Abstract

Although awareness of the Zika virus has existed since the 1950s, only recently has it attracted the interest of the international community. In 2015 and 2016, the virus spread throughout Brazil and suspicions on the possible relation between parallel increases in neurological disorders and the infection arose. By November 2015, this concern had developed into a National Public Health Emergency. On February 1, 2016, WHO formally declared its suspicion that this was a Public Health Emergency of International Concern (PHEIC), and sent a response in accordance with International Health Regulations (2005). Zika is present in almost all South American countries, and PAHO/WHO, Unasur, and Mercosur are developing responsive actions to the epidemic. The aim of this article is to present a critical analysis of the regional South American and Brazilian responses of February through September 2016, in respect of this PHEIC announcement, utilizing qualitative methodologies via bibliographical examination and document analysis. In this context, the PAHO/WHO played a prominent role as compared with the other organizations. Moreover, the political environment of the region also played a major role in the instability of both Mercosur and Unasur, which could impact the capacity and effectiveness of the response.

Zika virus; International cooperation; Global health; Regional Integration

Introduction

The Zika virus was identified in humans in Africa in the early 1950s. Since then, other countries on this continent, the Americas, and Asia became affected by the virus, a situation which attracted little interest from the global community.

The Zika virus is chiefly transmitted by a bite from the Aedes Aegypti mosquito, the vector for endemic diseases in South America such as Dengue Fever and Chikungunya. The endemic nature of these diseases exposes the ineffectiveness of vector prevention and control actions and highlights problems of urbanization, sanitation, use of the soil, and social inequality. All of these require structural changes significantly beyond just biomedical focus or pure and simple vigilance. Furthermore, they once again focus on the need for important discussions on women’s sexual health and reproductive rights¹1. Diniz D. Zika: do Sertão nordestino à ameaça global. Rio de Janeiro: Civilização Brasileira; 2016.,²2. Nunes J, Pimenta DN. A Epidemia de Zika e os limites da saúde global. Lua Nova 2016; 98:21-46..

The Zika symptoms of fever, headache, joint pain, conjunctivitis, nausea, and rashes were regarded as unimportant until countries, such as Brazil, France, and the USA, warned about a possible association between microcephalyand other neurological disorders and the Zika infection³3. World Health Organization (WHO). WHO statement on the first meeting of the International Health Regulations (IHR 2005). Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations. Washington: WHO; 2016..

On November 11, 2015, the Brazilian Government declared that the current epidemic – with cases registered throughout all states⁴4. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Boletim Epidemiológico. Brasília: MS; 2016.– was a national public health emergency. This was due to the significant increase of microcephaly in new-born infants, mainly in the Northeast of Brazil, the country’s poorest region that has historically been neglected by public policies²2. Nunes J, Pimenta DN. A Epidemia de Zika e os limites da saúde global. Lua Nova 2016; 98:21-46..

These data were formally communicated to the World Health Organization (WHO) and the Pan American Health Organization (PAHO), in compliance with the requirements of Art. 6 of theInternational Health Regulations (IHR)⁵5. World Health Organization (WHO). International Health Regulations. 2nd ed. Geneva: WHO; 2005.. This led to a declarationconfirming the relationship between the Zika virus fever and neurological alterations to be a Public Health Emergency of International Concern (PHEIC).

To contain this epidemic, that spread rapidly throughout the South American continent, regional organizations, in addition to PAHO, like the Union of South American Nations (Unasur) and the Mercosur responded to the epidemic technically and/or politically. These organizations play vital roles in the regional and global health diplomatic scenario, specially Unasurthat, since 2010, has led joint interventions as a bloc, drawing world attention to the integration process of South America⁶6. Faria M, Giovanella L, Bermudez L. A Unasul na Assembleia Mundial da Saúde: posicionamentos comuns do Conselho de Saúde Sul-Americano. Saúde Debate 2015; 39(107):920-934.. Its actions are impacted not only by economic or technical factors but, chiefly, by political issues.

The region’s political and economic context is one of significant instability, mainly caused by the emergence of conservative governments and exacerbated ideological conflicts, added to the economic crises that engulf so many of this sub-continent’s countries. There was also been a change in direction of Brazil’s foreign policy, particularly under the government of former President Dilma Rousseff, as compared with that of her predecessor, Luís Inácio Lula da Silva, in respect of this region and the roleof healthcare in this context.

The Zika epidemic and the PHEIC declaration require inter-sector answers. These answers are not limited to the technical/biological environment but, also, to upgrading healthcare and social protection systems, to infrastructure improvement and the creation of a legal framework supporting women to take their own reproductive health decisions. Joint solutions on a regional basis would empower the effects of this response and bolster international and healthcare diplomacy in South America.

The purpose of this article is to critically analyze the Brazilian and the South American regional response, from February to September, 2016, in the context of the declaration of the microcephaly outbreak and other neurological disorders such as PHEIC, announced by WHO in 2016.

Materials and methods

This article was based on the principles of a qualitative research approach. Accordingly, it includes techniques for its bibliographical research development – in specialized portals such as Capes (Coordination for Perfecting Graduate Personnel – Brazilian Portal) and Scielo (Scientific Electronic Library Online) Portals – and a document analysis via the study of official documents issued in the context of the organizations under study, relating to the scope of the studies launched after the PHEIC declaration, in February through September 2016. No studies similar to those proposed in the present article were found. Given the novelty of the epidemic and the response, this is a preliminary study seeking to identify and critically analyze the main responses and channels of action by Brazil and regional organizations in South America.

Foreign policy and healthcare diplomacy in the Zika era

Foreign policy deals with the actions and decisions generated by a country’s internal and external demands and opportunities that can be taken by players such as the States and international organizations⁷7. Pinheiro, L. Política externa brasileira: 1889-2002. Coleção Descobrindo o Brasil. Rio de Janeiro: Jorge Zahar; 2004.. If we regard as diplomacy the art and practice of conducting international relations, as a component of national foreign policy, healthcare diplomacy aims to comprehendnegotiation processes that involve several levels and players, and administer the global healthcare policy environment⁸8. Kickbusch I, Silberschmidt G, Buss P. Global health diplomacy: the need for new perspectives, strategic approaches and skills in global health. Bull World Health Org 2007; 85(3):230-232..

A vital healthcare diplomacycomponent is international technical cooperation, “technical and communal approach, whereby know-how, strategic guidance, and work can be shared, to ensure a more equitable development between different countries”⁹9. Buss PM, Ferreira JR, Alcazar S, Fonseca LR, Jouval HE. Governança em Saúde Global: diplomacia em saúde. Mimeo.. In turn, the term ‘global healthcare’ refers to healthcare matters deemed borderless and of collective responsibility, which demands collaborative actions between the countries in question¹⁰10. Kickbusch I, Berger C. Diplomacia da Saúde Global. Rev Electron Comun Inf Inov Saude 2010; 4(1):19-24..

Although healthcare began to be treated as an international issue as early as the 19^th century, its tardy appearance in Brazilian foreign policy can be explained: The access of non-specialists and diplomats was extremely difficult. It was subordinated as an economic issue related to trade and the workforce, which were adverse to the culture of healthcare, and healthcare structures played an extremely limited role in the Brazilian state environment¹¹11. Alcazar SLBF. A inserção da saúde na política exterior brasileira. Tese apresentada no 48º Curso de Altos Estudos do Instituto Rio Branco. Brasília: Ministério das Relações Exteriores; 2005..

The introduction of an open, independent, universal, and integral discourse of healthcare in 1988 with the SUS (Single Healthcare System), the expansion of the role of the Ministry of Health (Ministério de Saúde – MS), and of its budget, and, on the external level, renewed international interest in social matters, justify the emergence of healthcare as a Brazilian foreign policy issue¹¹11. Alcazar SLBF. A inserção da saúde na política exterior brasileira. Tese apresentada no 48º Curso de Altos Estudos do Instituto Rio Branco. Brasília: Ministério das Relações Exteriores; 2005..

The impact of the healthcare area on foreign policy, and vice-versa, suggests¹²12. Kickbusch I, Novotny TE, Drager N, Silberschmidt G, Alcazar S. Global Health Diplomacy: training across disciplines. Bull World Health Org 2007; 85(12):971-973.that Brazilian foreign policy is focusing increasingly on healthcare, to protect the country’s national security, free trade, and economic progress. One example is how Brazil used healthcare as a key point in its development and basis of the South-South Cooperation. Other authors¹³13. Feldbaum H, Michaud J. Health Diplomacy and the Enduring Relevance of Foreign Policy Interests. PLoS Med 2010; 7:4.claim that foreign policy interests were the main influence on the Global Health diplomacy agenda and that, as a rule, they determine the financing of its actions. This explains why certain topics such as endemic arboviruses receive neither the attention nor the money needed in proportion to their high disease rate.

The post-Cold War period has been identified as the moment of international cooperation expansion¹⁴14. Pinheiro L. Traídos pelo Desejo: Um Ensaio sobre a Teoria e Prática da Política Externa Brasileira Contemporânea. Contexto Internacional 2000; 22(2):305-335.

15. Vigevani T, Cepaluni G. A Política Externa de Lula da Silva: A estratégia da Autonomia pela Diversificação. Contexto Internacional 2007; 29(2):273-335.

16. Cervo AL, Bueno C. A inserção Global no século XXI. In: Cervo AL, Bueno C. História da Política exterior do Brasil. Brasília: Editora Universidade de Brasília; 2010. p. 491-521.-¹⁷17. Sato E. Cooperação Internacional: uma componente essencial das relações internacionais. Rev Electron Comun Inf Inov Saude 2010; 4(1):46-57., since the end of the bipolar world and of the dominance of war and peace issues gave way to the emergence of new interests and relationships between countries. Brazil has become increasingly involved in the diversification of foreign policy topics and players in healthcare-related matters. This is spearheaded by the Ministry of Health, with the support of its International Advisory team and their branches, such as Fiocruz, which are involved in coordinating and expediting several cooperation projects¹⁸18. Hirst M, Lima MRS, Pinheiro L. A política externa brasileira em tempos de novos horizontes e desafios. Nueva Sociedad 2010; 12:22-41..

It is possible to identify four international cooperation categories¹⁹19. Oliveira MF, Luvizotto CK. Cooperação técnica internacional: aportes teóricos. Revista Brasileira de Política Internacional 2011; 54(2):5-21.: vertical: in an assistance role; tout court: which works with developing countries as partners, and subsequently rising to a more active position; horizontal: cooperation with developing countries, by assuming the horizontal/South-South position; and, lastly, decentralized: incorporating horizontal cooperation features but, not necessarily, involving the Nation-State, such as that developed between municipalities, i.e., paradiplomacy.

The South-South Cooperation concept is not homogeneous. It is marred by an absence of specificity, normativism, and reductionism, and should be regarded²⁰20. Leite I. Cooperação Sul-Sul: Conceito, História e Marcos Interpretativos. Observador On-line 2012; 7(3):41. as a complex process of exchanges, one that presumes there will be a complex give-and-take process, that presumes the existence of mutual compensation between the cooperation players, thereby circumventing the reproduction of a vertical logic, the distinguishing feature of the North-South cooperation.

The innovative aspects of Brazil’s healthcare cooperation approach²¹21. Almeida C, Campos RP, Buss P, Ferreira JR, Fonseca LE. A concepção brasileira de “cooperação sul-sul estruturante em saúde”. Rev Electron Comun Inf Inov Saude 2010; 4(1):25-35.– Structuring Cooperation – are the emphasis on training human resources, organizational upgrades, and institutional development, in addition to utilizing autochthonic capacities and resources.

During former President Lula’s two governments (2003-2010) healthcare was a foreign policy agenda²²22. Ventura D. Saúde Pública e Política Externa Brasileira. SUR. Revista Internacional de Direitos Humanos 2013; 10(19):99-118. highlight, but, during Dilma Rousseff’s presidency, there was a significant deceleration or, certainly, a systemic decline in Brazilian foreign policy²³23. Cervo AL, Lessa AC. O declínio: inserção internacional do Brasil (2011-2014). Revista Brasileira de Política Internacional 2014; 57(2):133-151.instigated by Lula. This was caused mainly by factors such as decreasing budget support for the Ministry of Foreign Relations and also due to the President’s focus on domestic matters, and thus impacted the efforts of the Federal Government seeking to unite civil society to collaborate in an international plan²⁴24. Gómez E, Perez FA. Brazilian foreign policy in health during Dilma Rousseff´s administration. Lua Nova 2016; 98:171-197..

The problems encountered by healthcare diplomacy in the Rousseff Government significantly impacted the possibility of an international Brazil response to the Zika epidemic and the attempts by the regional players to carry out coordinated actions. Furthermore, Brazilian foreign policy was redirected under the Government of Michel Temer, which led to disquieting diplomatic conflicts for South America and the Regional Integration bodies.

WHO as a global health authority

WHO (founded in 1948) is the United Nations body specializing in health and, among its many roles, it acts as an international healthcare directing and coordinating authority. Its duties are to provide technical assistance, propose conventions, agreements, regulations and recommendations on international health²⁵25. World Health Organization (WHO). Documentos básicos. 48ª ed. Geneva: WHO; 2014..

WHO authority has been challenged with the loss of its major role before other organizations²⁶26. Ventura D, Perez FA. Crise e Reforma da Organização Mundial da Saúde. Lua Nova 2014; 92:45-77., such as the World Bank²⁷27. Brown TM, Cueto M, Fee E. A transição de saúde pública ‘internacional’ para ‘global’ e a Organização Mundial da Saúde. Hist. cienc. saude-Manguinhos 2006; 13(3):623-647.. The combination of its financing crisis (only 25% of its financing consists of regular contributions from member countries)²⁸28. Instituto Sul Americano de Governo em Saúde (ISAGS). Informe. 65ª AMS discutiu reforma da OMS com destacada atuação da Unasul. Rio de Janeiro: ISAGS; 2012.and, recently, the influenza-A (H1N1) pandemic further exacerbated this situation and revealed conflicts of interest²⁹29. Ventura D. Direito e saúde global. São Paulo: Expressão Popular, Dobra Editorial; 2013., communication difficulties, and internal governance problems²⁶26. Ventura D, Perez FA. Crise e Reforma da Organização Mundial da Saúde. Lua Nova 2014; 92:45-77..

A completeWHO Reform (2010) was justified by operational and financial issues, to reinforce its leadership position³⁰30. World Health Organization (WHO). Financiación de la OMS en el futuro. Resumen de las observaciones finales de la Directora General. Geneva: WHO, 2011.. Despite all this, WHO is still the hub where Global Health matters are debated, examined, and approved, since no substitute authority has been identified among existing organizations³¹31. Kastler F. Focus OMS – Des résolutions et une réforme cruciale en cours. Les Tribunes de la Santé 2013; 39:13-14..

The IHR

WHO has already approved two binding international legal agreements: a Framework Convention on Tobacco Control (2003) and the International Health Regulations (2005).

The IHR (International Health Regulations) is an international, binding, legal instrument whose objective is to “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade”⁵5. World Health Organization (WHO). International Health Regulations. 2nd ed. Geneva: WHO; 2005.. Its most recent edition introduces some innovation in relation to the preceding regulations (1969) since it does not limit its application to specific events; it presumes that each country has the capacity to respond to the regulations; it requires countries to report events that could represent a PHEIC; it authorizes WHO to utilize unofficial information; it authorizes the Director-General to formally declare a PHEIC and to issue recommendations after an Emergency Committee meeting, etc.⁵5. World Health Organization (WHO). International Health Regulations. 2nd ed. Geneva: WHO; 2005..

“Thus, membership of the IHR, is bound by an health emergency law, and to have appropriate conditions for its application, which shall be measured and controlled by an international mechanism”⁹9. Buss PM, Ferreira JR, Alcazar S, Fonseca LR, Jouval HE. Governança em Saúde Global: diplomacia em saúde. Mimeo., indicating the need for structural changes in the healthcare systems, which are frequently difficult to attain. Assessments on the basic capacity of the member States in the context of the IHR could be deemed fragile since they are self-declared and non-compulsory. This generated a debate in the 69^thWHA (World Health Assembly) Session, when countries debated the possibility of an outside assessment, claiming that this would have to be voluntary³²32. Instituto Sul-Americano de Governo em Saúde (ISAGS). Informe. Informe Especial sobre a 69ª Sessão da Assembleia Mundial da Saúde. Rio de Janeiro: ISAGS; 2016.. Moreover, these capacities relate to a legal structure to permit a response to these condition, requiring WHO to act to strengthen the legal structure as a means of improving responses to emergencies³³33. Marks-Sultan G1, Tsai FJ2, Anderson E3, Kastler F4, Sprumont D1, Burris S. National public health law: a role for WHO in capacitybuilding and promoting transparency. Bull World Health Org 2016; 94(7):534-539..

PHEIC (Public Health Emergency of International Concern)

When an event is deemed to be a PHEIC, formal notification to WHO must be delivered by the affected country, and must give a positive answer to at least two of the following questions⁵5. World Health Organization (WHO). International Health Regulations. 2nd ed. Geneva: WHO; 2005.: Will there be grave public health consequences arising from the event? Is this an iregularor unexpected event? Is there a grave risk of international proliferation? Is there a grave risk of restrictions to international travel or to international trade?

After such notification, the Director-Generalmay convene the Emergency Committee, comprised of experts on the event, to assess the case. The decision to announce a PHEICis based on the information reported by the respective Member Statein the decision agreement (Annex 2), on the Committee’s recommendations, in scientific evidence submitted, on the human health risk assessments, on the possibility that the disease could spread, and on the risk of interference with international traffic (Art.12/IHR).

There is no doubt that a declaration of a PHEIC raises the consciousness of the population regarding the event in question. It can also empower the Ministry of Health to increase its appeal for international funds, in addition to increasing coordination and international cooperation to report such events. However, this frequently has a negative impact on the transit of individuals and goods to the affected locations, since it brings economic losses, the risk of stigmatization of the affected population, and panic, with obvious political consequences³⁴34. Ventura D. Ebola e Zika são incomparáveis. Blog Saúde Global. [acessado 2016 fev 16]. 2016. Disponível em: https://saudeglobal.org/2016/02/01/ebola-e-zika-sao-incomparaveis-por-deisy-ventura/
https://saudeglobal.org/2016/02/01/ebola... .

Up until 2015, WHO declared three PHEIC: influenza-A H1N1 pandemic (2009), wild poliovirus (2014) and Ebola (2014), diseases spread via human contact. The specific distinctive idiosyncrasy of Zika is that it is chiefly transmitted by mosquitoes and also that it can cause mild symptoms in the population as a whole, but does not necessarily require those affected to seek medical assistance, thereby causing especially difficult control conditions.

Microcephaly and neurological disorders connected with Zika virus fever as a PHEIC

Three months after Brazil officially reported an disquieting increase in its own microcephaly cases and, after negative signs in France and the USA, WHO called the Committee that, on February 1, 2016, declared the recent outbreak to be PHEIC. This showed that “international cooperation has begun, and with a very specific basic concern: the containing of certain infectious diseases, in order to prevent their migration to the developed western world”²2. Nunes J, Pimenta DN. A Epidemia de Zika e os limites da saúde global. Lua Nova 2016; 98:21-46..

During the first meeting of the Committee, three chief recommendations were issued: standardization of, and increase in, the surveillance of microcephaly cases in the areas affected by the Zika virus and more in-depth etiological research to establish the causal relationship with the virus. For the Committee members, the difference between the Ebola and the Zika declarations were that, in the former case the emergency was declared based on what was already known about the disease and, in the latter, based on what was not known³⁵35. Heymann DL, Hodgson A, Sall AA, Freedman DO, Staples JE, Althabe F, Baruah K, Mahmud G, Kandun N, Vasconcelos PF, Bino S, Menon KU. Zika virus and microcephaly: why is this situation a PHEIC? Lancet 2016; 397(10020):719-721..

Once again, WHO leadership and action timing were criticized, as in the case of the Ebola epidemic. An article published on January 27 pointed out that this worldwide emergency was unquestionable³⁶36. Lucey DR, Gostin LO. The emerging Zika pandemic: enhancing preparedness. JAMA 2016; 315(9):865-866.and that the Committee should have taken immediate action.

For the scientific community, even at the beginning of the PHEIC, the probability of a connection between the Zika infection and neurological alterations, such as the Guillain-Barré Syndrome (GBS) was high. But, the Committee³⁷37. World Health Organization (WHO). WHO statement on the 2nd meeting of IHR Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations. Geneva: WHO; 2016.had not yet confirmed this connection. Only during its third meeting, held on June 14, was a definitive statement issued confirming that the Zika virus caused microcephaly and a trigger for GBS³⁸38. World Health Organization (WHO). WHO statement on the third meeting of the International Health Regulations (2005) (IHR(2005)) Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations. Geneva: WHO; 2016..

During the meeting, the Committee deemed the risk of increase in the number of Zika virus infections arising from the sheer numbers attending the 2016 Olympic Games, to be low. After the conclusion of the Games, at its fourth meeting, the Committee commended Brazil for its prevention and control actions³⁹39. World Health Organization (WHO). Fourth meeting of the Emergency Committee under the International Health Regulations (2005) regarding microcephaly, other neurological disorders and Zika virus. Geneva: WHO; 2016.. Brazil put in place two major surveillance fronts during the Olympic Games, via The Brazillian Health Regulatory Agency, with Guidelines for increased vigilance at crowded events and, also, the Integrated Operating Plan on Sanitary Surveillance, highlighting triangular planning for clinical analysis laboratories. In addition, Fiocruz introduced the Olympic Biome Project to analyze the transformation caused by this mega-event to the Rio de Janeiro microbiome⁴⁰40. Instituto Sul Americano de Governo em Saúde (ISAGS). As Olimpíadas do Rio e a Vigilância em Saúde. Rio de Janeiro: Instituto Sul Americano de Governo em Saúde (ISAGS); 2016. Informe..

Overall, the Committee’s recommendations related to the need to improve the following actions: surveillance, communication and risk assessment, vector control, clinical indications, and research and development. These involved investigating new diagnostics and treatments, development of vaccines, and other vector control measures.

Given the ongoing geographic expansion and the significant gaps in comprehension of Zika virus infections, the decision was taken to maintain the PHEIC⁴¹41. World Health Organization (WHO). Zika Situation Report. Zika Virus, microcephaly, Guillain-Barré Syndrome. Geneva: WHO; 2016..

Brazil’s response to the PHEIC

In Brazil, the autochthonic transmission of the Zika virus was identified in April 2015. Since then, there has been an increase of more than twenty times in suspected microcephaly cases. Moreover, French Polynesia, which was affected from 2013 to 2015 by the Zika virus, noted the occurrence in infants of neurological disorders deriving from this virus³⁶36. Lucey DR, Gostin LO. The emerging Zika pandemic: enhancing preparedness. JAMA 2016; 315(9):865-866.,⁴²42. Jouannic J, Friszer S, Leparc-Goffart I, Garel C, Eyrolle-Guignot D. Zika virus infection in French Polynesia. Lancet 2016; 387(10023):1051-1052..

The definition of the cases utilized by Brazil was challenged⁴³43. Victora CG, Schuler-Faccini L, Matijasevich A, Ribeiro E, Pessoa A, Barros FC. Microcephaly in Brazil: how to interpret reported numbers? Lancet 2016; 387(10019):621-624., because they were overstated. This served to underscore the importance of applying more specific parameters, including laboratory or radiological testing. In the first week of March, Brazil introduced new standardsaligned with WHO parameters, which differed for girls (< 31.5cm) and boys (< 31.9 cm), thereby increasing the capacity to identify positive cases.

According to epidemiology report No. 40⁴⁴44. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Informe Epidemiológico Nº 40 – Semana Epidemiológica (SE) 33/2016 (14/08/2016 A 20/08/2016) Monitoramento dos casos de microcefalia no Brasil. Brasília: MS; 2016., since November 2015, 9,091 suspected cases of central nervous system alterations were reported and the link with the Zika virus infection was confirmed in 1,845 cases, of which 83.3% were found in the Northeast of Brazil.

According to the Healthcare Surveillance Secretariat of the Ministry of Health (June 2016)⁴⁵45. Brasil. Ministério da Saúde (MS). Ações Realizadas para Enfrentamento da Emergência em Saúde Pública Relacionada à microcefalia. Brasília: MS; 2016., the Brazilian response to the epidemic is based on three chief pillars of inter-sector actions involving areas such as Social Developmentand Defense. Mobilization and combating the vectorare based on triangular epidemiology surveillancesystem, basic sanitation actions, and communication. Care, which comprehendsaction to develop protocols and diagnostics and treatment guidelines, organizationof the healthcare network and human resource training. And technological development, education and research, promoting the investigation of diagnostics, vector control, protocols, and guidelines for clinical handling, vaccines, and treatments.

A fourth and additional pillar, which is justified by the international importance of this epidemic and by action in Brazil in the field of health diplomacyisinternational cooperation. Brazil is in the process of forming alliances to increaseits response with technical cooperation and by entering into specific international conventions on the Zika virus.

Brazilh as carried out laboratory diagnostics training actions in five of the other eleven Unasur member countries (Bolivia, Ecuador, Paraguay, Peru, and Uruguay⁴⁵45. Brasil. Ministério da Saúde (MS). Ações Realizadas para Enfrentamento da Emergência em Saúde Pública Relacionada à microcefalia. Brasília: MS; 2016.) and has also signedtwo international agreements with the USAand issued two letters of intent on the cooperation activities between these countries on this matter, relating tovaccine research and developmentamong other aspects, including CDC (Centers for Disease Control and Prevention). It is important to point out that, in addition to the Ministry of Health, another vital partner in these achievements is the Instituto Evandro Chagas, associated with Fiocruz, which has played a prominent role Global Health diplomacy⁴⁶46. Ferreira JR, Hoirisch C, Fonseca LE, Buss PM. Cooperação internacional em saúde: o caso da Fiocruz. Hist Cienc Saude Manguinhos 2016; 23(2):267-276..

The regional response in South America

By September 2016, ten of the twelve independent South American countries had reported Zika virus fever cases, but only Brazil, Colombia (the two countries with the highest number of cases⁴⁷47. Organización Panamericana de Salud (OPS). Zika cases and congenital syndrome associated with Zika virus reported by countries and territories in the Americas, 2015 – 2016. Cumulative cases. Washington: OPS; 2016.), and Paraguay identified cases of neurological disorders in newborn infants. Suriname and Venezuela reported cases of GBS only.

The PHEIC Declaration by WHO, allied to the epidemic on our continent, require increased coordination and international cooperation⁴⁸48. Barreto ML, Barral-Netto M, Stabeli R, Almeida-Filho N, Vasconcelos PF, Teixeira M, Buss P, Gadelha PE. Zika virus and microcephaly in Brazil: a scientific agenda. Lancet 2016; 387(10022):919-921.efforts to tackle the situation. International health organizations active throughout South America are joining forces to combat this epidemic.

Pan American Health Organization – PAHO

PAHO (1902) is the WHO regional office for the Americas. Its mission is “to strengthen national and local health systems and improve the health of the peoples of the Americas”⁴⁹49. Organización Panamericana de Salud (OPS). Constitución de la Organización Panamericana de la Salud. Washington: OPS; 1999.. PAHO plays a vital role in regional healthcare cooperation. In 2013, its member countries approved RESCD52/11 on healthdevelopment cooperation, and accepted an updated policy on this topic. Its objective is “to strengthen cooperation among countries, agencies, and other agents of change to effectively address common health issues”⁵⁰50. Organización Panamericana de Salud (OPS). Resolución CD52/11 del 52 Consejo Directivo. Tema Cooperación para el desarrollo sanitario en las Américas. Washington: OPS; 2013.. It also states that one of the Director’s responsibilities is to strengthen relations between sub-regional organizations, reinforcing what was originally proposed in its Constitution.

In the context of health surveillance, it is the Organization’s⁵¹51. Organización Panamericana de Salud (OPS). Agenda de Salud Para las Américas 2008-2015. Ciudad de Panamá: OPS; 2007. to constantly prepare for dealing with disasters, pandemics, and disease, to strengthen joint actions at sub-regional, regional, and global levels, to prevent and control disease, among other actions.

In the context of the Zika virus epidemic⁵²52. Organización Panamericana de Salud (OPS). Zika: Missions to support countries. Ciudad de Panamá: OPS; 2016., PAHO has carried out missions in affected countries in order to support their governments’ surveillance, control and prevention actions, not only of Zika, but, also dengue fever and Chikungunya outbreaks. They carry out training work, workshops, and provide technical support for studies and policies. They have organized 58 technical cooperation missions to 26 countries; eight regional meetings on bioethics, surveillance, sexual and reproductive healthcare, etc., eleven sub-regional workshops on surveillance, vector control, and laboratories. It also distributed laboratory reagents to 22 countries and created an instrument partnership with the CDC, etc.

According to Document CD55/INF/4, which updates the situation of the epidemic in the Americas region, in December 2015, PAHO introduced an incident management structure, enabling the allocation of resources from its Epidemic Emergency Fund to fund actions involving monitoring the epidemic, vector controls, reinforcing healthcare systems and Zika virus research work. The Organization has also carried out communication actions in order to minimize risks and to control mosquito infestations. However, there is still a 70% gap in the total budget required to carry out the proposed activities⁵³53. Organización Panamericana de Salud (OPS). Actualización sobre el virus del Zika en la region de las Américas. CD55/INF/4. Ciudad de Panamá: OPS; 2016.. PAHO has also carried out joint actions with international bodies, such as Mercosur and Unasur.

Mercosur (Trade Association of Brazil, Paraguay, Uruguay, Venezuela, and Argentina

Mercosur (1991) originally consisted of Argentina, Brazil, Paraguay, and Uruguay, with the addition of Venezuela (2012), with associate member countries (Chile, Peru, Colombia, Ecuador, Guyana, and Surinam)⁵⁴54. Mercado Común del Sur (Mercosur). Mercosur. Montevideo: Mercosur; 2016. These associate countries take part in all meetings but hold no voting rights⁵⁵55. Mercado Común del Sur (Mercosur). Textos Fundacionales. Montevideo: Mercosur; 2012..

Its basic objective was to deal with economic and trade-related issues, but social topics were gradually included in its agenda. Health involves two specific areas: the Ministers of Health Meeting, which tackles political and other relevant matters affecting the bloc, and the Health Work Sub-Group (HWSG), which handles technical topics, such as legislation coordination, health surveillance, etc.⁵⁶56. Queiroz LG, Giovanella L. Agenda regional da saúde no Mercosul: arquitetura e temas. Rev. Panam Salud Publica 2011; 30(2):182-188..

A study⁵⁶56. Queiroz LG, Giovanella L. Agenda regional da saúde no Mercosul: arquitetura e temas. Rev. Panam Salud Publica 2011; 30(2):182-188.on the bloc´s health issue showed that the Intergovernmental Dengue Fever Control Commission has been in existence since the year 2000, in addition to the Healthcare Information and Communication Systems, inaugurated in 2006. At HWSG, healthcare surveillance (2006) represents 15% of the resolutions issued by the organization, and implementation of the IHR (International Health Regulations) is an integral part of its agenda.

On February 3, 2016, an extraordinary meeting of the bloc’s Health Ministers was called to discuss the epidemic of diseases transmitted by the AedesAegyptimosquito. Other organizations also took part, such as the South American Institute of Government in Health (ISAGS) and PAHO.

During this encounter, the Ministers discussed the possibility of improved integrated management strategies for dengue fever and other vector diseases as the major measure for confronting the regional epidemic. They also defined education campaigns and communication mechanisms, in addition to drawing up clinical protocols and guidelines, updating healthcare personnel, reciprocal support for Zika fever diagnostics. They also assessed the possibility of including Guillain-Barré Syndrome (GBS) medications in joint bloc negotiation rounds. An important achievement was the creation of an ad hoc emergency follow-up Group, during the Pro Tempore Presidency (PTP) of Uruguay which, at that time, also held the PTP of Unasur.

The bloc has experienced a number of major political reversals over the last few months, caused by the procedures for impeaching former President Dilma Rousseff and by the diplomatic divergences between the member States and Venezuela⁵⁷57. Télam D. Governo da Venezuela se declara presidente pro tempore do Mercosul. Brasília: Empresa Brasileira de Comunicação (EBC); 2016.. Under the rules, the latter countryshould have taken over the bloc PTP during the second semester of 2016. Due to the standoff involving Mercosur, all Zika virus actions have been stalled and the Ad Hoc Committee has not convened again.

Unasur (Union of South American Nations)

Unasur is a pioneering intergovernmental regional organization in South America, comprising its twelve independent countries. It is regarded as innovative as compared with all other prior experiments which made few advances in forming an effective continental integration system. It has submitted a wide-ranging regional development project which, in addition to covering economic or defense topics, also tackles social matters aimed at South American citizenship⁵⁸58. Simões AJF. Unasul: a América do Sul e a construção de um mundo multipolar. In: Simões AJF. Integração: sonho e realidade na América do Sul. Brasília: Fundação Alexandre de Gusmão; 2011. p. 55-64..

The bloc consists of Councils and other political and technical bodies, including twelve sector Councils. Health is the responsibility of the South American Health Council, and is formed by Ministers of Health of its member countries (highest level of decision making); a Coordinating Committee, consisting of ministers’ delegates; a technical secretariat formed by the current, past, and future PTP representatives;Technical Groups (TG), Structuring Networks, and the South American Institute of Governement in Health (ISAGS) (2011), headquartered in Brazil, an advanced study and political think tank for the development of health leadership and strategic human resources⁵⁹59. Instituto Sul Americano de Governo em Saúde (ISAGS). Estatuto do Instituto Sul-americano de Governo em Saúde. Rio de Janeiro: ISAGS; 2011..

Health surveillance issues are handled by the Technical Group (TG) Health Surveillance and Response Network (2009), based on the 2010-2015 Five-Year Plan. This Plan reports results such as how to ensure capacity for the application of the IHR (International Health Regulations) and the formation of Dengue Fever Network to alleviate its regional impact⁶⁰60. Unión de Naciones Suramericanas (Unasur). Consejo de Salud Suramericano. Plan Quinquenal 2010-2015. Cuenca: Consejo de Salud Suramericano, 2008..

On the IHR (International Health Regulations), a need has been noted to intensify cooperation strategies due to current gaps and for some “regional oversight of events, not only to share information on circumstances in the countries of the region, but, also to learn from each country’s experiences”⁶¹61. Carmo EH, More LFB, González CG, Salomón RR, Gualamo MC, Antman JG. Capítulo VI – Red Suramericana de Vigilancia y Respuesta en Salud: antecedentes, creación, agenda y desafios. In: Carmo EH, Gemal A, Oliveira S, organizadores. Vigilancia em Salud en Suramérica: epidemiológica,sanitária y ambiental. Rio de Janeiro: ISAGS; 2013. p. 115-128..

ISAGS and the Technical Groups (TG) drew up a joint report on the Zika virus epidemic in the region and on the activities in which the Council became involved on the issue of surveillance and responses. In a press conference, the Unasur Secretary-General, Ernesto Samper, and the then ISAGS Director, José Gomes Temporão, announced the creation of a Regional Protocol to combat and prevent the Zika virus. The proposal was accepted in the Mercosur Meeting, in order to reinforce cooperation, guarantee ongoing communication, increase the exchange of experiences, reinforce joint frontier surveillance capacities, etc.⁶²62. Instituto Sul Americano de Governo em Saúde (ISAGS). Informe. Unasul se mobiliza para enfrentar o vírus Zika. Rio de Janeiro: ISAGS; 2016..

The region’s conflicting policies, which impact Mercosur, also affect Unasur. The relationship between these countries and the Unasur PTP, currently headed by Venezuela, has cooled significantly, culminating in the deceleration of structures and projects. Another blow was the announcement of Samper’s resignation in January 2017⁶³63. Unión de Naciones Suramericanas (Unasur). Ernesto Samper no aspira su reelección en la Secretaría General y continuará en Unasur hasta enero de 2017. Cuenca: Unasur; 2016.. He was regarded as an important leader and mover in the region.

Closing considerations

The impacts of a PHEIC declaration are numerous and, as a result, the Zika virus epidemic in South America has been transformed into a highly favorable event for international cooperation, thanks to the demand for coordinated surveillance and response actions. Some authors predicted that the resulting increased visibility of the epidemic could attract greater investments to combat the disease³⁴34. Ventura D. Ebola e Zika são incomparáveis. Blog Saúde Global. [acessado 2016 fev 16]. 2016. Disponível em: https://saudeglobal.org/2016/02/01/ebola-e-zika-sao-incomparaveis-por-deisy-ventura/
https://saudeglobal.org/2016/02/01/ebola... ,⁶⁴64. Instituto Sul Americano de Governo em Saúde (ISAGS). Informe. Entrevista: José Gomes Temporão. Rio de Janeiro: ISAGS; 2016., thereby mobilizing regional structures to actually take on the commitments assumed in the past. However, what has actually been observed is a retreat in action by regional bodies, such as Unasur e Mercosur, to take action to jointly respond to the regional challenges imposed by PHEIC.

In the political context, several regional, national, and diplomatic aspects have interfered in this process. At the regional level, we highlight the emergence of the more conservative governments challenging the concept of the regional cooperation era that began in the year 2000. Then there was the lack of interest displayed by the Rousseff Government in foreign policy and health issues, and which underscored that the national context of Brazil, a major player in the international scenario, significantly impacted the progress of international cooperation in the region. Furthermore, with the impeachment procedures that removed President Dilma Rousseff from office, several member states withdrew or recalled their ambassadors to Brazil for consultation, as was the case with Bolivia, Ecuador, and Venezuela, and which had serious diplomatic outcomes.

The economic crisis, followed by a lack of funding, also significantly contributed to the subsequent constraints imposed on regional Zika virus combat operations. They also impacted financing of the sub-continent’s healthcare systems and, in all, seriously undermined the actions of these organizations.

Although all these factors also impacted the actions of PAHO and WHO, both organizations have maintained their actions, and commenced the surveillance and response mechanisms set forth in the IHR (International Health Regulations). In addition to the fact that have been in existence for a much longer time, are more established and institutionalized, they also both have significant penetration in the field of health diplomacy and in their Member-States. This greatly contributes to the greater resonance of their intervention actions.

We also highlight the interest of the USA in the Zika virus research and development field. This includes bilateral agreements with Brazil, with particular emphasis on a technical and biological response to the epidemic, as clearly evidenced by the leading role of the CDC in these agreements.

It must also be borne in mind that the PHEIC declaration represents an opportunity for governments and society in general, that cannot be allowed to vanish⁶⁵65. Horton R. Offline: Brazil – the unexpected opportunity that Zika presentes. Lancet 2016; 387(10019):633.,to call attention to diseases that have been neglected for far too long and that never attracted sufficient international attention in the first place. It also highlights the need to structure healthcare systems as a means to respond to the consequences of this epidemic – for instance, the irreversible neurological damage suffered by infants. It is also an opportunity for international organizations to reinforce their health diplomacy and international cooperation, by negotiating regional actions that could lead to common policies. Lastly, it also raises the question of what kind of regional integration we want.

Acknowledgments

To Deisy Ventura for her revision and support of the development of this research project.

References

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