Zika (15 page)

It was on the front page of our science section and had a fair number of readers.

But it got no traction at all. Nobody openly disagreed with it. Nor was there any discussion. It just died.

The CDC and WHO continued issuing the same advice: avoid mosquito bites. Use DEET, wear long sleeves. Hold tight while we work on a vaccine.

Off the record, however, people in the CDC and its overseer, the Department of Health and Human Services, told me the issue was splitting their agencies. It had become, they said, a debate between two camps: the infectious disease specialists, who felt that asking women to delay was the only way to save babies, versus the reproductive health specialists, who said the government should not tell women what to do with their bodies.

But no one in the infectious disease camp would be quoted disagreeing with CDC policy.

Dr. Frieden later acknowledged that debate, saying my article and a set of questions I had sent him had been passed around and “triggered a long conversation.”

In late February 2016, I went to Puerto Rico, since it was a piece of America right on the front lines, where the CDC was spearheading its efforts.

Zika was just beginning to take hold on the island; there were only about 100 confirmed cases. It was not even close to the point where everyone knew someone who had had it. Nonetheless, it was expected to overrun the island eventually.
Aedes aegypti
was everywhere. Serosurveys showed that 90 percent of all Puerto Ricans had had dengue, and 25 percent had had chikungunya, even though the latter had been there only eight months.

That didn't surprise me. I attended Zika classes given at WIC clinics—Women, Infants, and Children sites that give out what used to be called food stamps, teach breastfeeding, and offer other services. Since 92 percent of all pregnant women in Puerto Rico visit them, the government deemed them the perfect place to distribute information, insect repellent, mosquito nets, and condoms, and the CDC had created a 20-minute PowerPoint presentation for them.

“Ladies, this year's fragrance is DEET,” the instructor at one class I visited said as she held up a green can of repellent—a blatant knockoff of OFF! Deep Woods.“We all should smell like this.”

But Puerto Rico had been putting out scare messages about mosquito-borne diseases for years, and fatigue had set in. When I spoke to women from the class afterward, I got very different reactions.

The first was 21 and newly pregnant. She was scared for her baby and so wore ankle-length dresses. When I pointed at her open sandals, she said she wore repellent under them.

“I take baths in the stuff,” she joked. “I put it on in the morning and in the afternoon, and again when I sleep. And my mother is crazy with the bug spray.”

The second, by contrast, was 30, in her third trimester, and wearing a tiny pink top and short shorts.

“You're not exactly mosquito-proof,” I said.

“I know,” she said, smiling and putting a hand over her cleavage. “I should cover up more. But it's hot.”

She burned citronella candles at home, she said. Her father had come over to clear her rain gutters, and she had a neighbor with a “flea machine” who had fumigated her house as a favor. She was making an effort, but it wasn't going to protect her.

A third student said she never bothered with repellent because her two-year-old said it burned. Why not just wear it yourself? my translator asked her. She shrugged. “I didn't think of that.” She lived on the 16th floor of a nearby housing project, and “mosquitoes don't go that high,” she said.

Outside, I asked the instructor whether she didn't feel she ought to set an example. She was wearing a short white medical coat and red high-heeled sandals.

“Puerto Rican women are
not
going to stop looking good,” my translator—a good-looking Puerto Rican woman—interjected.

Was she wearing DEET? I asked the instructor.

“Oh, not today,” she said. “It smells. I usually wear pants.”

Then she dropped her voice a little, embarrassed. “I should,” she said. “I'm pregnant. We just found out.”

That moment—meeting a well-educated, caring woman in the path of the virus who was so familiar with the threat that she was teaching classes in it, and who was in her first trimester of pregnancy and yet too busy or too . . . something to follow life-saving advice—convinced me that all efforts to protect pregnant women were just pointless. If even
she
couldn't be perfect for nine months, nobody could.

“What are you going to do if you get Zika?” I asked.

“I
won't
get Zika,” she said firmly.

“OK. But if you do?”

“If that happens . . . I will have to face my baby's reality.”

“What does that mean?”

“The greatest percentage of women who get Zika do not get microcephaly.”

“OK, as far as we know from Brazil and Polynesia, you're absolutely right. But if you did?”

She said, very calmly, “I would face my baby's condition.”

I knew abortion was legal in Puerto Rico. It was available in major hospitals too; women didn't have to go to a clinic with shouting protesters outside.

“You wouldn't . . . ? Consider . . . ?”

She shook her head.

That happened several times in Puerto Rico: women would not only avoid discussing abortion; they often wouldn't even enunciate the word.

I also interviewed several of the country's top obstetrician-gynecologists. Some said they were privately advising patients not to get pregnant. It was too risky.

A TV-star doctor, Dr. Jose Alvarez Romagosa, a fertility specialist who headlined a show called
Latin Doctors
, told me that he'd dissuaded three patients that day from conceiving. His partner, Dr. Hiram Malaret, said he had stopped inducing ovulation because he was worried about the babies—and the malpractice suits.

Dr. Manuel Navas, a hospital director in Fajardo, which had some of the earliest Zika infections, said he was discouraging all his patients. That was the advice he would give his daughter, he said.

When I asked what advice the Puerto Rican government was giving, I got contradictory answers. Some said it had kept silent on the issue. I'd noticed that there had been no discussion of it during the WIC classes I'd sat through.

Some, on the other hand, said the island's health secretary, Dr. Ana Ríus, had given a radio interview saying women should wait. But she had run into a buzz saw. The archbishop of San Juan had attacked her, and a popular radio host had accused her of being alarmist. She had turned shy and dropped the subject, they said.

I met her right before I left. She spoke softly and did appear to be shy. But she was adamant: her position was still that women should wait until more was known about the disease. She had asked the WIC clinics to hand out condoms for that reason, she added.

I told her I had been to clinic classes, and they weren't conveying her message. They had said the condoms were to stop sexual transmission. “I didn't know that,” she said. “Thank you. I'll talk to the lady in charge of them.”

Did she get a hard time from the archbishop and a radio host?

“Yes, I was criticized. But I haven't changed my message. I am a very Catholic person, but for me, public health goes above the norms that the church makes.”

“Besides,” she said, smiling. “I'm backed by the pope.”

(Pope Francis had recently implied that condoms might be acceptable under the “lesser of two evils” doctrine, saying Pope Paul VI had permitted nuns in the Belgian Congo to use birth control because so many were being raped during the liberation struggle.)

Why hadn't her views been disseminated more? I asked. Why no big TV and radio campaign, billboards, newspaper ads?

There was no money, she said. Puerto Rico was broke. All she did was hold a weekly news conference to update the case figures and answer questions.

On March 8, 2016, the WHO issued an advisory echoing the CDC's. It suggested that pregnant women avoid traveling to areas where Zika was spreading.

During the telephone press conference afterward, I asked, not very politely, “If you're telling pregnant women not to
visit
countries with Zika because it's too dangerous, why aren't you telling women who
live
in those countries not to get pregnant? It seems inconsistent.”

Dr. Heymann, the advisory board chairman, answered, “We don't give national recommendations.” Dr. Chan, the director general, added, “We respect the law of the land.”

I had known David Heymann for years because he was in charge of polio eradication at the WHO when I started covering it. He had a long, noble history as a disease fighter, helping eradicate smallpox and running some of the first WHO teams tackling Ebola outbreaks. He had been close to the top of the agency but had left to chair England's Health Protection Agency and teach.

I emailed him later asking for a clearer answer. Both pregnancy and nonpregnancy were legal everywhere, so “respecting the law of the land” made no sense. Besides, the advisory had advocated making birth control widely available, which did flout some country's laws.

We ended up in an email conversation that lasted several days. He said women had to make the final decision. I said of course they did, but they needed clear medical advice. He said he and Dr. Chan had hesitated because birth control must be voluntary, and can be abused. China enforced it, and India awarded poor men radios for getting vasectomies.

He was right that in Africa, Latin America, and parts of Asia, birth control–related aid from Geneva or Washington can be controversial, whether it's Norplant to prevent conception or condoms to prevent AIDS. It is often seen as white people trying to stop brown people from reproducing. To avoid that charge, the WHO avoids the term “birth control.” They call it “birth spacing,” and emphasize the health benefits to the mother of “spacing” children.

I said we weren't talking about reducing childbirths but about delaying them, perhaps only briefly, to prevent lifelong misery. I made all the arguments I'd made before, sent him my February 5 article, and told him what I'd seen in Puerto Rico.

Finally, he said, “OK, you've convinced me.” But he would have a hard time winning over Dr. Chan and others, he added.

Then he said, “Would you like to co-author an article in the N.E.J.M. making the argument?”

That was a shock. I'm a jackal of the press with no medical degree. I've learned on the job by interviewing a lot of smart people and reading their work. I'd never been invited to do anything like write for the
New England Journal of Medicine
.

I said I was honored, but I had to check with our standards editor. The editor said no, a
Times
reporter couldn't ethically cover a debate and write a paper advocating one side of it. It was frustrating, but he was right.

On March 25, 2016, the CDC modified its guidelines for pregnant women. It did so in light of growing evidence that the virus persisted in semen for weeks.

To women
visiting
Zika transmission areas, it gave highly specific advice: Any of them wanting to get pregnant should wait eight weeks after their return before trying. If their partner had symptoms, they should wait six months. If she was already pregnant, they should avoid unprotected sex for the entire pregnancy.

But for women
living in
Zika-infested areas, the guidance was painfully wishy-washy. Timing pregnancy was a “very complex, deeply personal decision,” the guidelines stated. Women should consult their doctors.

The doctors in Puerto Rico had told me how frustrating they found this. Patients were terrified. The CDC said, “Talk to your doctor.” But it gave the doctors little guidance. They felt it passed the buck. Hundreds of thousands of Puerto Rican women of child-bearing age were left groping in the dark. Florida, Texas, and other areas would probably soon be next.

A CDC “Zika summit” in Atlanta was coming up. State and local health officials were invited, as were reporters. The former so they could share strategies and hear the CDC's latest thinking. The latter because the agency and the White House wanted to reinforce the message that Congress needed to vote the $1.9 billion the president had requested for fighting Zika.

As part of my reporting on the summit, I spoke to government doctors involved in the debate. None would publicly disagree with the CDC line because the Obama administration, as many White House correspondents have pointed out, very much dislikes internal dissent aired.

One doctor, who saw patients part-time at a clinic where almost everyone was on Medicaid, was very frustrated. You can't just give
hints
about life-altering decisions, she said. “Patients need to see the advice in black and white.”

Another doctor was just livid. “The CDC guidelines are bullshit! Bullshit!” he shouted. In discussions of the February 5 article, he said, “some people write you off because they don't think Puerto Rico is like Yap. It's not like an island in the South Pacific. It may be more like Brazil—the epidemic will smolder, not disappear. Same with Florida, even more so. But they fail to see that, even if you're wrong about that, what you say has validity. One-third of all pregnancies
are
planned. Those babies
could
be saved.''

He had hoped the American College of Obstetricians and Gynecologists would come out in favor of counseling patients to wait, he said, but their new Zika guidelines were also “milquetoast.”

Dr. Laura Riley, director of labor and delivery at Massachusetts General Hospital and the guidelines' chief author, said the college's members were also split. Privately, some were suggesting delay to patients, and she had tried to let the guidelines include that, “but in ways that aren't proscriptive.”