Zika

by Donald G. McNeil

  On the other hand, she said, nobody was sure how “efficiently” the tiger mosquito transmitted Zika.

  (Mosquitoes can be “inefficient transmitters” if viruses don’t grow as well in them, or because they wander off to bite birds or deer or something else instead of humans. Aedes aegypti is highly efficient because it will live inside human houses, breeding even in shower drains if it can. And, unlike most mosquitoes, which bite and hang on until they are full or squashed, it is a “sip feeder”—it bites three or four times, very briefly, before going off to lay eggs. So it can spread diseases within a family rapidly.)

  The rest of the conversation surprised me a bit. She was very noncommittal.

  She didn’t want to talk about Brazil and whether microcephaly was a threat. “Information is pretty limited, so it’s hard to comment,” she said.

  For now, the agency was therefore sticking with its travel advice. Brazil, like all the rest of Latin America and the Caribbean, was at a level 1 alert, which was just “Avoid mosquito bites.” That advice had been standard for a long time because of dengue and chikungunya. The CDC had no special advice for pregnant women. Nor for the Olympics. Just “If you go, don’t get bitten.”

  It felt a bit blasé. If the CDC was worried, it wasn’t showing.

  Simon’s story arrived, and it was powerful. It described pregnant women across Brazil in a panic. It quoted a health ministry official, Dr. Claudio Maierovitch, who advised that if women in the affected areas could wait to get pregnant, they should. The country normally had only about 150 microcephaly cases a year and was now investigating 2,782. Forty infants had died, and more were expected to.

  It quoted Gleyse Kelly da Silva, a 27-year-old toll taker from Recife. She had three kids, and then her youngest, Maria Giovanna, had been born with microcephaly in October. “I cried for a month when I learned how God is testing us,” she said. “I had never heard of Zika or microcephaly. Now I just pray that my daughter can endure life with this misfortune.”

  Simon’s story was up on the Times’s website on December 30 and on the front page the next day.

  From that point on, the Times was driving the story forward. We wrote about it frequently, and the stories were often on the front page and prominently displayed on the website and mobile platform.

  On January 4, 2016, the Times ran another article reporting that the United States was becoming more vulnerable to tropical diseases. Everyone blames global warming, but that was never the whole story. It was a combination of warmer weather moving mosquitoes north, of cheaper, more frequent jet travel helping more people reach new continents with viruses still fresh in their blood, and of the spread of urban slums like Brazil’s favelas, where viruses that would have died out if victims had lived far apart benefited from the multiplier effect of people being crammed close together. It was compounded by bad mosquito surveillance and the use of pesticides that don’t work anymore.

  At the time, there had been about a dozen reported cases of Zika in the United States. All were in returning travelers, who had all recovered.

  Then, on January 4, Puerto Rico reported its first case of locally acquired Zika—someone who had not been off the island recently had caught it. So now the disease was officially spreading on American soil.

  Still nothing from the CDC.

  (Actually, I learned much later that the CDC had noted the first Puerto Rico case on its website on December 31, 2015. But it kept Puerto Rico at its lowest travel alert level—“Take precautions against mosquito bites”—which was already in effect because of dengue. Its media office did not send out a news alert, and the case went unnoticed until an Associated Press reporter in San Juan heard about it from the health department on Monday, January 4, 2016, after the holiday weekend.)

  By then, twelve other countries besides Brazil were reporting locally acquired cases: Colombia, El Salvador, French Guiana, Guatemala, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Suriname, and Venezuela.

  Many, like Puerto Rico, were tourist destinations.

  I called Dr. Peter Hotez, the dean of the National School of Tropical Medicine at Baylor College of Medicine and a former president of the American Society of Tropical Medicine and Hygiene.

  He was very nervous about Zika. “Nothing does this kind of damage except rubella,” he said. Back in the 1960s, before Dr. Stanley A. Plotkin developed a vaccine, there had been an outbreak of rubella—German measles—that killed or crippled 20,000 American kids. Many had died in the womb, some had been born with microcephaly, many were born blind or deaf.

  Should the CDC issue a travel alert? I asked.

  Yes, absolutely, he said. “If my daughter was planning to get pregnant, I’d advise her not to go to the Caribbean.”

  “This is going to decimate the Caribbean tourism industry, Carnival cruises, et cetera,” he went on. “Think about it—why do you go to the Caribbean? You do it to do things that will conceive a child, intentionally or unintentionally.”

  His medical school was in Houston, on the tropical Gulf Coast, and, even though it was January, he was already imagining the city in serious trouble come summer. He had spoken to the head of communicable diseases for the city health department, he said.

  “I told him, ‘You have to do something. You can’t just wait until birth defects turn up in the labor and delivery suites.’”

  “I didn’t worry about Ebola coming to the U.S.,” he said. “This one I’m quite worried about. If this spreads, it’s a whole generation of neuro-devastated children.”

  I kept asking Tom Skinner why the CDC wasn’t issuing a travel alert. Didn’t the agency have a dengue-fighting operation in Puerto Rico? It was now on the front lines. Could I talk to the head of it?

  That official had recently retired, he said. The other people in San Juan were mostly lab people, who couldn’t comment. The vector-borne disease people were based in Fort Collins, Colorado. They saw this as like chikungunya: “There’s nothing you can do to ever get rid of all the mosquitoes. We can just keep an eye out for hot spots and try to do something about them.”

  Well what are you doing now? I asked.

  The lab people are leading classes for doctors so they can recognize the symptoms, he said.

  I started calling cruise companies—Royal Caribbean, Carnival, and Princess—to ask whether people were canceling cruises or whether they had any plans to protect guests from Zika. The first responses I got were “Zee-what?” I had to explain. Then they said they wouldn’t comment and I had to talk to the Cruise Lines International Association, which spoke for the industry.

  A spokeswoman there sent me an anodyne statement saying the association was aware that the CDC had noted a possible link between Zika and birth defects. Travelers should check with their local health authorities before taking cruises, it said, and the cruise industry “routinely instructs passengers” about wearing insect repellent and long sleeves.

  They did not want to discuss whether anyone was canceling reservations.

  It was high season, and pregnant colleagues were asking me whether I thought they should go on planned Caribbean vacations. “I’m a reporter, not a doctor,” I said. “You should get medical advice from doctors, right? OK? Good. Now that we’ve established that: No!”

  On January 11, I asked our research department to help me find women nervous about travel. Within hours, I had emails and phone numbers for people who had posted questions on TripAdvisor, Twitter, or elsewhere asking other travelers for advice about mosquitoes in various places.

  One woman I reached, Ashley, a 33-year-old lawyer, was very sweet. She was suffering a crisis of conscience: she had three young kids and was pregnant with a fourth, although it was so early that she wasn’t ready to tell anyone. Her mother had plans to take the entire family—17 people—to the El Conquistador resort on Puerto Rico. Her mom had already switched the trip from the Dominican Repu
blic because of chikungunya, and had paid $3,400 in change fees for that. And now there was Zika on Puerto Rico. Ashley was asking everyone she knew for advice because she couldn’t get any from the CDC. Her mother had two days left before she would lose her deposit.

  She had called her ob/gyn. “Normally, she’s almost overcautious, so I thought she’d say no. But she laughed and said, ‘Definitely! Go!’ Then I talked to another OB, and she said, ‘I wouldn’t cancel.’ I’m not sure what to do. I can’t be the only pregnant woman going to Puerto Rico. That’s why I posted the question on TripAdvisor. Someone wrote back to me. They said they had just been at the Conquistador, and they hadn’t even seen a bug, and there were lots of pregnant women.”

  “I’m really struggling,” she said. “Part of me feels—you have to live your life, so let’s go. I could skip going and still get hit by a car or catch West Nile or someone could sneeze on me. And part of me feels: This is my baby! I have to protect it!”

  We talked about what I knew about the virus and what experts like Peter Hotez had said to me.

  The next day, she emailed me to thank me, and said she and her husband had decided to drop out and let the rest of the family go.

  I asked her whether I could quote her—and could I please mention that she was pregnant, because otherwise the quotes wouldn’t make any sense. She said she needed to talk with her husband. She called back later to say that, since it would help other women in her situation, it was fine.

  (I later learned that El Conquistador, a spectacular Waldorf Astoria resort, was in Fajardo, on the island’s eastern tip, and that, early in Puerto Rico’s epidemic, Fajardo had more cases than any other place.)

  On January 13, I got an off-the-record phone call that pushed the CDC into action. The caller suggested I look at the website of the Brazilian health ministry because it had posted something important. I looked it up and Google-translated it.

  It was a report about autopsies on four babies; two were miscarriages, two were born full-term with microcephaly and had died within hours. All four mothers had had Zika symptoms during pregnancy. All four babies were positive for the Zika virus. In the microcephalic infants, it was found in their brains.

  This was a second smoking gun. The Brazilians had found similar results on their own weeks earlier: Zika virus in the tissue or amniotic fluid of three malformed fetuses. But this report mentioned that the lab work was done for the Brazilians by the CDC.

  But if the CDC did the work, it believed the results. This was important evidence. Why hadn’t it posted it?

  I called back the person who tipped me off. It was political protocol. The CDC had to wait for the Brazilians to announce. I said, They’re standing on protocol in the middle of an epidemic? While American citizens are waiting for advice? That’s ridiculous.

  But the person who had called me had clearly done it at the request of someone near the top of the CDC. They were trying to force the Brazilians’ hand.

  I wrote to a CDC media person and said I needed to interview someone as soon as possible about the new report and whether it was going to make the CDC change its travel advice.

  I also tried directly emailing the CDC’s head of quarantine, Dr. Marty Cetron, whom I knew from hanging around at tropical medicine conferences, to see whether he would talk to me. He said Tom Skinner would get back to me.

  Tom arranged a conference call with Dr. Lyle R. Petersen, the director of their division of vector-borne diseases.

  Yes, the report from Brazil was accurate, Dr. Petersen said. It was “stronger evidence of the linkage.”

  OK, I said—so was the CDC going to issue a travel warning?

  We’re discussing whether or not to change the recommendations, he replied.

  How can you not change them? I insisted. Pregnant women were making travel decisions right now, and you just told me you basically have proof that this deforms babies.

  Tom stepped in. “We’re optimistic that we’re going to change them.”

  When? I said.

  “We hope to have something Thursday or Friday.”

  It’s been two weeks, I said. What’s the holdup?

  “We can’t make these decisions in a vacuum,” he said. “We’re consulting with others outside the agency.”

  What others?

  “There are a lot of possible implications,” he said. “We have to implement this and get the word out.”

  He wouldn’t say, but it was obvious. For tourism-dependent countries, CDC travel warnings are nightmares. Millions of tourist dollars would disappear. Those countries would scream if the CDC suggested anyone—pregnant or otherwise—avoid them. They would complain through the State Department and the White House. The time was probably being spent soothing ambassadors who were calling their presidents. The tourism industry would scream, too, but through its lobbyists.

  So I wrote a story saying the CDC was debating whether to warn pregnant women and others against traveling. I put in Peter Hotez’s hypothetical advice to his daughter; Ashley, who feared for her baby; and described the head-in-the-sand attitude of the cruise industry. I noted that an estimated 1.3 million Brazilians had been infected, that they were now investigating 3,500 cases of microcephaly, and that the Dominican Republic had joined Brazil in saying it would advise women to not get pregnant.

  When I’d filed, I called Tom to let him know.

  “You’re writing something today?” he said, sounding dismayed.

  Yes, I said. I’m not waiting for a handout press release while you guys make up your minds. I know it’s happening.

  OK, thanks for letting me know, he said, resignedly. “I’ll give everyone a heads-up.”

  The story went up that evening.

  But the next day—nothing. I bugged Tom: Press conference?

  More likely tomorrow, he answered.

  Seriously? I thought. Seriously?

  The next day, Friday, January 15, was a circus. The CDC announced a noon press conference, then canceled it, then kept changing the hour. I hounded Tom. Just after noon, he said it would be posted on the website at one, and they would discuss it at two. “Go to CDC travel alert page and keep refreshing,” he wrote. I kept doing that. Hours went by. My “refresh” finger got sore. Editors were getting antsy. The press conference finally started at seven that evening.

  The agency issued “interim travel guidance.” Pregnant women “should consider postponing” travel to Brazil, to any of the other twelve countries with Zika transmission, or to Puerto Rico.

  Dr. Petersen described Zika as “a fairly serious problem.”

  The advice didn’t suggest that anyone else change plans because of the Guillain-Barré threat. But it did have advice for women considering pregnancy: they should “consult a doctor”—which is sometimes a CDC euphemism for “get on the Pill” when they don’t want to say it aloud because it might offend people opposed to contraception.

  The alert was for entire countries, not just regions or cities. Dr. Petersen was asked about that and said the alerts applied to “most of” each country unless there was “specific evidence” that the virus was not being transmitted in a particular region.

  That must have really upset some governments, I thought. A huge country like Mexico could have Zika in only one small region while much of the country, including mountainous destinations like Mexico City, remained totally mosquito-free. And pregnant tourists and pregnant businesswomen were still advised to avoid the entire country.

  I wondered what was going to happen when Florida had its first locally transmitted case; by this logic, pregnant tourists from overseas should then avoid even Minnesota.

  There were a lot of questions about the delay. Why had it taken so long? Dr. Cetron was on the line and said the alert affected a lot of countries and “we don’t like to blind-side partners.” The CDC had to give advance notice so other countries did
n’t “hear about it for the first time in the media.”

  It had taken a while, but the U.S. government was finally taking the problem seriously.

  The next morning, a new announcement drove home the consequences for Americans. The first American baby with microcephaly because of Zika was born. It was to a mother in Oahu, Hawaii, who had lived in Brazil the previous May, during her first trimester of pregnancy.

  6

  Fast and Furious

  THE CDC’S TRAVEL alert served as a global warning: This is dangerous. If you’re pregnant, stay away.

  People all over the world—and editors—were suddenly full of questions. What was Zika? What was microcephaly? What was Guillain-Barré? What would happen to the Olympics? What would happen during Carnival? What should people who weren’t pregnant think? What were women who were pregnant doing?

  And now that the CDC had spoken for America, what was the World Health Organization going to do for the rest of the globe?

  Up to then, the WHO appeared to be lying low. It had left most of the responsibility for tracking Zika to the Pan American Health Organization, its branch in the Americas, headquartered in Washington. PAHO’s website had much more to say about Zika than the WHO did.

  Also, the WHO tries very hard to avoid issuing travel advisories. As a UN agency, it is a big members’ club, and it answers to an annual convocation in Geneva of all the world’s health ministers. They elect the director general. It is politically very difficult for that director general, as club president, to point a finger at any member and tell the world, “His country is contaminated. Don’t go.” It had been hard enough for the CDC to warn American citizens, even though that was its national duty.

  So, two weeks later, when the WHO declared a global health emergency, it was almost anticlimactic. By that time, it was so obviously a crisis that one wanted to say, “Well . . . yeah!”