Zika (14 page)

I kept asking mosquito experts to name one place I could go where mosquito eradication was demonstrably lowering infection rates. I usually heard long pauses, followed by “I can't think of one.” It wasn't surprising. Dr. Frieden had said several times that there were examples from antidengue or antichikungunya campaigns in which mosquito populations, through herculean efforts, had been cut by 80 percent—with no effect on disease transmission. Ten to 20 percent of a mosquito population was enough to keep the virus circulating. Tests using traps inside homes showed that three mosquitos per household were enough, he said.

So how were women to avoid having microcephalic babies? To some Zika experts, the answer seemed screamingly obvious:

Women needed simply to not be pregnant. Not when the virus was peaking where they lived. Later—yes, fine, great, have children. But in the face of this unique epidemic, conception was uniquely dangerous.

And yet that insight was highly controversial for months. At the time of this writing, it still is.

For one thing, advising women to stop having children was unprecedented. Never in history had governments done so. (China's one-child policy was different: it was semipermanent and implemented for economic reasons.)

But the advice was also controversial because of the virulent reactions it provoked. Not just from the political right and the Catholic Church but from the left—from the very groups that were dedicated to defending women.

The controversy had begun as soon as the epidemic became known. The governments of six countries in the path of the virus separately made the suggestion.

In December, Dr. Claudio Maierovitch, who was in charge of Brazil's epidemic response, asked women in the northeast to postpone pregnancy if they could. Colombia and Ecuador followed suit in January, then Jamaica, El Salvador, and the Dominican Republic.

The length of their “suggested delays” kept growing. Alejandro Gaviria, Colombia's health minister, asked women to wait six to eight months. His Jamaican counterpart upped the ante: a year.
Then El Salvador proposed two years—no babies until 2018.

Roman Catholic archbishops in each country objected. There was nothing wrong with “practicing self-discipline,” as one put it, to prevent the birth of a deformed child. But if the health ministers were implying that women were supposed to use contraception, well, the church's opposition to that was well-known. It was using artificial means to frustrate the will of God. And abortion, the bishops said darkly, was of course out of the question. It was better to devote one's life to raising a handicapped child than to burn in hell for killing an innocent.

But that was predictable. The church's opposition barely made headlines. Churchmen were repeating what they had said for fifty years.

The more surprising, and much louder, backlash was from women's reproductive rights groups. They were angry because the advice came from men—not all the health ministers were men, but the first few to speak up were men from governments that had historically allied with the church.

The denunciations were furious.

They began with a January 22 Reuters story that was picked up around the world by everyone, ranging from the BBC to Fox News. It was actually a product of the Thomson Reuters Foundation, a charitable arm of Thomson Reuters that described itself as covering “humanitarian news, women's rights, trafficking, corruption and climate change.”

The article was the first to take notice of the fact that multiple governments had offered the same advice. It mentioned Colombia, Ecuador, El Salvador, and Jamaica. Journalistically, that was a coup, and refreshing. At the time, most Zika articles were bogged down in all the rumors about the “real causes” of microcephaly.

After establishing the trend—governments asking women to wait—the author asked for reactions. But she quoted only representatives of women's groups. Not a single doctor appeared in the story.

Prominently featured was Monica Roa, chief of strategy for the Madrid-based women's rights group Women's Link Worldwide, who said, “It is incredibly naïve for a government to ask women to postpone getting pregnant in a context such as Colombia, where more than 50 percent of pregnancies are unplanned and across the region where sexual violence is prevalent.”

In fact, contraception was free at Colombia's public clinics and abortion was legal in some cases. Roa acknowledged that, but said women had too little access.

That El Salvador's far more restrictive government was giving the same advice, she said, was “offensive to women and even more ridiculous in the context of strict abortion laws and high levels of sexual violence against girls and women.”

Sara Garcia, a member of the Citizen's Coalition for the Decriminalization of Abortion in El Salvador, believed advice to delay had to include a public discussion of unwanted pregnancies. “There are pregnancies that aren't planned, are imposed on women and girls and are the product of sexual abuse.”

American activists chimed in. “Once again, governments put the burden on women to protect themselves from any risk,” said Paula Avila-Guillen of the Center for Reproductive Rights in New York City.

This point of view began to snowball.

NPR's
Morning Edition
did an interview with Roa, who called the advice “ineffective, naïve and unrealistic” because so many pregnancies were caused by rape and sexual violence.

Almost immediately,
Time
magazine did a piece titled “Why Latin American Women Can't Follow the Zika Advice to Avoid Pregnancy.”

The article quoted Tara Damant, an Amnesty International activist who said governments were “putting women in an impossible position by asking them to put the sole responsibility for public health on their shoulders by not getting pregnant when over half don't have that choice.”

It also quoted Avila-Guillen, who called the advice “naïve” and “irresponsible,” noting that governments “were not issuing any recommendation for the men to use condoms, which is very unfair.”

In the United States, outrage became the conventional wisdom.

Emma Saloranta, a founder of Girls' Globe, which shared women's motherhood experiences around the world, wrote a piece called “Zika Virus and the Hypocrisy of Telling Women to Delay Pregnancy.”

The
Huffington Post
picked it up. The comments were almost uniformly favorable. Denying women both access and knowledge “sounds like a Republican wet dream.”

It also struck a chord with right-wing outlets, which dislike governments' telling people what to do in their personal lives.

When I heard it, I began stewing. Women
needed
to avoid pregnancy somehow. Because clearly nothing else was going to save their babies.

First, it seemed inevitable even in January 2016 that all the known antimosquito efforts were doomed to fail. No country in the hemisphere except the United States had stopped dengue or chikungunya, and the United States had succeeded in part because it was rich and in part because even Florida had cold spells.

Second, given that, putting all the onus on women to avoid mosquito bites seemed absurd. No one can avoid them 24 hours a day for nine months.

Third, vaccine specialists had made it clear that there was absolutely no hope of a vaccine in less than two years at the earliest.

Fourth, the outbreaks appeared to be very short-lived. Yap's peaked and crashed in five months, French Polynesia's in seven. Neither country had reported a case since, and WHO categorized their outbreaks as “terminated.” There were reports that northeast Brazil's and Colombia's were beginning to fade.

Fifth, if a woman wasn't pregnant, the disease was almost always mild. Getting it and recovering meant long-lasting protection. The disease itself was the perfect vaccine. And, if everyone around a woman was similarly “vaccinated,” there was no virus for mosquitoes to pick up and infect her with.

What governments should really do, I thought, was ask women to wait if they could—and
encourage
everyone to get bitten. Yes, there would be Guillain-Barré cases, but better that than microcephaly cases. (The typical Guillain-Barré victim is a male of late middle age or older. Even WHO crisis guidelines, which favor minimizing the loss of what it calls “disability-adjusted life years,” prioritize saving the lives of babies over saving those of old guys like me.)

Maybe, I thought, only half jokingly, people should donate blood to build up the supply of healthy plasma for Guillain-Barré victims, and then go get bitten.

Also, I was offended by the reproductive rights groups' rhetoric. I found it patronizing. In their scenarios, all women were victims and all men were monsters. Covering AIDS in Africa and elsewhere, I'd interviewed dozens of women about similar issues, and it wasn't that simple. Yes, there were teenage girls who couldn't avoid pregnancy. Yes, there were 40-year-old women who absolutely had to get pregnant. And yes, some men were monsters, and rape and sexual coercion were huge problems in various countries. But that wasn't the fate of
all
women. There were many married women with one or two children, who knew a doctor, who understood birth control. They had some power over their own bodies, and were able to say no, or negotiate a condom, or offer their partners another kind of sex. Presumably, their spouses or partners didn't want microcephalic babies either and would cooperate.

What had clearly gone wrong was that the health ministers had done a terrible job explaining
why
they were asking women to wait.

They had to realize they were not stopping the epidemic. Brazil and Colombia were already estimating millions of cases. They knew mosquito control was failing. Perhaps they didn't want to admit it. Perhaps they didn't want to insult those in charge of it—which was sometimes the army.

They also had to understand herd immunity. Most health ministers were doctors; they had studied the concept in medical school. But maybe they hadn't explained it in such a way that local reporters understood them. I'd read the stories from the countries concerned, and many of them were naïve. They quoted the ministers offering the advice, and then sometimes archbishops condemning it. But they hadn't asked, “Why?”

The debate had been hijacked; millions of poor women were being denied life-saving advice because it had become politically incorrect. I didn't see why women's groups had not taken the opposite tack. If they had embraced the advice, acknowledging that birth control and abortion would save women from misery, they could have used that as a wedge to try to get conservative governments to ignore fifty years of church pressure.

I had to see whether I was alone in this thinking. I started writing emails to virologists and public health experts, laying out my arguments above the final line: “Am I crazy? Or does this make sense?”

Almost universally, the answers came back: No, you're not crazy. Delaying pregnancy is good advice.

Dr. Marc Lecuit, a Zika expert at the Pasteur Institute in Paris who had studied Polynesia's outbreak, agreed. So did Dr. Weaver at UTMB. So did Dr. Albert I. Ko, a Yale School of Public Health infectious disease specialist who was helping set up a microcephaly study in Brazil. So did Dr. Ernesto T. A. Marques Jr., a Brazilian vaccine specialist who flew back and forth between Recife, his hometown, and the University of Pittsburgh's School of Public Health, where he taught.

Dr. William Schaffner of Vanderbilt went the farthest. Brazil had just announced that its army would join the fight. For one day, soldiers would go house to house looking for standing water and handing out pamphlets.

“They're mobilizing,” he said. “Perhaps they should also be handing out condoms.”

Everyone had caveats, of course.

“No government is going to say ‘go out and get bitten,'” Dr. Schaffner said. “Because of the Guillain-Barré risk.”

Asking people to hold off indefinitely would fail, Dr. Marques warned, because it would break up marriages.

He had another idea. When we spoke, in early 2016, everyone believed that the first trimester was the only dangerous period, so he proposed asking women to time their pregnancies so that their first trimesters did not fall in high mosquito season.

Also, the more I dug, the more the data confirmed that the reproductive rights groups had exaggerated women's helplessness. The Guttmacher Institute ranked countries according to how much access married women had to modern birth control.

Some Zika-hit countries ranked very low: in Guatemala, Bolivia, and Haiti, less than 35 percent could get it.

But others did well: in Colombia, it was 73 percent; in Brazil and the Dominican Republic, 70 percent; in El Salvador and Paraguay, 61 percent; in Ecuador, 58 percent.

Admittedly, those figures were for married women. Add teenagers, and the rates would drop. But that's true in every country, including the United States. Teenagers usually start having sex before consulting a doctor and are lucky if they have even a free condom from the basket outside the school nurse's office handy.

And Latin American and Caribbean women clearly had some power to choose. Fertility rates—lifetime births per woman—had been dropping across the region for two decades, just as they had two generations earlier in heavily Catholic European countries such as Italy, Spain, Portugal, and Ireland. The church was still effective at fighting abortion. But it had long ago lost its grip on birth control.

I also learned that there was a historical precedent for using epidemics to win reproductive rights. Long before
Roe v. Wade
, the 1964 rubella epidemic had played a role in the American abortion debate. That epidemic damaged 20,000 babies. By 1968, four states had passed laws permitting termination of a pregnancy if a serious birth defect was suspected.

On February 5, 2016, I wrote an article headlined “Growing Support Among Experts for Zika Advice to Delay Pregnancy.”