A report by Donald G. McNeil, Jr. for The New York Times.
The Zika epidemic that has spread from Brazil to the rest of Latin America is now raging in Puerto Rico — and the island’s response is in chaos.
There are only about 5,500 confirmed infections on the island, including of 672 pregnant women. But experts at the Centers for Disease Control and Prevention say they believe that is a radical undercount.
Most never get tested. Tests on donated blood, the most reliable barometer of the epidemic’s spread, show that almost 2 percent of the donors were infected in the last 10 days.
The proportion of pregnant women testing positive for the virus has risen sevenfold since January, the agency said on Friday. Officials warned that hundreds of infants could be born with microcephaly in the coming year.
Obstetricians, too, are quietly urging their infected pregnant patients to have regular ultrasounds and to consider abortion if brain damage turns up.
In an office at the University of Puerto Rico Hospital, the gentle curves of the graph on Dr. Alberto De la Vega’s computer screen trace a horror story. They are the head circumferences of dozens of fetuses whose mothers have been infected with the Zika virus for at least a month — and almost 75 percent are below the mean; normally, only half should be.
Only one was clearly microcephalic, with the extreme shrinkage and brain damage that is the worst consequence of the infection, and that curve abruptly ends: The mother chose abortion.
“We may be facing a generation with learning and behavioral disabilities,” he said.
On the scan of a patient who had fled his office fighting back tears, he pointed out three large white spots — clumps of dead cells.
A ‘Very Dire’ Situation
Cases of Zika infection are expected to keep rising through October, and by year’s end, a quarter of the island’s population of 3.5 million will have been exposed, a “very dire” situation, said Dr. Lyle R. Petersen, the C.D.C.’s chief of vector-borne diseases and director of its fight against Zika.
In a normal year, that would mean about 8,000 infected pregnancies, but the birthrate is dropping rapidly, said Jose A. Lopez, the health department’s demographer. In past years, births normally outnumbered deaths by about 400 per month, but since January, that ratio has reversed itself, and there have been, on average, 135 more deaths than births.
Federal health officials have accused Congress of stoking the epidemic here by failing to appropriate $1.9 billion requested by the administration to fight the Zika virus. But the story on the ground is far more complex.
In February, the governor’s office and the health department announced ambitious battle plans. Millions of old tires where mosquitoes breed would be collected. Cemeteries would be drained of standing water.
Septic tanks and water meters would get screens, as would all schools attended by girls old enough to get pregnant. Teams would visit pregnant women’s houses to spray larvicide and screen windows.
Some of that was done, sometimes effectively. Humacao, a town on the southeast coast with pharmaceutical and electric plants that provide a steady tax base, moved faster than most municipalities, said José L. Báez, its chief of emergency management.
Workers collected 200,000 tires, packing them into two abandoned factories. At the local historic cemetery, teams filled empty urns with sand. Spray trucks worked steadily.
But it was never enough. Discarded tires kept popping up on roadsides. Mosquitoes bred in garbage cans. Teams could not legally enter abandoned properties or even fill depressions in privately owned graves. The town’s permethrin insecticides turned out to be ineffective, and daily rains washed away previous efforts.
No cutting-edge plans like releasing genetically modified mosquitoesare ready for deployment yet. The C.D.C. lab here has developed a bucket trap that drastically cuts mosquito populations, but millions of them would be needed to cover the island.
Modern spray nozzles and GPS-guided planes were more accurate, he argued, and superfine mists with small amounts of naled would drift into houses where mosquitoes hid in closets. Counties in Florida and Louisiana had recently knocked down populations of the yellow-fevermosquito by up to 99 percent with naled, he and others noted.
Puerto Rico rebelled. Protest marches drew hundreds wearing gas masks and carrying bee puppets. Top radio personalities, already angry over Congress imposing a control board to run the territory’s finances, accused federal officials of “colonialism” and reminded listeners that the military tested Agent Orange on Puerto Rico’s jungles before deploying it in Vietnam.
Medical groups joined the opposition, including the largest, the Puerto Rican College of Physicians and Surgeons. Dr. Iván González Cancel, a surgeon famous for performing the island’s first heart transplant, denounced the plan, saying: “I don’t believe in conspiracy theories, but I think this is an experiment with the C.D.C. using Puerto Rico as a laboratory.”
That same week, Dr. Johnny Rullán, a former health secretary advising Governor Padilla on the epidemic, gave up his post, saying the whole atmosphere had become too vicious. Since January, he had held town meetings explaining the mosquito control plans to skeptical audiences. “I felt like a scratched record saying the same things over and over,” he said. When he endorsed aerial spraying, he was falsely accused of plotting to make millions by basing planes at a remote airport he was accused of owning. (It is owned by someone with a similar name.)
He resigned and left for a vacation in Spain. “In October,” he said, “I’ll write something saying, ‘I told you.’ ”
Seventy-two apparently healthy babies have been born to infected mothers while only one stillborn fetus has shown evidence of microcephaly, so no disturbing pictures of tiny-headed babies, like those in Brazil, have appeared. Although officials have explained that most of the 72 mothers were infected late in pregnancy, the sense that the danger is remote persists.
“Never!” she said loudly. “It’s stinky. And I don’t know anyone who’s had Zika.”
Asked how she protected herself, she mimed slaps to her bare arms and legs. “I smack every one I see.”
Indeed, the fight against birth defects is taking place largely in face-to-face meetings between doctors and patients like Ms. Sanchez.
Many obstetricians said they were urging women to put off pregnancy. And through the CDC Foundation, pharmaceutical companies like Bayer, Allergan and Merck have donated or discounted more than 100,000 sets of IUD’s, implants, vaginal rings and other contraceptives.
“I tell my patients: ‘If you can avoid pregnancy for one year, please do,’ ” said Dr. Carmen D. Zorrilla, founder of the University of Puerto Rico’s Maternal-Infant Studies Center, the territory’s leading maternal H.I.V.unit, which now holds workshops in Zika-related care.
Some religious women will say, “‘But this is God’s gift,’ ” Dr. Zorrilla said. “But at the same time, they’re afraid to have a baby they know will need assistance 24/7 for life.”
“Anecdotally, they’re on the increase,” Dr. Rullán said. “One doctor told me he did 15 in a period where he normally would have done one or two.”
Her fetus is 23 weeks along. On sonograms, Danelle, 36, can see a face, even hair: To her, the outlines resemble a small, sleeping child, nestled against the placenta as if it were a pillow.
Danger signs have appeared since Danelle was infected with the virus in late April. The fetus’s growth abruptly slowed and is now well below normal. An enlarged brain artery indicates that too little nutrition is crossing the placenta.
“But I’m the G.I. one,” she added, using a local term for hewing strictly to the book.
She was having ultrasounds every 14 days and must decide very soon whether to abort.
“The window is closing,” she said, wiping her eyes. “I don’t sleep at night. I don’t want to do this, but I don’t want her to come into this world and then suffer.