We are not ready in so many ways.
Given that the Zika virus and the mosquitoes that carry it from one human to another have been advancing north from South America through the Caribbean and Mexico, and that parts of the USA share the same permissive semi-tropical environments necessary for the disease to spread, most public health scientists and officials have assumed that home-grown Zika disease and its sequela would show up in the course of time. Officials in North Miami, Florida believe that time has come. Even with all the warning in the world, Congress could not be persuaded to act before leaving Washington for vacation. Imagine, public health being sacrificed at the altar of political control and the national shackling of anything having to do with women’s health policy to a self-defined pro-life lobby and the religious dogma that supports it. The failure to prepare now, as it has been in the past, is all about control of the levers of power that drives political life.
Background.
People, including pregnant women who have contracted Zika virus, have been present in the USA for some time, having caught the disease while traveling abroad in endemic areas, or having acquired the disease sexually from partners who did the traveling for them. (Yes, Zeka is also a sexually-transmitted disease.) Since the virus can linger for months in various places within the human body, we can assume that transfer of the disease by nonsexual intimate contact or exposure to body fluids is also possible. Blood donors in parts of Florida are already being told not to do so, and testing of donated blood for the virus more broadly is being advocated. It is likely that Zika is here to stay for a while, if not forever. “So what?” you may ask.
What is the risk of Zika infection?
Many if not most Zika infections are asymptomatic – a person does not realize that they have even been infected. This of course makes control of the disease even more difficult. For most of the rest of infected people, the disease runs a self-limited, if uncomfortable course with the fever, aches and pains, and rashes commonly found with other viral illnesses. For a very few people, the virus is associated acutely with significant and occasionally fatal neurological syndromes of the auto-immune type. It is important to note however, that follow-up of people with Zika has not been long enough to be confident about the presence or absence of other longer-term sequela of the disease.
The worst part.
The very real and most apparent acute complication of Zika is its effect on the development of the fetal brain. The virus has been shown in the laboratory and in human specimens of fetal tissue to have a special affinity for developing neurons, at least in the brain. In its more severe form, and especially if contracted in the early months of pregnancy, it results in the syndrome of microcephaly in which the entire head of the fetus or delivered child is much smaller than normal. Microcephaly is associated with profound intellectual and functional disability. In the days of the circus sideshow, such people were displayed as “pinheads.” Hundreds of such children have been born in south America. Any remaining microcephaly-deniers are either frankly ignorant science-deniers in general, or perpetrating a cruel hoax on people whose lives they are trying to control.
Advanced microcephaly is only the tip of the iceberg in terms of damage to the fetus. It is only manifest when the physical bulk of brain damage is so great that the growing skull does not have much brain tissue to enclose. We must assume that less extensive brain damage can occur that will not show up for months or years after an infected child is born. While obvious microcephaly or brain calcifications indicative of damage can be detected by maternal ultrasound or X-ray in the later stages of pregnancy, lesser degrees of brain damage will be undetectable at any stage of pregnancy! This is the reason behind the current emphasis on prevention of pregnancy in areas where Zika virus is present. At least one child with microcephaly has already been born in the USA. Others will undoubtedly follow with devastating effects on the children themselves and their families. An article in yesterday’s New York Times describes the the painful experiences now occurring in our own Puerto Rico where responses to the epidemic have faltered.
The way forward.
We have time-tested if not guaranteed-effective paths to follow. There is currently no treatment for the primary Zika virus infection itself other than providing symptomatic relief. An effective vaccine to prevent the disease is at least a year and likely several years away. Even then there will be the same barriers to the universal immunization necessary to confront the disease that currently has allowed the reemergence of several childhood diseases in the USA. We will simultaneously have to continue our centuries-long battle of mosquito control, but do so without killing off every other living thing including ourselves. The operative word here is control, not elimination of Zeka – which may be impossible. Our medical, public health, and scientific communities know what they have to do, but they need resources and the cooperation of the public to proceed.
You would think that our elected officials would be hot on the case to get the ball rolling. In my opinion, they have betrayed us, deciding in the best political tradition that trying to make the other guy look bad yields a safer, easier, and more profitable result than trying to do something good. The first thing I learned in my education as a lobbyist was that it is easier to kill a bill than to pass one. And so it is in our current Congress which adjourned for the summer without passing a Zika bill that it has been kicking around for months. Want to bet they will not come back early for a fix?
The stalled Zika Bill.
The House passed a bill that would provide $1.9 billion for research, education, and control, but it has failed to pass the Senate. Neither side is without some blame, but I assign the most blame to the Republican party which attached a number of poison pills to the bill that they knew Democrats could not swallow. The current bill sleeping in the Senate has been reduced to $1.1 billion, contains prohibitions against support for Planned Parenthood or similar woman’s health programs, reduces environmental protection laws for the benefit of the chemical Industry, and pays for the Zika initiatives by taking the money from our Ebola virus program. That party seeks also to damage further the Affordable Care Act, and to allow the Confederate flag to be flown in federal cemeteries. Even a Republican Senator from Florida is blocking the bill! One wonders if his tune will change when he returns from vacation. For now, legislative blackmail prevails. Public health officials are dismayed – as should be all of us.
There are a variety of political positions and strategies in play here, but the overriding factor is legislators’ fear of losing their seats because of actions by the pro-life and religious lobbies. In my opinion, even the Centers for Disease Control – which after all is just another governmental agency worried about what Congress will do to its budget – has been soft-pedaling its advice to the public about the dilemma we face from Zika virus. It has emphasized what we do not know at the expense of what we do as though there were no action that women of child-bearing potential and their partners needed to take right now. I do not recall seeing the word contraception used, and certainly no mention of the option of termination of pregnancy let alone use of the word abortion. Clearly prevention of pregnancy and abortion are the respective elephant and gorilla on the table!
Picking up the pieces.
We can deal collectively with prevention, treatment, and mosquito control. It is in dealing with the consequences of maternal, fetal, and neonatal Zika virus infection where our most difficult challenge lies. The current bills are silent on providing support for children and their families facing lifetimes of social and financial distress. In a webcast sponsored by the Kaiser Family Foundation– my hero in the constellation of organizations purporting to represent family values – it was estimated that the family with a child profoundly affected by Zika brain damage faces between $1 and $10 millions of lifetime expense. Blocking facilitated access to contraception or safe and accessible abortion, and rolling back the safety net of the Affordable Care Act and Medicaid expansion are exactly the wrong things to do medically or ethically! Sabotage of the Zika Bill assumes elements of true evil if such action is taken as an additional attempt to damage the legacy of a black President, or worship at the alters of a single religion or to the Confederate flag.
CBS News reports the Center for American Progress’s estimate that half of the 2 million women in the USA who will get pregnant this year live in areas potentially at risk of Zika infection. I cannot confirm this statistic, and we will not know what proportion of infected pregnant women will bear affected children until the epidemic is further into its course – but we are talking about many more than a handful. However, even a single woman who is not provided with fully informed options uncensored by religious dogma, or who is blocked or dissuaded from accessing legal medical and ethical intervention is one too many. We are not going to be able to control Zika this season. Vague mumblings about the need for abstinence, safe sex, or family planning are in my opinion cynically cruel and allow for much less than the fully informed status necessary for self-determination, personal liberty, and promotion of the general welfare.
It is not going to be easy.
The public discussion we must have today is going to be difficult. Some will oppose any promotion of contraception. We will be talking about abortion at earlier stages of pregnancy than we may be comfortable with. Waiting six months to learn if your fetus will have a life-long debilitating disorder is too long. Given currant limitations of diagnosis and prognosis regarding fetal Zika infection, some women and their partners will rightly want to make decision about abortion before it becomes even more painful or perhaps illegal.
As I have written about this matter earlier, we as a society have become more comfortable with making quality-of-life decisions at the end of life – even to the point of a permissive or assisted ending of one. It is therefore not inherently unreasonable to make the same kind of decisions at the beginning of life. Some will counter that doing so places us on a slippery slope towards the ugliness of eugenics, of holocaust, or even murder. There is some internal logic to such warnings. However, this argument, like that of exploiting an excessive fear of unintended consequences, cannot and must not be wielded to prohibit any change at all. Our evolving society allows it to view even weighty matters in different lights.
Life is complicated. The decisions we must make as individuals and as a society about issues like end-of-life decisions, contraception, or abortion are not, and never have been simple or easy. In my opinion, if consideration of such value-laden matters is not difficult, we are going about it wrong. If there exists any circumstance in which contraception and abortion are justifiable and should be safe and available options for women, the current epidemic of Zika virus proves the point.
Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
31 July 2016
In July 2016, the CDC published an Interim Response Plan to America’s Zika problem offering advice to health professionals and the public including on what to do with regard to pregnancy. In its 57 pages, the words “contraception” or “contraceptive” were found 8 times. The words “abortion” or “termination” were not found at all.
I have argued that censoring information given to participants in clinical research trials by excluding advice about contraception or the option of terminating an unplanned pregnancy is to provide less than fully informed consent. Termination of a Zika-infected pregnancy for medical reasons is the gorilla in the room. Not to mention this most difficult matter at all is in my opinion a similar unjustifiable lack of candor.
Locally acquired cases of Zika virus are now being reported in Miami Beach and on the Gulf Coast of Florida. Seems to me the cat is out of the bag. Given the severe flooding and social discombobulation in Baton Rouge LA, the entire Gulf Coast region is at risk.
Is should be no surprise by now that the Zika Virus is proving to be much more nasty than had been hoped. Microcephaly is clearly the tip of the iceberg. Destruction of developing nerve cells will be a real problem even for many with normal sized skulls. It is now also being pointed out that adults have a reserve of “young” nerve cells that allows for limited neuron replacement during adult life. If these are vulnerable, we may not know how “benign” the disease is in adults for many years.
The vulnerability of fetal and developing nerve cells was demonstrated very early in the course of the epidemic. I remain critical that the risk to the fetus was downplayed in what was in my opinion misplaced concern over how some religious communities would react. Women who acquired Zika infection during their pregnancy are currently being encouraged to register with health authorities so that the outcomes of their pregnancies can be “followed” to learn about the natural history of the disease. I cannot keep the Tuskegee study out of my head. Studying the natural history of syphilis was the stated goal of that thoroughly discredited research in which black men with syphilis were not offered an known effective medical intervention or even informed that an intervention was available. In my opinion, instead of emphasizing what was known, CDC recommendations to the public over-emphasized what was not known.
The Wall Street Journal reports today (subscription service) that six more cases of Zika virus infection have been discovered in the same Miami neighborhood as the first four. The new cases were all asymptomatic and discovered during a door-to-door urine collection screening initiative. There are undoubtedly more out there.
By 2:00 pm there are a total of 14 local cases!
On Tuesday there was a nice article in the Washington Post on the outbreak so far and its effect on tourism. A worried Gov. Rick Scott (R), formerly having done business in KY, tells tourists to come on down to a state “safe and open for business.” Just bring your bug spray. This reminded me of the Mayor’s welcome in the movie,”Jaws.” Just as it took the threat of losing NCAA games to get its Governor to rewrite his prized Indiana discriminatory laws against LGBTs, so the financial consequences of using public health as a tool of blackmail may get the ball rolling. Policy is the fruit of politics. It is said in the halls of congress that “politics trumps policy.” That is usually true, but not necessarily right.
Dear Professor:
I signed up for your email because I though I would get information about health policy issues in KY. I assumed that I would get information based on science. I am disappointed by this most recent issue. It is a thinly veiled anti-abortion screed, using the Zika virus as a pretext. I’d love to hear about the Zika virus and what we as health care professionals should know. An apolitical voice would be appreciated.