Zika (16 page)

“Telling women what to do in the midst of an epidemic is difficult,” she said. “For some people, 22 or 24, if there's an ability to wait, and you give them the tools, it makes sense. Our guidelines talk about making contraception available and talking to the patient about them. But if you're 41, it's not practical.”

The CDC, to which she was a consultant, “is stuck with the political situation,” she said. “Even if they said ‘Delay,' by the time it worked its way up through HHS and government, those lines are going to come out.”

If politics were holding the CDC back, I asked, couldn't her college, which had both private and government doctors as members, push them in that direction?

“Medical societies don't want to come out with recommendations different from the CDC.”

Later, Dr. Jeffrey S. Duchin, chair of the public health committee of the Infectious Diseases Society of America, used much the same language. The IDSA had not discussed the idea, he said, and even if his committee took it up and decided delay was sound advice, it was controversial, and he doubted the society would want to “get out ahead of the CDC.”

At the Atlanta summit, I sat next to Tom Skinner. I asked who the philosophical leader of the reproductive health camp was, and he pointed to the woman in a blue military Public Health Service uniform then at the podium, Dr. Denise J. Jamieson, an ob/gyn and team leader in the CDC's women's health and fertility branch.

Dr. Frieden confirmed that he was “guided by Denise's perspective as an ob/gyn” and added, “Here's one thing I've learned at CDC: if you're in disagreement with Denise Jamieson, you're probably wrong.”

I asked for an interview, and got permission for one. Every such request at the CDC has to be cleared. The interview quickly turned tense.

I went through my thinking about the unstoppable nature of the epidemic and the possibility that avoiding pregnancy, at least during the transmission peaks, could be the only way to prevent microcephaly. Why, I asked, would the CDC not advise women to wait?

“Some countries recommended that during the 2009 flu pandemic,” she said. “It was very poorly received.”

I covered that flu pandemic, I said. I never heard that. What countries?

She had been working in South Africa then and couldn't recall right now, she said.

Nonetheless, I said, delay would prevent microcephaly.

“Yes, it would,” she said. “But you'd also prevent
wanted
pregnancies, like those in women getting older.”

Since when do older women want deformed babies? I said.

“Most women in Zika-endemic areas will have healthy babies. The majority will.”

“Yes, but some
won't
. I don't see why you say it's ‘not a government doctor's job to tell women what to do with their bodies,'”

“That's right. It's not.”

“Well, why do women go to gynecologists, except for advice about what to do with their bodies? Don't you tell women who are marrying HIV-positive men to use condoms? The CDC keeps saying pregnancy is a ‘very complex, deeply personal decision that only a woman can make for herself,' right? But so is a double mastectomy. That's deeply personal advice about what to do with your body. Of course, the woman can only make it for herself. But if she has cancer, and you're her oncologist, and you don't tell her, ‘Ma'am, you need to have this operation or you'll die,' aren't you guilty of malpractice?”

She stayed firm.

“I think the government getting involved in highly personal decisions about when to have a baby is not likely to be very effective,” she said.

“Suppose you were in your job in 1964, and you knew that huge rubella outbreak was starting. There was no vaccine. You knew the consequences. Babies would suffer. What would your advice have been then?”

“I'd say, ‘This is an extraordinarily risky time to get pregnant.'”

“But you won't give the same advice now?”

“This is different. There was no vaccine then. Highly motivated women can avoid mosquito bites.”

“For nine months, 24 hours a day? Is that realistic?” I described what I'd heard from pregnant women in Puerto Rico.

“Well,” she said, “that gets to the limit of our ability to make recommendations.”

“To women who
visit
Puerto Rico and the Virgin Islands you issue very time-specific guidelines—wait eight weeks, wait six months, etc. Those are mostly white women, tourists. But to the women who
live
there, who are brown and black, you only say, ‘It's a very personal decision.' Their kids may end up deformed. What do you say to the view that that's racist? That, since it potentially kills babies, it borders on genocidal?”

“We'll give the same advice in Florida if and when there is ongoing transmission.”

“I spoke to ob/gyns in Puerto Rico. They say they want leadership on this, and there isn't any.”

“This
is
leadership. What we're saying is, ‘It's an individualized decision. It's not the same message for everybody.'”

No matter how aggressive and rude the question, Dr. Jamieson answered it. She didn't dodge. And she stuck to her principles and her argument. Journalistically, I had nothing to complain about.

On April 14, 2016, I wrote another article, entitled “Health Officials Split Over Advice on Pregnancy in Zika Areas.”

By this time, outside experts were even more aghast at the CDC's reluctance.

“It's a no-brainer,” said Peter Hotez, dean of the Baylor tropical medicine school. “They should say, ‘Don't get pregnant—watch TV for six months and you won't have a badly hurt baby.'”

Houston had just had a flood and was swamped in water. He published an op-ed piece in the
Times
saying how dangerous the summer was likely to be.
CBS News interviewed him, and he took the camera crew around a poor neighborhood, showing them old tires full of water that were mosquito havens.

He told me that he had specifically said during the interview that women in Houston should consider not getting pregnant. CBS decided not to use the statement.
He had said the same thing when
PBS NewsHour
interviewed him on April 18, and PBS did use it.

As of this writing, the CDC and the WHO are unmoved. Dr. Aylward acknowledged that the WHO was having its own internal debate—“theoretically, many have thought it may work”—but it was not going to issue official advice. There were too many unknowns, he said, including how long to wait. In a country of 200 million like Brazil, the epidemic would not necessarily fade away as it had on islands, and the risk period was now the whole pregnancy, not just one trimester.

PAHO was leaning more toward nodding approvingly as individual member countries suggested it. Dr. Marcos Espinal, who was running that agency's response, said he “did not have a problem with waiting three to six months,” as Colombia had suggested. “But I do have a problem with two years,” as El Salvador had, he said. “You're changing a whole generation.”

It could be argued that thousands of children with birth defects could change a whole generation to an even greater extent.

12

The Future

W
HAT NOW?

No one knows for sure. The epidemic is still emerging. Predicting how viruses will behave is a fool's errand. Predicting people is worse.

But some things are clear:

Zika is very much on the move. Transmission is increasing in Central America and the Caribbean, and will keep doing so at least until the fall. The disease is now headed for its first summer in the United States, where no one has immunity.

That doesn't mean an explosion is inevitable. The CDC expects “limited clusters” anywhere in Florida or in parts of Alabama, Louisiana, Mississippi, and Texas close to the Gulf of Mexico. Hawaii is also considered vulnerable. That has been the national experience thus far with dengue and chikungunya, which are carried by the same mosquitoes. There have been pockets of cases in Key West and Martin County in Florida, in Brownsville, Texas, and on several Hawaiian islands.

But the outbreaks stayed small because most Americans, even in poor neighborhoods, have screened windows and air-conditioning. From a mosquito's standpoint, we live in nearly impregnable castles. American children don't usually get dozens of bites each night as poor children in Brazilian slums do, so the mosquitoes can't spin up a viral whirlwind by transferring it frantically from neighbor to neighbor.

The other reason earlier outbreaks never spread was that the authorities sprang into action fast.
In 2009, it took only three dengue cases in Key West for the Florida Keys Mosquito Control District to roll out its helicopters and truck sprayers, to send teams down the island's streets with pesticide foggers and backpack tanks that shot larvicide into pools of water, to disperse other teams that went house to house asking residents to check their birdbaths and gutters, chlorinate their pools, and drop larvae-killing pellets into everything that collected rainwater. It was an impressive effort; although the outbreak ultimately lasted two years, it was held to ninety known cases.
Even more impressive: the first case was in faraway Rochester, New York, in a woman who kept going back to her doctor saying, “I don't feel right,” even after the doctor had diagnosed and treated her problem as a urinary tract infection. Eventually, on her third visit, the doctor consulted an infectious disease specialist, who suggested a dengue test because she had visited Key West—even though dengue had not been seen in Florida since 1934.

However, Zika is different. Many dengue victims and 80 percent of all chikungunya victims see doctors quickly because they have high fever, headaches, and joint pain. Outbreaks are spotted early.

But 80 percent of all Zika cases are silent, and many symptomatic ones are mild. People often ignore early signs for days and call a doctor only when they look in a mirror and see bright red bloodshot eyes and a chest covered with a rash.

As a result, outbreaks may spread widely before anyone calls the mosquito teams. The more that happens, the thinner the teams get stretched.

Zika's spread may end up more closely resembling West Nile's. That virus also has silent cases. It's unlike Zika in that it's carried by
Culex
mosquitoes, which live all over the country. Also, it must simultaneously circulate in birds, whose hotter blood amplifies the virus enough for new mosquitoes to pick it up and infect humans. Nonetheless, despite helicopter spray flights and plenty of scary public service announcements when it arrived, it proved unstoppable. It entered the United States in New York City in 1999 and made its way slowly but steadily west for six years. All that held it up was winter. It moved a few states west each summer, then had to wait for the birds and mosquitoes to come back. It didn't really infest the Pacific Northwest until 2005.

West Nile is now endemic in the United States. It circulates every summer. About 2,000 cases are diagnosed each year, and about 100 persons die of it; the typical victim is a man over 65. Occasionally, there are sudden outbreaks, like one in 2012 that killed 69 people in Dallas–Fort Worth, pushing that year's death toll to a record 286.

Even if something like that happens with Zika, there will probably never be a huge surge of microcephaly in the continental United States. If West Nile caused brain damage in 1 in 1,000 cases, then 2 babies would be harmed each year. (One-in-1,000 odds is a very crude estimate from Brazil, where it was estimated that 1.3 million infections occurred in 2015, and the country has had more than 1,400 confirmed cases of microcephaly. But cases are still being confirmed and infection numbers in Brazil are still growing, so the ratio could change.)

But there is no guarantee that Zika will follow that pattern. There are too many uncertainties. How far
Aedes aegypti
will range this summer will depend on how hot and wet the weather gets.
Aedes albopictus
mosquitoes will range farther, since they tolerate lower temperatures, but whether they will aggressively spread Zika is still unknown.

If the virus is ever going to hit hard, this summer will be its best opportunity, since virtually no one is immune. If it persists and becomes endemic like West Nile, each summer's outbreaks will be limited by the growing portion of the population that is immune.

On the other hand, if it does that, it will never completely go away. Even if many women choose to hold off getting pregnant this summer, that can't last forever, so they will eventually be at risk. Their best hope will be a vaccine.

Dr. Stanley A. Plotkin, inventor of a rubella vaccine, predicted in January that making a Zika one would be relatively easy. Vaccines against other flaviviruses, including yellow fever and Japanese encephalitis, already exist. So it should be possible to take the “spines” of those vaccines, he said, and just attach Zika antigens, the proteins that provoke the immune system to make the right antibodies.