the women and girl “warriors,” who have shown tremendous courage and grace in confronting the effects of the Zika epidemic on their families and communities.

[1] Gubio S. Campos, Antonio C. Bandeira, and Silvia I. Sardi, “Zika Virus Outbreak, Bahia, Brazil,” Emerging Infectious Diseases, vol. 21, no. 10 (2015), pp. 1885-1886, https://wwwnc.cdc.gov/eid/article/21/10/15-0847_article (accessed February 2, 2017); Camila Zanluca et al., “First Report of Autochtonous Transmission of Zika virus in Brazil,” Memórias do Instituto Oswaldo Cruz, vol. 110, no. 4 (2015), pp. 569-72; Carlos Brito, “Zika Virus: A New Chapter in the History of Medicine,” Acta Médica Portuguesa, vol. 8, no. 6 (2015), pp. 679-689.

[2] Department of Health Surveillance, Ministry of Health, “Epidemiological Bulletin: Monitoring of Cases of Dengue Fever, Chikungunya Fever, and Fever by Zika Virus until the Epidemiological Week 51” 2017, p. 8, http://portalsaude.saude.gov.br/index.php/situacao-epidemiologica-dados-dengue (accessed February 2, 2017).

[3] Jorg Heukelbach et al., “Zika Virus Outbreak in Brazil,” Journal of Infection in Developing Countries, vol. 10, no. 2 (2016), pp. 116-120, accessed February 2, 2017, http://www.jidc.org/index.php/journal/article/view/26927450/1450; World Health Organization (WHO), “Zika Virus Outbreak Global Response: Interim Report,” WHO/ZIK/SRF/ vol. 16 no. 2, May 2016, p. 4, http://apps.who.int/iris/bitstream/10665/207474/1/WHO_ZIKV_SRF_16.2_eng.pdf (accessed February 2, 2017).

[4] WHO, “Zika Virus (ZIKV) Classification Table,” May 24, 2017, http://apps.who.int/iris/bitstream/10665/255542/1/zika-classification-24May17-eng.pdf?ua=1 (accessed June 12, 2017).

[5] US Centers for Disease Control and Prevention (CDC), “Zika Virus: Transmission & Risks,” January 20, 2017, https://www.cdc.gov/zika/transmission/index.html (accessed February 2, 2017). For more information on the sexual transmission of Zika virus, see, e.g., Susan L. Hills et al., “Transmission of Zika Virus Through Sexual Contact with Travelers to Areas of Ongoing Transmission — Continental United States, 2016,” Morbidity and Mortality Weekly Report, vol. 65, no. 8 (2016), pp. 215-216, https://www.cdc.gov/mmwr/volumes/65/wr/mm6508e2.htm (accessed February 2, 2017); Alexandra M. Oster, et al., “Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016,” Morbidity and Mortality Weekly Report, vol. 65, no. 5, pp. 120-121, https://www.cdc.gov/mmwr/volumes/65/wr/mm6505e1.htm (accessed February 2, 2017).

[6] CDC, “Zika Virus: Symptoms, Testing, & Treatment – Symptoms,” January 4, 2017, https://www.cdc.gov/zika/symptoms/symptoms.html (accessed February 2, 2017).

[7] CDC, “Zika Virus: Symptoms, Testing, & Treatment – Testing for Zika,” November 18, 2016, https://www.cdc.gov/zika/symptoms/diagnosis.html (accessed February 2, 2017).

[8] CDC Vital Signs, “Zika Virus,” April 4, 2017, https://www.cdc.gov/vitalsigns/zika-babies/index.html (accessed May 25, 2017).

[9] CDC, “Zika Virus: Health Effects & Risks – Microcephaly & Other Birth Defects,” January 17, 2017, https://www.cdc.gov/zika/healtheffects/birth_defects.html (accessed May 25, 2017); Sonja A. Rasmussen et al., “Zika Virus and Birth Defects — Reviewing the Evidence for Causality,” New England Journal of Medicine, vol. 374, no. 20 (2016), http://www.nejm.org/doi/full/10.1056/NEJMsr1604338 (accessed February 2, 2017).

[10] Vanessa van der Linden et al., “Description of 13 Infants Born During October 2015–January 2016 with Congenital Zika Virus Infection without Microcephaly at Birth — Brazil,” Morbidity and Mortality Weekly Report, vol. 65, no. 47 (2016).

[11] CDC, “Zika Virus: Health Effects & Risks – Zika and Guillain-Barré Syndrome,” August 9, 2016, https://www.cdc.gov/zika/healtheffects/gbs-qa.html (accessed February 2, 2017).

[12] WHO, “Zika Virus,” September 6, 2016, http://www.who.int/mediacentre/factsheets/zika/en/ (accessed February 2, 2017).

[13] WHO, “Situation Report: Zika Virus, Microcephaly, and Guillain-Barré Syndrome,” January 5, 2017, http://www.who.int/emergencies/zika-virus/situation-report/05-january-2017/en/ (accessed February 2, 2017).

[14] Heukelbach et al., “Zika Virus Outbreak in Brazil,” Journal of Infection in Developing Countries, pp. 116-120.

[15] Department of Health Surveillance, Ministry of Health, "Epidemiologic bulletin: integrated monitoring of alterations in the growth and development related to Zika virus infections and other infectious etiologies, until the epidemiologic week 16/2017, April 2017, http://combateaedes.saude.gov.br/images/sala-de-situacao/2017-Monitoramento-alteracoes-Zika-e-outras-etiologias-infecciosas-SE16.pdf (accessed June 15, 2017).

[16] According to unpublished Ministry of Health data obtained through an information request by the Spanish newspaper El País, while the Ministry of Health’s bulletin registered 18 suspected cases until the second week of 2016, municipalities had notified 210 cases, and 159 births between November and December. São Paulo’s health authorities argued the discrepancy was that they reported microcephaly cases with evidence of Zika infection only. Talita Bedinelli, “São Paulo desrespeita regra federal e não reporta o nascimento de quase 200 bebês com microcefalia,” El País, January 26, 2016, http://brasil.elpais.com/brasil/2016/01/25/politica/1453755744_022637.html (accessed March 24, 2017). One month earlier, the Brazilian newspaper Estadão reported that 18 cases had not been included in the national bulletin. Fabiana Cambricoli, “Cidades paulistas apuram 18 casos de microcefalia,” Estadão, December 8, 2015, http://saude.estadao.com.br/noticias/geral,cidades-paulistas-apuram-18-casos-de-microcefalia,10000004157 (accessed March 24, 2017).

[17] Ministry of Transparency, Oversight and Control, “Programa de Fiscalização em Entes Federativos: Rio Grande do Norte,” August, 2016, p. 80, http://www.cgu.gov.br/assuntos/auditoria-e-fiscalizacao/programa-de-fiscalizacao-em-entes-federativos/2-ciclo/2o-ciclo/estados-1/rio-grande-do-norte (accessed March 24, 2017).

[18] Secretaria de Vigilância em Saúde, Ministério da Saúde, “Monitoramento dos casos de dengue, febre de chikungunya e febre pelo vírus Zika até a Semana Epidemiológica 15, 2017,” 2017, http://portalarquivos.saude.gov.br/images/pdf/2017/maio/05/Monitoramento-dos-casos-de-dengue-febre-de-chikungunya-e-febre-pelo-virus-Zika-ate-a-Semana-Epidemiologica.pdf (accessed May 18, 2017).

[19] Cyril Caminade et al., “Global Risk Model for Vector-Borne Transmission of Zika Virus Reveals the Role of El Niño 2015,” PNAS, vol. 114, no. 1 (2016), pp. 119-124, http://www.pnas.org/content/114/1/119.full (accessed May 25, 2017).

[20] Kirk R. Smith et al., “Human Health: Impacts, Adaptation, and Co-Benefits,” in Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change, Field et al., eds, p. 722ss, http://www.ipcc.ch/pdf/assessment-report/ar5/wg2/WGIIAR5-Chap11_FINAL.pdf (accessed May 25, 2017).

[21] Ibid.

[22] Andrew J. Monaghan et al., “The Potential Impacts of 21st Century Climatic and Population Changes on Human Exposure to the Virus Vector Mosquito Aedes aegypti,” Climate Change (2016), pp. 1-14, https://link.springer.com/article/10.1007/s10584-016-1679-0 (accessed May 25, 2017).

[23] Ministry of Environment, “National Adaptation Plan to Climate Change: Sectoral and Thematic Strategies Volume II,” May 2016, p. 124 http://www4.unfccc.int/nap/Documents%20NAP/English_PNA_Part2%20v4.pdf (accessed May 4, 2017).

[24] Ministry of Environment, “National Adaptation Plan to Climate Change: General Strategy Volume I,” 2016, p. 19, http://www4.unfccc.int/nap/Documents%20NAP/English_Brazil%20NAP%20Part%201.pdf (accessed May 25, 2017).

[25] Ministry of Environment, “National Adaptation Plan to Climate Change: Sectoral and Thematic Strategies Volume II,” May 2016, pp. 11, 171, http://www4.unfccc.int/nap/Documents%20NAP/English_PNA_Part2%20v4.pdf (accessed May 25, 2017).

[26] “Zika Virus: “Improved Water and Sanitation Services are the Best Answer” – UN Experts Note,” UN Office of the High Commissioner on Human Rights (OHCHR) press release, March 11, 2015, http://www.ohchr.org/EN/NewsEvents/Pages/
DisplayNews.aspx?NewsID=17212&LangID=E#sthash.7LcIqEmJ.dpuf (accessed March 25, 2017).

[27] WHO, “Investing in Water and Sanitation: Increasing Access, Reducing Inequalities: GLAAS 2014 Findings—Highlights for the Region of the Americas,” WHO/FWC/WSH/16.41, 2016, p. 17, http://apps.who.int/iris/handle/10665/204597, (accessed February 2, 2017).

[28] WHO, “Vector Control Operations Framework for Zika Virus,” WHO/ZIKV/VC/16.4, May 2016, http://www.who.int/csr/resources/publications/zika/vector-control/en/ (accessed February 2, 2017).

[29] Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “Relatório de Avaliação Anual: Ano 2014,” 2015, p. 78, https://www.cidades.gov.br/images/stories/ArquivosSNSA/PlanSaB/relatorio_anual_avaliacao
_plansab_2014_15122015.pdf (accessed May 07, 2017).

[30] WHO, “Investing in Water and Sanitation: Increasing Access, Reducing Inequalities: GLAAS 2014 Findings—Highlights for the Region of the Americas,” p. 17.

[31] Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “Sistema Nacional de Informações sobre Saneamento: Diagnóstico dos Serviços de Água e Esgotos – 2015,” February 2017, p. 25, http://www.snis.gov.br/diagnostico-agua-e-esgotos/diagnostico-ae-2015 (accessed February 22, 2017).

[32] Federal Constitution of the Republic of Brazil, 1988, arts. 21, XX and 23, IX; National Department of Sanitation, Ministry of Cities, “Investments in Sanitation: Historical Analysis and Estimated Needs” (“Investimentos em saneamento básico: análise histórica e estimative de necessidades”), 2014, p. 36, http://www.cidades.gov.br/images/stories/ArquivosSNSA/PlanSaB/panorama/vol_05_miolo.pdf (accessed March 31, 2017).

[33] Federal Constitution of the Republic of Brazil, 1988, art. 30, V; National Department of Sanitation, Ministry of Cities, “Investments in Sanitation: Historical Analysis and Estimated Needs,” 2014, p. 36.

[34] Ministry of Health, “Dengue,” http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secretarias/svs/dengue (accessed May 25, 2017). See also, Department of Health Surveillance, Ministry of Health, “Epidemiological Bulletin: Monitoring of Cases of Dengue Fever, Chikungunya Fever, and Fever by Zika Virus until the Epidemiological Week 52,2016” 2017, p. 3, http://portalarquivos.saude.gov.br/images/pdf/2017/abril/06/2017-002-Monitoramento-dos-casos-de-dengue--febre-de-chikungunya-e-febre-pelo-v--rus-Zika-ate-a-Semana-Epidemiologica-52--2016.pdf (accessed May 18, 2017).

[35] Department of Health Surveillance, Ministry of Health, “Epidemiological Bulletin: Monitoring of Cases of Dengue Fever, Chikungunya Fever, and Fever by Zika Virus until the Epidemiological Week 51,” 2017, p. 6 http://portalsaude.saude.gov.br/index.php/situacao-epidemiologica-dados-dengue (accessed February 2, 2017).

[36] Minas Gerais State Health Department, “Epidemiological Report on Yellow Fever,” February 1, 2017, http://www.saude.mg.gov.br/component/gmg/story/9020-informe-epidemiologico-da-febre-amarela-01-02 (accessed February 2, 2017).

[37] Ministério da Saúde, “Situação Epidemiológica/Dados,” 2017, http://portalsaude.saude.gov.br/index.php/situacao-epidemiologica-dados-febreamarela (accessed February 22, 2017).

[38] Ministério da Saúde, “Monitoramento dos casos e óbitos de febre amarela no Brasil. Informe – n° 43/2017,” May 31, 2017, http://portalarquivos.saude.gov.br/images/pdf/2017/junho/02/COES-FEBRE-A... (accessed June 12, 2017).

[39] WHO, “Epidemiological Update Yellow Fever: Situation Summary in the Americas,” March 23, 2017, http://reliefweb.int/sites/reliefweb.int/files/resources/2017-mar-23-phe-epi-update-yellow-fever.pdf (accessed March 25, 2017).

[40] Bedinelli, “El Pais Brasil. Casos de febre amarela aumentam em Minas Gerais e geram apreensão,” El País, January 17 2017.

[41] According to the Brazilian Institute of Geography and Statistics, in 2015, the northeast region of Brazil had the lowest household monthly income per person, and the highest rate of illiteracy among people ages 15 and older, as compared to the rest of the country. Instituto Brasileiro de Geografia e Estatística (IBGE), “Pesquisa Nacional por Amostra de Domicílios Síntese de indicadores,” 2015, http://biblioteca.ibge.gov.br/visualizacao/livros/liv98887.pdf (accessed May 25, 2017).

[42] Centro de Operações de Emergências em Saúde Pública sobre Microcefalias, Ministry of Health, "Informe Epidemiológico n° 56 – Semana Epidemiológica (SE) 50/2016 (11/122016 a 17/12/2016) Monitoramento dos Casos de Microcefalia no Brasil,” 2016, http://combateaedes.saude.gov.br/images/pdf/informe_microcefalia_epidemiologico56.pdf (accessed February 2, 2017).

[43] Fabiana Cambricoli, “1/4 das ães de bebês com microcefalia é adolescente,” Estadão, February 1, 2017, http://saude.estadao.com.br/noticias/geral,14-das-maes-de-bebes-com-microcefalia-e-adolescente,70001648576 (accessed February 2, 2017).

[44] This includes microcephaly from all causes, not just Zika-related cases.

[45] Cambricoli, “1/4 das mães de bebês com microcefalia é adolescente,” Estadão, February 1, 2017.

[46] Human Rights Watch interview with Ana Carolina Thé, Analista Ministerial Medica, Promotoria de Saúde, and Westei Conde y Martin Junior, Promotor de Justica, Procuradoria Geral de Justica, Ministerio Publico, Recife, Pernambuco, Brazil, September 13, 2016.

[47] Cambricoli, “1/4 das ães de bebês com microcefalia é adolescente,” Estadão.

[48] “Zika virus triggers pregnancy delay calls,” BBC News Online, January 23, 2016, http://www.bbc.com/news/world-latin-america-35388842 (accessed March 25, 2017).

[49] See for example, Mónica Roa, “Zika virus outbreak: reproductive health and rights in Latin America,” The Lancet, vol. 387, no. 10021 (2016), p. 843, February 12, 2016, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00331-7/fulltext?rss percent3Dyes (accessed March 25, 2017).

[50] Yale Global Health Justice Partnership, Expert Opinion, August 2016, http://media.wix.com/ugd/148599_9965c233186e490290360097549b4b2a.pdf (accessed March 25, 2017).

[51] Human Rights Watch interview with Thereza de Lamare, Ministry of Health official, Brasilia, April 19, 2017.

[52] Ministry of Health, “Orientações integradas de vigilância e atenção à saúde no âmbito da Emergência de Saúde Pública de Importância Nacional,” December 2016, http://combateaedes.saude.gov.br/images/pdf/orientacoes-integradas-vigil... (accessed May 18, 2017).

[53] Federal Constitution of the Republic of Brazil, 1988, art. 226, para. 7. Government of Brazil, Law 9,263 (Family Planning Law), 1996, arts. 1, 3; Ministry of Health, Instituto Sírio-Libanês de Ensino e Pesquisa, “Basic Attention Protocols: Women’s Health,” 2016, http://189.28.128.100/dab/docs/portaldab/publicacoes/protocolo_saude_mulher.pdf (accessed February 13, 2017).

[54] Ministério da Saúde, Centro Brasileiro de Análise e Planejamento, “Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher – PNDS 2006: Relatório Final,” 2008, p. 203, http://bvsms.saude.gov.br/bvs/pnds/img/relatorio_final_
pnds2006.pdf (accessed February 22, 2017); Ministério da Saúde, Centro Brasileiro de Análise e Planejamento, “Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher – PNDS 2006: Dimensões do Processo Reprodutivo e da Saúde da Criança,” 2009, pp. 141-142, http://bvsms.saude.gov.br/bvs/publicacoes/pnds_crianca_mulher.pdf (accessed May 25, 2017); See also, Elaine Fernandes Viellas et al., “Prenatal Care in Brazil,” Cadernos de Saúde Pública, vol. 30, suppl. (2014), pp. S3-S4; Ricardo C.L. Rocha et al., “Prematurity and Low Birth Weight among Brazilian Adolescents and Young Adults,” Journal of Pediatric & Adolescent Gynecology, vol. 23, no. 3 (2010), pp. 142–145.

[55] Mariza Miranda Theme-Filha et al., “Factors Associated with Unintended Pregnancy in Brazil: Cross-Sectional Results from the Birth in Brazil National Survey, 2011/2012,” Reproductive Health, vol. 13, suppl. 3 (2016), pp. 235-243, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073899/ (accessed May 25, 2017).

[56] Ibid.

[57] United Nations, Department of Economic and Social Affairs, Population Division, “Trends in Contraceptive Use Worldwide,” 2015, pp. 41, 48, http://www.un.org/en/development/desa/population/publications/pdf/family/
trendsContraceptiveUse2015Report.pdf
(accessed February 2, 2017).

[58] Cynthia Schuck-Paim et al., “Unintended Pregnancies in Brazil – A Challenge for the Recommendation to Delay Pregnancy Due to Zika,” PLOS Current Outbreaks (2016), http://currents.plos.org/outbreaks/article/unintended-pregnancies-in-brazil-a-challenge-for-the-recommendation-to-delay-pregnancy-due-to-zika/ (accessed May 25, 2017).

[59] Riva Rozenberg et al., “Contraceptive Practices of Brazilian Adolescents: Social Vulnerability in Question,” Ciência & Saúde Coletiva, vol.18, no. 12 (2013), pp.3645-3652, http://www.scielo.br/pdf/csc/v18n12/a20v18n12.pdf (accessed February 2, 2017).

[60] Government of Brazil, Penal Code, Decree-Law Number 2.848, art. 128; Justice Marco Aurélio, “Arguição de Descumprimento de Preceito Fundamental 54 Distrito Federal,” 2012. Yet, women and girls in Brazil who have the right to terminate pregnancies legally face obstacles in accessing legal abortion services. A study published in 2016 found only 37 institutions in the country offered legal abortion, mostly concentrated in capitals and large cities. Legal abortion services were not available at all in seven states. Alberto Pereira Madeiro and Debora Diniz, “Legal Abortion Services in Brazil – A National Study,” Ciência & Saúde Coletiva, vol. 21, no. 2 (2016), pp. 563-572.

[61] Government of Brazil, Penal Code, Decree-Law Number 2.848, art. 124, 126.

[62] Edgar Macial, “De 1 milhao de abortos ilegais no Pais, 33 viraram casos de policia em 2014,” Estadão, December 20, 2014, http://saude.estadao.com.br/noticias/geral,de-1-milhao-de-abortos-ilegais-no-pais-33-viraram-casos-de-policia-em-2014,1610235 (accessed December 9, 2016).

[63] Ministry of Health, Portaria n° 1.813, November 11, 2015. Diário Oficial da União – Seção 1, published on November 12, 2015; Operational Center of Emergencies in Public Health on Microcephaly, Health Surveillance Department, Ministry of Health, Nota Informativa n° 01/2015 – COES Microcefalias, November 17, 2015.

[64] Pan American Health Organization (PAHO) and WHO, “Epidemiological Alert: Increase of Microcephaly in the Northeast of Brazil,” November 17, 2015, http://www2.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid
=270&gid=32636&lang=en
(accessed April 24, 2017).

[65] CDC, “Zika Virus: 10 Public Health Achievements in 2016 and Future Priorities,” January 6, 2017, https://www.cdc.gov/mmwr/volumes/65/wr/mm6552e1.htm?s_cid=mm6552e1_e (accessed March 25, 2017); World Health Organization (WHO), “Zika Virus and complications,” http://www.who.int/emergencies/zika-virus/en/ (accessed March 25, 2017).

[66] PAHO, “Situation Room – Zika virus infection,” http://www2.paho.org/bra/index.php?option=com_content&view=category&layout=blog&id=1293&Itemid=880 (accessed March 25, 2017). PAHO also operated regionally, developing technical documents and, in June 2016, publishing its strategy for enhancing national capacity to respond to Zika virus epidemic in the Americas. Four objectives orient their activities: detecting introduction of the virus in a timely manner and monitoring the epidemic; reducing the risk posed by high vector density; providing tools and guidance for adequate response management; and developing a regional research agenda. The Strategy was budgeted in USD 17,300,000 until December 2016. According to the last update, on December 8, 2016, PAHO had only raised USD 7.8 million, mainly from the WHO Contingency Fund for Emergencies, DFID, and CDC. Pan American Health Organization (PAHO), “Strategy for enhancing national capacity to respond to Zika virus epidemic in the Americas,” June 2016, p. 5, http://www2.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=33130&lang=es (accessed March 25, 2017).

[67] Ministry of Health, “National Plan to Combat Microcephaly,” July 4, 2016, http://combateaedes.saude.gov.br/pt/plano-nacional (accessed March 14, 2017).

[68] WHO, “Zika Strategic Response Plan, revised for July 2016 – December 2017,” WHO/ZIKV/SRF/16.3, June 2016, http://apps.who.int/iris/bitstream/10665/246091/1/WHO-ZIKV-SRF-16.3-eng.pdf?ua=1&ua=1&ua=1&ua=1 (accessed February 9, 2017).

[69] “Actions intensify in response to the Zika vírus in Brazil,” UN Women News Stories, May 6, 2016, http://www.unwomen.org/en/news/stories/2016/4/world-health-day-and-response-to-the-zika-virus-in-brazil (accessed March 25, 2017).

[70] UN Population Fund (UNFPA), “Mais direitos, menos Zika Campaign,” http://maisdireitosmenoszika.org/a-campanha/ (accessed March 25, 2017). The initiative is funded by Japanese and United Kingdom (DFID) governments, CANADEM and UNFPA emergency’s fund.

[71] “Actions intensify in response to the Zika virus in Brazil,” UN Women News Stories. The public campaign received funds from the Embassy of Canada.

[72] “Fifth Meeting of the Emergency Committee under the International Health Regulations (2005) regarding Microcephaly, Other Neurological Disorders and Zika Virus,” WHO statement, November 18, 2016, http://www.who.int/mediacentre/news/statements/2016/zika-fifth-ec/en/ (accessed February 2, 2017).

[73] Margaret Chan, director general of the World Health Organization, “Zika: We must be ready for the long haul,” February 1, 2017, WHO Commentaries, http://www.who.int/mediacentre/commentaries/2017/zika-long-haul/en/ (accessed February 2, 2017).

[74] Donald G. McNeil Jr., “Zika Is No Longer a Global Emergency, W.H.O. Says,” The New York Times, November 18, 2016, https://www.nytimes.com/2016/11/19/health/who-ends-zika-global-health-emergency.html, (accessed February 10, 2017).

[75] Ministry of Health, “Ministério da Saúde declara fim da Emergência Nacional para Zika e microcefalia,” May 11, 2017. http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/28347-ministerio-da-saude-declara-fim-da-emergencia-nacional-para-zika-e-microcefalia (accessed May 25, 2017).

[76] Executive Secretary of Health Surveillance, Ministry of Health, State of Pernambuco, “Possible alteration of the pattern of occurrence of microcephaly (congenital anomaly) in live births in Pernambuco” (“Assunto: Possível alteração do padrão de ocurrência de microcefalia (Anomalia Congêntia) em nascidos vivos no Estado de Pernambuco”), Technical Release SEVS/DGCDA no. 43/2015, October 27, 2015, https://media.wix.com/ugd/3293a8_9dd502333c274e359226be4cd95598b7.pdf (accessed February 17, 2017).

[77] Executive Secretary of Health Surveillance, Ministry of Health, State of Pernambuco, “Clinical and Epidemiological Protocol to investigate the cases of microcephaly in Pernambuco, version no. 1”, (“Protocolo clínico e epidemiológico microcefalia, versao no. 1”), 2015, https://media.wix.com/ugd/3293a8_bdbc939959174a79941f197903ad3bc9.pdf (accessed February 15, 2017).

[78] Executive Secretary of Health Surveillance, Ministry of Health, State of Pernambuco, “Clinical and Epidemiological Protocol to investigate the cases of microcephaly in Pernambuco, version no. 2” (“Protocolo clínico e epidemiológico microcefalia, versao no. 2”), 2015, https://media.wix.com/ugd/3293a8_f8bf59781b39477289c57c75e94a40cf.pdf (accessed February 16, 2017).

[79] Ministry of Health, State of Paraíba, “Protocol for the investigation and follow-up of cases of microcephaly in Paraíba – updated version” (“Protocolo para investigação e acompanhamento dos casos de microcefalia no estado da Paraíba”), 2015, http://static.paraiba.pb.gov.br/2015/06/PROTOCOLO-ATUALIZADO-28.03.2016.pdf (accessed February 17, 2017).

[80] Executive Secretary of Health Surveillance, Ministry of Health, State of Pernambuco, “Clinical and Epidemiological Protocol to investigate the cases of microcephaly in Pernambuco, version no. 2,” 2015, p. 27.

[81] Ministry of Health, State of Paraíba, “Protocol for the investigation and follow-up of cases of microcephaly in Paraíba – updated version,” 2015, p. 8.

[82] Pernambuco State Health Department, “PE investirá R$25 milhões contra Aedes aegypti,” November 30, 2015, http://portal.saude.pe.gov.br/noticias/secretaria/pe-investira-r-25-milhoes-contra-aedes-aegypti (accessed March 21, 2017); Government of Paraíba, “Governo decreta emergência e planeja ações de combate às doenças transmitidas pelo Aedes aegypti,” December 4, 2015, http://paraiba.pb.gov.br/governo-decreta-emergencia-e-elabora-plano-de-enfrentamento-as-doencas-transmitidas-pelo-mosquito-aedes-aegypti/ (accessed March 21, 2017); Paraíba State Health Department, “Ricardo apresenta Plano de Combate ao Mosquito Aedes Aegypti nesta quarta,” December 15, 2015, http://paraiba.pb.gov.br/ricardo-apresenta-plano-de-combate-ao-mosquito-aedes-aegypti-nesta-quarta/ (accessed March 21, 2017).

[83] Pernambuco State Health Department, “Governo lança plano de combate às arboviroses,” December 6, 2016, http://portal.saude.pe.gov.br/noticias/secretaria-executiva-de-vigilancia-em-saude/governo-lanca-plano-de-combate-arboviroses (accessed March 21, 2017); Pernambuco State Health Department, “Plano de Enfrentamento das Doenças Transmitidas pelo Aedes do estado de Pernambuco,” November 2016, https://media.wix.com/ugd/3293a8_98f67921dd984159bead4edf844ece2d.pdf (accessed March 24, 2017).

[84] Gabrielle Kopko, “Ministério da Saúde anuncia edital de R$20 milhões para pesquisas contra o Aedes aegypti,” March 23, 2016, Ministry of Health press release, http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secretarias/sctie/fitoterapicos/noticias-fitoterapicos/22727-ministerio-da-saude-repassa-r-3-4-mi-para-custeio-de-projetos-de-plantas-medicinais-e-fitoterapicos (accessed March 20, 2017). All exchange rates are pegged to the conversion rate of April 26, 2017, which was R$3.20 to US$1.

[85] National Health Fund, Ministry of Health, Brazil, “Transparency Portal” (“Portal Transparência”), http://aplicacao.saude.gov.br/portaltransparencia/index.jsf (accessed March 21, 2017).

[86] Amanda Mendes and Camila Bogaz, “Laboratórios ampliam em 20 vezes a capacidade para testes de Zika,” January 20, 2016, Ministry of Health press release, http://combateaedes.saude.gov.br/pt/noticias/132-laboratorios-ampliam-em-20-vezes-a-capacidade-para-testes-de-zika (accessed March 17, 2017); Gabriela Rocha, “Ministério da Saúde finaliza pregão para compra de repelentes,” Ministry of Health press release, December 9, 2016, http://combateaedes.saude.gov.br/pt/noticias/896-ministerio-da-saude-finaliza-pregao-para-compra-de-repelentes (accessed March 20, 2017); Diogo Caixote, “Saúde libera R$7,5 milhões para centros de reabilitação,” March 22, 2016, http://combateaedes.saude.gov.br/pt/noticias/452-saude-libera-r-7-5-milhoes-para-construcao-de-mais-centros-especializados-em-reabilitacao (accessed March 17, 2017); Gustavo Frasão, “Ministério libera R$4,8 milhões para testes rápidos de gravidez,” March 21, 2016, http://combateaedes.saude.gov.br/pt/noticias/411-ministerio-libera-r-4-8-milhoes-para-testes-rapidos-de-gravidez (accessed March 20, 2017).

[87] Ministry of Health, Brazil, “Dengue, Chikungunya e Zika: Saúde destina mais R$ 135 milhões para reabilitação e pesquisas,” http://portalarquivos.saude.gov.br/images/pdf/2017/marco/30/RENEZIKA.pdf (accessed May 05, 2017).

[88] Email to Human Rights Watch from press office, Ministry of Health, May 31, 2017.

[89] “Plano contra Aedes prioriza ambulatório para chikungunya em PE,” G1 PE December 6, 2016, http://g1.globo.com/pernambuco/noticia/plano-contra-aedes-prioriza-ambulatorio-para-chikungunya-em-pe.ghtml (accessed March 24, 2017). See also Human Rights Watch interview with Luciana Caroline Albuquerque Bezerra, Executive Secretary of Health Surveillance, State of Pernambuco, Recife, Pernambuco, Brazil, October 20, 2016.

[90] Ministry of Health, Brazil, “Dengue, Chikungunya e Zika: Saúde destina mais R$ 135 milhões para reabilitação e pesquisas”.

[91] Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “PLANSAB – Plano Nacional de Saneamento Básico, mais saúde, qualidade de vida e cidadania,” 2015, pp. 147-149, http://www.cidades.gov.br/images/stories/ArquivosSNSA/PlanSaB/plansab_texto_editado_para_download.pdf (accessed May 05, 2017).

[92] Ibid, p. 170.

[93] Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “Sistema Nacional de Informações sobre Saneamento: Diagnóstico dos Serviços de Água e Esgotos – 2015,” February 2017, p. 55, http://www.snis.gov.br/diagnostico-agua-e-esgotos/diagnostico-ae-2015 (accessed February 22, 2017).

[94] Confederação Nacional da Indústria, “Burocracia e entraves ao setor de financiamento,” January 2016, p. 9, http://arquivos.portaldaindustria.com.br/app/conteudo_18/2016/01/11/10388/1101-BurocraciaeEntravessaneamento.pdf (accessed March 20, 2017).

[95] Pernambuco State Health Department, “PE investirá R$25 milhões contra Aedes aegypti.”.

[96] Ibid.

[97]“Pernambuco investirá R$78 milhões em novas ações contra zika, chicungunha e dengue,” Jornal do Commércio, December 6, 2017, http://jconline.ne10.uol.com.br/canal/cidades/saude/noticia/2016/12/06/pernambuco-investira-r-78-milhoes-em-novas-acoes-contra-zika-chicungunha-e-dengue-262780.php (accessed March 24, 2017).

[98] Pernambuco and Compesa, “Parceria Público-Privada Para A Universalização Do Esgotamento Sanitário Da Região Metropolitana Do Recife: Programa Cidade Saneada,” http://www.cbic.org.br/sites/default/files/palestra_ppp.pdf (accessed March 16, 2017).

[99] Marcela Balbino, “Prefeitos eleitos do Grande Recife falam em rever PPP da Compesa,” Jornal do Commércio, November 27, 2016, http://jconline.ne10.uol.com.br/canal/politica/pernambuco/noticia/2016/11/27/prefeitos-eleitos-do-grande-recife-falam-em-rever-ppp-da-compesa-261794.php (accessed March 16, 2017); Marina Barbosa, “PPP do Saneamento terá revisão,” FOLHA PE, December 19, 2016, http://www.folhape.com.br/economia/economia/economia/2016/12/19/NWS,10903,10,550,ECONOMIA,2373-PPP-SANEAMENTO-TERA-REVISAO.aspx (accessed March 16, 2017).

[100] National Department of Sanitation, Ministry of Cities, “Sistema Nacional de Informações sobre Saneamento: Diagnóstico dos Serviços de Água e Esgotos – 2015,” February 2017, p. 55, http://www.snis.gov.br/diagnostico-agua-e-esgotos/diagnostico-ae-2015 (accessed February 22, 2017).

[101] National Department of Sanitation, Ministry of Cities, “Sistema Nacional de Informações sobre Saneamento: Diagnóstico dos Serviços de Água e Esgotos – 2015,” February 2017, p. 55, http://www.snis.gov.br/diagnostico-agua-e-esgotos/diagnostico-ae-2015 (accessed February 22, 2017).

[102] Chan, “Zika: We Must Be Ready for the Long Haul,” WHO Commentaries.

[103] For detailed discussions regarding best practices in vector control, see WHO, "Global Vector Control Response 2017-2030," 2017, http://www.who.int/malaria/areas/vector_control/Draft-WHO-GVCR-2017-2030.pdf?ua=1&ua=1 (accessed April 26, 2017); CDC, “Zika Virus: Integrated Mosquito Management,” 2017, https://www.cdc.gov/zika/vector/integrated_mosquito_management.html (accessed April 26, 2017); Henk van den Verg et al., “Regional Framework for Surveillance and Control of Invasive Mosquito Vectors and Re-Emerging Vector Borne Diseases 2014-2020,” WHO Regional Office for Europe, 2013, http://www.euro.who.int/__data/assets/pdf_file/0004/197158/Regional-framework-for-surveillance-and-control-of-invasive-mosquito-vectors-and-re-emerging-vector-borne-diseases-20142020.pdf (accessed April 26, 2017).

[104] See e.g., WHO, “Malaria Control: The Power of Integrated Action,” The Health and Environment Linkages Initiative (HELI), http://www.who.int/heli/risks/vectors/malariacontrol/en/index3.html.

[105] See e.g. Ministry of Health, “National Plan to Combat Microcephaly,” July 4, 2016 http://combateaedes.saude.gov.br/pt/plano-nacional (accessed March 14, 2017).

[106] Ibid.

[107] WHO, “Pregnancy Management in the Context of Zika Virus Infection: Interim Guidance Update,” WHO/ZIKV/MOC/16.2 Rev. 1, May 13, 2016, http://www.who.int/csr/resources/publications/zika/pregnancy-management/en/ (accessed April 25, 2017).

[108] Brazilian authorities did invest significant resources in the short term. More than 266,000 community health agents (agentes comunitários de saúde), 49,000 endemic disease control agents (agentes de combate às endemias), and 5,000 military officers participated in these efforts. Together, they visited 250 million residences, factories, stores, vacant land and public agencies over the course of seven cycles of inspections in 2016 to identify possible mosquito breeding grounds. Juliana Hack, “Sala Nacional de Coordenação e Controle continuará ações,” July 15, 2016, http://combateaedes.saude.gov.br/pt/noticias/798-sala-nacional-de-coordenacao-e-controle-continuara-acoes-de-combate (accessed March 14, 2017). National Room for Coordination and Control to Combat Dengue, Chikungunya Virus and Zika Virus, Ministry of Health, Brazil. Reports can be found by visiting http://combateaedes.saude.gov.br/pt/sala-de-situacao and including the report number of interest. See, for example, “Report n° 07: Monitoring of the activities of the 1st cycle of visits to buildings in Brazil,” March 11, 2016, http://combateaedes.saude.gov.br/images/sala-de-situacao/informe-sncc-n-7.pdf (accessed March 14, 2017).

[109] National Room for Coordination and Control to Combat Dengue, Chikungunya Virus and Zika Virus, Ministry of Health, Brazil, “Report n° 07: Monitoring of the activities of the 1st cycle of visits to buildings in Brazil,” March 11, 2016, http://combateaedes.saude.gov.br/images/sala-de-situacao/informe-sncc-n-... (accessed March 14, 2017); National Room for Coordination and Control to Combat Dengue, Chikungunya Virus and Zika Virus, Ministry of Health, Brazil, “Report n° 19: Monitoring of the activities of the 7th cycle of visits to buildings in Brazil,” January 10, 2016, http://combateaedes.saude.gov.br/images/informes/informe-sncc-19-avaliacao-do-7-ciclo.pdf (accessed March 14, 2017).

[110] Ministry of Health, “National Plan to Combat Microcephaly.” [http://combateaedes.saude.gov.br/pt/plano-nacional (accessed June 28, 2017]

[111] Amanda Mendes, “Ministério da Saúde e Cufa fazem “faxinaço” nas periferias,” Ministry of Health press release, April 18, 2016, http://combateaedes.saude.gov.br/pt/noticias/517-ministerio-da-saude-e-cufa-fazem-faxinaco-nas-periferias-do-pais (accessed March 14, 2017); Gabrielle Kopko, “Saúde na Escola mobiliza 18 milhões de alunos em todo o país,” March 7, 2016, http://combateaedes.saude.gov.br/pt/noticias/395-saude-na-escola-mobiliza-18-milhoes-de-estudantes-no-combate-ao-aedes-aegypti (accessed March 14, 2017).

[112] “Selo UNICEF terá ‘ponto extra’ para municípios que realizarem mobilização contra Aedes aegypti,” UNICEF press release, March 15, 2016, https://www.unicef.org/brazil/pt/where_32575.html (accessed March 25, 2017); “UNICEF capacita 707 municípios para ações contra Aedes aegypti,” UNICEF press release, April 6, 2016, https://www.unicef.org/brazil/pt/where_32851.html (accessed March 25, 2017).

[113] Human Rights Watch interview with Luciana Caroline Albuquerque Bezerra, Executive Secretary of Health Surveillance, State of Pernambuco, Recife, Pernambuco, Brazil, October 20, 2016.

[114] Prefeitura da Cidade do Recife, Decree 29,279, art. 1, November 29, 2015; Prefeitura da Cidade do Recife, “Prefeito lança Plano Emergencial de Enfrentamento ao Aedes aegypti e nomeia profissionais para lidar com microcefalia,” December 7, 2015, http://www2.recife.pe.gov.br/noticias/07/12/2015/prefeito-lanca-plano-emergencial-de-enfrentamento-ao-aedes-aegypti-e-nomeia (accessed March 16, 2017).

[115] “Prefeito apresenta Plano de Enfrentamento à microcefalia ao ministro da Saúde,” Prefeitura da Cidade do Recife press release, November 24, 2015, http://www2.recife.pe.gov.br/noticias/24/11/2015/prefeito-apresenta-plano-de-enfrentamento-microcefalia-ao-ministro-da-saude (accessed March 16, 2017).

[116] Prefeitura da Cidade do Recife, “Plan to Combat the arboviruses transmitted by Aedes aegypti,” 2017, http://www2.recife.pe.gov.br/sites/default/files/aedes_aegypti_apresentacao_vf_3_16-9_0.pdf (accessed March 16, 2017).

[117] See for example, “Prefeito Geradlo Julio entrega ruas pavimentadas na Iputinga,” Prefeitura da Cidade do Recife press release, January 19, 2017, http://www2.recife.pe.gov.br/noticias/19/01/2017/prefeito-geraldo-julio-entrega-ruas-pavimentadas-na-iputinga (accessed March 26, 2017).

[118] Human Rights Watch interview with Luciana Caroline Albuquerque Bezerra, Executive Secretary of Health Surveillance, State of Pernambuco, Recife, Pernambuco, Brazil, October 20, 2016.

[119] Ministry of Transparency, Oversight and Control, “3° Ciclo do Programa de Fiscalização em Entes Federativos,” December 16, 2016, http://www.cgu.gov.br/assuntos/auditoria-e-fiscalizacao/programa-de-fiscalizacao-em-entes-federativos/3-ciclo/3o-ciclo/arquivos/apresentacao-resultado_3-ciclo.pdf (accessed March 21, 2017). Full reports for all 27 states can be found on the ministry’s website: http://www.cgu.gov.br/assuntos/auditoria-e-fiscalizacao/programa-de-fiscalizacao-em-entes-federativos/2-ciclo.

[120] Ministry of Health, “Sábado de faxina – Não dê folga para o mosquito da dengue,” Health Blog, November 28, 2015, http://www.blog.saude.gov.br/index.php/combate-ao-aedes/50392-sabado-de-faxina-nao-de-folga-para-o-mosquito-da-dengue (accessed March 16, 2017).

[121] Camila Bogaz, “Toda sexta-feira será o dia de combate ao Aedes aegypti,” Ministry of Health press release, November 4, 2016, http://combateaedes.saude.gov.br/pt/noticias/857-toda-sexta-feira-sera-o-dia-de-combate-ao-aedes-aegypti (accessed March 21, 2017).

[122] Paula Laboissière, “Investir em saneamento reduz gasto em saúde, diz ministro,” Ministry of Health, October 26, 2016, http://agenciabrasil.ebc.com.br/geral/noticia/2016-10/investir-em-saneamento-reduz-gasto-em-saude-diz-ministro (accessed March 21, 2017).

[123] Human Rights Watch interview with Talita Rodrigues da Silva, Coletivo Mangueiras, Recife, Pernambuco, October 17, 2016.

[124] Recife has a history of water-related infections, such as gastro-intestinal diseases, typhoid, and mosquito-borne illnesses that are linked to extreme poverty and a lack of water and sanitation services. “Poverty and Lack of Essential Water and Sanitation Systems are Paramount in the Outbreak of the Zika Virus: Interview with Dr. Esteban Castro, Coordinator of DESAFIO,” European Commission: Research & Innovation, undated, http://ec.europa.eu/research/social-sciences/index.cfm?pg=newspage&item=160225 (accessed February 25, 2017).

[125] Federal Law 11,445/2007.

[126] Human Rights Watch interview with Tiago Raposo, chief of staff at the Secretary of Sanitation, of the Ministry of Health, Brasília, Distrito Federal, Brazil, April 20, 2017.

[127] Brasil, Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “Sistema Nacional de Informações sobre Saneamento: Diagnóstico dos Serviços de Água e Esgotos – 2007,” February 2009, p. 33, http://www.snis.gov.br/diagnostico-agua-e-esgotos/diagnostico-ae-2007 (accessed May 26, 2017); Brasil, Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “Sistema Nacional de Informações sobre Saneamento: Diagnóstico dos Serviços de Água e Esgotos – 2015,” February 2017, p. 55, http://www.snis.gov.br/diagnostico-agua-e-esgotos/diagnostico-ae-2015 (accessed February 22, 2017).

[128] Brasil, Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “Sistema Nacional de Informações sobre Saneamento: Diagnóstico dos Serviços de Água e Esgotos – 2007,” February 2009, p. 18, http://www.snis.gov.br/diagnostico-agua-e-esgotos/diagnostico-ae-2007 (accessed May 26, 2017); Brasil, Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “Sistema Nacional de Informações sobre Saneamento: Diagnóstico dos Serviços de Água e Esgotos – 2015,” February 2017, p. 25, http://www.snis.gov.br/diagnostico-agua-e-esgotos/diagnostico-ae-2015 (accessed February 22, 2017).

[129] Brasil, Ministério das Cidades, Secretaria Nacional de Saneamento Ambiental, “Sistema Nacional de Informações sobre Saneamento,” http://app.cidades.gov.br/serieHistorica/ (accessed May 25, 2017).

[130] Human Rights Watch interview with Ricardo Benevides, head of the Regulatory Affairs Advisory Department at Cagepa, Paraíba’ sanitation company, João Pessoa, Paraíba, Brazil, April 05, 2017.

[131] Human Rights Watch interview with Jose Erivaldo, education secretary, Boqueirão, Paraíba, October 5, 2016.

[132] Human Rights Watch interview with Aldo Santos, director of articulation and environment, COMPESA, Recife, Pernambuco, Brazil, May 11, 2017.

[133] Ibid.

[134] Human Rights Watch Interview with Déborah Falcão, official in Recife Secretariat of Sanitation, Recife, Pernambuco, April 17, 2017.

[135] WHO, “Investing in Water and Sanitation: Increasing Access, Reducing Inequalities: GLAAS 2014 Findings—Highlights for the Region of the Americas,” p. 17.

[136] Human Rights Watch interview with Clara, Coelhos, Recife, Pernambuco, October 15, 2016.

[137] Human Rights Watch interview with Alícia, Campina Grande, Paraíba, October 13, 2016.

[138] Human Rights Watch interviews with Thaís, 17, Campina Grande, Paraíba, October 3, 2016; Karina, 34, Campina Grande, Paraíba, October 6, 2016; Alba, 26, Campina Grande, Paraíba, October 13, 2016.

[139] Human Rights Watch interview with Mirella, 48, Campina Grande, Paraíba, October 3, 2016.

[140] Human Rights Watch interview with Natália, 30, Campina Grande, Paraíba, October 6, 2016.

[141] Human Rights Watch interview with Ricardo Barretto, Director of New Business at COMPESA, Recife, Pernambuco, Brazil, May 11, 2017.

[142] Human Rights Watch interviews with Samara, 33, Campina Grande, Paraíba, October 6, 2016; Marcia, 29, Recife, Pernambuco, October 20, 2016; Luana, 42, Recife, Pernambuco, October 20, 2016.

[143] Human Rights Watch site visit to Coelhos, Recife, Pernambuco, October 15, 2016; Human Rights Watch site visit to Olinda, Recife, Pernambuco, October 18, 2016.

[144] Igor Adolfo Dexheimer Paploski et al., “Storm drains as larval development and adult resting sites for Aedes aegypti and Aedes albopictus in Salvador, Brazil,” Parasites & Vectors, vol. 9. no. 419 (2016).

[145] Human Rights Watch interview with Clara, Coelhos, Recife, Pernambuco, October 15, 2016.

[146] Human Rights Watch interview with Verônica Correa, 57, community health worker, Recife, Pernambuco, October 15, 2016.

[147] Human Rights Watch interview with Clara, Coelhos, Recife, Pernambuco, October 15, 2016.

[148] Human Rights Watch interview with Clara, Coelhos, Recife, Pernambuco, October 15, 2016.

[149] Human Rights Watch interview with Débora, 19, Recife, Pernambuco, October 15, 2016.

[150] Human Rights Watch interview with Rebeca, 25, Recife, Pernambuco, October 16, 2016.

[151] Human Rights Watch interview with Thaís, 17, Campina Grande, Paraíba, October 3, 2016.

[152] Human Rights Watch interview with Júlia, 23, Campina Grande, Paraíba, October 3, 2016.

[153] Human Rights Watch interview with Jessica, 24, Recife, Pernambuco, October 15, 2016.

[154] Human Rights Watch interview with Ana Sophia, 17, Jaboatão dos Guararapes, Pernambuco, October 16, 2016.

[155] Human Rights Watch interview with Helena, 34, Recife, Pernambuco, October 14, 2016.

[156] Human Rights Watch interview with Rossandra Oliveira, environmental surveillance manager at Campina Grande’ Secretary of Health, Campina Grande, Paraíba, Brazil, May 9, 2017.

[157] Human Rights Watch interview with Luciana Caroline Albuquerque Bezerra, Executive Secretary of Health Surveillance, State of Pernambuco, Recife, Pernambuco, Brazil, October 20, 2016.

[158] Human Rights Watch interviews with Aline, 33, Campina Grande, Pernambuco, October 3, 2016; Clarice, 16, Campina Grande, Paraíba, October 13, 2016; Rebeca, 25, Recife, Pernambuco, October 16, 2016; Erica, 45, Olinda, Pernambuco, October 18, 2016; Karen, 33, Recife, Pernambuco, October 20, 2016.

[159] Human Rights Watch interview with Paula Viana and Sueli Valongueiro, Grupo Curumim, Recife, Pernambuco, Brazil, September 15, 2016.

[160] Human Rights Watch interview with Edicléa Santos and Magda Santiago, Grupo Espaço Mulher, Passarinhos, Recife, Pernambuco, Brazil, September 14, 2016.

[161] Human Rights Watch interview with Vera Barone, Uiala Mukaji, Recife, Pernambuco, September 14, 2016.

[162] Human Rights Watch interview with Nina, 25, Recife, Pernambuco, October 20, 2016.

[163] See, e.g., Paige Baum et al., “Ensuring a Rights-Based Health Sector Response to Women Affected by Zika,” Cadernos de Saúde Pública, vol. 32, no. 5 (2016).

[164] Ministério da Saúde, “Vírus Zika: Informações ao Público,” Brasília, DF, 2016, http://portalarquivos.saude.gov.br/images/pdf/2016/janeiro/12/cartilha-informacoes-ao-publico-v2.pdf (accessed March 13, 2017).

[165] Ibid.

[166] UNFPA Executive Director Dr. Babatunde Osotimehin, “Voluntary family planning, including condoms, essential to prevent spread of Zika virus,” UNFPA, March 10, 2016, http://www.unfpa.org/press/statement-unfpa-executive-director-dr-babatunde-osotimehin-family-planning-and-zika-virus (accessed March 25, 2017).

[167] Human Rights Watch interview with Dr. Olimpio Barbosa de Moraes Filho, obstetrician/gynecologist and manager of maternity hospital, Recife, Pernambuco, October 14, 2016.

[168] Prefeitura da Cidade do Recife, “Plan to Combat the arboviruses transmitted by Aedes aegypti,” 2017, http://www2.recife.pe.gov.br/sites/default/files/aedes_aegypti_apresentacao_vf_3_16-9_0.pdf (accessed March 16, 2017).

[169] Debora Diniz et al., “Brazilian women avoiding pregnancy during Zika epidemic,” Journal of Family Planning and Reproductive Health Care, vol. 43, no: 80 (2017).

[170] See, for example, Chelsea B. Polis et al., “Typical-Use Contraceptive Failure Rates in 43 Countries with Demographic and Health Survey Data: Summary of a Detailed Report,” Contraception, vol. 94, no. 1 (2016), pp. 11-17.

[171] Human Rights Watch interviews with Joana, 47, Campina Grande, Paraíba, October 13, 2016; Antonella, 34, Recife, Pernambuco, October 19, 2016.

[172] Human Rights Watch interviews with Luna, 25, Recife, Pernambuco, October 17, 2016; Crislene, 27, Recife, Pernambuco, October 20, 2016; and Evelyn, 18, Recife, Pernambuco, October 20, 2016.

[173] Human Rights Watch interviews with Laura, 22, Recife, Pernambuco, October 18, 2016; Maria Carolina, Campina Grande, Paraíba, September 12, 2016.

[174] Human Rights Watch interviews with Thaís, 17, Campina Grande, Paraíba, October 3, 2016; Rebeca, 25, Recife, Pernambuco, October 15, 2016.

[175] Human Rights interviews with Veronica, 42, Santos Dumont, Recife, Pernambuco, October 15, 2016; Carla, 39, Coque, Recife, Pernambuco, October 16, 2016.

[176] Human Rights Watch interview with Veronica, 42, Santos Dumont, Recife, Pernambuco, October 15, 2016.

[177] Human Rights Watch interviews with Alícia, Campina Grande, Paraíba, October 13, 2016; Joana, Campina Grande, Paraíba, October 13, 2016; Evelyn, Recife, Pernambuco, October 20, 2016; Patrícia, Passarinhos, Recife, Pernambuco, October 15, 2016.

[178] Human Rights Watch interview, Brazil, October 2016. Name, location, and date withheld for security reasons.

[179] Human Rights Watch interview, Brazil, October 2016. Name, location, and date withheld for security reasons.

[180] Human Rights Watch interview with Susana, Recife, Pernambuco, October 17, 2017.

[181] Mario Francisco Giani Monteiro, Leila Adesse, and Jefferson Drezett, “Update to the Estimates of the Magnitude of the Induced Abortion Rates per Thousand Women and Reasons for 100 Live Births Induced Abortion by Age Group and Major Regions: Brazil, 1995 to 2013,” Reprodução & Climatério, vol. 30, no. 1 (2015), pp. 11-18.

[182] Debora Diniz, Marcelo Medeiros, and Alberto Madeiro, “National Abortion Survey 2016,” Ciência & Saúde Coletiva, vol. 22, no. 2 (2017), pp. 653-660. See also, Debora Diniz and Marcelo Medeiros, “Abortion in Brazil: A Household Survey Using the Ballot Box Technique,” Ciência & Saúde Coletiva, vol. 15, suppl 1 (2010), pp.959-66.

[183] Alberto Pereira Madeiro and Debora Diniz, “Legal Abortion Services in Brazil – A National Study,” Ciência & Saúde Coletiva, vol. 21, no. 2 (2016), pp. 563-572.

[184] Ibid. Some victims of sexual violence are likely denied access to abortion. The study found 14 percent of institutions required rape victims to present a police report in order to access a legal abortion and documented a lack of adequate training on sexual and reproductive rights. The study also showed how some physicians refused to perform abortion on moral or religious grounds, posing additional barriers to women accessing safe and legal abortion.

[185] Ibid.

[186] Email to Human Rights Watch from press office, Ministry of Health, May 31, 2017.

[187] Ibid.

[188] Human Rights Watch interview with Dra. Leila Katz, emergency obstetrician, Recife, Pernambuco, October 18, 2016.

[189] Ministry of Health, “Painel de Monitoramento da Mortalidade Materna,” Coordenação-Geral de Informação e Análise Epidemiológica, http://svs.aids.gov.br/dashboard/mortalidade/materna.show.mtw (accessed May 25, 2017).

[190] Ibid.

[191] Ministério de Saúde, “Atenção humanizada ao abortamento,” Serie Direitos Reprodutivos, no. 4 (2011), http://bvsms.saude.gov.br/bvs/publicacoes/atencao_humanizada_abortamento_norma_tecnica_2ed.pdf (accessed May 26, 2017).

[192] Human Rights Watch interview with Dra. Leila Katz, emergency obstetrician, Recife, Pernambuco, October 18, 2016; Human Rights Watch interview with Dr. Olimpio Barbosa de Moraes Filho, obstetrician/gynecologist and manager of maternity hospital, Recife, Pernambuco, October 14, 2016.

[193] Human Rights Watch interview, Brazil, October 2016. Name, location, and date withheld for security reasons.

[194] Human Rights Watch interview, Brazil, October 2016. Name, location, and date withheld for security reasons.

[195] See, e.g., Tábata Z. Dias et al., “Association between Educational Level and Access to Safe Abortion in a Brazilian Population,” International Journal of Gynecology & Obstetrics, vol. 128, no. 3 (2015), pp. 224-227; Gilberta S. Soares, Maria Beatriz Galli, and Ana Paula de A.L. Viana, “Advocacy for Access to Safe Legal Abortion: Similarities in the Impact of Abortion’s Illegality on Women’s Health and Health Care in Pernambuco, Bahia, Mata Grosso do Sul, Paraíba, and Rio de Janeiro,” Ipas, March 2011, http://www.ipas.org/en/Resources/Ipas%20Publications/Advocacy-for-access-to-safe-legal-abortion-Similarities-in-the-impact-of-abortions-illegal.aspx (accessed February 3, 2017).

[196] Human Rights Watch interview with Dra. Leila Katz, emergency obstetrician, Recife, Pernambuco, October 18, 2016.

[197] Adriana Brasileiro, “Illegal Abortions Claim Lives of Brazilian Women,” Reuters, November 5, 2014, http://www.reuters.com/article/women-abortion-idUSL6N0SU5WN20141105 (accessed February 13, 2017).

[198] Human Rights Watch interview, Brazil, October 2016. Name, location, and date withheld for security reasons.

[199] Ibid.

[200] Human Rights Watch interview with Dra. Leila Katz, emergency obstetrician, Recife, Pernambuco, October 18, 2016.

[201] Ibid.

[202] Supplement to: Abigail R.A. Aiken et al., “Requests for Abortion in Latin America Related to Concern about Zika Virus Exposure,” New England Journal of Medicine, vol. 375 (2016), pp. 396-398, http://www.nejm.org/doi/suppl/10.1056/NEJMc1605389/suppl_file/nejmc1605389_appendix.pdf (accessed February 2, 2017).

[203] Ibid.

[204] Monica Bernardes, “’Aedes’ faz parto cair e aborto avançar em Pernambuco,” Estadão, December 14, 2016, http://saude.estadao.com.br/noticias/geral,aedes-faz-parto-cair-e-aborto-avancar-em-pernambuco,10000094381 (accessed March 30, 2017).

[205] Projeto de Lei, no. 4396, “Para prever aumento de pena no caso de aborto cometido em razão da microcefalia ou anomalia do feto,” (2016) http://www.camara.gov.br/proposicoesWeb/prop_mostrarintegra;jsessionid=8DFB38FDDD490B5E9E0C07214F8A4C39.proposicoesWebExterno1?codteor=1433470&filename=Tramitacao-PL+4396/2016 (accessed May 26, 2017).

[206] “Defensores públicos questionam lei sobre combate a doenças transmitidas pelo Aedes aegypti,” Supremo Tribunal Federal press release, August 29, 2016, http://www.stf.jus.br/portal/cms/verNoticiaDetalhe.asp?idConteudo=323833 (accessed May 26, 2017).

[207] “ANADEP entra com Ação no STF para garantir políticas públicas às mulheres e crianças afetadas pelo Vírus Zika no Brasil,” ANADEP press release, August 24, 2016, https://www.anadep.org.br/wtk/pagina/materia?id=29504 (accessed May 26, 2017).

[208] Human Rights Watch interview with Leticia Katz, head of the Woman Health Care Department at Pernambuco’s Health Secretary, Recife, Pernambuco, Brazil, October 21, 2016.

[209] Human Rights Watch interview with Bianca Maria Souza Virgolino Nóbrega, obstetrician, Hospital Pedro I, Campina Grande, Paraíba, Brazil, October 4, 2016.

[210] Human Rights Watch interview with Larissa, 28, Recife, Pernambuco, October 20, 2016.

[211] Human Rights Watch interview with Júlia, 23, Campina Grande, Paraíba, October 3, 2016.

[212] Ministry of Health, “Sexual Health and Reproductive Health,” Cadernos de Atencao Basica, no. 26 (2010), p. 202, http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad26.pdf (accessed April 26, 2017).

[213] Human Rights Watch interview with Dr. Olimpio Barbosa de Moraes Filho, obstetrician/gynecologist and manager of maternity hospital, Recife, Pernambuco, October 14, 2016.

[214] Ibid.

[215] Human Rights Watch interview with Leticia Katz, head of the Woman Health Care Department at Pernambuco’s Health Secretary, Recife, Pernambuco, Brazil, October 21, 2016.

[216] Comissão Nacional de Incorporação de Tecnologias no SUS, “Relatório de recomendação: Implante subdérmico liberador de etonogestrel 68 mg para anticoncepção em mulheres de 15 a 19 anos de idade,” no. 208, April 2016, http://conitec.gov.br/images/Relatorios/2016/Relatorio_ImplanteEtonogestrel_Anticoncepo_final.pdf (accessed May 5, 2017).

[217] Human Rights Watch interview with Maria Carolina, 21, Campina Grande, Paraíba, September 12, 2016.

[218] Human Rights Watch interviews with Rafaela, 35, Campina Grande, Paraíba, October 4, 2016; Ines, 33, Campina Grande, Paraíba, October 5, 2016; Fernanda, 23, Campina Grande, Paraíba, October 6, 2016.

[219] Human Rights Watch interview with Luna, 25, Recife, Pernambuco, October 17, 2016

[220] Human Rights Watch interview with Luna, 25, Recife, Pernambuco, October 17, 2016.

[221] Human Rights Watch interview with Aline, 33, Campina Grande, Paraíba, October 3, 2016.

[222] Human Rights Watch interview with Karina, 34, Campina Grande, Paraíba, October 6, 2016.

[223] Human Rights Watch interview with Jessica, 24, Recife, Pernambuco, October 15, 2016.

[224] Instituto Patrícia Galvão and Locomotiva, “Zika e os Direitos das Mulheres: Mulheres Grávidas em Face da Síndrome Congênita do Zika,” August 2016, p. 43, http://agenciapatriciagalvao.org.br/wp-content/uploads/2016/08/Apresentacao-zika_Final.pdf (accessed February 22, 2017).

[225] “UNICEF e Johnson & Johnson anunciam iniciativa de apoio às famílias com bebês com microcefalia e outras deficiências,” UNICEF press release, July 20, 2016, https://www.unicef.org/brazil/pt/media_33711.htm (accessed March 25, 2017).

[226] CDC, “Zika Virus: Sexual Transmission & Prevention,” 2017, https://www.cdc.gov/zika/transmission/sexual-transmission.html (accessed May 26, 2017). For a detailed discussion of sexual transmission, see Christian L. Althaus and Nicola Low, “How Relevant is Sexual Transmission of Zika Virus” PLOS Medicine, vol. 13, no. 10 (2016), http://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1002157&type=printable (accessed May 26, 2017).

[227] Ministry of Health, “FAQ Section: how is the zika virus transmitted?” http://combateaedes.saude.gov.br/pt/tira-duvidas#chikungunya (accessed February 11, 2017).

[228] Department of Health Surveillance, Ministry of Health, “Protocol on Surveillance and Response to the occurrence of microcephaly and/or alterations of the central nervous system – version 2,” March 10, 2016, http://combateaedes.saude.gov.br/images/sala-de-situacao/Microcefalia-Pr... (accessed June 13, 2017); Department of Primary Care, Ministry of Health, “Protocol on Primary Care and Response to the occurrence of Microcephaly – version 3,” March 2016, http://combateaedes.saude.gov.br/images/sala-de-situacao/Protocolo_SAS_versao_3_atualizado.pdf (accessed , 2017).

[229] Departments of Health Surveillance and Health Care, Ministry of Health, “Integrated orientations on surveillance and health care within the public health emergency of national concern,” 2017, http://portalarquivos.saude.gov.br/images/pdf/2016/dezembro/12/orientaco... (accessed June 13, 2017).

[230] Human Rights Watch interview with Clarice, 16, Campina Grande, Paraíba, October 13, 2016.

[231] Human Rights Watch interviews with Karina, 34, Campina Grande, Paraíba, October 6, 2016; Samara, 33, Campina Grande, Paraíba, October 6, 2016; Jessica, 24, Recife, Pernambuco, October 15, 2016; Patrícia, 21, Recife, Pernambuco, October 15, 2016; Alana, 26, Recife, Pernambuco, October 20, 2016.

[232] WHO, “Pregnancy Management in the Context of Zika Virus Infection: Interim Guidance Update.”; also Olufemi T. Oladapo et al, “WHO interim guidance on pregnancy management in the context of Zika virus infection,” The Lancet, vol. 4, no. 8 (2016), pp. e510-e511, http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30098-5/fulltext (accessed May 26, 2017).

[233] Human Rights Watch interview with Júlia, 23, Campina Grande, Paraíba, October 3, 2016.

[234] Human Rights Watch interview with Alana, 26, Recife, Pernambuco, October 20, 2016.

[235] WHO, “Pregnancy Management in the Context of Zika Virus Infection: Interim Guidance Update.”; also Oladapo et al, “WHO interim guidance on pregnancy management in the context of Zika virus infection,” The Lancet.

[236] Human Rights Watch interview with Lorena, 22, Campina Grande, Paraíba, October 6, 2016.

[237] Human Rights Watch interview with Vitória, 31, Campina Grande, Paraíba, October 13, 2016.

[238] Instituto Patrícia Galvão and Locomotiva, “Zika e os Direitos das Mulheres: Mulheres Grávidas em Face da Síndrome Congênita do Zika,” August 2016, pp. 23, 34.

[239] WHO, “Pregnancy Management in the Context of Zika Virus Infection: Interim Guidance Update.”; also Oladapo et al, “WHO interim guidance on pregnancy management in the context of Zika virus infection,” The Lancet.

[240] Human Rights Watch interview with Thereza de Lamar, Ministry of Health official, in Brasilia, April 19, 2017.

[241] Diogo Caixote, “Saúde amplia acesso a diagnóstico e cuidado das gestantes e bebês,” Ministry of Health press release, November 18, 2016, http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secretarias/svs/noticias-svs/26386-saude-amplia-acesso-a-diagnostico-e-cuidado-das-gestantes-e-bebes (accessed May 26, 2017).

[242] Human Rights Watch interview with Eliane Germano, head of the Healthcare Department, Recife Secretariat of Health, April 6, 2017; Human Rights Watch interview with Leticia Katz, head of the Woman Health Care Department at Pernambuco’s Health Secretary, Recife, Pernambuco, Brazil, October 21, 2016.

[243] Human Rights Watch interview with Luciana Caroline Albuquerque Bezerra, executive secretary of health surveillance, State of Pernambuco, Recife, Pernambuco, Brazil, October 20, 2016.

[244] Ibid. For more information about the notification system, see Ministry of Health, “Sistema de Informação de Agravos de Notificação,” 2007, http://bvsms.saude.gov.br/bvs/publicacoes/07_0098_M.pdf (accessed May 26, 2017).

[245] Human Rights Watch interviews with Jessica, 24, Recife, Pernambuco, October 15, 2016; Giovanna, 24, Campina Grande, Paraíba, October 13, 2016; Stella, 25, Campina Grande, Paraíba, October 13, 2016.

[246] Human Rights Watch interview with Rebeca, 25, Recife, Pernambuco, October 16, 2016.

[247] Human Rights Watch interview with Débora, 19, Recife, Pernambuco, October 15, 2016.

[248] Ministry of Health, “Ministério da Saúde Finaliza Pregão para Compra de Repelentes,” December 9, 2016, http://combateaedes.saude.gov.br/pt/noticias/896-ministerio-da-saude-finaliza-pregao-para-compra-de-repelentes (accessed February 22, 2017).

[249] Department of Primary Care, Ministry of Health, “Guidelines on Early Stimulation: children from zero to three years old with delay in psychomotor development resulting from microcephaly – preliminary version,” 2016, http://portalarquivos.saude.gov.br/images/pdf/2016/janeiro/13/Diretrizes-de-Estimulacao-Precoce.pdf (accessed March 13, 2017); Department of Primary Care, Ministry of Health, “Protocol on Primary Care and Response to the occurrence of Microcephaly – version 3,” March 2016, http://combateaedes.saude.gov.br/images/sala-de-situacao/Protocolo_SAS_versao_3_atualizado.pdf (accessed February 13, 2017).

[250] “Núcleo de Desenvolvimento Infantil já está recebendo bebês do Recife com microcefalia,” Recife press release, January 4, 2016, http://www2.recife.pe.gov.br/noticias/04/01/2016/nucleo-de-desenvolvimento-infantil-ja-esta-recebendo-bebes-do-recife-com (acccessed March 16, 2017).

[251] Artur Lira, “Apenas três cidades têm atendimento para crianças com microcefalia na Paraíba,” Globo, February 21, 2016, http://g1.globo.com/pb/paraiba/noticia/2016/02/apenas-tres-cidades-tem-atendimento-para-criancas-com-microcefalia-na-pb.html (accessed February 17, 2017).

[252] Elisa Meirelles, “Ingressar na crèche: o novo desafio das crianças com a síndrome congênita do zika,” Medium, February 8, 2017, https://medium.com/@UNICEFBrasil/ingressar-na-creche-o-novo-desafio-das-crianças-com-a-síndrome-congênita-do-zika-f4685c860e08#.r83tb1a6v (accessed February 17, 2017).

[253] Department of Health Surveillance, Ministry of Health, “Epidemiological Bulletin: Integral Monitoring of Alterations in the Growth and Development related to Zika virus infection and other infectious etiologies until the Epidemiological Week 14, 2017,” 2017, http://combateaedes.saude.gov.br/images/pdf/Monitoramento-alteracoes-Zika.pdf (accessed May 7, 2017).

[254] Human Rights Watch interview with Thereza de Lamare, director of the Programatic and Strategic Actions Department, Ministry of Health, Brasília, Distrito Federal, Brazil, April 19, 2017. See also Ministry of Health and Ministry of Social Development, government of Brazil, Portaria No 405, March 2016.

[255] Human Rights Watch interview with Jadson Galindo, official in the Pernambuco’ Secretariat of Health, Recife, Brazil, April 7, 2017.

[256] Department of Health Surveillance, Ministry of Health, “Epidemiological Bulletin: Integral Monitoring of Alterations in the Growth and Development related to Zika virus infection and other infectious etiologies until the Epidemiological Week 14, 2017,” 2017, http://combateaedes.saude.gov.br/images/pdf/Monitoramento-alteracoes-Zika.pdf (accessed May 7, 2017).

[257] Human Rights Watch interview with Thereza de Lamare, director of the Programatic and Strategic Actions Department, Ministry of Health, Brasília, Distrito Federal, Brazil, April 19, 2017.

[258] Human Rights Watch identified the caregivers interviewed for this report largely through support groups and medical institutions, and their children with Zika syndrome were already receiving a range of services. It was beyond the scope of our methodology to identify children affected by Zika who were not linked to services. However, many children with Zika syndrome in Brazil may not be receiving the level of services accessed by the families interviewed for this report.

[259] Human Rights Watch interview with Luciana Caroline Albuquerque Bezerra, Executive Secretary of Health Surveillance, State of Pernambuco, Recife, Pernambuco, Brazil, October 20, 2016.

[260]“Plano contra Aedes prioriza ambulatório para chikungunya em PE,” G1 Pernambuco, December 6, 2016, http://g1.globo.com/pernambuco/noticia/plano-contra-aedes-prioriza-ambulatorio-para-chikungunya-em-pe.ghtml (accessed March 24, 2017).

[261] Human Rights Watch interview with Dra. Danielle Cruz, pediatrician and family health doctor, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), and Plínio Augusto, doctor, Sistema Único de Saúde, Recife, Pernambuco, Brazil, September 13, 2016.

[262] Human Rights Watch interview with Rafaela, 35, Campina Grande, Paraíba, October 4, 2016.

[263] Human Rights Watch interviews with Geuma Marques and Maria Jeanette de Oliveira Silveira, officials at Campina Grande’ Secretary of Health, Campina Grande, Paraíba, Brazil, May 9, 2017.

[264] Human Rights Watch interview with Aléxia, 20, Campina Grande, Paraíba, Brazil, May 9, 2017.

[265] Human Rights Watch interview with Rafaela, 35, Campina Grande, Paraíba, October 4, 2016.

[266] Human Rights Watch interview with Fernanda, 23, Campina Grande, Paraíba, October 6, 2016.

[267] Human Rights Watch interview with Stephanie, 26, Campina Grande, Paraíba, October 4, 20f16.

[268] Human Rights Watch interviews with Stephanie, 26, Campina Grande, Paraíba, October 4, 2016; Antonella, 34, Recife, Pernambuco, October 19, 2016; Thaís, 17, Campina Grande, Paraíba, October 3, 2016.

[269] Human Rights Watch interview with Antonella, 34, Recife, Pernambuco, October 19, 2016

[270] Human Rights Watch interview with Stephanie, 26, Campina Grande, Paraíba, October 4, 2016

[271] Human Rights Watch interviews with Jeime Leal, physical therapist, Pedro I Hospital, Campina Grande, Paraíba, September 12, 2016; Andréa Sonaira, occupational therapist, Pedro I Hospital, Campina Grande, Paraíba, September 12, 2016; Dra. Danielle Cruz, pediatrician and family health doctor, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, Pernambuco, Brazil, September 13, 2016; Marina Queiroz, occupational therapist, Juliana Gomes, occupational therapist, and Maria Elisa Farias, physical therapist, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, Pernambuco, Brazil, October 19, 2016.

[272] Federal Constitution of the Republic of Brazil, 1988, art. 203, sec. V; Government of Brazil, Law 8,742 (Organic Law of Social Assistance), 1993, arts. 2, 20.

[273] Government of Brazil, Law No. 13,301, art. 18. Various court cases are pending that challenge aspects of this provision, including the stipulation that the benefit will be limited to three years, and the stipulation that the benefit will be granted only after termination of paid maternity leave. The state of Pernambuco created a social benefit specifically for babies with Zika syndrome equivalent to one minimum wage, but state officials we spoke to were not sure how many were receiving the benefit.

[274] Human Rights Watch interview with Olívia, 35, Campina Grande, Paraíba, September 12, 2016.

[275] Human Rights Watch interview with Lucas, IMIP, Recife, Pernambuco, October 20, 2016.

[276] Human Rights Watch interview with Aline, 33, Campina Grande, Pernambuco, October 3, 2016.

[277] Human Rights Watch interviewed 30 women raising children with Zika syndrome for this report

[278] Human Rights Watch interview with Lídia, 34, Campina Grande, Paraíba, October 4, 2016.

[279] Human Rights Watch interview with Luna, 25, Recife, Pernambuco, October 17, 2016.

[280] Human Rights Watch interview with Evelyn, 18, Recife, Pernambuco, October 20, 2016.

[281] Human Rights Watch interview with Maitê, 29, Recife, Pernambuco, October 17, 2016.

[282] Human Rights Watch interview with Ines, 33, Campina Grande, Paraíba, October 5, 2016.

[283] Human Rights Watch interview with Monica, IMIP, Recife, Pernambuco, October 18, 2016.

[284] Human Rights Watch interview with Jusikelly, 32, Recife, Pernambuco, October 16, 2016.

[285] Women Enabled, an advocacy organization focused on the rights of women and girls with disabilities, recognized a global need for guidance on how to talk about and approach the issue of Zika syndrome from a disability rights perspective. It published important talking points for services providers and advocates in the first few months of the health emergency, imploring both services providers, government and media to use more nuanced language to reduce the risk of social stigma. These talking points can be found here: “Talking Points: Zika, Microcephaly, Women’s Rights, and Disability Rights,” Women Enabled International, April 15, 2016, http://www.womenenabled.org/pdfs/WEI%20Talking%20Points%20Zika,%20Microcephaly,%20Women's%20Rights,%20and%20Disability%20Rights%20ENGLISH%20June%202016.pdf (accessed May 26, 2017).

[286] Human Rights Watch interview with Rafaela, 35, Campina Grande, Paraíba, October 4, 2016.

[287] Human Rights Watch interview with Jacqueline Ioureiro, psychologist, Pedro I Hospital, Campina Grande, Paraíba, October 13, 2016.

[288] Human Rights Watch interview with Mayara, 20, Recife, Pernambuco, October 19, 2016.

[289] Human Rights Watch interview with Evelyn, 18, Recife, Pernambuco, October 20, 2016; Human Rights Watch interview with Luisa, 20, Campina Grande, Paraíba, October 6, 2016.

[290] Human Rights Watch interview with Stephanie, 26, Campina Grande, Paraíba, October 4, 2016

[291] Human Rights Watch interview with Crislene, 27, Recife, Pernambuco, October 20, 2016.

[292] Human Rights Watch interview with Luna, 25, Recife, Pernambuco, October 17, 2016.

[293] Human Rights Watch interview with Marina Queiroz, occupational therapist, Juliana Gomes, occupational therapist, and Maria Elisa Farias, physical therapist, Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, Pernambuco, Brazil, October 19, 2016.

[294] Ibid.

[295] Human Rights Watch interview with Susana, Recife, Pernambuco, October 17, 2016.

[296] Human Rights Watch interview with Jeime Leal, physical therapist, Pedro I Hospital, Campina Grande, Paraíba, September 12, 2016.

[297] “Fiocruz divulga carta A PEC 241 e os impactos sobre direitos sociais, saúde e a vida,” Fiocruz press release, October 4, 2016, https://portal.fiocruz.br/pt-br/content/fiocruz-divulga-carta-pec-241-e-os-impactos-sobre-direitos-sociais-saude-e-vida (accessed May 26, 2017).

[298] “Brazil 20-year public expenditure cap will breach human rights, UN expert warns,” OHCHR press release, December 9, 2016, http://www.ohchr.org/en/newsevents/pages/displaynews.aspx?newsid=21006&langid=e (accessed May 26, 2017).

[299] Human Rights Watch interview with Dr. Olimpio Barbosa de Moraes Filho, obstetrician/gynecologist and manager of maternity hospital, Recife, Pernambuco, October 14, 2016.

[300] Brian D. Foy et al., “Probable non-vector-borne transmission of Zika virus, Colorado, USA,” Emerging Infectious Diseases, vol. 17, no. 5 (2011), pp. 880-882, https://wwwnc.cdc.gov/eid/article/17/5/pdfs/10-1939.pdf (accessed February 11, 2017); D. Trew Deckard et al., “Male-to-Male Sexual Transmission of Zika Virus – Texas, January 2016,” Morbidity and Mortality Weekly Report, vol. 65, no. 14 (2016), pp. 372-374, https://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6514a3.pdf (accessed February 11, 2017); Susan L. Hills et al., “Transmission of Zika Virus Through Sexual Contact with Travelers to Areas of Ongoing Transmission – Continental United States, 2016,” Morbidity and Mortality Weekly Report, vol. 65, no. 8 (2016), pp. 215-216, https://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6508e2.pdf (accessed February 11, 2017).

[301] Didier Musso et al, “Potential Sexual transmission of Zika virus,” Emerging Infectious Diseases, vol. 21, no. 2 (2015), pp. 359-61, https://wwwnc.cdc.gov/eid/article/21/2/14-1363_article (accessed February 8, 2017); Barry Atkinson et al., “Detection of Zika virus in semen,” Emerging Infectious Diseases, vol. 22, no. 5 (2016), pp. 940, https://wwwnc.cdc.gov/eid/article/22/5/16-0107_article (accessed February 8, 2017); Jean Michel Mansuy et al., “Zika virus: high infectious viral load in semen, a new sexually transmitted pathogen?,” Lancet Infect Diseases, vol. 16, no. 4 (2016), pp. 405, http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)00138-9/abstract (accessed February 8, 2017); Luisa Barzon et al., “Infection dynamics in a traveller with persistent shedding of Zika virus RNA in semen for six months after returning from Haiti to Italy, January 2016,” EuroSurveillance, vol. 21, no. 32 (2016), pp. 1-4, http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=22556 (accessed February 8, 2017).

[302] Human Rights Watch interview with Marco, 40, Recife, Pernambuco, October 17, 2016.

[303] Human Rights Watch interview with Fábio, 27, Recife, Pernambuco, October 16, 2016.

[304] Human Rights Watch interviews with Karina, 34, Campina Grande, Paraíba, October 6, 2016; Samara, 33, Campina Grande, Paraíba, October 6, 2016; Jessica, 24, Recife, Pernambuco, October 15, 2016; Patrícia, 21, Recife, Pernambuco, October 15, 2016; Alana, 26, Recife, Pernambuco, October 20, 2016.

[305] Sueli Valongueiro, coordinator, Grupo Curumim, email message to Human Rights Watch, May 17, 2017.

[306] Human Rights Watch interview with Professor Jorge Lyra, professor and researcher of psychology, Federal University of Pernambuco, Recife, Pernambuco, October 17, 2016.

[307] Human Rights Watch interview with Susana, Recife, Pernambuco, October 17, 2016.

[308] Human Rights Watch interview with Rafaela, Campina Grande, Paraíba, October 4, 2016.

[309] Human Rights Watch interview with Jeime Leal, physical therapist, Pedro I Hospital, Campina Grande, Paraíba, September 12, 2016.

[310] Human Rights Watch interview with Lucas, IMIP, Recife, Pernambuco, October 20, 2016.

[311] Human Rights Watch interview with Lucas, IMIP, Recife, Pernambuco, October 20, 2016.

[312] Human Rights Watch interview with Lucas, IMIP, Recife, Pernambuco, October 20, 2016.

[313] Human Rights Watch interview with Gustavo, Recife, Pernambuco, October 18, 2016.

[314] Government of Brazil, Law 8,213 on Benefits of Social Security, 1991.

[315] Human Rights Watch interview with Rosalyn, Boquierão, Paraíba, October 5, 2016.

[316] Human Rights Watch interview with Gustavo, Recife, Pernambuco, October 18, 2016.

[317] Human Rights Watch interview with Lucas, IMIP, Recife, Pernambuco, October 20, 2016.

[318] Ibid.

[319] Human Rights Watch interviews with Lucas, IMIP, Recife, Pernambuco, October 20, 2016, Paulo, 44, Recife, Pernambuco, October 16, 2016, and Gustavo, 27, Recife, Pernambuco, October 18, 2016.

[320] Human Rights Watch interview with Paulo, 44, Recife, Pernambuco, October 16, 2016.

[321] Human Rights Watch interview with Gustavo, 27, Recife, Pernambuco, October 18, 2016.

[322] Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), res. 34/180, entered into force September 3, 1981, ratified by Brazil on February 1, 1984; International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A (XXi), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), 99 U.N.T.S. 171, entered into force March 23, 1976, ratified by Brazil on January 24, 1992; Convention on the Rights of the Child (CRC), adopted November 20, 1989. G.A. Res. 44/25, annex, 44 U.N. GAOR Supp. (No.49) at 167, U.N. Doc A/44/49 (1989), entered into force September 2, 1990, ratified by Brazil on September 24, 1990; Convention on the Rights of Persons with Disabilities (CRPD), adopted December 13, 2006, G.A. Res 61/106, entered into force May 3, 2008, ratified by Brazil on August 1, 2008; Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights, O.A.S. Treaty Series No. 69 (1988), signed November 17, 1988, ratified by Brazil on August 21, 1996.

[323] In the 1994 Cairo Programme of Action on Population and Development, delegates from governments around the world pledged to eliminate all practices that discriminate against women and to assist women to “establish and realize their rights, including those that relate to reproductive and sexual health.” In the 1995 Beijing Declaration and Platform for Action, delegates from governments around the world recognized that women’s human rights include their right to have control over and decide freely and responsibly on matters related to their sexuality free of coercion, discrimination and violence. See United Nations, Programme of Action of the United Nations International Conference on Population and Development (New York: United Nations Publications, 1994), A/CONF.171/13, 18 October 1994, para. 4.4(c) and United nations, Beijing Declaration and Platform for Action (New York: United Nations Publications, 1995), A/CONF.177/20, 17 October 1995, para. 223.

[324] CEDAW, art. 12

[325] CEDAW Committee, “General Recommendation 24, Women and Health (Article 12),” U.N. Doc. No. A/54/38/Rev.1 (1999), para. 14.

[326] United National Human Rights Office of the High Commissioner, “Upholding women’s human rights essential to Zika response – Zeid,” February 5, 2016, http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=17014 (accessed (March 27, 2017).

[327] ICCPR, art. 19(2); American Convention on Human Rights, art. 13(1). See also Inter-American Court, Claude-Reyes and others Case, Judgment of September 19, 2006 Inter-Am Ct.H.R., Series C. No. 151, para. 264.

[328] CEDAW, art. 16(e).

[329] See ICESCR, article 2(2). See also Committee on Economic, Social and Cultural Rights, “General Comment No. 14, The Right to the Highest Attainable Standard of Health,” U.N. Doc. E/C.12/2000/4 (2000), paras. 12(b), 18 and 19.

[330] Committee on Economic, Social and Cultural Rights, “General Comment No. 14, The Right to the Highest Attainable Standard of Health,” U.N. Doc. E/C.12/2000/4 (2000), para. 11.

[331] Ibid., para. 21.

[332] CESCR General Comment No. 22, para. 18.

[333] CEDAW Committee, “General Recommendation no. 21, on equality in marriage and family relations,” HRI/GEN/1/Rev.9 (Vol.II), para. 22.

[334] CEDAW Committee, “Statement of the Committee on the Elimination of Discrimination against Women on sexual and reproductive health and rights: Beyond 2014 ICPD review.”

[335] See, e.g., CRC concluding observations on Panama, U.N. Doc. CRC/C/PAN/CO/3-4 (2011), para. 57; Costa Rica, U.N. Doc. CRC/C/CRI/CO/4 (2011), para 64(f); and Nicaragua, U.N. Doc. CRC/C/NIC/CO/4 (2010), para. 65.

[336] CRC, General Comment No. 20, para. 64.

[337] Human Rights Watch submitted an amicus briefs to the supreme court of Brazil in April 2017 in support of two pending cases related to the decriminalization of abortion. The briefs provide detailed legal analysis of the relationship between international human rights law and abortion. Brief for HRW as Amicus Curiae, ADI n 5581 https://www.hrw.org/news/2017/04/25/amicus-curiae-decriminalization-abortion-context-zika-virus-brazil; Brief for HRW as Amicus Curiae, ADI n 5581 https://www.hrw.org/news/2017/04/25/amicus-curiae-decriminalization-abor....

[338] These numbers are from an analysis of the jurisprudence by Human Rights Watch staff, copy on file at Human Rights Watch.

[339] See, for example, Committee on the Rights of the Child, General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24), U.N. Doc. CRC/C/GC/15 (2013), para. 54.

[340] UN Committee on the Rights of the Child, Concluding Observations on the Combined Second to Fourth

Periodic Reports of Brazil, CRC/C/BRA/CO/2-4, October 30, 2015, para. 60.

[341] CEDAW Committee, “Concluding observations of the Committee on the Elimination of Discrimination against Women: Brazil” U.N. Doc CEDAW/C/BRA/CO/7, March 23, 2012, para. 29(b).

[342] CEDAW Committee, Alyne da Silva Pimentel v. Brazil (2011), Comm. No. 17/2008. U.N. Doc. CEDAW/C/49/D/17/2008, para. 7.7.

[343] United Nations General Assembly, “The human rights to safe drinking water and sanitation,” Resolution 70/169, U.N. Doc. A/RES/70/169, December 17, 2015.

[344] Ibid. See also, UN Human Rights Council resolution 15/9 of September 2010, resolution 16/2 of March 2011, resolution 18/1 of September 2011 and resolution 21/2 of September 2012.

[345] The Committee on Economic, Social and Cultural Rights is the UN body responsible for monitoring compliance with the ICESCR. UN Committee on Economic, Social and Cultural Rights, General Comment No. 15, The Right to Water, U.N. Doc. E/C.12/2002/11, adopted January 20, 2003, para. 12(a).

[346] The Committee on Economic, Social and Cultural Rights is the UN body responsible for monitoring compliance with the ICESCR. UN Committee on Economic, Social and Cultural Rights, General Comment No. 15, The Right to Water, U.N. Doc. E/C.12/2002/11, adopted January 20, 2003, para. 8, 12(b).

[347] United Nations General Assembly, “The human rights to safe drinking water and sanitation,” Resolution 70/169, U.N. Doc. A/RES/70/169, December 17, 2015.

[348] Ibid. See also, UN Human Rights Council resolution 15/9 of September 2010, resolution 16/2 of March 2011, resolution 18/1 of September 2011 and resolution 21/2 of September 2012.

[349] United Nations, report of the independent expert on the issue of human rights obligations related to access to safe drinking water and sanitation, July 1, 2009, U.N. Doc. A/HRC/12/24, para. 64; see also UN Committee on Economic, Social and Cultural Rights, Statement on the Right to Sanitation, U.N. Doc. E/C.12/2010/1 (2010).

[350] United Nations Human Rights Office of the High Commissioner, “Zika virus: “Improved water and sanitation services are the best answer” – UN experts note,” March 11, 2016, http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?
NewsID=17212&LangID=E (accessed March 26, 2017).

[351] CRPD Preamble, sec. (r)

[352] CRPD, art. 18(2)

[353] CRPD, art. 23(3)

[354] CRPD, art. 25(c).

[355] CRPD, art. 28

[356] UN Committee on the Rights of the Child, General Comment No. 9, The Rights of Children with Disabilities, U.N. Doc. CRC/C/GC/9 (2006), para. 41.

[357] UN Committee on Economic, Social and Cultural Rights (CESCR), General Comment No. 20, Non-Discrimination in Economic, Social and Cultural Rights, U.N. Doc. E/C.12/GC/20 (2009), para. 19(h); UN Committee on Economic, Social and Cultural Rights (CESCR), General Comment No. 5, Persons with Disabilities, U.N. Doc. E/1995/22 (1994), para 28.

Author: Human Rights Watch, Human Rights Watch
Posted: January 1, 1970, 12:00 am

Liu Xiaobo and his wife, Liu Xia.

© 2010 Reuters

(New York) – The Chinese government should immediately lift all restrictions on Nobel Peace laureate Liu Xiaobo and his wife, Liu Xia, Human Rights Watch said today. The couple should be able to go where they wish for medical treatment, and have unfettered access to family, friends, journalists, and foreign diplomats. Chinese authorities should also stop harassing and intimidating Liu’s friends and others who have voiced support for him.

“Chinese President Xi Jinping has shown astonishing disdain for Liu Xiaobo’s life, from his wrongful imprisonment to his treatment after being transferred to a hospital,” said Sophie Richardson, China director. “President Xi could still mitigate some of the harm to his reputation by allowing Liu and his wife to go wherever – and meet with whomever – they wish.”

On June 26, 2017, Liu Xiaobo’s lawyers told the media that Liu, who had been imprisoned since 2009 for his pro-democracy activities, had been “released on bail for medical treatment” and transferred to a hospital in Shenyang, Liaoning province, for treatment of advanced liver cancer. Liu was admitted to the hospital under a pseudonym, preventing journalists and others from locating him.

Other than Liu Xia and her brother, Liu Hui, it is unclear whether family members have been allowed to visit Liu at the hospital. Several people who have tried to visit the hospital describe security as extremely tight. Authorities have told Liu’s family and friends that they are prohibited from speaking to the media. A lawyer for Liu said the authorities had rejected Liu’s request to go abroad for treatment, but the Chinese government has not confirmed this.

Chinese President Xi Jinping has shown astonishing disdain for Liu Xiaobo’s life, from his wrongful imprisonment to his treatment after being transferred to a hospital.

Sophie Richardson

China Director

Since Liu’s illness became public, more than 1,500 people in China and abroad have signed an open letter calling for his full freedom, despite stringent censorship of news about him on Chinese social media. Police across the country have harassed more than 20 people who signed the letter, ordering them not to speak publicly about Liu, Human Rights Watch has learned.

Fei, a businessman in Zhejiang province, was detained in a police station for nearly 20 hours after he signed the petition in support of the couple. Police in Guangdong province raided a law office and installed a surveillance camera in front of the home of poet Wu Mingliang, known as Lang Zi, after two lawyers and the poet added their signatures to the petition. Guangdong authorities also blocked the incoming phone calls of Wu Yangwei, a dissident writer known by his pen name Ye Du, preventing him from giving interviews about Liu to foreign media.

Beijing police went to the home of Bao Tong, former secretary of the deceased premier Zhao Ziyang, warning him not to publish articles or give interviews to the media. Beijing police also forced activist Zhou Tuo and his wife out of the city. Hu Jia, another Beijing activist, said he has been under house arrest since the morning of June 27 to prevent him from trying to visit Liu Xiaobo in Shenyang. He too had signed the open letter.

Authorities have released little information about Liu’s medical condition. The Shenyang City Bureau of Justice issued a notice stating that prison authorities discovered Liu’s cancer following a routine physical on May 31, and that Liu had been treated by a team of eight experts. On June 28, a video of edited clips surfaced on the internet showing Liu receiving medical exams. In it, Liu praised prison officials and said that he is “very grateful” for the attention paid to his health. The circumstances surrounding the clips are unclear, including whether Liu had consented to the filming, when they were taken, or the precise nature of the exams.

In recent years, media outlets linked to the Chinese government have released videos showing purported confessions of detained activists or clips of them appearing physically well, to dispel criticism of their arrests or suspicions that they were tortured. Some activists, after being released, denounced their statements as forced. Such videos violate basic due process rights and may be connected to torture or other ill-treatment.

“Liu Xiaobo will be remembered for promoting freedom, democracy, and human rights in China,” Richardson said. “President Xi should demonstrate basic human decency and end these cruel, baseless restrictions.”

Posted: January 1, 1970, 12:00 am

Pineville Community Hospital, Pineville, Kentucky. 

© Americore Health Solutions

Rural America is in the midst of a health emergency that will probably get much worse if the US Senate’s healthcare bill passes.

According to the US Centers for Disease Control (CDC), people who live in rural areas are more likely to die of all of the five top causes of death, including heart disease and cancer, than their urban counterparts. Making matters worse, on average the 46 million people living in rural areas – 15 percent of the US population – are older, sicker, and have less access to health care than those who live in urban areas, and the gap has widened in recent years.

The Senate bill, currently a discussion draft, would leave millions of people across the country without health insurance, but those in rural areas are likely to be hardest hit. Most of the damage would be done through the bill’s decimation of Medicaid. Like the House’s healthcare bill, the Senate’s draft legislation includes a US$834 billion reduction in Medicaid spending over the next decade. Unlike the House bill, this spending cut would hit after 2020.

Today, 700 rural hospitals are already in danger of closing their doors due to federal budget cuts. Experts predict a dramatic rise in that number if either the Senate or House legislation is signed into law.

Cuts to Medicaid would also exacerbate the overdose epidemic that is raging in rural counties throughout the nation. Although all states have experienced increases in opioid use and overdose deaths in the past decade, the heaviest concentration of deaths are in states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. Many factors, such as poverty and unemployment, contribute to this disparity. But health insurance has proven to be a primary lifeline to recovery. Medicaid is the largest single source of health coverage for substance use disorders. In states that expanded Medicaid under Obamacare, more than 1.2 million people have been able to get drug dependence treatment.

President Donald Trump and the Republican Party are in control of the White House and Congress largely because of the rural vote. This Senate health care bill would repay support at the ballot box with a punch to the gut.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Roma children play in the Cesmin Lug Camp outside Trepca mine, on the outskirts of Mitrovica, June 22, 2009.

© 2009 Reuters

The United Nations may be undermining its own efforts to promote human rights, at a time when rights are under threat worldwide.

That’s the view of a UN panel of experts, which investigated complaints of human rights violations by the UN mission in Kosovo after the 1998-1999 war – including widespread lead poisoning at UN-run camps. Displaced members of the Roma, Ashkali, and Egyptian minorities lived there for more than a decade, and hundreds of them got sick, with many still suffering health consequences today.

The UN Human Rights Advisory Panel (HRAP), which conducted the investigation, recommended last year that the UN apologize and pay lead poisoning victims individual compensation.

However, last month UN Secretary-General Antonio Guterres’ press office suggested a different – and watered-down – plan. It announced that the UN was creating a voluntary trust fund for community assistance projects to help “more broadly the Roma, Ashkali and Egyptian communities.” In other words, UN member states would choose whether to donate to the fund, which could be used to provide services that do not specifically target those affected by lead poisoning.

Victims’ lawyers, Roma rights organizations and UN accountability advocates criticized the UN’s decision. Human Rights Watch urged Guterres to follow the HRAP’s recommendations.

Now the former HRAP members have called on the UN to change course. In a June 8 letter to Guterres, they argued that the trust fund fails to provide compensation for violations of the right to life and the right to health. They also warned Guterres that “at a time of backlash against human rights it is vital that the UN be seen to live up to the promise of the [UN] Charter and the obligations it has promoted.” If the UN does not hold itself accountable, “the human rights system as a whole is weakened,” they wrote.

It is high time for the UN to make amends for the suffering inflicted on hundreds of families from Kosovo who were exposed to toxic lead in camps – and who the UN failed to relocate until well after the health effects became clear.

Guterres, who inherited this problem, has promised to build a culture of accountability. But the UN’s refusal to take responsibility here undermines its ability to press governments to remedy their own human rights abuses. 

Author: Human Rights Watch, Human Rights Watch
Posted: January 1, 1970, 12:00 am

Summary

The president of Equatorial Guinea, Teodoro Obiang Nguema Mbasogo, once described the discovery of oil in the 1990s off the coast of the small Central African nation as “manna from heaven,” the Biblical life-saving bread that God sent Israelites as they wandered in the desert. Ravaged by almost six centuries of colonialism followed by an eleven-year brutal dictatorship, the country was one of the world’s poorest and most poorly governed in 1979 when Obiang deposed his uncle and took power.

The discovery of oil in 1991 had the potential to change the fortunes of Equatorial Guinea, and it did, in many ways. Before the discovery of oil the country’s total income was US$132 million, or $330 per capita. Within the next decade per capita gross domestic product (GDP) rose significantly, comparable to that of many industrialized nations—peaking in 2012 at $19 billion ($24,304 per capita). However, oil production has been in decline since 2012, and oil is expected to run dry by 2035 unless new reserves are found.

Equatorial Guinea’s mismanagement of its oil wealth has contributed to chronic underfunding of its public health and education systems in violation of its human rights obligations.

Suddenly the small country of about one million people occupying 28,050 square kilometers had a great but fleeting opportunity to deliver exemplary social services to its citizens in line with its human rights obligations. Obiang raised expectations, repeatedly saying he would prioritize health services and education, but budgetary allocations to health and education have in fact been dismal: in 2011, the most recent year for which there is data, the government spent three percent of its budget on education and less than two percent on health, according to the International Monetary Fund (IMF). Forty-five other countries in Equatorial Guinea’s per capita GDP range spent at least four times as much on health and education during the same period. Instead the country invested heavily in large-scale infrastructure projects, which comprised 82 percent of its total budget in 2011, an approach the IMF and World Bank have repeatedly criticized.

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Equatorial Guinea is one the smallest countries in Africa, with a population of around 1 million and a total landmass of just over 28,000 square kilometers.

Obiang, the world’s longest-serving president, justifies the huge investment in infrastructure as part of a strategy to lay the groundwork for a modern economy. Undoubtedly this investment has improved the country’s transportation infrastructure, which includes a network of more than 2,000 kilometers of roads, five airports, and eight ports, as well as several modern hospitals and a national university campus. But, according to the IMF, such an approach “contribut[es] to low provisions for health and education service delivery.” It also found that “costs and wastage have been high” for infrastructure projects, “because of limitations in oversight and pressure for prestige projects.”

This report shows how the government of Equatorial Guinea has for two decades paved the way for this reality, squandering the promise afforded by its discovery of oil by grossly underspending on social welfare and overspending on wasteful and corruption-riddled infrastructure projects. In the process, it has not fulfilled its human rights obligations to progressively realize the right to affordable and decent health care and education for its people. The report describes how, though upper middle-income on paper, Equatorial Guinea faces severe challenges that commonly affect low-income countries, especially in health and education. It documents how companies, fully or partially owned by the president, members of his family, or senior government officials, have been awarded large public contracts. In some cases, businesspeople allege that they were encouraged by government officials to submit inflated contracts so that the officials could collect considerable kickbacks.

In addition, this research adds to a significant body of work on corruption in Equatorial Guinea, including numerous international investigations that have uncovered evidence of high-level corruption. A 2004 United States Senate investigation into Riggs Bank, a Washington, DC-based commercial bank, for example, revealed direct transfers of millions of dollars from accounts holding the country’s oil wealth into accounts believed to be controlled by the president. Money-laundering investigations into the president’s eldest son, who was appointed vice president in June 2016, allege how within a period of about five years, he spent $110 million in the United States and €175 million (US$189 million at current exchange rate) in France. The French prosecutor alleged that €110 million was transferred from Equatorial Guinea’s public treasury to Teodorin’s personal accounts, part of which funded his French spending spree.

There is an ongoing trial in Spain based on evidence that senior government officials purchased mansions in the country with funds transferred from the Riggs Bank oil account. In Italy, the financial police, when investigating one of the largest construction companies operating in the country, found millions of dollars linked to a network of international bank accounts owned by the president and his son.

All of this contributes to the government’s woeful underinvestment in health and education, at great human cost.

Neglecting the Right to Health

With the discovery of oil, Equatorial Guinea had a great opportunity to improve healthcare by investing in the provision of potable water, adequate sanitation, infection control, and other key determinants of health, as well as in the strengthening of its public healthcare system.

For two decades it has largely failed to seize this chance due to underinvestment in the social sector, when compared to other countries in its income bracket, and misspending on capital projects, such as the sophisticated new La Paz hospitals in Malabo and Bata that appear to be almost exclusively for the benefit of elites—rather than on primary healthcare that benefits most citizens.

While a lack of data makes it hard to fully assess Equatorial Guinea’s performance on key health indicators, available data suggest that despite having far superior resources compared to other countries in the region, there has been little progress. For example:

  • Equatorial Guinea ranks 138 out of 188 countries in the United Nations Development Programme’s (UNDP) Human Development Index, a measure of social and economic development. Its score is similar to those of Ghana and Zambia, despite boasting a per capita income that is more than five times as high.
  • More than half of Equatorial Guinea’s population lacks access to safe drinking water in the vicinity, a rate that has not changed since 1995.
  • Vaccination rates for children have fallen dramatically since the late 1990s and are among the worst in the world. For example, the reported rate for tuberculosis vaccination for newborns and infants was 99 percent in 1997; 64 percent in 2014; and 35 percent in 2015, the last year for which data is available.

Additionally, a 2011 household survey studies found that one in four children are physically stunted due to poor nutrition, and two-thirds are anemic, as are half of women. The World Bank estimates that 60 percent of deaths are the result of communicable diseases or preventable maternal, prenatal, or malnutrition-related illnesses. Maternal mortality is one health indicator on which Equatorial Guinea has apparently made progress at a greater rate than most other countries in the region, with such deaths down from 1,050 per 100,000 live births in 1995 to 342 in 2015, according to the United Nations.

Despite being considered an upper middle-income country, Equatorial Guinea’s healthcare system continues to suffer from many of the ailments that typically afflict healthcare systems in low-income countries: inadequate staffing, long waiting times, stock-outs of basic medications and medical supplies, and frequent misdiagnoses. Doctors, nurses and patients told Human Rights Watch that Malabo General Hospital required out-of-pocket payment up front for any service, and that those who are unable to pay upfront are regularly turned away. “If people [in critical condition] don’t have money, they die,” a doctor who worked in the General Hospital in Bata said.

With the limited funds allocated to the health sector, the government has heavily invested La Paz, the two modern hospitals in Malabo and Bata staffed largely by foreigners. Both hospitals are well-equipped and charge fees that are well beyond what ordinary Equatoguineans can afford to pay.

Neglecting the Right to Education

Government neglect of education is reflected in the poor condition of facilities and quality of services, as well as outcomes that frequently lag behind regional averages and, in some cases, are even worse than the situation prior to the oil boom. For example:

  • In 2012 42 percent of primary school-aged children—46,000 children—were not in school, the seventh worst enrollment rate in the world, mostly topped by war-torn countries.
  • Half of children who begin primary school never complete it, and less than one-quarter who do go on to middle school.
  • Late starts and high repetition rates mean that the ages in any given class can vary widely. In 2012 only 57 percent of students were in the correct grade for their age, a ten percentage point decline from 2000, according to the United Nations Educational, Scientific and Cultural Organization (UNESCO), a specialized UN agency.

Equatoguinean law provides for free primary school, in line with international human rights law, which also requires Equatorial Guinea to work toward eliminating fees for secondary school as available resources allow. Yet local partners and education specialists said that public primary schools charge at least some fees to enroll.

Many teachers are poorly trained or have no training at all, leading to poor quality in public schools. Since 2006 many teachers have received training through a 10-year program jointly funded by the government and Hess Oil, which operates in the country. According to UNESCO’s data, just under half of primary school teachers had some kind of training in 2011.

Equatorial Guinea has invested only a tiny fraction of its budget in its education system, and the bulk of the money spent on education has gone to the university level. A confidential 2016 government report allocated 64 percent of the budget for a multiyear “Education for All” program to higher education, even though it only represents only 2 percent of students, according to the World Bank.

Overspending and Self-Dealing on Infrastructure

Government underfunding of health and education stands in marked contrast to lavish spending on large-scale infrastructure projects, many of which are of questionable social utility and risk being a key conduit for corruption and mismanagement. Human Rights Watch found evidence that senior government officials have stakes in companies that receive public construction contracts, including the president and his family.

After spending huge sums of money on buildings in both the island capital of Malabo and the largest city, Bata, which is located on the mainland and functions as an alternate capital, the government is now constructing a new administrative capital, Oyala, in the middle of the jungle. Although the total cost of Oyala is not known, it is expected to account for half of all public investment in 2016, according to an unpublished report by the IMF. Local content rules that require all companies operating in the country to have at least 35 percent local ownership appear to have been misused to steer business to companies that serve primarily to fill the pockets of politically connected people. The IMF notes the high spending on Oyala in the context of “limited movement on structural reforms, and weak governance and corruption [that] remain a serious impediment.”

After having spent hundreds of millions of dollars on government buildings in the capital of Malabo and economic center of the mainland, Bata, Equatorial Guinea is pouring billions of dollars into building a new administrative capital, Oyala, in the middle of the jungle. The IMF estimated that spending on Oyala would consume half the national budget in 2016. Above is a satellite image of the city under construction on January 12,2015. 

Satellite imagery © 2017 NASA

A US State Department cable made public by WikiLeaks alleged that the country’s sole cement importer, Abayak, is “partially owned by the president and first lady.” An Italian businessman, Roberto Berardi, founded a construction company with the president’s eldest son and putative successor, Teodoro Nguema Obiang Mangue (“Teodorin”), who was then the minister of forestry but was appointed vice president in 2016. Berardi wrote in a formal statement that Teodorin did not contribute any capital or time to the company, and his sole function was to secure subcontracts from lucrative public projects awarded to ABC Construction, at least partly owned by the first lady.

A US Department of Justice investigation, which ultimately settled in 2014, into alleged money laundering by Teodorin revealed allegations that he directed one of the largest construction companies operating in Equatorial Guinea to submit grossly inflated bills to the government, many of the funds from which were then transferred to his personal account.

The US investigation settled in October 2014 when Teodorin agreed to forfeit $30 million approximately the value of his mansion in Malibu, Californiato be given to a charitable organization and used for the benefit of the Equatoguinean people. A French court investigated Teodorin’s spending more than 175 million euro on a Paris mansion, fleet of luxury cars, designer goods, and other extravagances. Teodorin maintains that the money came from legitimate businesses, but on May 25, 2016, the three judges presiding over the case found sufficient evidence of suspected money laundering and diversion of public resources to order Teodorin to stand trial, expected to take place on June 19, 2017.

By squandering enormous wealth the government has already missed opportunities to invest in health and education. The long-term decline and inevitable demise of the oil sector now leaves the government very little time to correct course and invest significantly and sustainably in these sectors. The fall in oil production and historically low oil prices have already caused Equatorial Guinea’s GDP to shrink by 29 percent between its high in 2012 and 2016; the IMF expects future contraction.

De nombreuses zones résidentielles en Guinée équatoriale, comme ce quartier de la capitale, Malabo, ne bénéficient que de peu d'investissements gouvernementaux, voire d’aucune assistance financière, alors que des budgets colossaux sont consacrés à des dépenses liées à des bâtiments gouvernementaux et à divers projets prestigieux.

© 2016 Human Rights Watch

To meet its human rights obligation to progressively realize its citizens’ rights to affordable and decent health care and education, the government should immediately shift investment priorities and undertake comprehensive reform to stem corruption, regulate conflicts of interest, and make the public procurement process transparent and competitive.

Given the country’s small size even modest social investment could go a long way. It is not too late to take urgent measures that would put the country’s oil wealth to work for the good of all Equatoguineans, but the window of possibility is closing fast.

Recommendations

To the Equatorial Guinean Government

  • Regularly publish full accounts of projected and actual government revenues and expenditures. Classify expenditures by function, including health and education.
  • Conduct credible and independent investigations into allegations of misuse of public funds.
  • Increase investment in public health, the healthcare system, education services, and infrastructure that will benefit majority of the population. Take urgent steps to ensure that these services are accessible and available to all, and that all are provided timely care by qualified medical staff.
  • Ensure that healthcare services are affordable for all Equatoguineans.
  • Guarantee free primary school for all in line with international human rights standards and take steps to eliminate school fees for secondary school.
  • Institute and enforce laws that clearly define, regulate, and make transparent conflicts of interest between government officials and their private businesses in line with international best practices.
  • Institute and enforce laws to ensure a competitive and transparent public procurement process, including open bidding and names of companies awarded contracts, as well as their beneficial owners and the amount of and purpose of each contract awarded. Such rules should also extend to companies awarded subcontracts for public projects.
  • Ratify the United Nations Convention against Corruption and the African Union Convention on Preventing and Combating Corruption.
  • Ensure independence of the auditing body established in the 2011 constitutional reform and credibly investigate claims of corruption, including against senior government officials.

To the International Monetary Fund

  • Include expenditures on health and education, as well as analysis and recommendations on public financial management, in annual Article IV reports that assess the economic and financial developments of Equatorial Guinea. Include sources for all social indicators and articulate any identified methodological concerns relating to the data. Do not include unreliable social data.
  • Encourage and assist Equatorial Guinea to improve transparency and quality of information in government budgets and to reform its public financial management to bring it in line with international standards.
  • Encourage and assist Equatorial Guinea in establishing mechanisms for financial accountability, including an independent Court of Auditors, a body mandated by the 2011 constitutional reforms.
  • Press Equatorial Guinea to meet all necessary requirements to join the Extractive Industries Transparency Initiative and safeguard the right of media and civil society to speak out against corruption and human rights abuses.

To the World Bank

  • Regularly undertake and publish a Public Expenditure Review on Equatorial Guinea, including detailed information on the health and education sectors.

To Private Investors

  • Conduct due diligence to determine whether any existing or potential business relationships, including through subcontracts, benefit government officials or close members of the president’s family. Where possible, terminate or avoid such relationships. Where no viable alternative exists, ensure that the relationship is transparent and does not benefit from undue influence.
  • Ensure all company procurement is done through an open and transparent bidding process.

To Foreign Governments

  • Investigate potential money laundering or other financial crimes by Equatorial Guinean officials that are under domestic jurisdiction.
  • Institute and/or enforce rules requiring the publication of all beneficial owners of companies registered within your territory to mitigate the risk of money laundering and other financial crimes.
  • Institute and/or enforce rules requiring financial institutions and sellers to conduct due diligence into the source of funds for transfers or purchases over specified amounts to mitigate the risk of money laundering and other financial crimes.

Methodology

This report examines Equatorial Guinea’s spending on health and education and the impact of chronic underfunding. It also looks at large-scale infrastructure projects, the public financial management system governing such projects, and allegations of self-dealing by senior government officials and members of the presidential family.

Equatorial Guinea has by far the world’s largest gap between per capita wealth and score on the United Nations Human Development Programme’s (UNDP) Index that measures social and economic development. The country’s oil wealth puts it in the league of those countries with sufficient resources to invest in social services, including health and education, and to progressively realize economic and social rights in line with its regional and international human rights obligations.

In researching this report Human Rights Watch reviewed publicly available reports of international financial institutions, as well as one unpublished draft document; national budget documents for all years between 2003 and 2016 except 2012 and other government documents; documents related to investigations into alleged money laundering by a senior Equatoguinean official being conducted by the United States Department of Justice; international and domestic data on health and education; and other documents.

Due to the absence of credible, comprehensive, and current government data, Human Rights Watch relied on a range of sources, using the most up-to-date data available while also privileging, where possible, data collected through surveys or studies over projections based on mathematical models. In some cases there are discrepancies in the data reported by different institutions. In the case of discrepancies regarding financial data Human Rights Watch relied on International Monetary Fund (IMF) figures, as it is based on information obtained and analyzed by IMF experts working in the country rather than solely on government submissions.

Where available, we have included health data from a 2011 household survey conducted by ICF International, along with more recent data from international institutions based on projections or government submissions to these institutions. Given the government’s poor record of data collection the household survey should be viewed as more reliable. For education data we used international and government data, noting any differences between the two sources.

Human Rights Watch staff conducted field research for 10 days in Malabo and Bata in 2016, interviewing a total of 35 people. For security reasons we were unable to interview a larger number of people. Interviewees included nurses, employees of international institutions active in the country’s health sector, former patients at the General Hospitals in Malabo and Bata, teachers, and education specialists employed by international institutions active in the country. In addition Human Rights Watch conducted phone or in-person interviews with three IMF experts and an Equatoguinean budget specialist; an Equatoguinean lawyer; a specialist on the Extractives Industry Transparency Initiative; a specialist for the transparency non-governmental organization (NGO) Publish What You Pay; US government officials; lawyers and representatives of organizations involved in corruption-related legal actions against Equatoguinean officials; and others. A Spanish translator facilitated some of the interviews.

Human Rights Watch withheld the identity of some of the interviewees for fear of possible reprisals; the report indicates where pseudonyms were used. All interviewees freely consented to be interviewed, and Human Rights Watch explained to them the purpose of the interview, how the information gathered would be used, and did not offer any remuneration.

Human Rights Watch wrote letters to some of the companies mentioned in the report, but did not contact others because they are defunct, have no publicly available correspondent or email address, or are only mentioned fleetingly in the report. We also wrote letters to La Paz hospitals in Malabo and Bata and shared the preliminary findings of the report with the Equatorial Guinean Embassy in Washington, DC and requested relevant information from the Ministries of Health, Education, Finance and Budget, and Planning and Development. The embassy confirmed receipt and agreed to pass along to the relevant ministries. We have not received any response to these letters.

The findings of this report are based overwhelmingly on the documentary evidence and basic indicators described above, which provide tangible examples of the systemic problems this report describes.

Note of currency conversion: this report used an exchange rate of 622 Central African Franc (CFA francs) per US dollar for current rates, the exchange rate on February 21, 2017. Sums in CFA francs for past years were calculated based on the rate on December 31 of that year.
 

I.Background

Before Oil: Colonialism, the Macías Dictatorship, and Obiang’s Coup

Colonialism & the Macías Dictatorship

Colonized by Spain until 1968, Equatorial Guinea is the only independent Spanish-speaking country in Africa. Portugal ceded the territory to Spain in a land swap treaty in 1777, but Spain’s early activity there was sporadic and it did not exercise full control until the early twentieth century.[1] In the final decades of its rule Spain began to more intensively exploit Equatorial Guinea’s exceptionally rich soil to cultivate cocoa and coffee. The large colonial plantations relied heavily on workers from neighboring countries, primarily Nigeria, who often worked under abysmal conditions.[2]

As a result of this history, when Equatorial Guinea gained independence in 1968, it had significantly less developed administrative institutions and infrastructure than other countries in the region.[3] Its per capita income was one of the highest in sub-Saharan Africa, but its economy depended almost entirely on a couple of cash crops cultivated by a
foreign workforce.[4] The country also lacked a developed legal system or local law, and the constitution at independence designated Spanish law to fill the gap.

Following independence Francisco Macías Nguema became Equatorial Guinea’s first president. The 11 years of Macías’ rule were marked by political violence and fiscal mismanagement that ruined the economy and many state institutions.[5] Following a coup attempt in 1969, Macías suspended all civil liberties and outlawed political parties other than the ruling party. Those suspected of political disloyalty—usually members of the political, intellectual, or cultural elite—were routinely arrested, tortured, or killed, frequently following real or claimed coup attempts.[6] Macías also had little tolerance for education and intellectuals.[7] Describing himself as the “Unique Miracle,” he outlawed private education, shut down all newspapers, banned the collection of statistics—and even went so far as to prohibit the use of the word “intellectual.”[8]

On August 3, 1979, Teodoro Obiang Nguema Mbasogo, the vice-minister of the armed forces at the time and Macías’ nephew, successfully led a coup to overthrow his uncle. By that time, one-third of the population of 300,000 had gone into exile and at least another 20,000 were believed to have been killed.[9] The economy had collapsed and nearly all public administrative activity had ceased.[10] There were virtually no basic services, such as electricity, banking, postal services, transportation, or telephone lines.[11] There were no universities and most secondary and vocational schools had shut down.[12] Macías kept what little revenues the state had in his home in Mongomo, paying himself millions of dollars in salary and squirreling away suitcases full of cash into his foreign accounts.[13]

It is hard to overstate the devastation wrought by centuries of colonialism followed by Macías’ reign of terror, and its long shadow is still evident in the country’s severely limited administrative capacity, abysmal social indicators, and repressive political system. This history, however, in no way excuses present-day human rights abuses, including the neglect of economic and social rights. On the contrary, the government should work to counter the ill effects of colonial rule by actively promoting transparency, accountability, and the rule-of-law, and by investing in health and education.

President Obiang’s Government

President Obiang is the world’s longest-serving non-royal ruler. When he first came to power, he pledged to rule democratically and respect human rights.[14] Following the coup, the state began once again to carry out its basic functions; schools reopened and public utilities were restored. As time passed, some social indicators, including life expectancy and child mortality, began to improve.[15] Nevertheless, in many respects, the coup did not lead to fundamental change in governance and respect for human rights. The United Nations was sufficiently concerned about the human rights situation in the country that it maintained an independent expert for Equatorial Guinea for 20 years.[16]

Until the discovery of oil off the coast of Equatorial Guinea, the economic situation did not markedly improve under Obiang and the country remained one of the poorest in Africa. In 1991, the year that oil production began but had yet to make any significant economic impact, the total GDP was US$132 million—equal to $330 per capita.[17] The country did, however, begin to receive large amounts of foreign aid, thanks to improved relations with foreign countries, including the United States and Spain.[18] But government corruption undermined the efficacy of some of aid-funded projects, such as the World Bank Coffee Cocoa Rehabilitation Project.[19] The $9.3 million project, which was implemented between 1985 and 1990, was intended to provide coffee and cocoa farmers with credit and strengthen their capacity as a means of reviving the country’s once lucrative cocoa production.[20] Robert Klitgaard, an IMF official living in Equatorial Guinea at the time the project was ongoing, wrote in a book about his work that the government abused the program by nationalizing the choicest cocoa farms in anticipation of the loans that would be made available to farmers, and then transferring them to members of the ruling elite, including the president. Many of these new cocoa farmers never repaid the loans they took out, which they used to fund lavish lifestyles rather than invest in cocoa farming.[21]

The Era of Oil: Political Repression, Corruption, and Lack of Transparency

The discovery of oil transformed the country within a few years from one of the world’s poorest to boasting a per capita GDP on par with many industrialized nations. The Texan oil company Walter International first began to produce oil from the Alba field in 1991, but the meteoric rise of Equatorial Guinea’s GDP began with Mobil’s (now ExxonMobil) discovery of the 1.1-billion-barrel Zafiro oilfield in 1995. Production began the following year, propelling the annual growth rate to double—even triple—digits as billions of dollars poured into the state’s coffers.[22] It is difficult to put an exact figure on the value of the oil contracts as they are not made public. As a partial measure the World Bank estimates that the state took in $25 billion in oil revenue between 2000 and 2008.[23] According to a 2015 budget document obtained by Human Rights Watch, the state took in an additional $20 billion in hydrocarbon revenue from 2009 to 2013.[24]

This massive influx of resources has not translated into significant improvement in living conditions for the majority of the population. Despite having the highest per capita gross national income of any African country, Equatorial Guinea ranks 138 out of 188 countries in the United Nations Human Development Programme’s (UNDP) Index that measures social and economic development. This gap between wealth and human development score is by far the world’s largest. Section III of this report details the conditions of the health and education sectors.

Human Rights Watch documented in its 2009 report Well Oiled: Oil and Human Rights in Equatorial Guinea how pervasive corruption, nepotism, mismanagement, and political repression, as well as unaccountable and non-transparent governance, contributed to large amounts of oil revenue being siphoned off by the ruling elite while the population remained mired in poverty. The persistence of these problems despite shrinking government resources due to the decline in oil production and prices threatens to erode the already weak public health and education systems.

Political Repression

Obiang retained Macías’ prohibition on political activity, citing the dire economic situation, until 1991 when he lifted the ban.[25] But the arrest of political opponents continued under Obiang, especially following real or claimed coup attempts.[26] Obiang has also installed close family members, including his sons, in key government positions and holds full control over the country’s bank accounts, blurring the line between the public purse and his family’s personal pockets.

The constitution, enacted in 1982 and last amended in 2012, reserves considerable power for the president.[27] For example, the president is the first magistrate and appoints all Supreme Court judges without parliamentary oversight, compromising the independence of the judiciary.[28] In 2011 Obiang initiated a process of constitutional reform, the results of which were widely criticized as further consolidating presidential power and undermining accountability.[29] However, the reform also included a presidential term limit of two consecutive seven-year terms, the introduction of a bicameral legislature, and the establishment of a Court of Auditors and Ombudsman to foster transparency and accountability in governance.[30] The Court of Auditors has yet to be established, and the Ombudsman’s office was established in 2015.[31] Another amendment eliminates a maximum age limit of 75 years for presidential candidates—setting the stage for the then 69-year-old Obiang to continue to run for president.

The US State Department and others have long documented the harassment and arrest of opposition leaders and members in advance of elections, as well as rampant procedural violations and fraud on election day, including voter intimidation, opening of ballots, and voting on behalf of children and the deceased.[32] Similar problems plagued the most recent presidential elections, held on April 24, 2016. The election date, which was eight months before the official end of Obiang’s term, was announced by presidential decree only six weeks earlier. Obiang declared victory with 93.7 percent of the vote.

Obiang ran in the elections after declaring that the constitutional amendment limiting presidents to two consecutive seven-year terms is not retroactive.[33] The opposition parties maintained that the early election date violated a constitutional provision that says elections should be held no earlier than 45 days before the end of the president’s term.[34] The parties boycotted the elections citing harassment, procedural irregularities, the absence of an independent electoral body, and lack of media access.[35] Human Rights Watch, the United States embassy, and others criticized the restrictive atmosphere prior to elections, including reports that the military surrounded the headquarters of a political opposition party and that the country’s leading independent group promoting good governance was suspended, making it unable to act as a domestic observer.[36] The embassy noted that its election day observers witnessed cases of voter intimidation, violation of voting secrecy, and other irregularities.[37]

Lack of Transparency

Transparent governance that gives the public access to their government’s administrative decisions such as on income, budgets, and public procurement is fundamental to holding governments accountable and fighting corruption. However, as a recent report by the IMF notes, in Equatorial Guinea “even the most basic data are very hard for the public to access.”[38]

Failed Extractive Industries Transparency Initiative Bid

The government publishes scant information on its income or spending.[39] One exception is a report released in 2010 as part of its failed bid to join the Extractive Industry Transparency Initiative (EITI), a voluntary standard requiring government to publish payments they receive from oil and mining companies, as well as other information.[40] Equatorial Guinea was accepted as an EITI candidate in February 2008, in what was supposed to be a hopeful step toward transparency and civil society participation in overseeing the country’s resources. While the EITI does not require governments to publish information on spending, they must work in a national multi-stakeholder group along with industry and civil society to decide on objectives for EITI implementation.

The government published its first report on oil revenues just before its deadline for becoming EITI-compliant on March 9, 2010, leaving no time for an external validator to review it as required.[41] The government requested an extension from the EITI board, but under EITI rules, extensions are only given in the case of “exceptional and unforeseeable” circumstances beyond the control of the candidate country.[42] The board denied the request because it found the delay unjustified. An EITI specialist with the NGO Publish What You Pay who was closely involved in the process told Human Rights Watch that the EITI board was also influenced by restrictions on civil society.[43]

The president has since affirmed that he remains committed to transparency and the EITI. After protracted delays, a national EITI steering committee, which includes representatives from government, oil companies, and civil society, was re-established in 2015 with the goal of re-applying for membership. However, the process stalled in March 2016 when the minister of internal affairs ordered the suspension of one of the civil society groups on the steering committee.[44] The committee finally met again in November 2016 and February 2017, but restrictions on civil society remain a point of contention.[45]

Available Financial Information

The government released some general budget information for the first time in 2015, leading the International Budget Partnership, an independent group that partners with civil society to use budget analysis and advocacy to improve governance and reduce poverty, to raise the country’s score from zero to four out of one hundred on its measure for budget openness.[46] The measure scores countries based on a 140-question survey on public access to key budget documents in line with international best practice.

International financial institutions such as the IMF have also produced some financial information on Equatorial Guinea. The IMF generally holds annual meetings with each of its member countries to provide its assessment of the country’s economic health and recommendations for improvement. As part of this process it produces a report with summaries of its findings and the government’s responses, called Article IV reports, which it makes public unless the government objects. Since 2003 the IMF published such reports for Equatorial Guinea except for the years covering 2004, 2009, 2010, 2011, and 2014.[47] In 2010 the World Bank released a detailed Public Expenditure Review of Equatorial Guinea, which includes invaluable data and analysis on government spending. Human Rights Watch has also been able to obtain government budgets for nearly every year since 2000, but these documents are not publicly available.

Even beyond government budget information, very little official government business is made public. Brief and vague summaries of meetings and events are sometimes published on the government’s official webpage, but there are no protocols of parliamentary or other official meetings. Nor is there a centralized legal database housing all the country’s laws and executive decrees, making it difficult to find many laws.[48] Human Rights Watch was unable to obtain a copy of the education law, for example, placing some restrictions on our analysis of the education sector.

In many cases, basic financial and social data is not even collected, hampering the government’s ability to implement effective policies. A representative of the IMF who provides technical assistance to Equatorial Guinea on revenue administration told Human Rights Watch the absence of data is the “main weakness” for improving tax and customs collection. “We don’t have any idea how much global revenue is collected and where it goes. This blind spot makes it very hard to work with them on tax collection.”[49]

 Poor Socio-economic Data Collection

The government collects very little reliable socio-economic data, impeding assessments of indicators such as health, education, and poverty. The lack of reliable social and economic data presents a serious obstacle not only to making informed policy decisions, but also to assessing the social impact of these decisions, including budget allocations. The 2015 IMF report notes a “critical shortage of macroeconomic and socio-demographic data” leading to “considerable uncertainties regarding demographic data—and in turn social indicators.”[50]

Equatorial Guinea has no comprehensive online legal database or library, but hard copies of many laws can be purchased at certain government offices. Above are law pamphlets available for sale at the Delegation for Foreign Affairs in Bata.

© 2016 Human Rights Watch

Even the size of the population is uncertain: international figures put the 2015 population at 845,000 but the government claims it was 1.2 million for that year, revised downwards from the government’s estimate of 1.6 million in 2012.[51] The IMF has long pressed the government to improve its transparency and data collection not only to improve governance and accountability, but also because “the lack of published data could impede prospective foreign investors.”[52] Ironically, the president has hidden behind this deficiency to defend his government from criticism, claiming that critics are using outdated information.[53]

The government has taken some positive steps in recent years to address its acute statistical data weakness. It legally established the Equatorial Guinea National Statistics Office (INEGE) in 2001, although it only became active in the last few years and inaugurated its offices in May 2016. However, it is difficult to assess the reliability of the data generated by the office. For example, INEGE reported to the UN and IMF that poverty declined from 77 percent in 2006 to 44 percent in 2011 and that extreme poverty fell from 33 percent to 14 percent in those years.[54] Both institutions published those findings, although an IMF staff member who worked on the publication told Human Rights Watch that he discussed this data “with the resident UN agencies, and we agreed there are significant methodological weaknesses.”[55] These reservations were not included in the 2016 IMF report in which this data appears, which rather positively notes that a “high quality National Statistical Development strategy has been developed.” However, the previous year, the IMF found that the agency had “relatively few experienced staff.”[56] In a positive step, the government subscribed in 2016 to the IMF’s General Data Dissemination System (GDDS), which sets out standards for the quality, scope, and dissemination of national statistical data.[57] Authorities had resisted IMF recommendations to subscribe to the system for years, making it one of only two countries in sub-Saharan Africa not to do so.[58]

II. Under-Investment in Health and Education

Equatorial Guinea’s health care and education systems are plagued by problems common across poor and developing countries, except that technically, Equatorial Guinea has not been a poor nation since its oil boom began two decades ago. The country stands out for the vast gap between its available resources and the amount that it spends on addressing these problems. This is reflected in health and education outcomes far below other countries in its wealth bracket, and in many cases trailing averages even for poor countries. Public spending is examined in this section, while outcomes are addressed in the following section.

Equatorial Guinea has a human rights obligation to use its public resources, largely derived from oil wealth, to progressively improve the country’s woeful health and education systems, as well as to increase access to basic services, such as potable water and sanitary facilities. Yet, despite pledges to prioritize social spending, the government spends a relative pittance on health and education. Instead it pours most of its resources into large-scale construction projects such as government buildings and transportation infrastructure, some of which have minimal social value. The neglect of health and education violates Equatorial Guinea’s human rights obligations toward its citizens.

Equatorial Guinea’s window of opportunity to invest in improving the social conditions of its population and diversifying its economy to prepare for a post-oil era is quickly closing. Production is already in decline, made worse by historically low oil prices. This has precipitated a sharp drop in the state’s income that is expected to continue for the foreseeable future. Having hit its peak in 2012, the GDP shrunk in the past 4 years; it decreased by 7.4 percent in 2015 and the IMF expects it to further contract by 9.9 percent in 2016.[59] According to the World Bank, known oil reserves are expected to be depleted by 2035.[60]

Lack of Budget Transparency

It is impossible to comprehensively analyze Equatorial Guinea’s budgets because of the paucity of available data and the fundamental weaknesses of the budgets themselves. Equatorial Guinea does not publish government budgets, although, as noted in the previous section, in 2015 it made some general information available for the first time. Human Rights Watch was able to obtain numerous documents related to budgets; however, their usefulness for bringing transparency and accountability to government expenditures is limited because they are apparently incomplete and do not disaggregate and classify spending by function.

It appears that government budgets in Equatorial Guinea do not capture all spending and in many cases there is no accounting of how much money is actually spent. As one World Bank report put it: “The public budget does not record all public spending and the amount of extra-budgetary spending is difficult to evaluate.”[61] An IMF advisor who provides technical assistance to Equatorial Guinea’s revenue administration told Human Rights Watch: “We don’t have any idea how much global revenue is collected and where it goes.”[62]

The budgets also do not classify spending by function (e.g., defense, transportation, health, education). Functional classification is standard practice for government budgets, and the IMF considers it essential for supervising budget implementation, analyzing allocation of resources among sectors, and tracking poverty-reducing expenditures.[63] Instead the budget is divided into capital and current expenditures. Capital spending includes investments in assets such as buildings, roads, and airports, whereas current (also known as recurrent) spending includes salaries and other goods and services for a particular year. The budget divides current expenditures into approximately 180 line items, but capital expenditures, which comprise the bulk of the budget, are recorded in one lump sum. The absence of functional classification in Equatorial Guinea’s budgets not only makes analysis difficult, it also points to underlying “weaknesses in monitoring and control mechanisms,” according to the IMF.[64]

While these deficiencies make it challenging to quantify total expenditures in the social sector and compare them with social spending by other countries in the region, it is possible to draw some conclusions based on the available information. Economists sometimes use current expenditures as a measure for assessing a budget’s ability to deliver quality social services.[65] A 2010 World Bank Public Expenditure Review on Equatorial Guinea and regularly published IMF reports provide additional windows into the country’s finances, as do budget documents on the country’s public investment program (PIP).[66] The PIP consists almost entirely of construction projects, and, unlike the general budget, the PIP is classified by function. The four categories of social, public administration, production, and infrastructure are further subdivided, offering the most precise information available on health and education spending. Taken together, these documents offer a compelling, if fragmentary, picture of government spending on health, education, and infrastructure.

Neglecting Health and Education in Favor of Infrastructure Projects

In 1997, shortly after the start of the oil boom, the government convened a development conference where it committed 40 percent of public expenditure to the social sector, with 15 percent dedicated to education and science and 10 percent to health.[67] The government never came even close to realizing this commitment and replaced it a decade later with a new two-phase plan, called Horizon 2020, with a declared aim of turning Equatorial Guinea into an emerging economy by 2020. On paper, the focus of the first phase, which ended in 2013, was to transform the country’s economic base by investing in infrastructure, good governance, social welfare, and human capital, while the ongoing second phase is supposed to build the pillars of a diversified economy by improving the business climate, investing in human capital, and developing alternative industries such as agriculture, fishing, and tourism.[68]

In practice significant investments in the social sector did not materialize; instead the government has poured the majority of its resources into infrastructure projects. Capital expenditures typically makes up around one-quarter to one-third of a country’s budget (the average is 30 percent for sub-Saharan Africa), and the rest of the budget is spent on current expenditures.[69] Equatorial Guinea’s spending on capital investments, which averaged US$4.2 billion, or 81 percent, from 2009 to 2013, is the mirror image of the norm.[70]

Between 2009 and 2013 Equatorial Guinea took in an average of $4 billion per year in resource revenue and $400 million in tax revenue and other income, and spent an average of around $5.2 billion annually.[71] In absolute terms Equatorial Guinea spent more than $20 billion on capital investments in those five yearsand possibly additional spending not recorded in its budgets. In contrast, in 2011 the government spent roughly $140 million (or 3 percent of its total expenditures) on education and $92 million (2 percent) on health, according to the IMF.[72] Similarly, in 2008 it spent $60 million (2 percent) of its budget on education and $90 million (3 percent) on health.[73]

The IMF notes that Equatorial Guinea’s spending on health and education “is substantially below other high-income countries, even those with lower per capita GDP.”[74] On average countries with a per capita GDP on par with Equatorial Guinea spent around 14 percent of their budgets on each education and health; in a comparison of around 45 countries within Equatorial Guinea’s broad per capita GDP bracket, no other country spent less than 5 percent on either category.[75]

According to an unpublished draft of the IMF’s 2016 report, the situation remains the same despite transitioning, in 2014, to the second phase of Horizon 2020:

To date, there has been limited movement on structural reforms, and weak governance and corruption remain a serious impediment. However, large-scale prestige projects are still ongoing, of which the new capital city at Oyala is expected to account for roughly half of public investment during 2016.[76] 

One explanation for the persistently high amount of infrastructure spending may be that Equatorial Guinea established a “golden rule” that dedicates all oil revenue to physical investments and tax income to current expenditure, according to the World Bank.[77] The logic of this principle, as stated by the World Bank, is to ensure that oil revenues are used for the benefit of future generations.[78] It is not clear when Equatorial Guinea established this rule and in any case it is not strictly followed, since capital spending frequently exceeds annual oil revenues, forcing the government to dip into previous years’ oil proceeds, and current expenditure often exceeds tax revenues. However, it does appear to largely shape the government’s budgets.[79]

From a human rights perspective, there is nothing inherently problematic about investing heavily in new construction; many of the projects were needed to modernize an extremely underdeveloped country. Moreover, some of this spending— albeit only a small fraction —paid for vital health and education infrastructure, including a national university campus and modern hospitals.

But, in the case of Equatorial Guinea, overspending on infrastructure is a problem for two reasons. First, as documented in this section, the government’s extreme emphasis on capital investments comes at the expense of the social sector, including health and education. Second, as documented in the following section, these capital investments appear to be plagued by significant levels of corruption and mismanagement due in part to rules and practices governing public contracts that enable self-dealing by government officials.

In 2016, the IMF concluded that high spending on infrastructure led to low social spending:

Expenditure composition is currently 2:1 in favor of capital spending, whereas it is the inverse in other CEMAC [Gabon, Cameroon, the Central African Republic (CAR), Chad, the Republic of the Congo] countries, contributing to low provisions for health and education service delivery. Budget allocations should be better aligned with the national development program’s social priorities.[80]

This echoes repeated World Bank and IMF criticisms of Equatorial Guinea’s massive spending on physical investment as not financially or socially sustainable, a concern that has become more pronounced since the onset of the oil crisis. The World Bank has said Equatorial Guinea’s golden rule “does not provide an adequate macroeconomic framework” and may lead to overinvestment.[81] It has also found that “despite the considerable public outlays, the budget structure does not favor social investment” and “social sector spending is too low to address the needs of the country’s poor population.”[82]

Health and Education Spending

Available data on government spending on health and education is very limited. The World Bank’s 2010 Public Expenditure Review for Equatorial Guinea, mostly based on 2008 data, offers the most recent (and perhaps only) publicly available comprehensive analysis on government spending on these sectors.[83] However, more recent data from IMF reports and confidential government budget documents suggest that trends detailed in the World Bank report persist.

2008

In 2008 the government was projected to take in $4.7 billion in revenue, $4.4 billion of which came from oil, according to the IMF.[84] The same year, its total executed budget was $2.8 billion.[85] It spent $90 million (3.2 percent) on the health sector, although only $17.7 million went to current spending.[86] The World Bank notes that while total health expenditures increased significantly since 2004, the additional funds went mostly to capital investments, “resulting in a very low current per capita public expenditure of €16 (FCFA 10,600) that fails to meet the population’s health care needs.”[87] Indeed it found that current expenditure was so low that user fees were needed to supplement the budget for salaries of health officials.[88] In other words the personnel costs were passed on to the patients using the system.

Another problem the World Bank found was that there was “excessive” spending on administration and “hospital treatments that do not meet the needs of the general population.”[89] Based on its review of health outcomes and government expenditures, the World Bank concluded:

Unlike most countries of Sub-Saharan Africa, Equatorial Guinea has the financial means to improve the health of its population. However, the concentration of expenditure on [capital] investments has yet to produce any visible impacts, either in improved health conditions or in the quality and quantity of health services.

To correct this problem, it recommended that “infrastructure in the health sector must be complemented by a large increase in human capital.”[90]

The government spent even less on education than on health in 2008. Total spending was $60 million (2.14 percent).[91] In the five years between 2004 and 2008, only seven percent of government expenditures went to education, according to the World Bank report. As the World Bank notes, this is significantly below the percentages allocated by other countries in the region such as Uganda and Tanzania (30 percent), Ghana (25 percent), or Cameroon, Congo, and Gabon (16 percent).[92] Put another way, Equatorial Guinea’s public expenditure on education hovered around one percent of its GDP for those five years, which is one of the lowest shares in the world.[93] In contrast middle-income countries spent an average of 4.3 percent of GDP, and the average spending in sub-Saharan Africa was 3.9 percent.[94]

The imbalance between capital and current expenditures was not as extreme in the education sector as it is in health, but it still skewed heavily in favor of infrastructure. Of the US$60 million of public money spent on education in 2008, $25 million went to current expenditures and $35 million to capital.[95] The relatively higher current spending, however, is largely due to the nearly $12 million spent on scholarships for university students to study abroad and on sports federations, rather than on improving teacher salaries or quality of education at the primary and secondary levels.[96] Spending greatly favored higher education despite the fact that it represents only two percent of the student population: the government spends $410 per primary student as opposed to $11,435 per student in higher education, among the most unequal ratios in the region, according to the World Bank.[97]

As in the health sector, allocation decisions in education disfavor personnel salaries. According to the World Bank report, teachers who finished secondary school earned $175 per month, those with a teaching certificate earn $232, and those with a university degree $296. The report also finds that some 40 percent of teachers are considered “volunteers” and are paid directly by parents rather than by the state. The report also points to a “huge disparity” between education sector salaries, with managerial staff earning seven times more than teachers. Based on its analysis the World Bank concluded that “public financing of the [education] sector is insufficient given the dire needs” and that “authorities need to increase recurrent expenditures to the sector (rather than capital spending) to ensure a stable source of financing to train and hire more teachers.”[98]

2010 and 2011

Spending on health and education did not significantly change in 2010, although there was a slight overall decline in capital spending relative to current, going from 81 percent of the budget in 2008 to 75 percent in 2014.[99]

Budget documents for public investment projects in 2010 and 2011 obtained by Human Rights Watch indicate that the portion of capital expenditures devoted to the social sector remained in the same low range as in previous years. In 2011 Equatorial Guinea earned $4.8 billion in revenues, $4.4 billion of which came from the hydrocarbon sector. The government’s total expenditures for the year were $4.6 billion. As already noted only around $140 million (3 percent) of its budget went to education and roughly $92 million (2 percent) to health.[100]

By June 2011 only 1.3 percent ($18.6 million) of the PIP budget went to education and 1.8 percent ($27 million) to health.[101] This is in line with spending between 2005 and 2008 when 1 to 3 percent of capital spending went to health and 0.5 to 4 percent went to education. In comparison, during the same period, a quarter of the PIP budget ($365.7 million) was spent on airports, roads, and urban infrastructure. These numbers, dismal as they are, were better than the previous year: in the first three months of 2010, only 0.4 percent ($3.3 million) of the PIP budget went to education and 2.7 percent ($20 million) to health. In comparison, during the same period, 23.6 percent of the PIP budget ($175 million) was spent on airports, roads, and urban infrastructure.[102]

Moreover, the projected annual spending on health and education both years was significantly less than the amounts approved by law, while it nearly doubled for spending on airports, roads, and urban infrastructure. The 2011 Budget Law approved between $100 million and $125 million each for education, health, and potable water, but by June 30 the government had only spent a combined $60 million on all three categories. At the same time it had already spent over $80 million on sports, overspending its total approved budget for the year, and expenditures on airports, roads, and urban infrastructure were projected to climb from an approved $783 million to nearly $1.5 billion. According to the IMF only 3 percent of capital expenditures ultimately went to health and education in 2011, while 50 percent went to airports, roads, and urban infrastructure.[103]

The differences between approved and actual spending in the social sector were likely even wider in 2010. The law approved $687.8 million, but by the end of March, only 7.4 percent of that had been spent and the revised projected total for the year was decreased by roughly a third to $465 million. Education suffered in particular: $123.7 million was approved for the sector, but by the end of March only 2.6 percent had been spent, and the revised projection for the year was $43.8 million, approximately one-third the approved amount. On the other hand, as in 2011, the 2010 Budget Law approved $756 million for spending on airports, roads, and urban infrastructure, but that number was projected to rise to nearly $1.5 billion by the end of the year. Human Rights Watch was not able to obtain documents reflecting total PIP expenditures for 2010.

2014 to 2016 and the Looming Economic Crisis

Only limited data is available on social spending for years subsequent to 2011. The IMF’s 2016 Article IV report states that 14 percent of the investment budget was allocated to the social sector, a term it does not define, and it does not include data for actual expenditures, which in previous years fell far short of allocations.[104] In the first half of 2014 6.2 percent of the investment budget was allocated to health, education, and sanitationtotaling $827 million out of a total investment budget of $13.3 billion.[105] The IMF also notes that “current spending remains low ... with relatively low provisions for education and health.”[106]

A confidential 2016 government report written in collaboration with the World Bank includes budget information for the government’s flagship multi-year health and education programs“Education for All” and “Health for All”although it is not clear which years or what portion of the total education budget these cover. According to the report, the government spent $37 million on completed “Education for All” projects, with another $1.18 billion worth of projects underway (and approximately the same amount allocated for future projects). The distribution of the spending, however, is in line with priorities of previous years: only 1 percent is dedicated to teaching and the rest to “access and infrastructure”21 percent ($262 million) to building and renovating preschools, primary, and secondary schools, and 64 percent for higher education ($800 million).[107] The total value of “Health for All” projects that have been completed or are underway, according to the report, was similarly $1.23 billion (with another $475 million planned).[108]

The 2015 and 2016 government budgets on file with Human Rights Watch together include actual expenditures for 2009 to 2014, as well as allocations for 2015 and 2016.[109] Given the poor classification system described previously in this report, their usefulness is mostly limited to comparing overall current and capital expenditures. Even though, as noted, current expenditures are broken down into around 180 line items, most descriptions are too vague or broad to categorize social spending. Based on Human Rights Watch’s calculation line items that explicitly relate to education make up 0.8 to 3.1 percent of current spending for 2009 to 2014, while the range for health is 1.8 to 3.6 percent.[110] The amended budget for 2015 and projected budget for 2016 were slightly above this range, with roughly 4 percent of current spending allocated to health and education each for both years, although actual spending on the social sector has often been less than allocated amounts.[111]

Government officials have pledged that the new phase of Horizon 2020 will dedicate more resources to the social sector. In May 2016 President Obiang said his “top priorities right now are health services and education.”[112] But there is a real risk that the impending economic crisis caused by low oil prices and slowing oil production will negatively impact government spending on these sectors. From January 2014 to 2015 the price of oil halved from $100 per barrel to $50, forcing the government to amend its 2015 budget. The cuts were wide-ranging, but the hardest hit item by far was university scholarships, which were slashed by 60 percent in 2015.[113] At the time the US-based Equatoguinean human rights organization EG Justice reported that students in Malabo and Bata peacefully protested the cuts, but the police dispersed them with tear gas. According to EG Justice, around 100 students were arrested, 56 of whom were detained for 10 days without charge. The Ministers of Education and National Security allegedly questioned some students about the political party behind their protests before police officers beat them with batons.[114]

Spending on Unproductive Investments

The IMF has found that the outsized and opaque budgets for infrastructure projects have led not only to low social spending but also to excessive spending and investments with minimal development value. In 2013, for example, it noted that “costs and wastage have been high because of limitations in oversight and pressure for prestige projects.”[115] The following year it similarly concluded that “some of the largest projects have limited economic payoff.”[116] More specifically, it found: “The infrastructure investment program has also included projects with a weak impact on social indicators, including sports facilities and a new administrative capital city at Oyala.”[117]

The staggering amount of money that has poured into Oyala makes it a prime example of investments with dubious benefits. Equatorial Guinea’s official capital is Malabo, located on Bioko island, but the government operates six months a year out of Bata, the country’s largest city located on the mainland. To accommodate what are effectively dual capitals, the government built gleaming new buildings to house the various ministries in each city. Yet around five years ago, the government began to build a new capital city in the middle of the jungle, some 65 kilometers (40 miles) from the president’s hometown of Mongomo, in effect pouring billions of dollars into a third capital for a country with a population of around one million.

In a 2012 media interview Obiang cited security as the justification for building the new capital. He said that Malabo and Bata’s location on the water make him vulnerable to a coup.[118] According to the IMF’s 2015 report planned spending on Oyala was $8 billionmaking up almost a quarter of the total multiyear public infrastructure program budget of $36 billion.[119] An unpublished draft of the IMF’s most recent report concludes that it is expected to account for half of all government expenditures in 2016.

This bias in favor of infrastructure has also led to inefficient health and education spending, according to the IMF and World Bank. Spending in these sectors is not only too low, it also disproportionately favors capital investmentssuch as hospital buildings, administrative offices, and university campusesover current spending on items such as salaries and trainings for doctors and teachers, medicine, and textbooks. Out of a total planned multiyear public investment budget of $36 billion, $2.5 billion (7 percent) was allocated to health, education, and sanitation.[120] While the government has only executed a part of the planned projects, the IMF found that the bias in favor of infrastructure has led to uneven progress in health and education:

While development indicators that depend on infrastructure, e.g. access to water and electricity, have improved markedly, low overall spending on health and education delivery has led to vaccination and primary school completion rates that have fallen well short of the achievement of other SSA [sub-Saharan African] countries with much lower per capita incomes. In the face of significantly reduced oil revenues, the authorities need to shift limited resources to health and education sector [sic].[121]

This finding reflects past IMF and World Bank conclusions. In 2015 the IMF recommended that budget allocations be “overhauled” in line with development priorities, “notably health and education.”[122] The World Bank noted in 2010 that the government’s “current expenditures are insufficient to provide meaningful public social services.”[123]

The huge sums of money spent on infrastructureand the paltry sums used for health and educationmust also be viewed in the context of evidence indicating that government officials have amassed enormous wealth from public contracts.

III. The Human Cost of Underfunding Health and Education

Ordinary Equatoguineans pay a heavy price for their government’s failure to invest in health and education.

Equatorial Guinea was undoubtedly burdened by the legacy of extreme poverty and brutality of the Macías dictatorship, which ended 38 years ago but gutted the country’s institutions and left it with few qualified doctors and teachers. This should have been all the more reason for the government to invest a significant part of its oil revenues in the social sector, particularly in health and education. While the country has improved on some key health indicators, such as maternal mortality rates, available education indicators show no significant improvements. On many health and education indicators Equatorial Guinea has merely kept pace with general improvements across the African continent, despite its massive resource advantage. Incredibly, some indicators, such as vaccinations and net primary school enrollment rates, have worsened since the start of the oil boom.

Health

Health Data

As noted above, Equatorial Guinea does not routinely collect or publish data on health or other indicators, complicating a comprehensive assessment of its performance. Yet a review of available data and estimatesfrom UN reports and a 2011 household surveysuggests that despite a massive increase in resources, progress on most health indicators has been limited and often falls below other, poorer countries in the region, and in some cases health indicators have actually worsened.

Indicator

Equatorial Guinea’s Performance

Context

Life expectancy

57.6 (2014)

In 2014 Equatorial Guinea’s life expectancy trailed the sub-Saharan African average of 58.6 years by 1 year, while it was slightly above the regional average in 1995 when the oil boom started. Average life expectancy in upper middle-income countries was 74.4 in 2014.[124]

Human Development Index

138 (2015)

Equatorial Guinea ranks 138 out of 188 countries, making it the country with the largest gap between its per capita wealth and the state of human development. Its score is almost identical to that of Ghana and Zambia, despite boasting a per capita income that is more than five times as high.[125]

Infant mortality (per 1,000 births)

65 (2011, DHS)[126]; 68.2 (2015, WB)[127]

Equatorial Guinea’s infant mortality rate has consistently been higher than the average for sub-Saharan Africa, decreasing at a similar pace as the rest of the continent. In 2015 the average for sub-Saharan Africa was 56.4 (World Bank) and 15.2 for upper middle-income countries.[128]

Under-5 Mortality (per 1,000 births)

113 (2011, DHS)[129]; 94.1 (2015, WB)[130]

At the start of the oil boom, Equatorial Guinea’s under-5 mortality was slightly lower than the average for sub-Saharan Africa, but since 2003 it has consistently failed to keep pace with regional progress. In 1995 its rate was estimated at 171.2 deaths per 1,000 births, compared to a sub-Saharan Africa average of 173.2; in 2015 World Bank data estimated 94.1 deaths per 1,000 births, compared to a region-wide average of 83.2. The household survey suggests the actual number is higher than World Bank projections.[131]

Maternal Mortality (per 100,000 live births)

308 (2011, DHS)[132]; 342 (2015, WB)[133]

Equatorial Guinea’s progress on this indicator has significantly outpaced that of the sub-Saharan African region. In 1995 Equatorial Guinea’s rate of 1,050 deaths per 100,000 live births was among the worst in the region. By 2015 its rate was well below the average for sub-Saharan Africa (547), although still significantly higher than the average for upper middle-income countries (54).[134]

Access to improved water (% of households)

56% (2011, DHS)[135]; 47.9% (2015, WB)[136]

The rate of access to improved drinking water in Equatorial Guinea has not improved over the last 20 years, hovering around 50% throughout that period. In 1995 Equatorial Guinea’s score on this indicator was similar to the average for the sub-Saharan African region; by 2015 the regional average had increased to 67.6%, according to the World Health Organization (WHO).[137]

% of infants between 12-23 months completely vaccinated

27% (2011, DHS)[138]

Equatorial Guinea’s vaccination rates for children have fallen dramatically since the late 1990s and are among the worst in the world. For example, the reported rate of tuberculosis vaccination for newborns and infants was 99 percent in 1997; 64 percent in 2014; and 35 percent in 2015, the last year for which data is available.[139]

% of children under 2 that received no vaccines at all

25% (2011, DHS)[140]

The percentage of children under two that have received no vaccines is among the highest in the region. For comparison, the rates were 5% in Cameroon (2011, DHS); 4% in Gabon (2012, DHS); 21% in Nigeria (2013, DHS); and 3% in São Tomé and Príncipe (2009, DHS).[141]

The above data and estimates tell a clear story: Equatorial Guinea is an upper middle-income country that performs worse than many low-income countries on numerous key health indicators.

Nearly six in ten people die from communicable diseases or maternal, prenatal, or nutrition conditions.[142] Equatorial Guinea’s performance on vaccinations is illustrative of the failure of the government to invest in its population’s health. A senior employee of a humanitarian agency active in the country told Human Rights Watch that UNICEF supported Equatorial Guinea’s vaccination program in the 1990s, when the vaccination rate for polio and DPT was over 80 percent.[143] When oil money started filling the country’s coffers toward the end of that decade, UNICEF discontinued its financial support since the Equatoguinean government was supposed to step in. It did not, however. Between 1998 and 2000 vaccination rates for, among others, polio and DPT dropped to around 40 percent. Overall the rates have worsened since the start of the oil boom for every vaccine that the World Health Organization (WHO) tracks.[144]

In the last few years, after a slight recovery, vaccination rates declined further and fell dramatically from 2014 to 2015, the most recent year for which data is available. According to a 2011 household health survey, one quarter of children under 2 receive no vaccines at all and only one quarter of children received all recommended vaccinations.[145] The vaccination rate for tuberculosis in 2015 (35 percent) was the second-lowest rate in the world.[146] Measles vaccination similarly dropped from an 82 percent high in 1997 to 43 percent in 2014 to 26 percent in 2015. Even before this last 17-point drop in 2015, Equatorial Guinea had the second-worst rate in the world, besting only Central African Republic. Polio vaccination rates were the worst in the world at 27 percent in 2015, having fallen from a high of 64 percent in 1997; Somalia has the second worst rate at 42 percent. The decline in vaccination rates tracks the overall decline in Equatorial Guinea’s economy, raising concerns about how expected continuing economic contraction may harm public health programs.

The government’s failure to improve access to safe drinking water over the last 20 years is similarly egregious. While the lack of access is especially severe in rural areas, many neighborhoods in Malabo and Batathe capital and economic centeralso rely on contaminated water from wells or the river, creating tough choices for ordinary Equatoguineans. For example, Arturo, a father of two who lives in Malabo and works in an administrative position for an international agency, told Human Rights Watch that he cannot afford to boil the river water before drinking it: “We prefer to save the money to use the gas for cooking rather than [for] boiling water.”[147] The health risks of contaminated water and poor sanitation are particularly high for children. Researchers conducting a health survey in 2011 found that one in five children under five had experienced diarrhea in the two weeks prior to their visit and nearly one in three had had a fever.[148]

Lack of Access to Affordable Health Care

Equatorial Guinea’s government is obliged under international law to ensure access to healthcare services that are affordable to all. In practical terms credible efforts to meet this obligation are also an indispensable part of any successful government effort to progressively realize the right to health over time.[149] International human rights law is not prescriptive on how countries should achieve this, but the Committee on Economic, Social and Cultural Rights (CESCR), the body of independent experts that monitors implementation of the International Covenant on Economic, Social and Cultural Rights by states party to the convention, has clarified that:

Payment for health-care services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households.

Since 2005 the World Health Assembly has urged countries to introduce health financing systems that provide for “sharing risk among the population and avoiding catastrophic health-care expenditure and impoverishment of individuals as a result of seeking care.”[150]

The Sustainable Development Goals, a UN-led universal call to action to end poverty, protect the planet, and ensure that all people enjoy peace and prosperity by 2030, call for the introduction of universal health coverage, which would ensure access to quality essential health services and protect patients against catastrophic health expenditure.[151]

Equatorial Guinea’s Health System

The Ministry of Health and Social Welfare oversees the administration of Equatorial Guinea’s public health system. The ministry’s budget is determined by the Ministry of Finance and Budget, although the Ministry of Planning and Development oversees the implementation of capital spending, which comprises most of the budget.

In 2009, the most recent year for which there is data, there were 45 publicly funded health centers, which provide basic medical services, and 18 hospitals (12 district; 4 provincial; and 2 regional). Rural areas are often served by smaller health posts, which are not necessarily staffed by doctors but can administer basic tests. Although public hospitals and health centers are generally the cheapest option for receiving health care, they still charge user fees, and research by Human Rights Watch indicates that the system does not provide for any mechanism to waive or reduce fees for the poor.[152]

The state also subsidizes employer-based social security insurance called INSESO (Instituto Nacional de Seguridad Social), which covers around 60,000 people.[153] INSESO operates its own network of hospitals and health centers and falls outside the purview of the Ministry of Health. The insured and their minor children receive 50 percent discounts to access INSESO’s services, which reportedly provide better quality care than the public system. INSESO is funded through a combination of employer and employee contributions and public funds; its expenses make up a significant amount of the budget’s current expenditures even though it covers a relatively small percentage of the population.[154]

There is no data on the extent of private health care use, but the World Bank in 2010 noted that “given the lack of public sector coverage, private sector involvement is extensive.”[155] Many charge fees that are considerably higher than the public sector, putting them out of reach of most Equatorial Guineans. However, there are also lower-cost clinics that are funded by foreign aid; most are run by the Catholic church.

Many of the doctors, nurses, and patients interviewed by Human Rights Watch said that those for whom the public option is too costly simply have no access to health care. A nurse at the General Hospital in Malabo said that even women in labor who cannot pay in advance will be turned away.[156] She recalled how one patient who had complications during childbirth that required treatment only available at La Paz Hospital, a publicly funded hospital discussed in more detail below, died after being unable to pay for the necessary medical care. Another nurse in the same hospital confirmed that they turn away patients every day because they are unable to pay, adding that some patients’ conditions worsen while waiting for treatment and trying to get the money together.[157] Expressing her exasperation at the system, she said: “I would understand if this were a private hospital but this is public!”

A doctor who worked in the General Hospital in Bata had the same experience: “If people [in critical condition] don’t have money, they die,” she said.[158] One interviewee told Human Rights Watch that when he is sick, he usually stays home because he doesn’t have the money to pay.[159] He said that when he can afford it, he prefers a private clinic because he doesn’t believe the General Hospital provides quality care. But, he added, a consultation at the clinic costs 7,000 CFA francs (US$11.25). “If right now I had to pay that kind of money, I would die,” he said, laughing incredulously.

The government has heavily invested in two modern, well-equipped hospitals that were built with public funds but charge fees that put them out of reach for most Equatoguineans. These two hospitals, the crown jewels of the country’s health system, are in Malabo and Bata, both called La Paz, and are staffed almost entirely by foreigners.[160] Multiple sources told Human Rights Watch that the hospitals are privately owned but are at least partially government funded.[161] “The line between public and private health carelike for everything elseis very thin in Equatorial Guinea,” a senior employee of a humanitarian agency, told Human Rights Watch.[162] Two medical professionals at La Paz also described the hospital as private, although they said that the government pays their salaries.[163]

La Paz charges fees for services including delivery that make it unaffordable to most Equatoguineans, according to several people interviewed.[164] Patients who arrive at the emergency room at La Paz are expected to pay 30,000 CFA francs (US$49) prior to service, a doctor who works in a private clinic in Bata told Human Rights Watch. One member of the medical staff at La Paz Malabo told Human Rights Watch that the hospital would not turn away urgent cases, such as trauma, even if they could not pay upfront, although they would still be billed. Non-emergency patients who cannot pay upfront are denied service at La Paz, they said.[165]

In some cases, the government apparently subsidizes payment for services at La Paz Hospitala system that may help some patients but does not satisfy the requirement of equitable access under the right to health. Human Rights Watch was unable to determine how often and in which cases the government grants such letters. A number of people interviewed said that they were reserved for the politically connected. One medical staff member at La Paz said that he frequently receives patients with such letters, but most are either senior government officials or connected to them. He gave one example of a well-off foreign employee of a member of the presidential family receiving subsidized treatment.

A number of people who are not politically connected told Human Rights Watch that La Paz was only for the elite. When asked whether he had tried to request subsidized treatment at La Paz, a father who earns roughly $300 per month and has two children who suffer from a costly blood disorder said: “It’s a hospital that’s here, but we don’t consider it to be here,” he said. An elderly woman who has worked in government services since 2005 said that her family spent two years applying for such assistance for her grandchild, who has cerebral palsy and requires CT scanning only available at La Paz, but has yet to receive any help. “It depends on who you are, on whether you have government connections,” she said. Two peopleincluding the La Paz staff membersaid that in any case the government has stopped issuing or honoring these letters in recent years due to the economic crisis. Moreover, the barrier to accessing La Paz in Malabo is not only financial. Unlike the General Hospital, which is centrally located, La Paz is situated in an enclave of the island called Sipopo, which can be difficult to reach since it is separated from the city by a tollbooth and police checkpoint. The location reinforces the impression that the hospital was built to serve the elite rather than the broader community; besides a few houses belonging to the members of the president’s family, the enclave has no residential space for Equatoguineans.[166]

Inadequate Quality of Care

Despite having vastly greater resources, Equatorial Guinea’s healthcare system continues to be troubled by many challenges that are common in low-income countries. The doctors, nurses, patients, and foreign professionals with whom Human Rights Watch spoke all stressed that poor quality of care is a major problem. Interviewees raised a lack of qualified staff, frequent misdiagnoses, long waits, and stock-outs of medicines and medical supplies as key concerns about the quality of care. According to the WHO, “a large part of ... health clinics [in rural areas] are not functional given the lack of personnel, equipment, and essential medicine required to provide effective services.”[167] The dismal health indicators described above would seem to bear this out.

Several of the people we interviewed said they were reluctant to seek treatment at the General Hospital in Bata or Malabo out of fear of being misdiagnosed, preferring to meet the higher fees being charged by private clinics if they could afford them.[168] One doctor who works in a private clinic said he frequently sees patients who have been misdiagnosed at public hospitals. As an example he recounted a patient who was diagnosed at the General Hospital with liver cancer but turned out to have a liver abscess: “That's the situation: the doctors [in the General Hospital] can't tell the difference between liver cancer and an abscess,” the doctor said. Another doctor who works at La Paz Malabo said that when patients are transferred in critical condition from the General Hospital, he often thinks to himself that they would have been better off had they never been treated.[169]

Low salaries likely contribute to the inability of the public healthcare system to attract qualified staff. Interviewees said that local doctors are paid around 200,000 CFA francs (US$322) monthly and nurses earn 120,000 CFA francs (US$193).[170] In its 2010 Public Expenditure Review on Equatorial Guinea, the World Bank noted: “The low wages earned by public sector workers with medical training prompt young people in these professions to emigrate to other countries.”[171] Salaries for foreign staffand particularly staff in La Paz Hospital Malaboare significantly higher. One medical staff member there said he earns twice what he would earn in his home country, where the average monthly salary for his field is almost $4,500.[172] He said that cleaners at the hospital make 150,000 CFA francs, or more than a nurse in a public hospital.

Several interviewees told Human Rights Watch that extremelyand sometimes dangerouslylong wait times are common at the General Hospital in Malabo.[173] One interviewee who took his son who had typhoid and malaria to the General Hospital in Malabo told Human Rights Watch that he waited four hours for service.[174]

An obstetrician told Human Rights Watch of a tragic incident that had occurred the morning of our interview to illustrate the conditions of the public hospital system. A pregnant woman named Maria had come to his private clinic the previous night, after she had already been in labor for more than a day. She had never been to a prenatal check-up and did not know if she was full term. She began the delivery at home with a mid-wife, but had complications, so the mid-wife sent Maria to the General Hospital in Bata, Equatorial Guinea’s largest city. There, she waited all day but did not see a doctor, he said. When she left after the hospital closed and came to the doctor’s clinic, it was already too late. Her baby died in the morning, hours after delivery.[175]

Education

The physical condition of many schools in Equatorial Guineafrom crumbling buildings overcrowded with student benches to unsanitary facilities and a lack of drinking wateris a visible symptom of the government’s neglect of the sector. But the problems in the sector go far deeper: high rates of children who never started school, dropped out, or had to repeat multiple grades; unaffordability of even primary education; and low rates of teacher certification, etcetera. Some education indicators, such as rate of children not enrolled in primary school, have in fact deteriorated since the start of the oil boom.

Under international human rights law, Equatorial Guinea’s government is obliged to provide free primary education and to progressively realize the right to education more broadlymeaning an improvement over time in the availability and quality of education.[176] Available data suggest that Equatorial Guinea has not met its minimum obligations despite its vast oil wealth. Interviews with teachers, parents, students, and educational specialists reinforce that view and offer insight into the human cost of that reality.

A telling sign about the poor quality of public schools is how assiduously parents try to avoid them. According to a 2015 government report to UNESCO, more than half of students attend private schools.[177] The report does not offer any reasons for this. One parent told Human Rights Watch that he sent his children to private schools even though he could not even afford to use cooking gas to boil drinking water at home.[178]

Equatorial Guinea’s Education System

Equatorial Guinea’s education system is divided into three levels—pre-school, primary, and secondary—each of which lasts six years. Pre-school begins with nursery for one- to three-year-olds and transitions to kindergarten for children aged four to six. Children begin primary school at age 7 and are expected to graduate at 12. Students who achieve a Primary Studies Certificate may go on to secondary school (also called high school), while those who do not successfully complete their primary school exams have the option of pursuing vocational training. After graduating from secondary school students must take preparatory courses before applying to the National University of Equatorial Guinea, the country’s sole university.

The Ministry of Education, Science and Sport is responsible for administering the public education system. A 2007 law makes pre-school and primary school compulsory and free. In reality, high percentages of students are too old for their grade, many drop out or never enroll, and all educators and parents interviewed told Human Rights Watch that schools charged fees. More than half of students attend private schools.

Missing Children and Repetition

In 2012, the most recent year for which UNESCO has data on the country, 42 percent of children age 7 to 12 were not in primary school, the seventh worst rate in the world.[179] This is worse than before 2000, prior to the onset of oil wealth, when 33 percent of primary school age children were out of school.[180] Many children were never enrolled in primary school, and only half of those enrolled complete it. Remarkably the highest dropout rate is after first grade: in 2011, 12 percent of children left school after first grade and never re-enrolled, according to UNESCO.[181] Another 24 percent repeated first grade, so that only about two-thirds of the class moved on to second grade.[182]

While highest for first graders dropouts and repetition remain problems at every level. This, combined with late starts to education, means that the ages in any given class can vary widely. In 2015 only 56 percent of primary school students were in the correct grade for their age—a 10 percent decline from 2000.[183] “In first grade, you can find kids ranging from 6 to 13 or 14. How do we deal with this?” Ignatio, an expatriate who is an education

specialist working in the country, told Human Rights Watch.[184] Secondary school, which begins in the seventh grade, fares even worse, based on the little data available: less than one-quarter of secondary students are in the correct grade for their age.[185]

As Ignacio noted, the sad state of education is particularly unfortunate since the small size of the country’s population means that even a modest investment would go a long way. For example, the total number of out-of-primary-school children in 2012 was 45,885.[186] “You can practically fit them in one school bus,” he joked. Yet the government “has never invested in education in a substantial way, even though they could do it with pocket change.”[187]

Overcrowding and Dilapidated Schools

A bathroom at the high school, where there is no running water. 

© 2016 Human Rights Watch

The physical condition of schools is often a barrier to learning; 332 of 857 schools have no latrines at all, according to a 2015 government report to UNESCO, and 600 lack electricity.[188] The development plan makes investment in educational infrastructure a priority, but, as discussed in the previous section, most funds are diverted to higher education.[189]

A bathroom at the high school, where there is no running water.

© 2016 Human Rights Watch

Seventy or eighty students per class was common in public high schools, a former public high school teacher, Cristian, said. Another teacher, Diego, told Human Rights Watch he once had 105 students in a class.[190]

Human Rights Watch visited both a recently renovated middle school and a high school that was in very poor condition. In the high school classrooms were tightly packed with around 40 to 50 double benches, and the ceiling panels were completely torn. There was no running water in the bathrooms; cobwebs covered the sinks and the latrines and floors were covered in excrement. There was no running water in the bathrooms; cobwebs covered the sinks and the latrines and floors were covered in excrement. The middle school had around 30 double benches per classroom and running water in the bathrooms. Human Rights Watch also visited a private primary school in Malabo. Conditions were somewhat better than at the public high school. Classrooms held around 25 double benches. There was no running water in the bathrooms, but they were clean and water was available in a well just outside the bathroom for washing hands.

Poor Teacher Training and Low Pay

A number of teachers whom Human Rights Watch interviewedall of whom worked in both public and private schools at some pointblamed the high dropout and repetition rates partly on low teacher pay, lack of accountability in schools, and minimal or no training.

A classroom at an urban public high school. Each classroom held around 40 double benches. Teachers told Human Rights Watch that classes commonly had 70 to 80 students; one said he had 105 students in a class he taught the previous year. The teachers said that the physical conditions of the school were typical and that some schools, particularly in rural areas, fare worse. 

© 2016 Human Rights Watch

Teachers interviewed by Human Rights Watch said that salaries were so low and training so poor that teachers lack both the motivation and skills to meet the challenges of overcrowded classrooms, and the absence of any system of accountability exacerbates the problem. “If a student ends up with a teacher who doesn't have training, he's lost,” one public middle school teacher, Alphonso, said.[191]

Hernando, 19, who recently graduated from high school and transferred from a private to a public high school after his family moved out of Bata, described his experience:

First of all, many times the teachers didn’t even show up. There were 70 kids in my class compared to around 30 in private school. There were no textbooks. The teacher had the book, used it to write on the board, and the class would copy it down. If you want to correct your work, you can. If not, not. They don’t care at all.[192]

A low level of teacher training undermines the quality of education. A government report states that 59 percent of teachers have a professional degree, and, according to UNESCO, 49 percent of primary school teachers have training.[193] Alphonso said that he is among 5 of 13 teachers in his middle school who are certified.[194]

Both according to the international data and an education specialist interviewed by Human Rights Watch, there has been an improvement in teacher training since 2008, when a study found that only 30 percent of primary school teachers had the requisite training.[195]

But the extent and quality of training is also a problem. The same study found “that a high ratio [of teachers] had problems with written expression, spelling, and penmanship.”

Improved training is largely due to a program called el Programa de Desarrollo Educativo de Guinea Ecuatorial (PRODEGE), which is jointly funded by the oil company Hess and the government and fully implemented by US-based NGO FHI 360. Hess and the government contributed $50 million toward the program (Hess pays the full amount and deducts it from what it owes to the government).[196] The ten-year program, which began in late 2006, has trained nearly 1,000 of around 3,500 primary school teachers during its first phase; its second phase focuses on secondary education.[197]

While the educators with whom Human Rights Watch spoke about PRODEGE generally had a positive view of the program, some also said they found it troubling that this is the only well-resourced government education program since its model is unsustainable: the programs ends in 2017 and there are no plans to continue it.[198]

Costs

Equatorial Guinea’s National Education Act mandates that public schools be free, in line with the government’s human rights obligations. However, all educators and parents Human Rights Watch interviewed said that students are required to pay fees for enrollment, although the amounts they gave varied widely. The reason for the variation may be that the official cost is lower than what officials actually charge, Clara, an education specialist active across the country, told Human Rights Watch, and the amounts they demand can vary between schools.[199] Although Human Rights Watch was unable to verify fee amounts, a number of teachers Human Rights Watch interviewed believe that high school fees, particularly in secondary schools, contribute to high dropout rates.[200]

IV. Self-dealing in Infrastructure Projects

The paltry resources Equatorial Guinea invests in its health and education systems can be partly explained by its unusually high spending on infrastructure, which consumes nearly all of its oil revenues, as documented in Section II of this report. Human Rights Watch findings suggest that such massive spending on infrastructure has led to corruption and at least some of those public funds have found their way into the pockets of top government officials and their relatives who own businesses that benefit richly from these public contracts.

In the five years between 2009 and 2013 Equatorial Guinea spent around US$20 billion on infrastructure projects, or an average of around $4 billion annually.[201] In contrast, neighboring Gabon, population 1.62 million with a similar overall GDP, earmarked $1 billion for infrastructure in its 2015 budget.[202] Put another way, Equatorial Guinea spent around one-third of its GDP on infrastructure projects between 2008 and 2013, which is three times the regional average.[203]

Equatorial Guinea has inadequate laws regulating conflicts between government officials’ private interests and public duties, and the enforcement of existing conflict of interest laws are at best spotty, as discussed in Section V of this report. In addition the procurement process for government contracts is informal and opaque. Local content laws require that a minimum 35 percent of all companies operating in the country be owned by Equatoguineans; these types of laws seek to ensure that domestic businesses benefit from investments by multinational businesses, but in Equatorial Guinea they seem to have fueled corruption and self-dealing. This section examines how the legal environment and opaque management of public finances provide fertile ground for foreign businesspeople to partner with powerful officials, whose companies may only exist on paper but who use their influence to secure large government contracts from which they profit. In addition, it appears that it frequently leads to inflated contract prices and approval for projects with little social value that are causing the wasteful diversion of resources away from the neglected social sector, which includes health and education.

Equatorial Guinea has invested hundreds of millions of dollars in building highways, but most residential areas, even in the capital, remain unpaved. Rains often leave large pools of water on the unpaved roads, making driving difficult for residents.

© 2016 Human Rights Watch

Equatorial Guinea’s massive investment in public infrastructure has succeeded in transforming the physical landscape of the country to lay the groundwork for a modern economy. Prior to the oil boom the country had just 60 kilometers of paved road; it now has a road network of more than 2,000 kilometers across the country.[204] The government also built three new airports and modernized the two existing ones in Malabo and Bata, and extended eight seaports. Some investment went toward health and education: the government constructed or rehabilitated 62 primary schools and 65 health clinics and hospitals in the last decade.[205]

But this achievement does not mitigate the waste resulting from conflicts of interest and an opaque procurement process documented in this section, nor does it justify the related neglect of health and education. Indeed, the IMF, World Bank, and others have repeatedly found that the impact of the infrastructure investments on improving social indicators and diversifying the economy is impeded by “deep-seated deficiencies in public financial management.”[206]

This section examines the pernicious self-dealing in Equatorial Guinea’s infrastructure sector. Court cases and other official documents reveal an extensive record of mismanagement and corruption in the sector involving enormous sums of public money that directly contribute to the government’s chronic and extreme underfunding of health and education. However, self-dealing is by no means limited to the infrastructure sector and appears to be deeply rooted in Equatorial Guinea’s political and financial systems. A 2009 US State Department cable made public by WikiLeaks explains what it calls Equatorial Guinea’s “peculiar financial management mechanisms” as a legacy of the government not having sufficient resources to pay salaries. Citing the Equatoguinean treasurer who served until 1993, the cable says that the government often compensated officials with “in-kind transfers” in the form of seized land, operating licenses, and import concessions. Officials were also only expected to work three days a week, and to devote the remainder of their time to earning a living. When oil revenues began to flow, this mix of official and private business proved enormously lucrative. According to the cable:

Most ministers continue to moonlight and conduct businesses that often conflate their public and private interests. The custom of simultaneously maintaining both official and private activities that became entrenched in the era of skinny cows has not been altered for the fat ones. [207]

International Corruption Investigations

Equatoguinean officials have been under frequent scrutiny and investigation for money laundering and corruption, including in the US, Spain, France, and Switzerland. The findings of these investigations offer an invaluable window into the government’s financial system and high-level officials’ business dealings.

US Senate Investigation and Spanish Criminal Case

A subcommittee of the US Senate conducted one of the first investigations in 2003, when it scrutinized a Washington, DC bank for compliance with US money-laundering statutes. Equatorial Guinea was the largest client of Riggs Bank, which, between 1995 and 2004, operated 60 accounts belonging to the government, officials, and family members worth as much as $700 million.[208] Withdrawals from an account that held deposits from American oil companies active in Equatorial Guinea (primarily ExxonMobil and Marathon) required the signature of President Obiang and either his son, Minister of Mines Gabriel Obiang Lima, or his nephew, Secretary of State for Treasury and Budget Melchor Esono Edjo.[209] Obiang was the sole signatory on two investment accounts, which were linked to a money market account from which any of these three individuals could authorize withdrawals. Between 2001 and 2004, these three accounts had combined balances of up to $500 million.[210]

In 2004 the US Senate Permanent Subcommittee on Investigations concluded that Riggs Bank approved more than $35 million in wire transfers from the government account into the accounts of two companies, Kalunga Co. and Apexside Trading, and the committee stated it had “reason to believe that at least one of these recipient companies is controlled in whole or in part by the E.G. President.”[211] The report found other suspicious transfers and unexplained large cash deposits into officials’ personal accounts. It also found that US oil companies made payments into a student scholarship fund, but “[m]any and perhaps all of these students were the children or relatives of E.G. officials.”[212] The US government imposed a $25 million fine on Riggs Bank for “willfully violating its legal obligations to implement an adequate anti-money laundering program.”[213] The bank subsequently closed and merged with PNC Financial Services.

An investigation by a Spanish human rights organization, Asociación Pro Derechos Humanos de España (APDHE), found that at least five of the transfers from government accounts at Riggs Bank into the Kalunga account closely coincided with nine real estate purchases in Madrid, Gijón, and Las Palmas de Gran Canaria in the Canary Islands on behalf of Obiang, members of his family, and other close associates.[214] A total of $26.5 million was deposited into the Kalunga account at Banco Santander from 2000 to 2003.[215]

In May 2008 APDHE filed a criminal complaint against 11 senior Equatoguinean government officials and family members in Spanish court for alleged money laundering. As part of the investigation, Spanish authorities arrested Vladimir and Julia Kokorev and their son Igor, who they allege registered Kalunga and opened its accounts as a front company for government officials.[216] Officials allege that the couple transferred large amounts of money from their accounts into those of senior Equatoguinean government officials, for example a $2 million transfer to Fausto Abeso Fuma, Obiang’s son-in-law and the aviation minister.[217]

The government press responded to these allegations as “unfounded” and “part of the usual attitude of many Western media and institutions, of denigrating and humiliating the African continent and leaders.”[218]

Teodorin Corruption Cases

The outrageous spending habits of Obiang’s eldest son, Teodoro Nguema Obiang Mangue (known as Teodorin), have made him a target of several international money-laundering investigations. Teodorin was appointed vice president in June 2016.[219] Many believe he is a favorite to succeed his father as president.

Corruption Allegations in the United States

Between 2004 and 2010, Teodorin, at the time a minister of forestry and agriculture and earning a salary of under $100,000 a year, went on a $110 million US shopping spree, purchasing a mansion in Malibu, California, a Gulf Jetstream airplane, a fleet of luxury cars, and, famously, a $1 million assortment of Michael Jackson memorabilia including the white crystal-covered glove the pop star wore on his “Bad” tour.[220] The purchases set off alarm bells among US anti-money-laundering authorities, and in 2010 the US Senate Permanent Subcommittee on Investigations published a report detailing its reasons for believing they were bought with ill-gotten gains. The following year the US Department of Justice’s (DOJ) Anti-Kleptocracy Initiative filed a complaint to seize $70.8 million worth of these assets, alleging that they were bought with the proceeds of foreign corruption in violation of US law.[221]

Interviews conducted over the course of the DOJ’s investigation offer a revealing window into how Teodorin used his official position to extort millions of dollars in “taxes” and kickbacks. The DOJ ultimately settled the case after Teodorin agreed to forfeit $30 million in assets, which “will be given to a charitable organization to be used for the benefit of the

people of Equatorial Guinea.”[222] Human Rights Watch research indicates that the money has yet to be distributed.

Rather than initiate its own investigation in the face of overwhelming evidence of Teodorin’s corrupt activities, the Equatorial Guinean government issued a statement condemning the US Senate report as “racist, xenophobic, arrogant, and segregationist.” It defended Teodorin by claiming that under Equatorial Guinean law, government ministers “are perfectly authorized to conduct business and other types of work on the margins of their ministerial obligations.”[223] In court, Teodorin argued that anti-corruption laws that prohibit self-dealing by a “funcionario público” (or government official) apply only to civil servants and not to senior government officials.[224]

Corruption Allegations in France and Switzerland

During the same years as his US spending spree Teodorin allegedly spent €175 million (US$189 million at current exchange rate) in France on a mansion on the exclusive Avenue Foch in Paris, a collection of 26 luxury cars and 8 motorcycles, high-end art, luxury designer goods, hotels, and vintage wines.[225] Two French nongovernmental organizations, Transparency International France and Sherpa, filed a criminal case against Teodorin in 2008, alleging he had violated France’s anti-money-laundering laws. The three judges presiding over the case indicted Teodorin in March 2014, and two years later they ruled that there was sufficient evidence for Teodorin to stand trial.[226] The trial, initially scheduled for January 2, 2017, has been set for June 19, 2017.
 

The case documents are sealed, but Human Rights Watch and the media were able to obtain some information related to the charges. The judicial decision ordering Teodorin to stand trial alleges that between 2004 and 2011, nearly €110 million (US$119 million at current exchange rate) was transferred from the public treasury into accounts held by Teodorin. In particular, it alleges he used his forestry and construction companies, SOMAGUI, SOCAGE, and EDUM, to funnel money to France, although funds for many of the larger expenses passed through five Swiss companies established for that purpose.

In response to the French prosecutor’s decision to indict Teodorin the Equatorial Guinean government issued a statement on May 27, 2016, expressing its “repulsion” that the French prosecutor “does not value the institutional figure of our Second Vice-President” or recognize his immunity.[227] The following month, Equatorial Guinea filed a complaint with the International Court of Justice (ICJ) arguing that France was in breach of its obligation to respect Teodorin’s immunity.[228] The complaint also claimed that the Equatorial Guinean government used the Avenue Foch mansion as a diplomatic mission, and as such similarly deserves official immunity. About a week after filing the complaint President Obiang promoted his son to be his vice president. On December 7, 2016, the ICJ dismissed Equatorial Guinea’s claim that the French prosecution breached Teodorin’s immunity, finding it lacked jurisdiction.[229] However, it ordered France to respect the diplomatic protections of the mansion until it reached a final decision to determine its status.[230]

Switzerland opened a separate investigation into Teodorin in October 2016.[231] It seized 11 luxury cars in connection with the investigation, and Dutch authorities seized a $100 million yacht allegedly belonging to Teodorin at the request of Swiss courts.[232]

Self-Dealing in Public Infrastructure Contracts

Investigations by the US Department of Justice, France, and others exposed how government officials allegedly siphoned off millions of dollars in public money, oftentimes through shell companies that did not appear to do any actual work.[233] For instance, sources interviewed by US investigators pointed to Teodorin’s road construction company SOCAGE (Sociedad de Carreteras de Guinea Equatorial) as an example of a minister-owned shell company whose sole purpose was to steal government money.

As part of separate case filed by a South African businessman in Johannesburg, Teodorin acknowledged in 2006 that SOCAGE’s profits came from public contracts, which, he said, were also a source of wealth for other ministers. That South African businessman claimed he was owed money by the Equatoguinean government and sued to legally seize two Cape Town houses owned by Teodorin. The businessman argued that Teodorin, who was minister of forestry and agriculture at the time, bought the houses with money belonging to the government, and they therefore could be used to satisfy a debt the government allegedly owed him. In response Teodorin filed an affidavit defending his ownership over the homes, claiming that he bought them with money transferred from SOCAGE, which, he wrote, sourced the funds legally, even if the money originated from the public treasury:

Cabinet Ministers and public servants in Equatorial Guinea are by law allowed to own companies that, in consortium with a foreign company, can bid for government contracts and should the company be successful, then what percentage of the total cost of the contract the company gets, will depend on the terms negotiated between the parties. But, in any event, it means that a cabinet minister ends up with a sizeable part of the contract price in his bank account.[234]

While sources interviewed by US and French investigators mostly focused on Teodorin’s companies as the subject of the investigations, according to sources these interviews and other documents indicate that self-dealing is widespread among senior government officials, including the president. The president acknowledged his “private interests” to US officials, according to the 2009 State Department cable made public by WikiLeaks.[235] “I have to take care of my family, soI maintain private interests on the side," he told them. The lack of transparency makes it impossible to quantify the value of public contracts to public officials and their family members, but fragments that offer clues have come to light.

Three IMF advisors who worked in Equatorial Guinea told US investigators that the practice of officials inflating public contracts for private gain is widespread. One IMF expert said:

The leaders of the country who are engaged in building roads, schools, airports and hospitals are not concerned for its citizens. All of these companies are performing these projects under control and being operated by a company which is owned by the President of EG. The perception that the President is attempted to transcend [sic] was he was developing the country of EG, but ... the President and his family members are profiting personally because they have an ownership venture in all these companies.[236]

A second IMF economist similarly “believes that projects requiring public investment and expenditures are significant sources of corruption in EG. These projects include airports, harbors, buildings, and roadways.”[237] A third, hired to work on Equatorial Guinea’s fiscal policy, said he or she had seen indications that “substantial government contracts being awarded from the public treasury accounts maintained at the BEAC [Bank of Central African States] to companies owned by government ministers,” noting that the “largest company in EG is owned by President Obiang which is a construction company.”[238] That company was awarded a contract for a three-mile road between Malabo and the airport, according to the expert, but it took three years to complete because “it was in the best financial interest of the construction company to charge inflated prices and stay on the job longer so that both the company and the EG official would earn more money and collect more payments from the EG public treasury.”[239]

Abayak

A billboard in  Malabo, the capital, installed by the construction company Arab Contractors wishing the president and the people of Equatorial Guinea  a happy new year. Arab Contractors has been awarded numerous lucrative public construction contracts in the country. There are credible allegations that the president has a 12 percent stake in the company through his company Abayak, and that his son and the vice president Teodorin has an 8 percent stake through his company Sofona. 

© 2016 Human Rights Watch

It is possible that the IMF fiscal expert was referring to Abayak, a large construction company that imports construction related-material and is involved in real estate. The US Senate investigation alleged that Abayak, “is controlled by the E.G. President who is also identified in Riggs KYC [Know-Your-Customer] documentation as the company’s president.”[240] Human Rights Watch obtained what appears to be Abayak’s certificate of incorporation, which states that the company was established on November 6, 1998, andgrants the president 75 percent of the shares, the First Lady 15 percent, and Teodorin the remaining 10 percent.[241] According to the state department cable Abayak holds the single license to import cement into the country; it similarly described the company as “partially owned by the president and first lady.” Abayak is also involved in other sectors. For example, according to the US Senate investigation, “in 1998, ExxonMobil established an oil distribution business in Equatorial Guinea of which 85 percent is owned by ExxonMobil and 15 percent by Abayak S.A.”[242] The US Senate report also found that Abayak partially owns a telecommunication company and is the 75 percent owner of a company with a stake in gas and methanol facilities.[243]

According to a personal account by a high-level businessperson who owned various companies in Equatorial Guinea for more than a decade following the discovery of oil and enjoyed a close business relationship with the president, Abayak also owns a 12 percent share in Arab Contractors, one of the largest construction companies in the country. Sofona, a company owned by Teodorin, reportedly owns an 8 percent share.[244] The businessperson claims that they worked as a subcontractor on a project awarded to Arab Contractors for 3,000 social housing units, worth a total of $142.5 million. The businessperson’s account also claims that the president and Teodorin have large stakes in Somagec, another large construction firm, although the exact size of their stake is not noted.

General Works and SOCAGE

General Works was at one point in time one of the largest construction companies operating in Equatorial Guinea. It has been awarded dozens of public projects including constructing highways, bridges, public buildings, and military barracks.[245] According to US and Italian investigators, the company was a major conduit through which the president and his family profited from public contracts.[246] An Italian businessman, Igor Celotti, was CEO of General Works and a majority shareholder until a month before he died in an airplane crash on June 21, 2007. Suspecting foul play the Italian financial police launched an investigation into the presidential family’s interests in the company following the crash.[247]

According to a declaration by the lead DOJ investigator in the US case, Roberto Manzanares, the Italian police found that a month before he died, Celotti transferred 45 percent of the company’s shares to his wife and the remainder to members of the president’s family without receiving compensation, giving them a controlling stake in the company.[248] The police believed that 45 percent of General Works’ revenue “was funneled as kickbacks to [Teodorin].” Based on an analysis of Celotti’s financial and banking records, the Italian police also concluded that Teodorin and his father jointly owned a “network of international bank accounts that contained stolen millions of dollars in government monies misappropriated from EG's treasury through General Work's government construction contracts.”[249] Three construction executives who worked in Equatorial Guinea independently confirmed to US investigators that Teodorin “used General Works as a vehicle through which to misappropriate tens of millions of dollars from EG’s public treasury,” one of whom also said that the president’s family “owned and controlled General Work.”[250]

In addition to profits the president and his family allegedly took in through any ownership of General Works, two former senior employees told US investigators that the company would routinely inflate the cost of the contract and then subcontract a part of the work to shell companies owned by Teodorin, including SOCAGE. One showed DOJ investigators a contract between General Works and SOCAGE and told them:

Even though Minister Obiang’s companies, like SOCAGE, would be listed as a purported subcontractor of General Works in performing various government construction projects, these companies did not actually exist (except on paper). These entities were vehicles through which Minister Obiang could steal and receive payment from the EG government (through General Works) pursuant to some kind of inflated and fraudulent public contract. The actual work described in these contracts, and which were supposed to be performed by Minister Obiang’s companies, were in actuality performed by General Works’ construction crews.

The source produced documents that, according to the investigators’ summary of the interview, “corroborate his/her version of what transpired.” The person also showed the investigators hundreds of original check stub banking records from General Works to Teodorin or his middleman, as well as bank records of two of Teodorin’s companies, SOCAGE and SOMAGUI.

The second former General Works employee told investigators virtually the same thing. Teodorin’s companies, the source said,

only existed on paper and had no real personnel or operations, did not have the ability to pave roads and therefore GW had to complete projects for them. These work projects were a means for Minister Obiang to steal money from the E.G. treasury. GW provided kickbacks to Minister Obiang for various contracts, which were highly inflated at Minister Obiang’s direction.... For instance... if the real cost of a construction project was 2 million dollars, Minister Obiang would instruct GW to prepare and submit a project invoice to the E.G. government for 10 million dollars so that he could receive a ‘kick back’ of 8 million dollars.[251]

Human Rights Watch has received reports that General Works was recently dissolved, but we were unable to confirm these reports or obtain more detailed information.

Eloba and ABC

An Italian businessman, Roberto Berardi, described a business arrangement he allegedly had with Teodorin and Equatorial Guinea’s First Lady Constancia Mangue, to gain access to public contracts. Teodorin and Berardi jointly owned a construction company, called Eloba Construcción. In 2013 Equatoguinean police arrested Berardi at Teodorin’s behest, accusing him of embezzling money from Eloba.[252] Berardi was found guilty and sentenced to more than two years in prison. Berardi claims that the arrest was retaliation for confronting Teodorin over allegations in the US DOJ’s money-laundering complaint that Teodorin used Eloba’s account to funnel nearly $1 million to the US. The legal battle led Berardi to shine light on what he claims were the inner workings of an Equatorial Guinea-based construction company that would under normal circumstances be guarded from public view.

On June 19, 2013, soon after Berardi was provisionally charged with embezzlement, he wrote a letter to his lawyer and the Italian embassy in Equatorial Guinea describing his business arrangement with Teodorin. According to the letter Berardi founded Eloba Construcción in 2008 in partnership with Teodorin, who held a 60 percent stake in the company even though he didn’t contribute any capital or otherwise participate in its administration. Teodorin’s role, rather, was to help secure public contracts, from which he and his mother would also profit.

Berardi, who was living in Equatorial Guinea, explained in the letter an example of how this worked: “One day I received an unexpected call from his [Teodorin’s] offices telling me he has a job list for our company ... the work is subcontracted from ‘ABC’ Company, owned by the First Lady (his mother) ... for a total of 8.8 billion francs (13.5 million).”[253] According to Berardi’s statement the initial subcontracts were for two projects, the Bikuy and Ikunde markets in Bata, but Teodorin was quickly able to secure many more for the company, such as the Bata industrial zone, three military barracks, a public slaughterhouse, and a pulp mill.

In an interview with Human Rights Watch after Berardi was released from prison and had returned to Italy, Berardi said that ABC functioned as a shell company and was awarded millions of dollars in public contracts that it would then subcontract to Eloba and other companies for a fraction of the original contract price.[254] He gave one example where he says ABC was paid 30 billion CFA francs (US$50 million) for a project that the First Lady then subcontracted to Eloba for 12 million (US$13 million).[255]

Berardi said the contracts kept coming in, along with personal requests from the First Lady to complete other public works contracted to ABC, but he said he was rarely paid for his work.[256] In his written statement Berardi claimed that when the company did receive small advances on projects, Teodorin would demand half the amount, even though Berardi had yet to recoup his capital investment or receive a salary as director general of Eloba.[257]

Berardi was freed from prison on July 9, 2015. According to his family and other confidential sources, during his detention Berardi was tortured and subjected to long periods of solitary confinement, as well as frequent denial of access to medical attention and legal counsel.[258]

Laws Enabling Corruption

Conflict of Interest

President Obiang and other officials have defended their actions by stating that it is legal in the country for government officials to operate private businesses and to contract with the government. As noted, Teodorin defended himself in South African and US courts by arguing that the activities of his companies are lawful in Equatorial Guinea. His government has similarly invoked domestic law in response to international corruption investigations.[259]

Equatorial Guinea’s weak legal system is a fundamental part of the problem.[260] In order to avoid conflict of interest in public procurement, Transparency International, a leading anti-corruption civil society group, recommends that countries enact guidelines that clearly define conflict of interest and require officials involved in the process to disclose information on their private interests and assets, in addition to being prohibited from making certain decisions or performing certain functions where opportunities for conflict of interest exist.[261] It also recommends transparency, stakeholder participation, and clear review mechanisms to ensure the guidelines are effectively implemented and enforced. Equatorial Guinea, however, appears to have only skeletal rules regulating conflicts of interest between government officials’ public duties and private companies and even these seem not to be enforced.[262]

Project Appraisal and Procurement Policies

While the practical absence of conflict of interest rules plants the seeds of self-dealing, the opaque and informal process for appraising projects, awarding contracts, and overseeing payments provide fertile ground for it to flourish. In its Public Expenditure Review, the World Bank criticized the “extensive informality” of Equatorial Guinea’s public financial management, highlighting the infrastructure sector in particular as a potential source of misappropriation:

The lack of a legal framework for public finance management is especially obvious in the infrastructure sector where there are neither legal rules for executing expenditure and procurement nor guidelines for project appraisal and selection.... [T]he authorities’ determination to implement projects quickly exacerbates already loose budget constraint. However no up-to-date list of ongoing or finished infrastructure projects in the last five years exists, which limits the capacity to identify newly built infrastructure or the cost of ongoing projects.... Ultimate investment allocation is decided by the Presidency, without the need to record the investment project into the Budget being implemented, bypassing any formal screening and budgetary system in place.[263]

Even in cases where regulatory frameworks exist, they are not always publicly availablethe World Bank, for example, was unable to obtain the 2003 law regulating state public finances for its Public Expenditure Review.[264] (Human Rights Watch succeeded in obtaining a copy). This opacity also extends to contracts: “There are no external audit reports and contract awards are not published. The current lack of transparency reduces agency accountability and increases opportunities for misappropriation.”[265] The opacity of the process gives high-level officials inordinate influence over which projects are approved, who gets the contract, and how much they get paid. According to IMF officials who have worked in the country, the president decides which companies are awarded contracts and how much they are paid. An IMF expert told US DOJ investigators in 2011: “There is no formal process whatsoever relating to how contracts are awarded in EG. It is solely based on the President awarding contracts. He decides what company is allowed to business [sic] in EG.”[266]

A related problem is scant oversight of payments. The National Payments Committee is charged with reviewing and approving all payments, but it does not regularly meet, according to the IMF’s 2015 report.[267] Rather, the job of approving payments appears to fall to the president: an IMF economist told US investigators in 2011 that the “President of EG authorizes all the payments for public investments and expenditures.”[268] An IMF expert who currently provides the country with technical assistance on its national accounts recently confirmed to Human Rights Watch that this remains the case, adding, “The way they deal with their budgets is not proper. Without reform, we can’t know very much.”[269]

Taken together, this opaque and informal system incentivizes foreign businesses to partner with senior government officials to meet the local content law’s requirement that at least 35 percent of companies operating in the country are Equatoguinean owned. Interviews conducted by the US DOJ as part of their money-laundering investigation indicate that the case of Berardi partnering with Teodorin for public contracts via ABC Constructiona company at least partly owned by the First Ladyis not exceptional.

A former senior official at General Works told investigators: “If a person/corporation wanted to do business in EG, that person/corporation would be required to have contacts or friends in key positions within the EG government to be awarded contracts.”[270] The IMF fiscal policy expert said virtually the same thing: “There are no formal or transparent processes of awarding public contracts other than knowing a government official.”[271] Christopher Kernan, former country program director for Conservation International for EG and Gabon, under a contract from US AID similarly told investigators: “It was difficult to have a business in EG if a company did not have an Obiang family connection. Therefore, companies recruited a member of the family to be on their board of directors and companies entered into joint ventures with EG owned companies.”[272]

Anonymous Companies and Bank Secrecy Laws

Foreign countries that allow companies to incorporate within their jurisdictions without revealing the owners’ names make it easier for corrupt officials in countries like Equatorial Guinea to hide the tracks of money laundering and self-dealing. Teodorin used an anonymous company registered in California to purchase a $35 million mansion in Malibu; he also used anonymous companies to open bank accounts in California, enabling him to hide his identity and skirt US special anti-corruption procedures for political figures.[273] US DOJ prosecutors allege that these companies were conduits for the transfer of illicit funds.

Anonymous companies can also provide a screen for deals tainted by conflicts of interest. For example, the Equatorial Guinean government awarded a company named International Medical Services GE a contract worth 45.3 billion CFA francs (US$75 million) to build a hospital in Oyala, according to what appears to be the contract dated July 11, 2011, obtained by Human Rights Watch.[274] The contract lists Ovadia Yardena, an Israeli with close ties to the President, as the company representative, but what appears to be the company’s certificate of incorporation, also obtained by Human Rights Watch, does not include any names of company shareholders.[275] Equatorial Guinean law requires at least 35 percent local ownership, and this lack of transparency can make it very difficult to discern whether local partners include government officials or their family members.

Foreign countries’ bank secrecy laws also can help shield corruption. The 2004 investigation by the US Denate found that Riggs Bank transferred $35 million in public funds to two companies that US investigators believed belonged to the president, but they were unable to confirm ownership due to Spanish bank secrecy laws. The US Senate report on the investigation found: “This bar on disclosure ... presents a significant obstacle to U.S. anti-money laundering efforts.”[276]

V. Equatorial Guinea’s Human Rights Obligations

The Rights to Health and Education

The International Covenant on Economic, Social and Cultural Rights (ICESCR) recognizes “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”[277] The Committee on Economic, Social and Cultural Rights (CESCR), an expert body charged with interpreting the ICESCR, has defined the right to health as including health services, goods and facilities that are available, accessible, acceptable, and of good quality.[278] Such services should include “a system of health protection providing equality of opportunity for everyone to enjoy the highest attainable level of health; the right to prevention, treatment and control of diseases; access to essential medicines; maternal, child and reproductive health; equal and timely access to basic health services.”[279] According to the CESCR, the right to health also extends to “underlying determinants of health,” such as safe drinking water, adequate sanitation, and adequate nutrition.[280]

The Convention on the Rights of the Child (CRC), which Equatorial Guinea ratified in 1992, similarly protects a child’s right to health. Under the CRC governments are obliged to take steps to diminish child mortality; ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care; combat disease and malnutrition; and ensure appropriate pre-natal and post-natal health care for mothers.[281]

Equatorial Guinea’s constitution provides that “the State encourages and promotes primary health care as the cornerstone of its development strategy in this sector,”[282] but its laws and budgets do not reflect this prioritization.

The right to education is protected under both the ICESCR and CRC, with both mandating that primary education be compulsory and available free to all, and that secondary education should generally be available, accessible to all, and progressively made free.[283] The CRC also calls on states to “take measures to encourage regular attendance at schools and the reduction of drop-out rates.”

The CESCR maintains that the right to education requires education to be available, accessible, of acceptable quality, and adaptable to the changing needs of society. Availability depends not only on having sufficient facilities but also requires that the facilities meet certain conditions depending on the “developmental context,” but likely requiring at a minimum “buildings or other protection from the elements, sanitation facilities for both sexes, safe drinking water, trained teachers receiving domestically competitive salaries, teaching materials, and so on.”[284] The ICESCR also provides that “the material conditions of teaching staff shall be continuously improved.”[285]

Equatorial Guinea’s constitution calls education a “primary duty of the state” and mandates that “every citizen has the right to primary education, which is compulsory, free and guaranteed.[286] Despite repeated efforts Human Rights Watch was unable to obtain a copy of the Equatorial Guinea education law from government or other sources. The law’s inaccessibility raises obvious concerns about the extent to which it is being seriously implemented.

More generally, Equatorial Guinea’s constitution explicitly commits the country to act in accordance with international law and “reaffirms its adhesion to the rights and obligations that emanate from the charters of the organizations and international organisms to which it has acceded.”[287]

Progressive Realization and Immediate Obligations

The CESCR maintains that certain “core” components of the rights to education should be understood as the immediate obligation of all states, rather than goals to be progressively realized over time. This includes, inter alia, the obligation to provide free primary education to all and minimum levels of essential primary health care.[288] In general, however, international law recognizes that the capacity of states to realize the rights to health and education varies and is heavily dependent on the financial resources at governments’ disposal. With this in mind the ICESCR provides that in general the rights to health and education, as well as others, are to be realized progressively over time. Equatorial Guinea, like other states party, is obliged to “take steps ... to the maximum of its available resources, with a view to achieving progressively the full realization” of the rights to health and education.[289]

Because the concept of progressive realization is a flexible one that acknowledges varying levels of state capacity and the reality of legitimate, competing spending priorities, it is generally not possible to define with precision the minimum resource commitments any one government should be required to make. For the same reasons it is generally difficult to assert that a particular state has manifestly violated its obligation to “progressively realize” the rights to health and education, or other rights over time. But Equatorial Guinea represents an extreme case and in Human Rights Watch’s view, the government has clearly violated its obligation to progressively realize the rights to health and education.

Equatorial Guinea has failed to make progress on key health and education indicators, which in many cases remain among the world’s worst. The dismal status quo has persisted and in some cases even worsened despite a massive and indeed transformative increase in the government’s financial capacity in recent decades. This failure to achieve progress is not merely due to the failure of policy implementation, but to an extremely low level of investment in health and education relative to both Equatorial Guinea’s regional neighbors and to countries in other parts of the world with comparable income levels. What limited investments the government has made have been unduly focused on university education and the maintenance of elite hospitals that serve only a tiny part of the population. The remainder of the government’s budget has been focused to a highly unusual degree on infrastructure projects. Many of those investments are of questionable social utility and more to the point, there is considerable evidence that at least many large infrastructure projects have served as vehicles for self-dealing or corruption.

Prohibition on Corruption

Corruption is not, in and of itself, a human rights violation. However, corruption that impacts on a state’s ability to progressively realize economic and social rights such as health and education can give rise to a violation of its obligations under the ICESCR.[290]

The United Nations Convention against Corruption, which entered into force in December 2005, was established as an instrument for states to more effectively prevent and investigate acts of corruption and hold public officials to account for any violations. The convention calls on states to “maintain and strengthen systems that promote transparency and prevent conflicts of interest.”[291] In particular, states should require public officials to declare “their outside activities, employment, investments, assets and substantial gifts or benefits from which a conflict of interest may result with respect to their functions as public officials.”[292] States are also expected to establish a procurement system “based on transparency, competition and objective criteria” as part of a litany of measures they should take to prevent corruption.[293] Equatorial Guinea is one of about a dozen countries that are not party to the treaty.[294]

The African Union Convention on Preventing and Combating Corruption also requires states to enact legislation to, for example, prohibit enumerated forms of corruption, enhance transparency, and establish independent and adequate measures to ensure accountability.[295] Equatorial Guinea has signed, but not ratified, the Convention.

The country has, however, signed on to the United Nations Convention against Transnational Organized Crime, which calls on member states to criminalize corruption and to “take measures to ensure effective action by its authorities in the prevention, detection and punishment of the corruption of public officials.”[296] The Convention also calls on states to “institute a comprehensive domestic regulatory and supervisory regime” for financial institutions “in order to deter and detect all forms of money-laundering.”[297] Equatorial Guinea is also part of the Central African Economic and Monetary Community (CEMAC) and is subject to their money-laundering regulation, which requires, for example, that financial institutions identify the ultimate beneficial owners of their clients.[298]

A 2004 Equatoguinean law, Ethics and Dignity in the Exercise of Public Duties, places relatively narrow restrictions on public officials. It forbids them from managing or otherwise rendering services to companies with a public concession or contract only if their position has “direct authority” over the concession or contracting.[299] It does not, however, appear to prohibit ownership of such companies.[300] The law does prohibit officials from receiving gifts or donations of any kind “due to or in the course of the performance of their duties,” and includes some financial disclosure requirements. [301] Certain public officialsincluding all members of the executive branchmust submit a financial disclosure statement listing all assets and income of the official, his or her spouse, and minor children, to the National Commission on Public Ethics within 30 days of taking office.[302] Unelected officials most also submit their work history.[303] These statements are kept confidential except for verification purposes.[304] In addition to these reporting requirements, officials “who have had decisional involvement in the planning, development, and realization of concessions to companies or public services are forbidden from having a role in these entities or in the regulatory commissions of such company or services.”[305] It is not clear whether these reporting requirements are followed.

A Spanish regulation governing public contracts dating from 1968, which is applicable as supplementary to Equatorial Guinea’s law, prohibits government officials from bidding on public contracts.[306] It also mandates that, except in certain situations, public contracts may only be awarded through a transparent and competitive bidding process.[307] All contracts above a certain amount must be reviewed by auditors and published in an official bulletin.[308] It is unclear whether the government recognizes the application of this law and it does not appear to follow it.

Acknowledgements

This report was researched and written by Sarah Saadoun, researcher in the Business and Human Rights division of Human Rights Watch.

It was reviewed and edited by Arvind Ganesan, business and human rights director; Leslie Lefkow, Africa deputy director; Diederik Lohman, health and human rights director; Elin Martinez, children’s rights researcher; Chris Albin-Lackey, senior legal advisor; and Babatunde Olugboji, deputy program director. Additional editorial and production assistance and research support were provided by Amelia Neumayer, business and human rights associate. Research support was also provided by intern Michelle Stacey. The report was prepared for publication by Olivia Hunter, publications/photography associate; Jose Martinez, senior coordinator; and Fitzroy Hepkins, administrative manager.

Human Rights Watch offers its gratitude to the individuals and organizations that helped facilitate this research, including those that have generously supported our work on business and human rights. Human Rights Watch would particularly like to thank the staff of EG Justice and all the individuals who agreed to be interviewed for this report.

[1] Spain largely neglected the area for the first 40 years following the treaty, then leased it to Great Britain from 1817 to 1843. At that point Spain started to take a greater interest in economically exploiting the territory but faced tough resistance from the people living there. Many missionaries died of disease. Spanish Guinea, British Foreign Office Handbook (London: HMSO, 1920). See also Ibrahim K. Sundiata, Equatorial Guinea: Colonialism, State Terror, and the Search for Stability (Oxford: Westview Press, 1990), p. 25. In 1907, only 404 Europeans lived in what was then called Spanish Guinea. Ibid., p. 32.

[2] Cocoa exports rose from a total of 900 tons in 1900 to nearly 40,000 by 1968, the year of the country’s independence. By 1960 there were 35,000 Nigerians working in Spanish Guinea, compared to a total native population of around 213,000, as well as 6,000 Europeans. Randall Fegley, Equatorial Guinea: An African Tragedy (New York: Peter Lang Publishing, 1989), pp. 42, 44.

[3] See, for example, Spanish Guinea, p. 34.

[4] World Bank, “Report and Recommendation of the President of the International Development Association to the Executive Directors on a Proposed Development Credit of SDR 9.1 Million to the Republic of Equatorial Guinea for a Cocoa Rehabilitation Project,” January 18, 1985, p. 1.

[5] See Arturo Artucio, The Trial of Macías in Equatorial Guinea: The Story of a Dictatorship (International Commission of Jurists and the International University Exchange Fund, 1979); Sundiata, Equatorial Guinea: Colonialism, State Terror, and the Search for Stability, pp. 63-74; Fegley, Equatorial Guinea: An African Tragedy, pp. 37-110.

[6] Ibid.

[7] Fegley, Equatorial Guinea: An African Tragedy, pp. 106-07.

[8] Ibid., pp. 78-80; Artucio, The Trial of Macías in Equatorial Guinea, p. 11.

[9] Artucio, The Trial of Macías in Equatorial Guinea, p. 2; Fegley, Equatorial Guinea: An African Tragedy, p. 266.

[10] Sundiata, Equatorial Guinea: Colonialism, State Terror, and the Search for Stability, pp. 42, 91; Fegley, Equatorial Guinea: An African Tragedy, p. 92.

[11] Artucio, The Trial of Macías in Equatorial Guinea, p. 14.

[12] Ibid., p. 17.

[13] Ibid., pp. 35-39.

[14] Fegley, Equatorial Guinea: An African Tragedy, p. 175

[15] For example, average life expectancy rose from an abysmal 43 years in 1979 to 50 by 1995 and under-5 mortality dropped from 217 per 1,000 in 1983, the first year for which there is data, to 171 in 1995. World DataBank, “World Development Indicators: Equatorial Guinea,” “Life Expectancy at Birth” and “Mortality Rate, under-5,” http://databank.worldbank.org/data/reports.aspx?source=2&country=GNQ (accessed February 23, 2017).

[16] An independent expert was first appointed in 1982, and the title and mandate of the monitor changed until the post was abolished by an evenly split vote in the UN Human Rights Commission in 2002. See Human Rights Watch, Well Oiled: Oil and Human Rights in Equatorial Guinea, July 2009, https://www.hrw.org/sites/default/files/reports/bhr0709web_0.pdf, p. 15.

[17] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. I, https://openknowledge.worldbank
.org/bitstream/handle/10986/3011/516560ESW0GQ0P00disclosed0120130110.pdf?sequence=1&isAllowed=y (accessed February 24, 2017).

[18] Equatorial Guinea received virtually no foreign aid throughout the 1970s. Aid began to trickle in as soon as Obiang came to power, steadily climbing to $70 million in 1990, when it began to taper off due to the discovery of oil. OECD Statistics, “Aid (ODA) Disbursements to Countries and Regions,” http://stats.oecd.org/index.aspx?datasetcode=TABLE2A# (accessed February 23, 2017). In 1984, for example, the Gross National Product was $67 million and foreign aid and loans were estimated at $30 million. Robert Klitgaard, Tropical Gangsters: One Man’s Experience with Development and Decadence in Deepest Africa (Basic Books, 1990), p. 27.

[19] Ibid., p. 61.

[20] World Bank, “Projects & Operations: Coffee Cocoa Rehabilitation Project—Equatorial Guinea,” http://projects.worldbank.org/P000638/coffee-cocoa-rehabilitation-project?lang=en (accessed February 23, 2017).

[21] Klitgaard, Tropical Gangsters, p. 61.

[22] World Bank DataBank, “World Development Indicators: Equatorial Guinea,” “GDP Per Capital Growth (Annual %), 1995-2005.”

[23] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. i.

[24] Equatorial Guinea, 2015 Budget Law, p. 1. The 2012 International Monetary Fund Article IV report puts oil revenue from 2007-2011 at $5 billion annually, which is higher than what is recorded in the 2015 budget document on file. IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, March 28, 2013, p. 5, http://www.imf.org/external/pubs/ft/scr/2013/cr1383.pdf (accessed February 24, 2017).

[25] See Artucio, The Trial of Macías in Equatorial Guinea, p. 6, for original justification for barring political activities, and Equatorial Guinea’s 1991 Constitution, article 1, for introduction of “multipartism,” https://www.constituteproject.org/constitution/Equatorial_Guinea_1995.pdf (accessed February 23, 2017).

[26] Human Rights Watch, Well Oiled: Oil and Human Rights in Equatorial Guinea, p. 11.

[27] Equatorial Guinea Constitution (2012), http://www.guineaecuatorialpress.com/imgdb/2012/
LEYFUNDAMENTALREFORMADA.pdf (accessed April 24, 2017). See Fegley, Equatorial Guinea: An African Tragedy, p. 210-11; Sundiata, Equatorial Guinea: Colonialism, State Terror, and the Search for Stability, pp. 76-77.

[28] Equatorial Guinea Constitution (2012), arts. 92 and 98.

[29] See, for example, “Equatorial Guinea: A Move to Consolidate Power,” Human Rights Watch news release, November 11, 2011, https://www.hrw.org/news/2011/11/11/equatorial-guinea-move-consolidate-power.

[30] Ibid. and Government Press, “Summary of the Constitutional Reform,” October 31, 2011, http://www.guinea
ecuatorialpress.com/noticia.php?id=2039 (accessed February 23, 2017).

[31] Government Press, “Installation of the Office of Ombudsman,” August 28, 2015, http://www.guineaecuatorialpress.com/noticia.php?id=6863 (accessed February 23, 2017).

[32] See, for example, US Department of State, “Country Reports on Human Rights Practices for 2010: Equatorial Guinea,” https://www.state.gov/documents/organization/160119.pdf, p. 17-18 (accessed February 24, 2017); US Embassy in Malabo, “Equatorial Guinea: Concerns Regarding the Political Environment in Equatorial Guinea Before and After the April 24th Election,” April 27, 2016, https://malabo.usembassy.gov/news-events/latest.html (accessed February 28, 2017); Human Rights Watch, Well Oiled, pp. 11-15; “Joint Statement Urging a Halt of Pre-Election Civil Society Crackdown in Equatorial Guinea,” Human Rights Watch, March 30, 2016, https://www.hrw.org/news/2016/03/30/joint-statement-urging-halt-pre-election-civil-society-crackdown-equatorial-guinea. For a report documenting legal and practical limitations on civil society, see EG Justice, “Disempowered Voices: The Status of Civil Society in Equatorial Guinea,” March 3, 2011, http://www.egjustice.org/es/node/666 (accessed February 23, 2017).

[33] Transcripts: CNN’s Amanpour Interview with President Teodoro Obiang of Equatorial Guinea, October 5, 2012, http://edition.cnn.com/TRANSCRIPTS/1210/05/ampr.01.html (accessed February 23, 2017).

[34] Equatorial Guinea Constitution (2012), art. 36.

[35] EG Justice, “Opposition Party Boycotts Presidential Elections,” April 18, 2016, http://www.egjustice.org/post/opposition-party-boycotts-presidential-elections (accessed February 23, 2017). For a list of incidents of political repression related to the elections, see Human Rights Watch, World Report 2017 (New York: Human Rights Watch, 2016), Equatorial Guinea chapter, https://www.hrw.org/world-report/2017/country-chapters/equatorial-guinea.

[36] “Joint Statement Urging a Halt of Pre-Election Civil Society Crackdown in Equatorial Guinea,” Human Rights Watch, March 30, 2016; US Embassy in Malabo, “Ambassador’s Corner: Thoughts on the Democratic Process in Equatorial Guinea,” May 4, 2016, https://malabo.usembassy.gov/ta-050416.html (accessed February 23, 2017); US State Department Daily Press Briefing, Mark Toner, Deputy Spokesperson, April 27, 2016, https://video.state.gov/detail/videos/category/video/4866119970001/?autoStart=true (accessed February 28, 2017).

[37] US Embassy in Malabo, “Ambassador’s Corner: Thoughts on the Democratic Process in Equatorial Guinea,” May 4, 2016, https://malabo.usembassy.gov/ta-050416.html (accessed February 23, 2017).

[38] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 19.

[39] See Transparency International, Corruption by Country: Equatorial Guinea, http://www.transparency.org/country/GNQ (accessed February 23, 2017). The country ranks in the bottom one percent in the NGO’s transparency ranking.

[40] EITI website, “Who We Are,” https://beta.eiti.org/about/who-we-are (accessed February 23, 2017).

[41] EITI, “Intensive Validation Activity as Deadlines Approach,” December 10, 2009, https://eiti.org/es/node/4002 (accessed February 23, 2017); Human Rights Watch interview with Asmara Klein, EITI Programme Officer, Publish What You Pay, Barcelona, August 17, 2016.

[42] Letter from Dr. Peter Eigen, EITI Chairman, to H. E. Teodoro Obiang, April 29, 2010.

[43] Human Rights Watch interview with Asmara Klein, August 17, 2016.

[44] “Joint Statement Urging a Halt of Pre-Election Civil Society Crackdown in Equatorial Guinea,” Human Rights Watch, March 30, 2016.

[45] Government press, “Third Meeting of the EITI/ITIE-GE National Commission,” November 16, 2016, http://www.guineaecuatorialpress.com/noticia.php?id=8878 (accessed February 23, 2017).

[46] The global average is 45, with nearby São Tomé e Príncipe scoring 29, Nigeria 24, and Sierra Leone 52. See International Budget Project, Open Budget Survey 2015: Equatorial Guinea, http://www.internationalbudget.org/wp-content/uploads/OBS2015-CS-Equatorial-Guinea-English.pdf (accessed February 23, 2017). The budget information released in 2015 is available on the website of the government press and titled, “The Senate studies the Amending Budget for 2015,” April 10, 2015, http://www.guineaecuatorialpress.com/noticia.php?id=6425 (accessed February 23, 2017).

[47] IMF, “Republic of Equatorial Guinea and the IMF: Article IV Staff Reports,” http://www.imf.org/external/country/gnq/
index.htm?type=9998#top
. There is no publicly available information to determine for which of these five years the IMF did not produce a report and for which the government objected to its publication.

[48] There are some unofficial online legal databases, but to the best of Human Rights Watch’s knowledge, none are comprehensive. Some laws are available for purchase at the specific government buildings, but many are not publicly available. For example, Human Rights Watch observed around 40 law pamphlets available for sale during a visit to the Delegation for Foreign Affairs in Bata, Equatorial Guinea’s largest city. We were told that the corruption law was not available because it was under parliamentary review. Laws may also be requested from the president’s office, but requests do not always yield a response. For example, the World Bank notes in one report that it was unable to obtain certain relevant laws essential to its analysis. See World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 38.

[49] Human Rights Watch phone interview, name withheld, July 26, 2016.

[50] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, September 15, 2015, p. 19, http://www.imf.org/external/pubs/ft/scr/2015/cr15260.pdf (accessed February 24, 2017).

[51] World Bank Data: Equatorial Guinea, http://data.worldbank.org/country/equatorial-guinea (accessed February 24, 2017); Government Press, “Preliminary Results of the 2015 Population Census,” September 24, 2015, http://www.guineaecuatorialpress.com/noticia.php?id=6943 (accessed February 24, 2017). For the government’s previous figure, see IMF, 2015 Article IV Staff Report on Equatorial Guinea, p. 4.

[52] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, p. 4. See also IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 17.

[53] See, for example, Transcripts: CNN’s Amanpour Interview with President Teodoro Obiang of Equatorial Guinea, October 5, 2012, http://edition.cnn.com/TRANSCRIPTS/1210/05/ampr.01.html (accessed February 23, 2017).

[54] Equatorial Guinea’s National Report About the Millennium Development Goals (2015), p. 15; IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 36.

[55] Email from IMF staff member, name withheld, to Human Rights Watch, December 2, 2016.

[56] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, p. 21; IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 19.

[57] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 19.

[58] The other country is Eritrea. IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 19; IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 19.

[59] IMF, “IMF Board Concludes 2016 Article IV Consultation with the Republic of Equatorial Guinea,” September 8, 2016, http://www.imf.org/en/News/Articles/2016/09/08/PR16399-Republic-of-Equatorial-Guinea-IMF-Executive-Board-Concludes-2016-Article-IV-Consultation (accessed February 24, 2017); World Bank DataBank, “World Development Indicators: Equatorial Guinea,” “GDP” and “PPP (constant 2011 international dollar).”

[60] IMF, Republic of Equatorial Guinea: 2007 Article IV Consultation Staff Report, May 14, 2008, p. 12 http://www.imf.org/external/pubs/ft/scr/2008/cr08156.pdf (accessed February 24, 2017).

[61] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 38.

[62] Human Rights Watch phone interview, IMF Fiscal Affairs Department, Revenue Administration, July 26, 2016.

[63] IMF, Budget Classification, December 2009, p. 3, https://www.imf.org/external/pubs/ft/tnm/2009/tnm0906.pdf (accessed February 24, 2017).

[64] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 15.

[65] See, for example, World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 24.

[66] The IMF has published three Article IV reports on Equatorial Guinea—in 2013, 2015, and 2016—since the release of the World Bank’s 2010 Public Expenditure Review (PER). Human Rights Watch also obtained a copy of the 2011 and 2012 public investment projects (PIP) budgets, as well as the 2015 and 2016 general budgets, which include some information on expenditures since 2009. (The data covered in the PIP is generally from the year prior to publication, while the IMF reports is from two years prior.)

[67] See state submission to Committee on the Rights of the Child, CRC/C/11/Add. 26, January 28, 2004. In its submission the state admits: “The 10 % of the general State budget allocated to health by the National Economic Conference has not been disbursed to the sector” and that “For various reasons the Government’s efforts are not yet sufficient to meet the education and survival needs of children from poor families” (paragraph 131), http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=6QkG1d%2fPPRiCAqhKb7yhspWF7dyE4I9U8mmAPSFwafAa%2fWWvnzsC03EPefyLMa%2fZCrD9ioW8xFdiOxxzTbIeUvGKiYZyxKA3%2fg%2fZGUWu8vW9Sn1dHLRpGYPp%2bFY%2bZMlC (accessed February 24, 2017).

[68] Equatorial Guinea Ministry of Planning, Economic Development, and Public Investments, “Guinea Ecuatorial 2020: Agenda para la Diversificación de las Fuentes del Crecimiento,” November 2007 [on file with Human Rights Watch].

[69] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, September 2015, p. 38.

[70] Based on government figures in the 2015 Budget Law, p. 4 (some of these figures are also available in the IMF’s 2012 and 2014 Article IV staff reports). Human Rights Watch converted from local currency based on exchange rates on December 31 of each year and calculated the averages of the available information. See Table below.

[71] Ibid. Non-hydrocarbon government revenue consists mostly of taxes raised from rents and utilities; a value-added tax on goods and services; and import and export licenses, as well as property rentals and sales; administrative fees; and concessions, such as for telecommunications and airports. See, for example, Republic of Equatorial Guinea, Presentation of the General Budgets of the State, 2016 [on file with Human Rights Watch].

[72] The raw numbers are calculated by Human Rights Watch based on percentages appearing in graphs in IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, March 2013, p. 8. Note that a UNICEF worldwide survey of health expenditures has a higher number, but this is likely based on data provided by the government data and may refer to budget allocation rather than actual expenditures. The IMF data is based on the institution’s expert analysis and more reliable.

[73] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, pp. 91-92.

[74] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, March 2013, p. 8.

[75] Ibid. UNESCO recommends that 20 percent of a government’s budget go toward education. UNESCO, “Education for All Global Monitoring Report: Policy Paper 12,” March 2014, http://unesdoc.unesco.org/images/0022/002270/227092E.pdf (accessed February 24, 2017).

[76] Unpublished draft of IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 12 [on file with Human Rights Watch]. The published version retains the first sentence, but removes the reference to Oyala comprising half the 2016 budget in the second sentence.

[77] World Bank, Equatorial Guinea Public Expenditure Review (PER), January 2010, p. 12.

[78] Ibid.

[79] Ibid.

[80] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 11.

[81] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 12.

[82] Ibid., i, 29.

[83] The World Bank plans to release an update to this report in mid-2017.

[84] Calculated based on IMF, Republic of Equatorial Guinea: 2007 Article IV Consultation Staff Report, p. 35.

[85] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 137

[86] Ibid., pp. 91-2.

[87] Ibid., p. 92.

[88] Ibid., p. 93.

[89] Ibid.

[90] Ibid., p. x.

[91] Ibid., p. 137.

[92] Ibid., p. 71.

[93] UNESCO’s data is incomplete and does not include Equatorial Guinea, but the lowest percentage recorded for 2008 for the approximately 80 countries for which data available is 1.29 percent (Central African Republic), and the next lowest is 2.04 percent (Lebanon), http://data.uis.unesco.org/?queryid=181 (accessed February 24, 2017).

[94] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 71.

[95] Ibid., p. 137.

[96] Ibid., p. 72.

[97] Ibid. Between 2004 and 2008, Equatorial Guinea spent an average of nearly 40 percent of its budget on higher education, whereas the average of 10 neighboring countries was 22 percent. Based on Human Rights Watch’s calculations of World Bank data. Ibid.

[98] Ibid., p. x.

[99] Equatorial Guinea, 2014 and 2015 Budget Laws.

[100] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 8; see footnote 72 above.

[101] Conversions based on value of CFA franc on June 30, 2011.

[102] Conversions based on value of CFA franc on June 30, 2010.

[103] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 12.

[104] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, pp. 35-36. The social sector classification in the government’s PIP budget includes health, education, housing, potable water, electricity, sports, and culture; it is unclear whether the IMF’s use of the term reflects this classification.

[105] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, p. 12. Note that the execution rate for projects was only 39 percent and in previous year, social projects had lower execution rates than other sectors.

[106] Ibid.

[107] Ministry of Economy, Planning, and Public Investment, Asistencia Técnica para el Fortalecimiento de los Sistemas de Inversión Pública y Monitoreo al PNDES Horizonte 2020, Informe Annual 2016, p. 18 [on file with Human Rights Watch].

[108] Ibid., p. 22.

[109] The amended 2015 budget is on file with Human Rights Watch.

[110] The percentages for health spending are only slightly below what the World Bank reported in previous years: 3.1 percent of current expenditures in 2008 and 5.1 in 2004. World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 92.

[111] According to the Equatoguinean organization Centro de Estudios Guineaoecuatorianos’ analysis of the 2015 amended budget, only 2.67% of current expenditures were allocated to health and 2.09% to education, http://cesge.org/index.php?option=com_content&view=article&id=92:presupuesto-guinea-ecuatorial-2015&catid=41:economia&Itemid=56 (accessed February 24, 2017).

[112] Talk Africa, Interview with Equatorial Guinea president Teodoro Obiang Nguema Mbasogo, May 29, 2016, https://www.youtube.com/watch?v=qMfu-6RrVao (accessed February 24, 2017).

[113] Equatorial Guinea, 2015 Amended Budget Law [on file with Human Rights Watch].

[114] EG Justice, “Crackdown of Peaceful Student Protestors,” April 7, 2015, http://www.egjustice.org/post/crackdown-peaceful-student-protesters (accessed February 24, 2017).

[115] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 19.

[116] IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 4.

[117] Ibid., p. 13.

[118] BBC, “Hardtalk,” December 19, 2012.

[119] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, p. 12.

[120] Ibid., p. 12.

[121] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 5. While access to water has improved in urban areas, it has declined in rural areas; as a result, national figures remain virtually unchanged since 2000. See notes 136 and 137.

[122] IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 12.

[123] World Bank, Equatorial Guinea Public Expenditure Review (PER), January 2010, p. 24.

[124] Life expectancy statistics and regional averages estimated by World Bank, data available at World Bank DataBank, “Health Nutrition and Population Statistics,” http://databank.worldbank.org/data/reports.aspx?source=health-nutrition-and-population-statistics (accessed December 1, 2016).

[125] United National Development Programme, “Human Development Report 2015,” 2015, http://hdr.undp.org/sites/default/files/2015_human_development_report_1.pdf, (accessed December 6, 2016), p. 49.

[126] Ministerio de Sanidad y Bienestar Social (Républica de Guinea Ecuatorial), Ministerio de Economía, Planificación e Inversiones Públicas (Républica de Guinea Ecuatorial) and ICF International, “Equatorial Guinea Demographic and Health Survey 2011,” 2012, p. 97, http://dhsprogram.com/pubs/pdf/FR271/FR271.pdf (accessed February 27, 2017).

[127] World Bank DataBank, “Health Nutrition and Population Statistics.”

[128] United National Development Programme, “Human Development Report 2015,” http://hdr.undp.org/sites/default/files/2015_human_development_report_1.pdf, (accessed December 6, 2016), p. 49.

[129] “Equatorial Guinea Demographic and Health Survey 2011,” p. 97.

[130] World Bank DataBank, “Health Nutrition and Population Statistics.”

[131] Under-5 mortality rate estimates developed by the UN Inter-agency Group for Child Mortality Estimation, data available at World Bank DataBank, “Health Nutrition and Population Statistics.”

[132] “Equatorial Guinea Demographic and Health Survey 2011,” p. 229.

[133] World Bank DataBank, “Health Nutrition and Population Statistics.”

[134] Estimates developed by the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, http://www.wssinfo.org/. Data available at World Bank DataBank, “Health Nutrition and Population Statistics.”

[135] “Equatorial Guinea Demographic and Health Survey 2011,” p. 11.

[136] World Bank DataBank, “Health Nutrition and Population Statistics.”

[137] Estimates developed by the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, http://www.wssinfo.org/. Data available at World Bank DataBank, “Health Nutrition and Population Statistics.”

[138] “Equatorial Guinea Demographic and Health Survey 2011,” p. 125.

[139] World Health Organization, “WHO vaccine-preventable diseases: monitoring system. 2016 global summary: Equatorial Guinea,” last updated December 1, 2016, http://apps.who.int/immunization_monitoring/globalsummary/coverages?c=GNQ (accessed February 27, 2017).

[140] “Equatorial Guinea Demographic and Health Survey 2011,” p. 128.

[141] Institut National de la Statistique (INS), Ministère de l’Économie de la Planification et de l’Aménagement du Territoire (République du Cameroun), Ministère de la Santée Publique (Yaoundé, Cameroun) and ICF International, “Cameroon Demographic and Health Survey 2011,” 2012, http://dhsprogram.com/pubs/pdf/FR260/FR260.pdf, (accessed December 1, 2016), p. 140; Ministère de l’Économie, de l’Emploi et du Développement Durable (République Gabonaise), Ministère de la Santé (République Gabonaise), Direction Générale de la Statistique (Libreville, Gabon) and ICF International, “Gabon Demographic and Health Survey 2012,” 2013, http://dhsprogram.com/pubs/pdf/FR276/FR276.pdf, (accessed December 1, 2016), p. 139; National Population Commissions (Federal Republic of Nigeria) and ICF International, “Nigeria Demographic and Health Survey 2013,” 2014, http://dhsprogram.com/pubs/pdf/FR293/FR293.pdf, (accessed December 1, 2016); Instituto Nacional de Estatística (INE) (São Tomé e Príncipe), Ministério de Saúde (São Tomé e Príncipe) and ICF Macro, “ São Tomé and Príncipe Demographic and Health Survey 2008-2009,” 2010, http://dhsprogram.com/pubs/pdf/FR233/FR233.pdf, (accessed December 1, 2106), p. 133.

[142] World Bank DataBank, ““Health Nutrition and Population Statistics,” 2012.

[143] Human Rights Watch interview, senior employee of humanitarian agency, 2016.

[144] For Equatorial Guinea’s immunization coverage, see “WHO vaccine-preventable diseases: monitoring system. 2016 global summary: Equatorial Guinea.” For a comparison with all the countries the WHO tracks, see http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tscoveragebcg.html (accessed February 27, 2017).

[145] “Equatorial Guinea Demographic and Health Survey 2011,” p. 128.

[146] “WHO vaccine-preventable diseases: monitoring system. 2016 global summary: Equatorial Guinea.” Sweden made a policy decision to only vaccinate certain groups of babies for tuberculosis resulting in the lowest rate.

[147] Human Rights Watch interview with Arturo (not real name), Malabo, 2016.

[148] “Equatorial Guinea Demographic and Health Survey 2011,” p. 135.

[149] See Section V. V. Equatorial Guinea’s Human Rights Obligations.

[150] World Health Assembly (WHA) resolution 58.33, http://apps.who.int/medicinedocs/documents/s21475en/s21475en.pdf (accessed February 27, 2017).

[151] UN, “Sustainable Development Goals: Goal 3,” http://www.un.org/sustainabledevelopment/health/ (accessed February 27, 2017).

[152] Human Rights Watch interviews with Mariana (not real name), doctor in General Hospital in Bata until 2015, Madrid, 22016; Alonso (not real name), doctor in private clinic formerly employed in General Hospital in Bata, Bata, 2016; Jimena and Sofia (not real names; joint interview), nurses in General Hospital in Malabo, Malabo, 2016; research director, EG Justice, 2016.

[153] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 91. There is no more recent available data.

[154] “There is a clear inequality in the health care coverage for INSESO’s subscribers in comparison to the rest of the population since INSESO finances 43 percent of total recurrent health expenditure, which only benefits 60,000 members (or approximately 10 percent of the population) who therefore receive a higher per capita health expenditure than the rest of the population.” Ibid.

[155] Ibid., p. 89.

[156] Human Rights Watch interview with Jimena, nurse, Malabo, 2016.

[157] Human Rights Watch interview with Isabella (not real name), nurse, Malabo, 2016.

[158] Human Rights Watch interview with Mariana, doctor in General Hospital in Bata until 2015, Madrid, 2016.

[159] Human Rights Watch interview with Jose (not real name), private primary school teacher, Malabo, 2016.

[160] Human Rights Watch was unable to find official documentation regarding the full amount and extent of public funding, but government communications make clear that the hospitals were built with public money, and two medical staff there said they are paid by the government. Government Press, “The delegations attending the APU sessions visit Malabo and its surrounding areas,” December 3, 2010, http://www.guineaecuatorialpress.com/noticia.php?id=1133 (accessed February 27, 2017) and “The President of the Republic Visits the Infrastructure Works in the City of Malabo,” October 5, 2010, http://www.guineaecuatorialpress.com/noticia.php?id=939 (accessed February 27, 2017). Two medical staff at La Paz Malabo and a senior official at a humanitarian agency also said it was at least partially funded by the government. Human Rights Watch interviews, Malabo, 2016.

[161] Human Rights Watch interviews with Geraldo (not real name), senior employee of a humanitarian agency, Malabo, 2016; Mariana, doctor in General Hospital in Bata until 2015, Madrid, 2016; Rafael and Daniel (not real names; separate interviews), medical staff at La Paz Malabo, Malabo, 2016; Jimena and Sofia (joint interview), nurses, Malabo, 2016.

[162] Geraldo also said that the health clinics Guadalupe in Malabo and Bata are publicly funded but privately owned by the First Lady.

[163] Human Rights Watch interviews with Rafael and Daniel (separate), medical staff at La Paz Malabo, Malabo, 2016.

[164] Fee amounts are based on interviews with doctors and patients because Human Rights Watch did not receive a response to letters requesting this information from La Paz Bata and Malabo. Human Rights Watch interviews with Geraldo, senior employee of a humanitarian agency, Malabo, 2016; Alonso, doctor in private clinic, Bata, 2016; Andres (not real name), school director, Bata, 2016; Cristian (not real name), Malabo, 2016; Diego (not real name), Malabo, 2016; Alphonso (not real name), Bata, 2016.

[165] Human Rights Watch Interview with Rafael, medical staff at La Paz Malabo, Malabo, 2016.

[166] For example, Sipopo is home to 52 luxury villas that the government built, along with a conference center and golf course, to house the heads of state when it hosted a week-long African Union summit in 2011. Government Press, “Inauguration of the City of Sipopo,” June 10, 2011, http://www.guineaecuatorialpress.com/noticia.php?id=1643 (accessed February 27, 2017).

[167] WHO African Health Observatory, “Health System Outcomes: Equatorial Guinea,” http://www.aho.afro.who.int/profiles_information/index.php/Equatorial_Guinea:Health_system_outcomes (accessed February 27, 2017).

[168] Human Rights Watch interviews with Jose (not real name), teacher, Malabo, 2016; Cristian (not real name), teacher, Malabo, 2016; Alphonso (not real name), teacher, Bata, 2016.

[169] Human Rights Watch Interview with Daniel, medical staff at La Paz Malabo, Malabo, 2016.

[170] Human Rights Watch interview with Isabella, nurse, Malabo, 2016; Interview with Mariana, doctor in General Hospital in Bata until 2015, Madrid, 2016.

[171] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 88.

[172] Human Rights Watch interview with Daniel, medical staff at La Paz Malabo, Malabo, 2016.

[173] Human Rights Watch interviews with Mariana, doctor in General Hospital in Bata until 2015, Madrid, 2016; Isabella, nurse in General Hospital, Malabo, 2016; Andres, school director, Malabo, 2016; Diego (not real name), Malabo, 2016.

[174] Human Rights Watch interview with Diego, teacher, Malabo, 2016.

[175] Human Rights Watch Interview with Alonso, doctor in private clinic, Bata, 2016.

[176] See Section V. V. Equatorial Guinea’s Human Rights Obligations.

[177] República de Guinea Ecuatorial, Ministerio de Educación y Ciencia, “Guinea Ecuatorial, Revisión Nacional 2015 de la Educación para Todos,” p. 9, http://unesdoc.unesco.org/images/0023/002317/231718s.pdf (accessed February 27, 2017).

[178] Human Rights Watch interview with Arturo (not real name), Malabo, 2016.

[179] Reuters, “Liberia Tops UNICEF Ranking of 10 Worst Countries for Access to Primary School,” September 1, 2016, http://www.reuters.com/article/us-africa-education-idUSKCN1173PE (accessed February 27, 2017).

[180] UNESCO data accessed via FHI360, Education Policy and Data Center (EPDC), http://epdc.org/country/equatorialguinea (accessed March 6, 2017).

[181] UNESCO data via FHI360, EPDC, http://epdc.org/country/equatorialguinea (accessed March 6, 2017).

[182] Ibid.

[183] Ibid.

[184] Human Rights Watch phone interview with Ignacio (not real name), education specialist, September 16, 2016.

[185] UNESCO data via FHI360, EPDC, http://epdc.org/country/equatorialguinea (accessed March 6, 2017).

[186] UNESCO Institute for Statistics, Equatorial Guinea: Education and Literacy, http://uis.unesco.org/country/gq (accessed April 12, 2017).

[187] Human Rights Watch phone interview with Ignacio (not real name), education specialist, September 16, 2016.

[188] República de Guinea Ecuatorial, Ministerio de Educación y Ciencia, “Guinea Ecuatorial, Revisión Nacional 2015 de la Educación para Todos,” p. 9.

[189] See footnote 107.

[190] Human Rights Watch interview with Diego, teacher, Malabo, 2016.

[191] Human Rights Watch interview with Alphonso (not real name), Bata, 2016.

[192] Human Rights Watch interview with Hernando, Bata, 2016.

[193] República de Guinea Ecuatorial, Ministerio de Educación y Ciencia, “Guinea Ecuatorial, Revisión Nacional 2015 de la Educación para Todos.”

[194] Human Rights Watch interview with Alphonso, Bata, 2016.

[195] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 63.

[196] Human Rights Watch phone interview with John Gillies, Director of Global Learning, FHI360, September 16, 2016.

[198] Human Rights Watch interview with Clara, Bata, 2016. John Gilies, Director of Global Learning, FHI 360, confirmed in an email to Human Rights Watch, November 28, 2016, that there were no plans to continue the program passed 2017.

[199] Human Rights Watch interview with Clara, Bata, 2016.

[200] Human Rights Watch interviews with Cristian, Malabo, 2016 and Diego, Malabo, 2016.

[201] Based on Human Rights Watch calculations of general budget documents on file.

[202] Stevie Mounombou, “Loi de finances rectificative 2015 : Un budget de 2 651,2 milliards de francs,” Gabon Review, April 13, 2015. http://gabonreview.com/blog/loi-de-finances-rectificative-2015-un-budget-de-2-6512-milliards-de-francs/ (accessed February 27, 2017).

[203] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. viii.

[204] Republic of Equatorial Guinea, Ministry of Economy, Planning and Public Investment, “EG’s Strategic Plan: Horizon 2020,” http://www.egindc.com/presentations/8-8-14/6.pdf (accessed March 1, 2017).

[205] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 35.

[206] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 15.

[207] US State Department Cable from US Embassy in Malabo, “Equatorial Guinea Raw, Paper 4: The Business of Corruption,” March 12, 2009.

[208] US Senate Permanent Subcommittee on Investigations, Committee on Governmental Affairs, Money Laundering and Foreign Corruption: Enforcement and Effectiveness of the Patriot Act – Case Study Involving Riggs Bank [US Senate Riggs Bank report], July 15, 2004, p. 38.     

[209] Ibid., p. 41.

[210] Ibid., p. 43. See also Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012), p. 10.

[211] US Senate Riggs Bank report, 2004, p. 3.

[212] Note that the US Senate report did not accuse any of the oil companies providing the scholarships of wrongdoing, nor did US law enforcement authorities. Ibid., p. 104.

[213] Ibid., p.17.

[214] Criminal Complaint filed by Asociación Pro Derechos Humanos de España (APDHE), October 22, 2008, available at https://www.opensocietyfoundations.org/litigation/apdhe-v-obiang-family (accessed February 27, 2017).

[215] Ibid., p. 9; see also US Senate Riggs Bank report, 2004, p. 54-55.

[216] José María Irujo, “The long hunt for the Kokorevs,” El Pais, September 23, 2015, http://elpais.com/elpais/2015/09/23/inenglish/1443001757_417136.html (accessed February 27, 2017).

[217] Ibid.

[218] Government Press, “Russia Condemns the False Information of Some Spanish Newspapers,” May 9, 2012, http://www.guineaecuatorialpress.com/noticia.php?id=2626 (accessed February 27, 2017).

[219] Government Press, “Presidential Decree Naming Vice-President of the Council of the Republic,” June 22, 2016 http://www.guineaecuatorialpress.com/noticia.php?id=8024 (accessed May 16, 2017).

[220] US Senate Riggs Bank report, 2004, pp. 20, 97. See also Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012), p. 20 and Attachment A-1.

[221] US Department of Justice, “Department of Justice Seeks to Recover More Than $70.8 Million in Proceeds of Corruption from Government Minister of Equatorial Guinea,” October 25, 2011, https://www.justice.gov/opa/pr/department-justice-seeks-recover-more-708-million-proceeds-corruption-government-minister (accessed February 27, 2017).

[222] US Department of Justice, “Second Vice President of Equatorial Guinea Agrees to Relinquish More Than $30 Million of Assets Purchased with Corruption Proceeds,” October 10, 2014, https://www.justice.gov/opa/pr/second-vice-president-equatorial-guinea-agrees-relinquish-more-30-million-assets-purchased (accessed February 27, 2017).

[223] Office of the Government Spokesperson, “The Government of Equatorial Guinea Regarding the Information Featured in the International Press about the Report, ‘Keeping Foreign Corruption Out of the United States: Four Case Histories’,” February 15, 2015.

[224] Claimant Motion to Dismiss Complaint for Forfeiture In Rem, p. 29, US v. One Gulfstream G-V Jet Aircraft (January 23, 2012, Case 1:11-cv-01874-ABJ). The Spanish authors of a leading criminal law treatise and a Spanish-English legal dictionary testified that the correct translation of “funcionario público” is “government official,” and would undoubtedly apply to members of government. Exhibit A, Ibid.

[225] Source document on file with Human Rights Watch. See also Simon Piel and Joan Tilouine, “‘Biens Mal Acquis’ : les dépenses astronomiques de Teodorin Obiang,” Le Monde, May 27, 2016, http://www.lemonde.fr/afrique/article/2016/05/27/bien-mal-acquis-les-depenses-astronomiques-de-teodorin-obiang_4927959_3212.html (accessed February 27, 2017).

[226] For a timeline of the case see Transparency International France, “Biens mal acquis : les dates clefs pour comprendre,” March 2007, https://transparency-france.org/project/biens-mal-acquis-dates-clefs-comprendre-2/ (accessed February 27, 2017). See also William Bourdon, Transparency International, “The legal right to fight corruption in France,” September 9, 2016, https://www.transparency.org/news/feature/the_legal_right_to_fight_corruption_in_france (accessed February 27, 2017).

[227] Government Press, “Communique in answer to the French National Financial Prosecutor,” May 27, 2016, http://www.guineaecuatorialpress.com/noticia.php?id=7862 (accessed February 27, 2017).

[228] International Court of Justice Press Release No. 2016/18, June 14, 2016, http://www.icj-cij.org/docket/files/163/19028.pdf (accessed February 27, 2017).

[229] ICJ jurisdiction over contentious cases requires the consent of both state parties, either in the individual case or in a treaty governing the disputed issue. Equatorial Guinea argued that France consented by ratifying the UN Convention against Transnational Crime, but the ICJ concluded that the dispute does not arise out of the Convention. International Court of Justice, Immunities and Criminal Proceedings (Equatorial Guinea v. France), December 7, 2016, para. 50.

[230] Ibid., para. 92.

[231] “Swiss open probe into son of Equatorial Guinea’s president,” Associated Press, October 18, 2016, http://bigstory.ap.org/article/d85c61812b7f4ddbb6c33ec8c8347e6d/swiss-open-probe-son-equatorial-guineas-president (accessed February 27, 2017).

[232] “Geneva Investigates Son of Equatorial Guinea’s leader,” TheLocal.ch, November 4, 2016, http://www.thelocal.ch/20161104/geneva-opens-probe-against-son-of-equatorial-guineas-leader (accessed February 27, 2017); Mfonobong Nsehe, “Dutch Authorities Seize $100 Million Yacht Allegedly Owned by African Dictator’s Son,” Forbes, December 8, 2016, http://www.forbes.com/sites/mfonobongnsehe/2016/12/08/dutch-authorities-seize-100-million-yacht-allegedly-owned-by-african-dictators-son/#570d7eb34c4a (accessed February 27, 2017).

[233] The IMF defines “shell companies” as “legal structures that have little or no employment, operations, or physical presence in the jurisdiction in which they are created. They are typically used as devices to hold assets and liabilities, and do not undertake production.” IMF Statistics Department, “Special Purpose Entities (SPEs) and Holding Companies,” December 2004, http://unstats.un.org/unsd/nationalaccount/AEG/papers/m2holdingcompanies.pdf (accessed February 27, 2017).

[234] Affidavit, Maseve Investments 7 v. Equatorial Guinea and Teodoro Nguema Obiang (High Court of South Africa, No. 1407/2006, paras 11.2 and 11.2.1.

[235] US State Department Cable from US Embassy in Malabo, “Equatorial Guinea Raw, Paper 4: The Business of Corruption,” March 12, 2009.

[236] Exhibit 31 at 4, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012). The interview was conducted on May 2, 2012 with a macroeconomics professor who was hired by the IMF to prepare a macro fiscal model for Equatorial Guinea. The interview was based on notes the interviewee took during a visit to the country and which formed the basis for the IMF’s Article IV report, which investigators viewed.

[237] Exhibit 49 at 3, Ibid. Interview conducted on April 25, 2012, with economist who worked in Equatorial Guinea for the IMF as an economic advisor.

[238] Exhibit 30 at 6-7, Ibid. Interviews were conducted on October 18, 21, and 26, 2011, with an IMF fiscal policy expert for Equatorial Guinea

[239] Ibid., p. 7.

[240] US Senate Riggs Bank report, 2004, p. 49.

[241] Republic of Equatorial Guinea, Ministry of Justice and Culture, “Authorized Copy of Certificate of Incorporation for Abayak,” Malabo, November 6, 1998 [on file with Human Rights Watch].

[242] Ibid.

[243] Ibid. p 50.

[244] Confidential report on file with Human Rights Watch. For Teodorin’s ownership of Sofona, see, for example, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012), p. 38.

[245] See Manzanares Declaration, Exhibit 6 at 57, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012). For a partial list of its projects, see http://www.ge-proyectos.com/es/taxonomy/term/176 (accessed February 27, 2017).

[246] See Manzanares Declaration, p. 57.

[247] The Italian financial police told US investigators that they believed that the “circumstances surrounding this crash were suspicious.” Manzanares Declaration, p. 57. Cellotti’s Cessna went down while flying from Mongomo, Obiang’s native city, to Bata, and only he and a Spanish pilot were on board. According to media accounts the pilot was virtually unscathed and disappeared immediately after the crash, and the Equatoguinean government failed to conduct a credible investigation into the incident. “Il giallo dell’italianoin affari con il dittatore,” La Stampa, August 20, 2008, http://www.lastampa.it/2008/08/20/italia/cronache/il-giallo-dellitaliano-in-affari-con-il-dittatore-nAqV8Pi1juIWIZw9cj35hP/pagina.html (accessed March 2, 2017).

[248] Manzanares Declaration, p. 57.

[249] Ibid.

[250] Ibid. The company is sometimes called General Work.

[251] Exhibit 8 at 5, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012).

[252] “Equatorial Guinea: Halt Prisoner Torture,” Human Rights Watch news release, July 30, 2014, https://www.hrw.org/news/2014/07/30/equatorial-guinea-halt-prisoner-torture#1.

[253] A confidential report by a high-level businessperson active in Equatorial Guinea obtained by Human Rights Watch corroborates Berardi’s claim that the First Lady at least partially owns ABC Construction.

[254] Human Rights Watch phone interview, October 21, 2016.

[255] Ibid. Current exchange rate.

[256] Written statement by Roberto Berardi, June 19, 2013.

[257] Ibid. In an interview with Human Rights Watch, Berardi accused Teodorin of opening bank accounts in the company’s name of which he was not aware and that Teodorin would simply pocket deposits from ABC. Human Rights Watch phone interview, October 19, 2016.

[258] “Equatorial Guinea: Halt Prisoner Torture,” Human Rights Watch news release.

[259] Claimant Motion to Dismiss Complaint for Forfeiture In Rem, p. 42, US v. One Gulfstream G-V Jet Aircraft (January 23, 2012, Case 1:11-cv-01874-ABJ) and Affidavit, Maseve Investments 7 v. Equatorial Guinea and Teodoro Nguema Obiang (High Court of South Africa, No. 1407/2006, paras 11.2 and 11.2.1.) See also footnotes 224 and 225.

[260] See Section V. V. Equatorial Guinea’s Human Rights Obligations. The Equatoguinean Penal Code from 1963, which is adopted from the Spanish penal law, prohibits much of the business activity documented in this report, including taking advantage of an official position to involve oneself in a business directly related to the scope of one’s official duties. Second Amended Verified Complaint for Forfeiture In Rem, p. 8, US v. One White Crystal-Covered “Bad-Tour” Glove (C.D. Cal. June 11, 2012). Based on the government responses to corruption allegations, it appears that it does not consider these laws to apply.

[261] Transparency International, Anti-Corruption Helpdesk: Conflict of Interest in Public Procurement, 2013, pp. 2-3. http://www.transparency.org/files/content/corruptionqas/Conflict_of_interest_in__public_procurement.pdf (accessed February 27, 2017).

[262] See Section V. V. Equatorial Guinea’s Human Rights Obligations.

[263] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 37.

[264] Ibid.

[265] Ibid. p. 39.

[266] Exhibit 31 at 6, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012).

[267] IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 12.

[268] Exhibit 31, p. 6, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012).

[269] Human Rights Watch phone interview, August 9, 2016.

[270] Exhibit 10, p. 4, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012).

[271] Exhibit 30, p. 6, Ibid.

[272] Exhibit 7, p. 5, Ibid.

[273] Ibid., pp. 49 and 89.

[274] Contract between GEPROYECTOS and IMS-International Medical Services G.E. S.A., July 11, 2011.

[275] Republic of Panama, Twelfth Circuit Notary, November 18, 2011.

[276] US Senate Riggs Bank report, 2004, p. 57

[277] International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, art. 12. Equatorial Guinea ratified the ICESCR in 1987.

[278] Committee on Economic, Social and Cultural Rights, General Comment No. 14 (2000), para. 12, http://www.refworld.org/pdfid/4538838d0.pdf (accessed February 27, 2017). See also Office of High Commissioner for Human Rights and World Health Organization, “The Right to Health: Fact Sheet No. 31,” June 2008.

[279] Office of High Commissioner for Human Rights and World Health Organization, “The Right to Health: Fact Sheet No. 31,” June 2008, p. 3-4 (based on General Comment No. 14).

[280] Committee on Economic, Social and Cultural Rights, General Comment No. 14 (2000), para. 4.

[281] Convention on the Rights of the Child (CRC), adopted November 20, 1989, G.A. Res. 44/25, annex, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), entered into force September 2, 1990, art 24.

[282] Convention on the Rights of the Child (CRC), art. 23.

[283] International Covenant on Economic, Social and Cultural Rights (ICESCR), art. 13; CRC, Convention on the Rights of the Child (CRC), art. 28.

[284] Committee on Economic, Social and Cultural Rights, General Comment No. 13, E/C.12/1999/10 (December 8, 1999), para 6, http://www.refworld.org/docid/4538838c22.html (accessed February 27, 2017).

[285] International Covenant on Economic, Social and Cultural Rights (ICESCR), art. 13.

[286] Equatorial Guinea Constitution (2012), art. 24.

[287] Equatorial Guinea Constitution (2012), art. 8.

[288] Committee on Economic, Social and Cultural Rights, General Comment No. 13, para 57; Committee on Economic, Social and Cultural Rights, General Comment No. 14, paras 43-45.

[289] International Covenant on Economic, Social and Cultural Rights (ICESCR), arts. 2, 12, 13. Note year of EG ratification (1987).

[290] The Limburg Principles, established in 1986 by a distinguished group of international law experts to guide implementation of the ICESCR, provide that, “In determining whether adequate measures have been taken for the realization of the rights recognized in the Covenant attention shall be paid to equitable and effective use of and access to the available resources.” Limburg Principles on the Implementation of the International Covenant on Economic, Social, and Cultural Rights, UN Doc. E/CN.4/1987/17 (January 8, 1987), Article 27.

[291] Convention against Corruption, adopted October 31, 2003, G.A. res. 58/4, U.N. Doc. A/58/422, entered into force December 14, 2005, art. 7.

[292] Convention against Corruption, art. 8.

[293] Convention against Corruption, art. 9.

[294] There are 180 state parties to the Convention. See https://www.unodc.org/unodc/en/treaties/CAC/signatories.html (accessed February 27, 2017).

[295] African Union, African Union Convention on Preventing and Combating Corruption, adopted July 11 2003, entered into force August 5, 2006, arts. 5-7.

[296] Convention Against Transnational Organized Crime, adopted November 15, 2000, G.A. Res. A/Res/55/25, annex I, U.N. GAOR, 55th Sess., Supp. No. 49, at 44, U.N. Doc. A/45/49 (Vol. I) (2001), entered into force Sept. 29, 2003, arts. 9 and 10.

[297] Convention Against Transnational Organized Crime, art. 7.

[298] CEMAC Regulation No 01/03, Relating to the Prevention and Suppression of Money Laundering and Financing of Terrorism in Central Africa, Article 10.

[299] Decree Law 1/2004 on Ethics and Dignity in the Performance of Public Service, Equatoguinean Penal Code art. 12.

[300] See Claimant Motion to Dismiss Complaint for Forfeiture In Rem, p. 6, US v. One Gulfstream G-V Jet Aircraft (January 23, 2012, Case 1:11-cv-01874-ABJ).

[301] Decree Law 1/2004, art. 17

[302] Decree Law 1/2004, art. 5.

[303] Decree Law 1/2004, art. 11.

[304] Decree Law 1/2004, art. 10.

[305] Decree Law 1/2004, art. 13

[306] "Reglamento General para la Aplicación de la Ley de Contratos del Estado” (Spanish regulation), 1968, art. 20. Presidential decree 4/1980 made Spanish laws and regulations applicable in Equatorial Guinea in the absence of specific domestic laws.

[307] "Reglamento General para la Aplicación de la Ley de Contratos del Estado,” arts. 92-94. For exceptions, see art. 117.

[308] "Reglamento General para la Aplicación de la Ley de Contratos del Estado,” arts. 39 and 119.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Senator Bill Cassidy

520 Hart Senate Office Building

Washington DC 20510

 

​Dear Senator Cassidy,

Human Rights Watch is an independent, non-governmental organization that monitors and advocates for human rights, including the right to health. In the last several years, Human Rights Watch has interviewed hundreds of people in every corner of Louisiana about access to health care and services, and released two major reports focused on access to HIV treatment and care.[1] We have worked closely with people living with HIV and their advocates as well as health care providers, state public health officials, correctional officials, state legislators and many others to promote greater access to care, particularly for the most vulnerable populations. As the Senate considers health care reform, particularly changes to the Medicaid program, we write to highlight the impact that such action would have upon residents of Louisiana.

A man with cerebral palsy, epilepsy, and HIV. A mother of two who was legally blind, and now has limited vision. A school bus driver who got Medicaid through the expansion and now can pay for her HIV medications. The director of a drug treatment center who has seen a “sea-change” in who can afford treatment since Medicaid expansion. These are the stories of Louisianans who would suffer if the Senate adopts the Medicaid provisions of the American Health Care Act (AHCA).

Current GOP proposals threaten to decimate the Medicaid program: the AHCA would strip 880 billion dollars from Medicaid over the next ten years, and the administration’s budget proposal removes another 660 billion dollars on top of that. The AHCA would also phase out the Medicaid expansion by 2020, an action that experts estimate would do severe harm to the Louisiana economy, including the loss of 26 billion dollars in federal funding, an estimated 37,000 jobs, and 639 million dollars in state and local tax revenue.[2]

Overall, some experts estimate that under funding cuts proposed by the AHCA, states would have to increase their Medicaid budgets by an average of 37 percent by 2026 in order to maintain Medicaid benefits at current levels.[3] In a state that a recent study recently ranked 50th in economic strength, such drastic cuts in federal funding could be devastating to Louisiana’s economy.[4]

The health impact of phasing out the Medicaid expansion by 2020 would be enormous; in less than one year, expansion has provided health insurance to more than 425,000 Louisiana residents, provided preventive care to 96,000 people, screened more than 14,000 women for breast cancer, and enabled 8,000 people to access treatment for substance use amid a severe opioid crisis.[5]

Nationwide, more than 40 percent of people living with HIV depend on Medicaid, including people like Roberta, a 47-year-old school bus driver who lives in Campti, Louisiana. (Like other Medicaid recipients referenced in this letter, she preferred to use a pseudonym to protect her privacy.) Maintaining her health has not been easy for Roberta. A single mom, she struggled to pay for her HIV medications until the state expanded Medicaid last July. “I couldn’t always afford my medications. Sometimes I had to buy pills from people I knew had extra, a few pills at a time.” Now with Medicaid coverage, she has gotten glasses, been to the dentist, discovered a thyroid condition through blood tests, and most importantly, not missed a dose of her HIV medicine.

 “Maybe President Trump doesn’t realize that these programs help people,” said Steven, a 49-year-old man from Natchitoches. Steven has cerebral palsy, epilepsy, and HIV. He takes 15 medications, all of which are paid for by Medicaid, as are his home health aides who help him with every aspect of his daily activities. For Steven, Medicaid is more than health insurance—it is nothing less than a lifeline.

It is difficult for Ellen, another Natchitoches resident, to imagine how she and her family would survive with less assistance from Medicaid. Ellen, 44, is a mother of two boys. She worked for many years for the school system as a teaching assistant, but in 2006 she became legally blind. After several cornea transplant operations, she has limited vision. Ellen also is HIV-positive and Medicaid pays for her anti-retroviral medications. When asked what impact reduction of Medicaid benefits might have on her, Ellen replied simply, “It would be overwhelming.”

Medicaid benefits are also critically important to efforts to combat the opioid crisis. Nationwide, more than 1.2 million formerly uninsured people have accessed substance use treatment through Medicaid expansion, including 7,000 in Louisiana.[6] Leigh Ann de Monredon is the director of Odyssey House Louisiana, a health clinic that also provides residential drug treatment in New Orleans. Ms. de Monredon described the difference at Odyssey House since the state expanded Medicaid as a “sea- change” in access to care: more people can afford residential treatment as well as medications that are the standard of care for opioid dependence. “We can now give them medications like Suboxone and Vivitrol, and our relapse rates are much lower,” she said. The clinic also provides preventive care services, so that “our doctors can identify potential drug problems before they become addictions.” These services are vitally important in a city where drug overdose deaths doubled in 2016.[7]

These are just some of the stories gathered by Human Rights Watch that demonstrate the importance of protecting Medicaid—both its financial viability and its expansion—in states like Louisiana.  As a sponsor of the Patient Freedom Act, a bill that would permit states to preserve their Medicaid expansions, we know that you share this concern. For the sake of Roberta, Steven, Ellen and thousands like them, we urge you to take all steps necessary to protect Medicaid and continue the progress that is currently underway in promoting public health and human rights in Louisiana.

Sincerely,

Megan McLemore

Senior Researcher

Health and Human Rights Division

 

[1] Human Rights Watch, In Harm’s Way: State Response to Sex Workers, Drug Users and HIV in New Orleans, December 2013, https://www.hrw.org/report/2013/12/11/harms-way/state-response-sex-worke... Human Rights Watch, Paying the Price: Failure to Deliver HIV Services in Louisiana Parish Jails, March 2016, https://www.hrw.org/report/2016/03/29/paying-price/failure-deliver-hiv-s....

[2] Center for Budget and Policy Priorities, “Impact of ACA Repeal, State Fact Sheets”, http://www.cbpp.org/sites/default/ files/atoms/files/12-7-16health-factsheets-la.pdf (accessed June 8, 2017); The Commonwealth Fund, “Repealing Federal Health Reform: Economic and Employment Consequences for States,” January 5, 2017, http://www.commonwealthfund.org/ publications/issue-briefs/2017/jan/repealing-federal-health-reform (accessed June 12, 2017).

[3] People-to-People Health Foundation, “Can the States Survive the Per Capita Medicaid Caps in the AHCA?” post to “Health Affairs Blog” (blog), May 17, 2017, http://healthaffairs.org/blog/2017/05/17/can-states-survive-the-per-capi... (accessed June 8, 2017).

[4] Richie Bernardo, “2017’s Best and Worst State Economies,” WalletHub, June 5, 2017, https://wallethub.com/edu/states-with-the-best-economies/21697/ (accessed June 8, 2017).

[5] “LDH Medicaid Expansion Dashboard,” Louisiana Department of Health, http://ldh.la.gov/healthyladashboard/ (accessed June 8, 2017).

[6] Christine Vestal, “ACA Repeal Seen Thwarting State Addiction Efforts,” Pew Charitable Trusts, February 6, 2017, http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/0... (accessed June 8, 2017).

[7] Rebecca Santana, “Coroner: New Orleans Drug Overdose Deaths Doubled in 2016,” the Associated Press, March 27, 2017, https://www.usnews.com/news/best-states/louisiana/articles/2017-03-27/co... (accessed June 8, 2017).

Posted: January 1, 1970, 12:00 am

Equatorial Guinea is one the smallest countries in Africa, with a population of around 1 million and a total landmass of just over 28,000 square kilometers.

Posted: January 1, 1970, 12:00 am

Ijaz Paras Masih sits in a hospital bed in Thailand (date unknown). 
 

© 2017 British Pakistani Christian Association

(New York) – The government of Thailand should immediately investigate the death of a Pakistani man in immigration detention, Human Rights Watch said today. The case points to the need for Thailand to urgently end the indefinite detention of refugees and asylum seekers.

On May 27, 2017, Ijaz Masih, a 36-year-old Christian Pakistani, had a heart attack at the Immigration Detention Center in Bangkok, where he had been detained for more than a year on an illegal entry charge. The United Nations High Commissioner for Refugees (UNHCR) had rejected his refugee claim the day before. He died shortly after he was transferred to the Police General Hospital.

“Thai authorities are putting people who seek refugee protection at grave risk by keeping them in awful conditions in immigration detention centers,” said Brad Adams, Asia director. “Ijaz Masih’s death should be a wake-up call to end this abusive policy of incarcerating asylum seekers awaiting application results and refugees.”

Thai authorities are putting people who seek refugee protection at grave risk by keeping them in awful conditions in immigration detention centers.

Brad Adams

Asia Director


Ijaz Masih was one of hundreds of Pakistani Christian asylum seekers who claim to have been persecuted in Pakistan and ended up in squalid immigration detention centers in Thailand, where authorities treat them as illegal immigrants without rights – including asylum seekers, as well as those recognized as refugees by the UNHCR. In Pakistan, members of religious minorities face discrimination, criminal charges of blasphemy, and other forms of persecution – including violent attacks.

Under Thai law, all migrants with irregular immigration status – including children, asylum seekers, and recognized refugees – can be arrested and detained for illegal entry. Many immigration detention centers in Thailand are severely overcrowded, provide inadequate food, have poor ventilation, and lack access to medical service and other basic necessities. Detainees are restricted to small cells resembling cages, where they barely have room to sit, much less sleep. Children are frequently incarcerated with adults.

Thailand’s immigration detention facilities have long been reported to fall far short of international standards, but the Thai government has not acted to address the serious problems. Human Rights Watch documented these shortcomings in a comprehensive report on immigration detention of children in 2014, and a report on the treatment of refugees – including the detention of urban refugees – in 2012.    

Thailand is not a party to the 1951 Refugee Convention and has never enacted a law to recognize refugee status and set out procedures to assess asylum claims. Given its own lack of asylum procedures, the Thai government should respect UNHCR-issued persons-of-concern documents and refrain from detaining people who have pending claims for international protection. Besides ending the detention of asylum seekers, Thailand should also adopt alternatives to detention that are being used effectively in other countries – such as open reception centers and conditional release programs.

“The Thai government should recognize that its punitive detention policy towards asylum seekers is both inhumane and counterproductive,” Adams said. “Punishing people who are fleeing ghastly conditions at home will not keep them away but just add to their misery.”

Posted: January 1, 1970, 12:00 am
Posted: January 1, 1970, 12:00 am