Zika virus is not the birth defect risk Scotland should be most worried about

Images of babies with severe microcephaly caused by the Zika virus are upsetting. Our hearts go out to these abnormally small-headed babies whose lives and life chances have been compromised – as well as to their families.  

With the Rio Olympics now underway, the risks of contracting this birth defect causing illness -- from mosquito bites (or sexual relationships with those already infected) -- has received an enormous amount of media and governmental attention.

Although low – especially in Scotland (and other definitely non-tropical climates) – Zika is a risk. The warnings and advice from public health officials should be taken seriously.

In an era when brain development has become better understood and highly prized, the prospect of life-long, irreversible brain damage to a baby evokes both fear and sympathy.

And yet, it is more than ironic for Scotland’s media to be so bugged about the Zika virus. It is unlikely that even 5 babies will be born here this year with severe Zika-caused microcephaly.

Meanwhile, it is a very safe bet that at least 500 Scottish babies will be born this year with life-long, irreversible brain damage. The main cause will not be mosquitos, but rather alcohol. Fetal Alcohol Spectrum Disorder (FASD) is not new in Scotland, nor (sadly) is the societal and governmental failure to either prevent it or properly support the children and parents affected.

The startling estimate of more than 500 harmed babies born here each year – which adds up to at least 9,000 under 18 year-olds affected in Scotland today -- is based upon the most conservative epidemiological evidence from other wealthy, Western nations.

While he was still Scotland’s Chief Medical Officer, Professor Sir Harry Burns declared that fetal alcohol harm is the leading known, preventable cause of learning disabilities. Our current CMO (an obstetrician), Dr Catherine Calderwood, agrees and offers sound advice.

These harmed-before-birth babies innocently, but significantly, widen Scotland’s education attainment gap. For most brain-damaged children, this gap will remain a chasm no matter what is done later. Recent international research has also revealed a strong association between FASD and major (and costly) adult physical and mental health conditions.

As the Christie Commission highlighted five years ago, prevention remains the best choice. So, why is the Zika virus a crisis in the Scottish imagination that must be dealt with decisively, while the reality of FASD remains low on Scotland’s media and governmental priority list?

There are four main reasons:

* Severe microcephaly (like a Down Syndrome or a Thalidomide baby) is immediately identifiable, whereas (except for the smallest fraction of new-borns) fetal alcohol harm is, and may long remain, invisible.  Our emotional impulse to aid them is dulled by the fact that FASD babies usually look so normal and healthy.

* The media ‘debate’ about fetal alcohol harm has been confused and misleading; too often pitting two extreme (and factually wrong) sides against one another. People are left to choose between the scare-mongering that one drink while pregnant at your cousin’s wedding will doom your baby and the wholly–false reassurance that drinking what you want at any time during pregnancy is just fine (or the equally widespread nonsensical belief that having wine every night with dinner isn’t ‘really’ drinking). The truth is that alcohol exposure of any type during any trimester of any pregnancy carries a real, but unpredictable, risk to the baby – with the eventual individual outcome neither a positive nor a negative certainty.

* People prefer to dwell on dangers and risks for which they will never be blamed if the outcome is bad. Think, for example, of the sympathy for the innocent victims of airplane crashes (since passive passengers are never the cause of such tragedies). Feelings tend to be much more ambivalent about car crashes (even though the number of victims – and the level of risk – is exponentially higher for ground transport than for planes). That is because the behaviour of drivers is often the cause; even though these sad events are almost always rightly called ‘accidents’. Zika is analogous to the blessedly rare plane wreck, while FASD is analogous to the all-too-common auto accident.

* The lessons of Scotland’s highly successful public health campaign to reduce drink driving have not been learned in relation to fetal alcohol harm. The two-sided message: ‘If you drive, don’t drink – and if you drink, don’t drive’ helped to spark a dramatic cultural shift toward safer, healthier behaviour. The que sera sera attitude toward pregnancy among many Scots remains a cultural barrier. This ambivalence weakens effective avoidance of pregnancy (e.g. improved choices among Long Acting Reversible Contraceptives) while continuing to drink, as well as effective avoidance of alcohol while actively trying to become a parent.

Does Kirsty (the Holyrood baby) have FASD? If her mother did not drink alcohol during any stage of pregnancy, then the answer is no. If she did, then the answer remains temporarily unknown.

The time is long past due for governmental officials at all levels – and for Scotland as a caring society – to finally take robust, meaningful, early action to prevent fetal alcohol harm and to properly support people whose harm was not prevented.

Doing so emphatically does not mean naming, blaming and shaming the people involved; as that is both cruel and ineffective. Virtually no one has ever intentionally sought to harm a baby by drinking alcohol.

The starting point is to understand that it is a near universal desire (if parenthood is an option) to have a safe pregnancy, a healthy baby and a rewarding parenting experience. Preventing FASD is one crucial way to help parents really get what they already most deeply desire – as well as to save a huge amount of money for the public purse and end the even higher human and social costs. That, in turn, requires helping prospective parents deal well with the forces – individual and societal -- driving them to drink (when doing so is contrary to their own long term goals).

Fetal alcohol harm is one, but only one, of the major risks to the pregnancy and birth outcomes Scots want for themselves and their babies. The missing piece across our nation is fully preparing for pregnancy and parenthood across the life course. Fathers truly matter (whether positively or negatively and by their presence or their absence). And yet, the key is for girls and women to feel, and be, empowered and well informed about their reproductive options. Being in control of whether to get pregnant at all; with whom; when; and, under the circumstances most likely to lead to the outcomes they want, has not been a strong enough priority across Scotland.

Preparation is the essence of the last stage of preconception health, education and care. For more up-to-date information, international evidence and Scotland-specific recommendations, please read my work for NHS Greater Glasgow and Clyde. 

Scotland’s future seems particularly uncertain at the moment. There are challenges, opportunities and unresolved issues galore. But, one certainty is that this new Scottish Parliament will be making decisions, allocating resources and taking (or failing to take) actions that will profoundly affect the roughly 350,000 pregnancies and 250,000 live births of babies across Scotland over the next five years.

These are the younger members of the Holyrood baby’s generation. Like Kirsty’s future, their fates will be influenced powerfully by the choices Scotland’s public sector makes, as well as by those made by individual parents, families and communities.

‘Blame It On Rio’ was a cute film title. But, neither Rio nor the Zika virus is the challenge of Olympian proportions facing Scottish babies or the adults having responsibility right now for their health, wellbeing and life chances.

FASD is one, but only one, of Scotland’s very real and present dangers. The bite of Zika-carrying mosquitos pales in comparison to the bite that alcohol during pregnancy continues to take out of Scotland’s health, education and increasingly scarce public resources.

What we collectively decide -- and then actually do -- will determine what kind of nation, and what kind of society, Scotland will become by 2020. Will we be gold medalists or merely ‘also ran’s in events having repercussions far more enduring and significant than any results at the Rio Olympics?

Whether we implement, or continue to side-step, preconception health, education and care is a good test of our nation’s resolve to live up to our rhetoric.

Dr Jonathan Sher is an independent consultant based in Edinburgh. In addition to authoring two recent e-publications on preconception health, education and care, he led Children in Scotland’s development of the first, and still active, on-line course/resource on fetal alcohol harm commissioned by NHS Education Scotland in 2013​