A 4-month-old baby with
microcephaly being examined in Brazil this month. Her mother was infected with
the Zika virus while she was pregnant.
Almost a year ago, the World
Health Organization declared the Zika epidemic a global health
emergency, calling for an epic campaign against a virus that few had ever heard
of. As it spread to almost every country in the Western Hemisphere, scientists
and health officials at every level of government swung into action, trying to
understand how the infection caused birth defects and how it could be stopped.
The W.H.O. ended the emergency status in November, but the
consequences of the outbreak will be with us for years to come. So maybe now is
a good time to ask: How’d we do?
Not so great, according to
more than a dozen public health experts who were asked to reflect on the
response. The battle was a series of missed opportunities, they said, that
damaged still-uncounted numbers of babies across a whole hemisphere.
“Latin America was pretty
much left to its own devices,” said Lawrence O. Gostin, director of the O’Neill
Institute for National and Global Health Law at Georgetown University. “I
didn’t see the kind of interactive response like the one that brought Ebola
under control.”
Yet there were some notable
successes. The biggest was that travel advisories issued in January kept many
pregnant tourists and business travelers from venturing to areas where they
might have been infected, with terrible consequences.
The Rio Olympics went ahead
without spreading the virus, and new diagnostic tests for Zika were swiftly
designed and deployed. Scientists are moving ahead with multiple vaccine candidates and new ways to fight mosquitoes without pesticides.
But the positives were
counterbalanced by many negatives, experts said. They harshly criticized the
partisan bickering that delayed a Zika-funding bill in Congress for months, and
they decried the failure of every city in the hemisphere — other than Miami —
to control mosquitoes.
Most praised the W.H.O. for
declaring an emergency on Feb. 1, but also condemned as premature its decision
to end it on Nov. 18.
But the greatest failure,
all agreed, was that while tourists were warned away from epidemic areas, tens
of millions of women living in them — many of them poor slum dwellers — were
left unprotected.
As a result, a wave of brain-damaged babies is now being born.
Their families are already suffering, and their medical care will eventually
cost hundreds of millions of dollars.
The failure to advise women
to postpone pregnancy, if they could, until the epidemic passed “was the single
greatest travesty of the epidemic,” said Amir Attaran, a professor of law and
medicine at the University of Ottawa.
It was “hideously racist
hypocrisy,” he added. “Female American tourists were given the best and safest
public health advice, while brown Puerto Rican inhabitants were told something
else entirely.”
A health worker carrying insecticide that being used to try to kill
mosquitoes in Sao Paulo, Brazil this month.
Politics Got in the Way
Impoverished Latin American
and Caribbean women were badly served in many ways, other experts said.
Trucks sprayed pesticides
that often did not work. Admonitions from on high to wear repellent and long
sleeves were given with no studies proving that they could protect
indefinitely.
And health authorities,
fearful of offending religious conservatives, never seriously discussed
abortion as an alternative to having permanently deformed babies — even in
countries where abortion is legal.
That reluctance created an
unusual gulf between official advice and actual practice. Many gynecologists
interviewed said privately that they offered abortions to patients whose
ultrasound scans showed abnormally small heads or brain damage.
But they did so without
official support or guidance from the W.H.O. or the Centers for Disease Control
and Prevention.
During the epidemic, when
health officials were asked why they did not advise delaying pregnancy or
seeking abortions, they said that to do so would interfere with women’s reproductive
rights or prevent older women from conceiving in time to have children.
At the W.H.O., Dr. Bruce
Aylward, head of the Zika emergency response, called pregnancy “a complicated
decision that is different for each individual woman.”
Dr. Thomas R. Frieden,
director of the C.D.C., said he followed the advice of Dr. Denise J. Jamieson,
chief of the agency’s women’s health and fertility branch, who said it was “not
a government doctor’s job to tell women what to do with their bodies.”
Dr. Gostin said he felt the
agencies had been too cautious, out of fear of criticism from women’s groups.
“Public health ought to
trump that,” he said. “Giving women advice is very different from controlling
women.”
Michael T. Osterholm,
director of the University of Minnesota’s Center for Infectious Disease
Research and Policy, gave a blunter explanation for the shyness from officials.
“The C.D.C. always gets in
trouble with Congress when it talks about contraception or bullets,” he said.
(By the latter, he meant that it was hard for the officials to point out that
gunshots are a major cause of American deaths for fear of offending the gun
lobby.)
“And abortion?” he added.
“You talk about third rails in politics? Abortion is the fifth rail. They can’t
touch it. If the C.D.C. had pushed the envelope any farther, its funding would
have been at risk.”
C.D.C. guidance on Zika was
“a little coy,” agreed Dr. William Schaffner, chairman of preventive medicine
at Vanderbilt University Medical School.
Paulo Sergio with his 6-month-old son, who was born with microcephaly in
Rio de Janeiro, Brazil.
“A recommendation to put off
pregnancy until the risk abated should have been front and center — and much
more explicit.”
Brazil, by far the
hardest-hit country in the epidemic, really let its women down, said Dr. Artur
Timerman, president of the medical society for dengue and arbovirus specialists
there.
“For religious concerns, we
have a lot of restrictions regarding advising women on birth control, so we
were very far from giving them correct information,” he said. “I think we will
have a lot of women infected yet, as we see lower levels of awareness.”
Missed Opportunities
Experts praised the C.D.C.
for its work on developing new Zika tests and getting them to state
laboratories quickly. Better antibody tests that identify past infections are
still needed.
Most countries did not focus
enough on preventing sexual transmission, experts said. Even New York City,
which has a respected health department, filled its subways with posters
showing big mosquitoes.
Yet not one of the nearly
1,000 cases diagnosed there by year’s end was transmitted by a local mosquito;
all were either picked up elsewhere or transmitted sexually.
The number of children
damaged by the epidemic is still unknown, but is likely to ultimately run into
the tens of thousands across the hemisphere. As of the end of 2016, the W.H.O.
had recorded more than 2,500 cases of Zika-related microcephaly in 29
countries.
Studies suggest that
microcephaly — which results in an abnormally small head — represents only a
small fraction of the damage done. Babies are being born blind, deaf or with
rigid limbs or frequent seizures, and it seems likely that many more will eventually
have learning and emotional problems.
The epidemic also showed
that most nations remain inept at mosquito control.
“Miami is the one place that
responded effectively,” said Duane J. Gubler, an expert in mosquito-borne
diseases at the Duke-NUS Medical School in Singapore. “Others were mediocre or
poor.”
Miami used both aerial and
ground spraying of insecticide and larvicide, along with teams going
house-to-house looking for breeding sites.
The Zika scare made
pest-control officials and local residents more willing to test new
technologies, including releasing male mosquitoes that pass on a
life-shortening gene and female mosquitoes carrying bacteria that suppress
their ability to transmit viruses.
A Dangerous Disconnect
Experts in Brazil, where the
epidemic started, said doctors there acted quickly but were often thwarted by
the country’s political and economic chaos — President Dilma Rousseff was ousted in August — or by hesitant foreign scientists.
“Brazil reacted with
seriousness and foresight,” said Dr. Albert I. Ko, a Yale epidemiologist who
has also worked in Salvador, Brazil, for many years. “The people in the
trenches, the city and state public health officials, should be regarded as
heroes.”
Both he and Dr. Ernesto T.
A. Marques Jr., an infectious disease specialist at the University of
Pittsburgh and at the Oswaldo Cruz Foundation in Brazil, said Brazilian
scientists felt let down when they looked for outside help — at first from
European donors and health agencies.
“The local researchers’ role
was mainly to collect samples,” Dr. Marques said bitterly.
The C.D.C.’s initial
reluctance to accept Brazilian scientists’ work also slowed the international
response, said Dr. Peter J. Hotez, the dean of the National School of Tropical
Medicine at Baylor College of Medicine.
Even when the Brazilians
found Zika virus in two women’s amniotic fluid and in the brain of a
microcephalic fetus, “The C.D.C. would not accept it until they had done it
themselves,” he said. “I saw that as hubris.”
The news media, for once,
got relatively high marks from the experts — or at least higher marks than it
did in the 2014 Ebola epidemic or the 2009 swine flu pandemic.
Three years ago, pictures
from Africa showing men in spacesuits carrying dead bodies exaggerated the risk
of Ebola to America, they said. By contrast, pictures of tiny-headed babies
made Americans take Zika seriously but sensibly.
“In Brazil, the press was
the first to sense that something was going on,” said Dr. Karin Nielsen, a
pediatrician at the David Geffen Medical School at the University of
California, Los Angeles, who also works in Rio. “It was pushing it even before
the medical specialists were.”
The North American media,
several experts said, did a good job debunking various myths that arose early
in the epidemic, such as rumors blaming microcephaly on genetically modified
mosquitoes, larvicide in drinking water or vaccines.
In Brazil, those rumors
diverted attention for precious weeks, even prompting some cities to stop
fighting mosquitoes temporarily.
Experts also felt scientific
collaboration often faltered. For example, plans announced in
February to gather 5,000 Zika-infected women into one study never
materialized.
One big question remains:
Will the virus return?
That is unknowable, most
experts said, because no studies show how many people are now immune through
previous infection.
Some Brazilian cities,
including São Paulo, have not had big outbreaks and may be due for one, said
Dr. Scott C. Weaver, a virologist at the University of Texas Medical Branch in
Galveston who was one of the first to predict that Zika was likely to strike the
Americas. So might Bolivia, Paraguay and Uruguay.
More than half of Puerto
Rico’s population is probably still vulnerable, so Zika may flare up again, as
it might anywhere along the Gulf Coast outside Miami.
“And even if Zika’s not bad
next year,” Dr. Weaver said, “without a vaccine, these viruses are going to
come and go.”
Global Health, By DONALD G.
McNEIL Jr. CreditVanderlei Almeida/Agence France-Presse — Getty Images
CreditPaulo
Whitaker/Reuters, CreditVanderlei Almeida/Agence France-Presse — Getty Images
