Despite mischief caused before, “Aedesaegypti” has acquired an international important status in view of recent zika outbreak in Brazil and consequently of the impressive numbers of Brazilian babies with microcephaly - approximately 2,106 cases in the last epidemiological week of October, 2016. In March 2016, the Brazilian Ministry of Health published the “Protocol” for the health care response to Zika-related microcephaly, but the number of cases has just increased. In the present case report we present the alarming numbers of microcephaly, mainly in Northeast and Southeast of country, and poor living conditions of cities. As we shall see, the “Aedesaegypti” seems to have won the battle against citizens because they were cunning and have adapted quickly to deplorable urban conditions and to climate change. In contrast, the executive entities eventually put their prescriptions against imbalance health system in practice, just in some isolated cases. There is a distinct gap between government’s actions and population’s reality, which suggests that special attention to vulnerable populations should be priority, especially for those who are going to be born, because they represent the future of nation. Analyzing available information, we could conclude that given the situation, it would be regrettable to consider that citizens are mere spectators, dependent on previously defined actions, when in reality the society should occupy a prominent position in any process, demanding appropriated decisions in order to ensure the effectiveness of health and housing programs.

Keywords: contemporary, Brazilian cities, human settlement, disease vectors, “aedes” ecology, urban future

Brazil hasexperienced one of the highest levels of zika incidence transmitted by “Aedesaegypti” with 2,106 of microcephaly cases confirmed in metropolitan areas where almost 80% of the population lives. In the last year, the World Health Organization (WHO) has raised alarm about the distribution and severity of microcephaly caused by zika. Social and environmental determinants have a strong influence on a wide number of cases which include the government failures to manage important factors such as:

1. Urban growth;
2. Increased movement of humans and vectors (by travel and commerce drives);
3. Land use change(with deforestation, agroindustry,ecological change, atmospheric and climate change).

The development of insecticide-resistancein mosquitoes.^1–5 Effects of climate change on health are also determinants that will affect most populations in urban areas⁶ Especially, climate change has been associated with increased frequency and intensity of epidemic diseases, exacerbating the extent of impacts on the currently hazard-prone areas (IPCC, 2014).⁷ Urban growth combined with extreme events will cause a shift in the burden of disease.^7,8 In recent decades, the extreme weather events have become more frequent and severe with increases in extreme heat, intense precipitation, and drought.⁹ The period of rain is becoming more irregular with intense rainfall events concentrated in a short period separated by warm dry periods (IPCC, 2014).⁷ However, no political action has effectively taken into account the impacts of biophysical environmental conditions and the vulnerability of populations.¹⁰ Particularly, the absence of management in Brazilian cities refers to legal blameworthiness and lack of responsibility in each area of environmental law that in reality should include health and social economic equality compatible with sustainable goals. Such objectives are established by law and include measures to reduce the potential environmental exposure at local level.^11–13

This situation is exacerbated by broad disparities of income opportunities across spatial distribution of population.^14–16 Low-income groups are often settled in segregated spaces disconnected from adequate urban infrastructure,^14,17,18 and under these circumstances housing is frequently made of inappropriate building materials that do not provide minimum dwelling conditions.¹⁷ In general, the slums constitute the only affordable housing for the poorest, filling the gap between the demand and supply of residences. They are often polluted, located on hazardous and deteriorated Socially, this scenario includes land tenure insecurity, informal income-generation strategies, limited access to credit (in the formal Real Estate market) and scanty formal jobs due to poor quality education, stigmatization, and discrimination combined with poor livelihood.^17,19

In this context, some important questions related to the future of Brazilian cities still call for an answer. For example, how the trajectory of Brazilian cities interferes on population health? The existent public policies are being put in practice to enhance the life at cities? What is the design-reality gap? It is marked that contemporary urban contexts can no longer be conceived without clear communication and social interaction. We need to re-establish the public space as a place of all, where we include cooperation, respect, and participation. Therefore, additional research is needed to better understand the health risks and effective responses to this complex situation,¹⁰ which requires knowledge about social-ecological systems focusing on the interactions between biophysical and social systems.²⁰ The objective of this case report is to describe the situation through a socio-ecological perspective, presenting the numbers of microcephaly cases in urban areas of Brazil.

The emergence of zika

Several cases of microcephaly have been reported in Brazil since last year (2015-2016), when it was announced by World Health Organization (WHO) that one specific disease, apart from dengue and chikungunya, has been transmitted by “Aedesaegypti”, namely zika. Zika was just declared a global public health emergency after being linked to brain deformities in babies in November, 2015 - when it was reported 739 suspected cases. Zika was previously isolated in 1947 (in Uganda and Nigeria), investigated in 1968, and during studies conducted between 1971 and 1975.^21,22 More recently, epidemics in the Pacific were revealed by World Health Organization, the first in Micronesia with 5,000 cases registered (2007), and the second one, extremely significant, with 55,000 patients in Polynesia (2013). In Malaysia, about 23,966 cases of dengue were reported,²³ in Africa (Gabon) 20,000 people were affected by dengue, chikungunya and zika,²⁴ andin America, the population is experiencing the major zika epidemic,²⁵ with 492,820 suspected cases reported from 45 countries through September 1, 2016.²² In February 2014, it was reported by the Ministry of Health of Chile, the first autochthonous case in the Americas. In February 2015, the number of cases reported by Ministry of Health of Brazil has already soared. In October 2015, the ministry of Brazil warned about an unusual increase in the number of cases of microcephaly reported in the State of Pernambuco, where 141 cases were identified in less than one year, versus only about 10 cases in past years.²²

A study developed by Fiocruz-Parana (in Brazil) using histochemistry confirmed the presence of the zika virus in the placenta, and similar situation has been reported by other local governments. In response to the situation, on 11 November, the Ministry of Health of Brazil declared a national public health emergency to give greater support to the investigations.²² In January 2016, twenty countries have confirmed autochthonous circulation of zika virus in the Americas, such as Brazil, Barbados, Bolivia, Chile (Easter Island), Colombia, Ecuador, El Salvador, Guatemala, Guiana, French Guiana, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Puerto Rico, Saint Martin, Suriname, and Venezuela.²⁶

In February 2016, about 3,893 cases were reported in Brazil with 199 municipalities in state of dengue, chikungunya and zika outbreak risk, and other 665 municipalities in a state of alert.²⁶ Several pregnant women submitted to zika virus gave birth to babies with microcephaly (Table 1) due to the neurological and auto immune complications associated to zika virus²⁷ such as Guillain-Barré syndrome and congenital syndrome in newborns²⁷ The Northeast (Figure 1) was the region with the highest prevalence of microcephaly at birth (223 cases), 40.4 cases per 10,000 live births according to the second epidemiologic week report.²⁸ Until October 29, 2016 (week 43), about 10,039 cases were reported according to the protocol settings surveillance (newborn, stillbirth, abortion or fetus). Of these, about 7,933 cases were investigated and 2,106 were confirmed (Table 1) for microcephaly and/or change in the central nervous system which suggests congenital infection. By region, the most significant prevalence rates were 1,669 cases in Northeast, 232 cases in Southeast (Figure 2), 108 cases in Western, and 77 cases in North, but all over the country about 3,091 cases still being investigated.²⁸ In general terms, the situation has not improved, every day new cases were notified, and it seems that they were becoming unnoticed cases.

Figure 1 Microcephaly cases reported in the Northeast.

Figure 2 Microcephaly cases reported in the Southeast.

Table 1 Distribution of microcephaly cases reported, investigated, and confirmed by Brazilian states between 2015-2016.
Source: Ministry of Health (2016).

The role of the State, spatial segregation, and population health

Although the urban management and public health share a common vision on preventing urban disease outbreaks, there is no clear correlation between them and their decisions, which has contributed to uncoordinated actions.^29,30 For example, during the past decades, the Brazilian cities have suffered a significant socioeconomic transformation caused by pressures of globalization, industrial relocation (deconcentration), investments in technological development, changes in labor market, and accelerated urbanization, causing an expansion of metropolitan areas.³¹ From the beginning of 21rst century, the country was number two of the emerging economies in the world, receiving high levels of foreign direct investment as a member of BRICs.³²

Despite this positive scenario of foreign investments, the housing shortage has not significantly change, especially for the poorest in large urban centers.³³ The income per capita of people living in subnormal agglomerates (e.g. favelas) was U$ 104.20, which represented less than half of the minimum wage. In these subnormal areas, about half of the population over 16 years did not even have the full 1st degree.³⁴ Nowadays, we have 85% of the population living in urban areas; about 20% live in precarious conditions at slums.³⁵ The precariousness of employment is high, with almost 11% of the unemployed labor force and about 42.3% engaged in informal activities underpaid, with strong presence of unregistered workers and self-employed.³⁶ Brazilian cities have common problems related to inadequate urban management and lack of control over land use with abuse of Real Estate Market.³⁷ As the urban areas have spread in extension, density, and occupancy without control, the mosquito has invaded these habitats with striking speed and admirable capacity of adaptation. One outcome of this factis the evolution of commensalism or "Aedes domestication”, which results in disastrous consequences like the preference for a stable blood source.³⁸ To aggravate the situation, the water supply is irregular in the majority of poorest neighborhoods; several houses are not even connected to the public water system. For this reason, there are more possible breeding areas (e.g. water tanks, cisterns) and chances of “Aedesaegypti” survival in under-privileged homes.³⁹ The context of inadequate shelter, insufficient and unsafe water, and poor sanitation pose significant risk factors associated with outbreaks of disease.⁴⁰ The government claims that have invested in the housing sector, but in reality they invested significantly greater financial resources to the program “My Home My Life” than to the social housing programs (with a housing deficit nearly 5.8 million units). The program “My Home My Life” was created in July 2009 by Law 11,977 and actually it came to prioritize financial assistance to affordable housing for low-income households, but instead the program has favored families with income around 10 minimum wages, which correspond to the Brazilian middle class.³³

In parallel, the “BolsaFamilia” (Basic Family Aid) is the benefit offered by Brazilian government to improve the living conditions of these people, but only families in conditions of extreme deprivation and poverty have access, which means that only those with per capita monthly income of U$ 26.00 is entitled to this benefit (the scanty monthly installment of benefit is U$ 26.86). http://calendariobolsafamilia2016.org/bolsa-familia-valor/ For pregnant women, there is a benefit called Exchange Family to Pregnant Women and during the nine months of pregnancy the benefit is provided to the family of the child (the monthly installment of benefit offered to pregnant woman is U$ 12.18) http://calendariobolsafamilia2016.org/bolsa-familia-valor/ Because of government parsimony with poorest people, the majority of the low-income households have no access to public health services and hospitals (Young, 2016) and pregnant and lactating women continue to face compromised access to reproductive health (Baum et al., 2016). The health system situation is characterized by the prevalence of health facilities that are no longer fully operational due to a lack of professionals and damage to facilities, equipment and supplies, exacerbating and increasing the chances of infection and complications (Young, 2016). To worsen the epidemic situation, unsafe abortion is a “public health reality in Brazil that can bring more uncertainties about related cases and their consequences”.⁴¹

Not so simple as it seems, the decision of changing the brain size parameters (i.e.criteria for head circumference was changed by Ministry of Health on December 4, 2015) for compute the new microcephaly’s cases⁴² will not be able to contain the ferocity of the mosquito “Aedes”. Recently, Li et al.⁴³ have shown evidences that Zika virus (ZIKV) can also infect neural stem cells in the adult brain causing many damages. The analysis suggests that both adult as well as fetal neural stem cells are vulnerable to zika neuropathology. It is important to highlight that, a single mosquito survives 45 days and can contaminate 300 people. As we can notice, despite of health actions efforts and the fact that Zika virus (ZIKV) is considered a transient infection in adult humans without significant long-term effects, there may be serious consequences in the future.⁴³

Climate change and vector-borne diseases: an important reality to be considered

In recent decades, climate change has been linked to disease outbreaks^44,45,10,7 because the climatic phenomena have potential to impact any health outcome that is seasonal.¹⁰ However, it could be precipitate to make a direct cause-effect relationship between possible climate variations and zika outbreaks. Although the Earth’s climate is significantly warmer than it was a century ago, there is no evidence that climate change has specifically favored infectious diseases.⁴⁵ In the case of “Aedesaegypti”, the climate variability can produce positive and/or negative effects on the number of mosquito eggs or larvae depending on the severity and duration of weather events.⁴⁶ Over the past 30 years, the variability and frequency of droughts, storms, and cyclones have become critical issues among Brazilian experts. From a scientific perspective,^47–50 the behavior of anomalies follows the standards identified in the mathematical prediction models with more intense and severe events of temperature and precipitation (e.g. extremely cold and heat; extremely dry and rainy). Basically, variables such as temperature, humidity, and precipitation influence the mosquito development in different stages.^51,52 It is recognized that “Aedesaegypti” uses a variety of strategies to exploit the advantages of timing and location depending on climate variability.⁵ When temperature raises nearly everything about “Aedesaegypti” biology speeds up. The adult stage, for example, can range from two weeks to a month depending on environmental conditions^53,54 Under moderate temperature fluctuations,⁵⁵ the hotter the air the longer the mosquito survives as an adult to take blood, develop eggs, and lay those eggs in an aquatic setting. Laid eggs can survive for more than a year in a dry weather conditions; however they hatch immediately once submerged in water (Kearney et al., 2009), making the control of mosquito extremely challenging. The warmer the water faster it will be the transitions from egg to adult. For this reason, the level of precipitation and temperature is a critical factor⁵¹ since it creates sources of water (puddles, reservoirs, and tanks), and maintains water tables of reservoirs.⁵⁶ Besides, the increasing soil moisture has important implications on the potential distribution of “Aedesaegypti”, though malaria vector species in Africa have adapted to ecosystems ranging from humid forests to dry savannas.⁴⁴

An overview aboutregional climate phenomena

The 2015–2016 El Niño Southern Oscillation (ENSO) might has contributed to the emergence of Zika virus (ZIKV) in Latin America and the Caribbean,⁵⁷ primarily evidenced (i.e. evidence-based guidelines) at the beginning of the rainy season and higher temperatures,⁵⁸ following the same pattern of dengue epidemics that were associated with warm rainy El Niño phenomenon.^45,59,27 Generally, the high temperatures in Brazil are concentrated in the areas close to the Equator, spreading and diluting over the Western, Northeast, Southeast and South regions, but lately the average temperature in the Brazilian territory shows a progressive warming trend, mainly through the 21st century.⁶⁰ Under the Representative Concentration Pathways (RCP 4.5) scenario, the whole country has surpassed the threshold of 2˚C warming and the Western region exceeds 4˚C, indicating that the territory is likely to warm more than the world average.⁶⁰ Most regional changes in precipitation are attributed either to internal variability of the atmospheric circulation as well to global warming (Marengo et al., 2013a) that are changing the spatial-temporal distribution of temperatures (Lambert et al., 2011; Stott et al., 2010). Recognized meteorological studies^61,62 describe the pattern of rainfall in tropical Atlanticorganizedon monthly timescales into several convective zones. Basically, it depends on the development of intense convective activity over the continent in the North of the equator. The convergence of the winds associated to the meridional Hadley circulation produces a zone of intense convection recognized as inter tropical convergence zone (ITCZ). Basically, ITCZ appears as a mass of air (band of clouds) circulating the globe near the equator and its movement depends on the intensity of the northeast and southeast trade winds which is associated to sea level pressure (SLP) and sea surface temperature (SST) in the tropical North and South Atlantic.^63,50

The ITCZ is the axis of confluence of the trade winds, where the trade winds from the north and south hemispheres meet. Trade winds are driven by subtropical high pressure areas over the oceans. The mechanism of the circulation of the monsoon and the seasonal migration of the Inter tropical convergence zone (ITCZ) affect the patterns of precipitation.⁶⁴ The main core of precipitation in South American occurs in the tropical region, following the ITCZ and local low-level jet structures, controlled by thermal gradients and topography, the main mechanisms of rainfall distribution in the continent.⁶⁵ Meantime, over the Atlantic, both the transient frontal system and mean low-level convergence lead to the formation of a diagonal band of precipitation maxima, known as the South Atlantic convergence zone (SACZ).^66,67 This zone extends through the “southeastward from the great continental convective zone of tropical South America generated by moisture convergence between the South Atlantic high pressure and the continental thermal low pressure zones”^63,7,23 and is an important mechanism of long-term climate variability in Amazonia.⁴⁸ The oceanic ITCZ and the SACZ are different systems, but the summer rainfall distribution over most of tropical South America is strongly induced by these two atmospheric convergence zones.^67–70 A combination of factors related to the Sea Surface Temperature (SST) in the Pacific and Atlantic oceans can affect the dynamic of these two important meteorological systems. Both zones have a pronounced maritime component and present fundamental dynamical differences.⁶⁹ Convergence movements of the ocean-atmosphere system result in local warming of air temperatures and an increase in rainfall, basically when sea surface temperatures become anomalously warm.²⁷ The ITCZ lies over warmer surface waters, while the oceanic portion of the SACZ occurs predominantly over cooler surface waters.⁶⁹

Health risk and the“Aedesaegypti”ecology

The ecology of “Aedesaegypti” is complex and intricate, indicating a series of possible explanations for large numbers of mosquito under different latitudes. Experimental associations between climate and disease along with historical evidences have shown that vector diseases can be affected by latitudinal, altitudinal, seasonal, and inter annual variations in a nonlinear fashion.⁴⁵ High temperatures (e.g. equator and tropical zones), precipitation and humidity with availability of the preferred breeding habitats favorable to larval development at distinctive immature stages can lead to an increased number of emerging adult species.^51,46 From the bio-ecological perspective, the presence of the vector mosquito “Aedesaegypti” and the quantity of breeding grounds and nurseries are extremely important^71,72 because domestic water storage containers are appropriated sites for them.⁴⁵ Particularly, in dry periods, the irregularities or inexistence of water supply from the public sphere leads to store water in containers. In households less privileged, where the water supply is irregular, the frequent use of water storage containers such as tanks and improvised cisterns creates appropriate environmental conditions with a great number of breeding areas. Variations in climatic parameters affect the viruses and influence “Aedes” survivorship. Particularly, temperature affects the rate of development in different mosquito life stages.⁴⁵

Despite of the maximum temperature to the survival of pathogen has not been provided by IPCC (2001), the report highlights that 11.9˚C is the minimum temperature required for disease transmission, and respectively 6–10˚C is the minimum temperature for biological activity of mosquito. The temperature variability is extremely important because it affects the rate of mosquito larval development, vector size, geotropic cycle, and adult survival, as well as the incubation period of the virus in the vector.^73,74 Experimental analysis achieved by Delatteet⁷⁵ has shown the influence of temperature on immature development, survival, longevity, fecundity, and geotropic cycles of “Aedes”. Lambrechts et al. (2011) have shown that diurnal temperature range (DTR) affects the distribution and abundance of mosquito. They observed that large temperature fluctuations have reduced the probability of vector survival, but the mosquitoes have lived longer when the variation in the amplitude of daily temperature was moderate. At night, warm temperature favors the survival of “Aedesaegypti”, while cool at night is harmful to the mosquito activity.⁷⁶

Landscape and housing conditions

Indeed, as we mentioned, temperatures have risen during the last 30 years and the weather is hotter (IPCC, 2014), however “Aedes” outbreaks depends on a set of related factors .Environmental conditions strongly influence the distribution of Aedesaegypti and the risk prone areas arise as a combination of physical, socioeconomic, cultural, and institutional circumstances.^77–79 Humans travel among different climatic regions more than they did decades ago, cities in tropical countries are becoming overcrowded with multiple deficiencies⁸⁰ full of poor and unhealthy settlements, creating nurseries for “Aedesaegypti” with a set of conditions caused by disregard of building standards and lack of urban management (WHO, 2010). Fundamentally, the landscape of mosquito can be represented by a set of unhealthy conditions associated to available standing water. Eggs are laid on damp surfaces in areas likely to temporarily flood, such as man-made containers (e.g. discarded bottles, tins, tires, discarded furniture, jars, pots, buckets, flower vases, plant saucers, tanks, etc).⁸¹ Normally, “Aedesaegypti” has preference for this kind of environment selecting them for laying its eggs.^4,82 After hatching of the eggs, the larvae feed on organic particulate matter in the water, such as algae and other microscopic organisms.⁴ With sufficient water supply and suitable temperature “Aedesaegypti” can remain in the larval stage for months. Of course, there are a number of other environmental aspects that can also influence the spatial distribution of host species, such as the topography (e.g. flat areas with standing water accumulation), the human settlement density (e.g. after taking a blood meal, female mosquitos produce on average 100 to 200 eggs per batch), and other that can be equally important.

The female mosquito will not lay the set of eggs at a single site, but rather spread out over several sites, laying their eggs separately. Eggs will most often be placed at varying distances above the water line and it can take hours or days, depending on the availability of suitable substrates.⁸³ In Brazil, there is a considerable heterogeneity in the environmental conditions from neighborhood to neighborhood.⁸² The large number of vectors at lower elevations may be due to phenomenon of rapid and unplanned urbanization with presence of water-storage containers in shanty towns that represent opportunities to lay eggs.⁴⁶ Although unhealthy locations are most occupied by the poorest people, there are examples of high and middle income groups living close to informal settlements. In the last case, the decision to build in high-risk areas is a matter of available land, the wish to live in the most scenic areas, or just a matter of affordable price (with recognition or not of risks).⁷⁸ People and “Aedes” distribution are connected in many cities of Brazil (e.g. São Paulo, Rio de Janeiro, Recife, Salvador, São Luiz do Maranhão, Fortaleza), where we can find a significant amount of potable water containers and most of them have no appropriated protection.⁸² A significantly high percentage of Brazilian middle class have a private water supply system, but even in some middle class houses with running water, people use tanks to reserve the water during scarcity periods.⁸² In many cases, the tanks are reminiscent of a seasonal drought when the water supply is extremely precarious. Most informal settlements exhibit physical vulnerabilities due to their location and construction practices. Normally, these settlements are often placed on in appropriately and for habitation, most susceptible to flooding.^83,84 Squatters and slums dwellers settle in deteriorated areas of inner-city or in areas where is possible survive inside of polarized urban spaces (of poor and rich). Often, the prone areas to contamination are the only option for livelihoods and survival of many people.⁷⁸

Therefore, along with poverty conditions and inadequate settlements, the residents have become increasingly susceptible to “Aedesaegypti” outbreaks,⁷⁹ which make population particularly vulnerable to a chain of reactions such as the babies’ microcephaly and its consequences (Health Ministry, 2016).The physical exposure in squatter communities and poor settlements is accompanied by inadequate building materials and structures that are often built with non-permanent materials, such as plywood walls, roofs with cardboard, tin and wood material.⁷⁹ There is a wide range of unhealthy conditions associated, such as dark spaces without sun light, poor sanitation, crowding, and inadequate ventilation, making these places extremely hot and practically destitute of airing. A significant number of problems remain, such as absent of plumbing and sewage that normally are not affordable for households. Especially the walls, floors and ceilings of bathrooms are lined internally with un-plastered and un-lined materials that increase the humidity indoors, aiding reproduction of the “Aedes” mosquito. The most important factor for survival of adult mosquito inside the houses is the relative humidity, the best condition for this kind of mosquito, because it favors the processes of colonization and survival of these species.⁸⁵ A humid and warm ambient is pivotal to adult feeding behavior, reproduction, survival period, the rate of larval development, and speed of virus replication.

The high humidity inside the houses provides the ideal environment for adult forms of “Aedes”.⁸⁵ Caprara et al. (2009) have mentioned that would be possible to infer that constructions with high level of indoor humidity can facilitate the presence of “Aedes” adult forms, even if the relative humidity indoors or outdoors has not been measured. Identically, the presence of trees may protect these breeding areas from sunlight, as well as water bowls for domesticated animals can improve the conditions for the multiplication of larvae and increase the number of potential breeding spots. The puddles formed during the rainy season in the yards may increase humidity, which may allow adult “Aedesaegypti” to survive longer. In Brazil, unprivileged homes have possibly much more breeding suitable for “Aedesaegypti” survival.. Hales (2002) analyzed the distribution of dengue fever on the basis of vapor pressure, which is a measure of humidity, showed that annual average vapor pressure was the most important individual predictor of “Aedes” distribution. Vapor pressure proved to be the single best natural predictor for the potential “Aedes” occurrence at any given place. In fact, this variable can explain almost 90% of the variability on its incidence around the world.

Let us try to address some specific points to summarize the importance of zika outbreaks in Brazil. Indeed, the main point of this discussion is focused on the recurrent contradiction of the socioeconomic expansion(e.g. of the last decades), which has changed the main Brazilian cities, obviously not contributing to an evolution of the country, but affecting the environmental conditions, contributing mainly to health inequities experienced by specific groups of population. One of the main reasons of social deficiencies is related to some patterns of urbanization expressed by poor housing, absence of sanitary conditions, and lacking of health care. Half of the Brazilian population does not have access to sewage and the National Plan for Basic Sanitation, which establishes the universalization of services throughout Brazil until 2033 with an estimated expenditure of U$ 1,600 billion, and is not meeting the target.⁸⁶ Such of those circumstances, which imposes a marginal living in fragile environments, can be easily found in the great majority of Brazilian cities, visible to the naked eye in metropolitan regions like Rio de Janeiro (RJ), Recife (Pernambuco), Salvador (Bahia), Fortaleza (Ceara), between other.

Proper attention should be given to the fact that the vulnerability of the population and adaptive capacity vary from region to region, but normally the rapid spread of zika lied on the extension of urban areas with multiple deficiencies such as high population density, unplanned settlements, insufficient urban infrastructure, and lack of institutional capacity for dealing with burden of diseases in hazard-prone areas as well clarified by Gencer.^78,79 This also can be evidenced by the latest cases of Brazilian yellow fever in 2017. Equally, greater clarity was provided by IPCC (2014) about climate impacts on diseases outbreaks. More than ever, drought, flooding, storms, and disease outbreaks constitute our reality. El Niño-Southern Oscillation (ENSO) is expected to have severe impact over the coming years, which may also lead to extreme drought situations and overwhelming storms. Consequently, altered patterns of rainfall and temperature may change the geographic distribution of “Aedes”. For this reason, it is so important to highlight that housing conditions are particularly linked with these multiple factors that affect “Aedesaegypti” ecology, showing the intrinsic relationship among each component of environment. It should be noted that life value must be examined from the point of future view. Therefore, cities and local governments should offer opportunities to reverse the excessive concentration of population in precarious housing, upgrading interventions, and monitoring the climate conditions related to the evolution of diseases.^87–92

Environment involves factors that, for the most part, are beyond the control, because it is systemic and interconnected, with emergent properties that arise from a tangled network. It is important to observe how urban environment changes so that we can adapt our strategies appropriately. This principle highlights the statement that actions may have consequences for the individual as well as for others. In the case of microcephaly, changes in life expectancy will greatly influence individual life cycle and consequently important demographic aspects. For example, with lower birth rates or brain problems in newborns, younger generations are smaller relative to older generations. The average economic behavior varies systematically with age and health conditions. Actually, income, consumption and labor market have varied across age at different periods over the past half century.⁸⁶ Ignoring or denying the link between actions and their corresponding consequences will often make things worse. Therefore, the only way to achieve different consequences is to alter the actions. It represents great value to many economic segments because the benefits received are recognized as even greater than the “sacrifice” made. Concluding, there are no connections between government’s interventions and the veracity of health reports which suggests that special attention should be given to the provision of primary health care for the most vulnerable, reshaping the function of public sphere. The health system should be tangible for women in this situation, which means providing maternal and child health care, including treatment and prevention in areas of high impact (with zika outbreak). Accordingly, specific actions should be taken to strengthen the epidemiological surveillance system into the health and housing sectors through an integrated management system. Improvements in public infrastructure and housing are pivotal. Public plans are needed to clarify what kinds of strategic objectives the national health organization would like to achieve and how this can be done in order to prevent the negligence in socio spatial terms and the outbreak prevalence.^93–99

None.

We have no conflict of interest to declare. We warrant that the article has not received prior publication and is not under consideration for publication elsewhere.

None.

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