Global Efforts to Combat the Zika Virus

FASKIANOS: Good afternoon from New York, and welcome to the Council on Foreign Relations Conference Call Series. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR.

We are pleased to have participants in both our Religion and Foreign Policy Initiative and our State and Local Officials Initiative on the call today. As a reminder, today’s call is on the record and online transcript will be available on our website, CFR.org.

We are delighted to have Laurie Garrett with us to talk about the domestic and international ramifications of the Zika virus outbreak. Laurie Garrett is CFR’s senior fellow for global health and an expert in global health systems, chronic and infectious diseases, and bioterrorism.

She’s the only writer ever to have been awarded all three of the big P’s of journalism: the Peabody, Polk, and Pulitzer. Ms. Garrett is a best-selling author of The Coming Plague: Newly Emerging Diseases in a World Out of Balance as well as Betrayal of Trust: The Collapse of Global Public Health. And you can find her recent coverage of the Zika virus on our website at CFR.org.

So, Laurie, thank you very much for being with us today. We’ve heard in recent days officials are talking about how the impact of the Zika virus on theUnited Statescould be more severe than initially predicted. So it would be great if you could talk about those statements that have come out of the CDC as well as our preparedness or lack thereof to deal with this virus as it spreads.

GARRETT: Thanks, Irina. And welcome to all of you who are on the phone.

The Zika virus is not a new virus. And it’s very important to understand that neither the mosquitoes nor the virus are new, that humanity has been aware of the existence of this virus since the late 1940s when it was discovered in Uganda. But it has only, in the last six to seven years, begun to spread around the world, starting with outbreaks in the Pacific island nations, across Polynesia, and eventually emerging in 2013 in Latin America, widely believed to be associated with a traveler who came to Brazil to go to the World Cup soccer match. That’s not an absolutely proven association but it seems to coincide appropriately with the beginning of this now historic epidemic.

Because it’s spread by mosquitoes—and the key mosquito population involved is African mosquito Aedes aegypti that has been in our hemisphere since the days of slavery, brought in slave ships. There’s a tendency to think of mosquito-carried diseases as somehow less ominous, less spectacular than those that are directly airborne transmitted from one human to another without any intermediary. And I think that had something to do with why the Zika virus outbreak inBrazilwas initially viewed by non-Brazilians as a kind of an odd, interesting thing but not a particularly frightening prospect.

But now of course it has spread widely from southernChileall the way up to lapping at our shores in Puerto Rico andCuba, and it seems only inevitable that we will be experiencing a very serious Zika outbreak in our strongest sort of mosquito-ridden states in the southern states of theUnited States.

The virus has now proven to be considerably more worrisome that was thought even a couple of months ago, much less a couple of years ago. Not only is it associated with these terrible birth defects—the microcephaly that many of you have undoubtedly seen pictures of with the babies born with the crushed skulls and compressed brains—but there seems to be a whole range of syndromes that are neurological that are caused by this virus.

And some of the newfound urgency that you’re hearing out of our United States scientific leadership and public health leadership reflects very new studies released just in the last three weeks that demonstrate that the virus specifically targets what are called progenitor cells in the neurological system and stem cells in the brain in a manner that not only kills those cells and therefore results in inadequate brain development in a fetus but also can affect replacement cell populations in the brain of adults.

The result is that it looks like Zika causes a very broad range—a kind of what we have to think of as a full-range neurological syndrome that goes all the way from at the bottom end—and probably the vast majority of humans who are infected—a mild flu-like syndrome with a skin rash and perhaps the more immediate brain sorts of effects that would feel like strong headaches, perhaps blurred vision, hallucinations, inability to form sentences, almost feeling drunk or disoriented, all the way to the far extreme of permanent paralysis in some adults, epilepsy and massive seizure disorders, and then of course the birth defects in babies.

And I would add one more dimension to that. There are very few Zika babies out there for scientists to look at who have now reached key milestones of child development. In other words, most of this is so new that we don’t have a large pool of children to look at who are now three, four, five, six years old. And therefore, a lot of the things that we would be worried about as, let’s say, one step below microcephaly, neurological disorders in babies, cannot yet be ascertained, but we do know that some babies are being born without proper vision, even blind; without proper hearing, even deaf.

And this is looking more and more like rubella infection in utero in the pre-vaccine days for German measles. Those of you old enough to recall will remember that it was a time when women were very, very frightened about becoming infected during pregnancy and the possible range of outcomes for their babies.

Here in theUnited Stateswe have several factors that leave us ill-prepared to face this. First of all, Congress and the White House continue to be at loggerheads, as they are on absolutely every issue in our country today, and on—in particular, the White House requested $1.9 billion in additional support for Zika preparedness that would be spread over everything from backing WHO programs to basic research and some help and assistance at the state and local levels across the United States.

Congress, in the GOP leadership, advocated that, instead, remaining funds in a pot designated for Ebola be turned to Zika purpose. In a showdown, the White House, just a few days ago, moved about a half-a-billion dollars’ worth of the Ebola money towards Zika efforts, declaring this a temporary measure and an inadequate one, and it remains to be seen whether Congress with ultimately agree to put any special funds towards Zika. I would only note that the Ebola funds are all committed and promised for various overseas programs. So it’s not as if they’re just sitting around waiting to be used for some purpose, despite what was said regarding the ease with which they could be transferred to Zika.

Also, in theUnited States, everything that you would consider Zika prevention, such as mosquito control programs, are local functions. They are not federal functions. In most states they aren’t even state functions. They are county functions. And in some places such asNew York City, where we have several counties within the city, they’re actually city functions.

And the sort of legal parameters and levels of funding support associated with these things vary widely from state to state and within states from county to county. So we are facing this problem with a real patchwork of government functions, funding differentials, even local regulations that vary widely from one part of the country to another, and with a huge discrepancy in what is considered appropriate funding to support such efforts, so that in some major cities that are considered to be at very, very high risk for Zika we have mosquito abatement funding at the level of about four (cents) or five cents per capita—four (cents) or five cents per capita per year in spending for mosquito control, whereas in a neighboring city it is maybe as high as seventy-five (dollars) to $100 per capita.

There’s no difference in scientific need or public health risk. This is entirely about budgeting, and city and local and state budget processes and how much is dedicated to these particular public health functions.

And the other thing that varies widely is how state law applies to the acceptability of pregnancy termination in the event of positive sonograms, MRIs, CAT scans, what have you, indicating fetal maldevelopment and the proof of microcephalic skull development in a mother known to be exposed to Zika. In at least eight states in theUnited Statesit would not be legal to terminate on that basis, regardless of what trimester you’re talking about.

And the other issue that varies widely across theUnited Statesis the ability to perform autopsies and examinations of spontaneously aborted or—the spontaneously aborted fetuses that may have aborted due to Zika infection and/or newborns that die shortly after birth due to Zika infection. In at least eight states it would be illegal to do any research on that fetal tissue or the immediate postpartum tissue under laws passed fairly recently, the earliest one being in 2013 inNorth Dakota.

And all combined, I think this put us in a very unique set of circumstances here in the United States as we see our nation warming up and getting warm enough that the mosquitoes are coming out of their winter hibernation and the probability of Zika coming across in our mosquito populations rises with each degree of temperature increase across the United States.

Irina?

FASKIANOS: Yes. Thank you, Laurie. That was a great overview.

Let us open it up to questions from the group.

OPERATOR: And at this time we’ll open the floor for questions. (Gives queuing instructions.)

Our first question will come from Egon Cholakian with Harvard University.

CHOLAKIAN: Hello. Interesting picture you painted. Thank you very much.

A question that arises in my mind’s eye: Whose jurisdiction within, I presume, the federal government would this matter fall into with respect to lobbying and taking charge of this political movement to accept a uniform standard of practice from state to state on the federal level? How would you—how are you proposing and whose—that could get undertaken and under whose jurisdiction would you presuppose that would be undertaken in as well?

GARRETT: Well, it’s impossible. Under our legal system there are certain aspects of classic public health measures that are under federal jurisdiction but the vast majority of it is entirely local, at the very least at the state level. And most states have long since—in fact, going back in some states almost two-hundred years—designated public health as a local function.

And the kinds of things that do fall under federal jurisdiction include, for example, the Environmental Protection Agency determining the safety and permission to use certain pesticides to control mosquito populations, or larvicides to eliminate the mosquito babies, if you will, and under what kind of circumstances they’re designated safe for human exposure. And the FDA may regulate certain aspects of drug use and vaccine, of course, approval, should there be candidate vaccines that reach the FDA’s attention.

But the vast majority of this is decided at the local level and that’s not likely to change. And that has been the case for virtually all aspects of public health, from cleaning up your water supply on up since the beginning of theUnited States.

FASKIANOS: Thank you.

Next question.

OPERATOR: Thank you.

(Gives queuing instructions.)

And our next question will come from Lavanya Vemsani with Shawnee State University.

VEMSANI: Hello? Thank you for taking my question.

GARRETT: Yes.

VEMSANI: I was wondering if there are any precautions we can take. Just stay away from mosquitoes? Or what can we do as a precaution?

GARRETT: Right. So there are two major ways that a person can become infected with Zika. The first is to get bit by a mosquito that carries the virus. And the second is sexual transmission, so far only proven to go in one direction, from man to woman, by a man who is carrying the Zika virus. Let me take the first one first, the mosquito-borne infection.

You know, if we as a country were facing this prospect of the arrival of Zika with great wisdom and sagacity, we would be looking at the experiences of our southern neighbors and learning from them right now and taking the appropriate steps to protect ourselves.

And the most amazingly appropriate step, and the easiest one, and the cheapest one, is to get out now with all our mosquito abatement budgets and eliminate the first emerging populations of the annual seasonal mosquito populations so that before they’re able to reproduce, before they lay eggs all over the place, and before we have that classic July, you know, swatting the mosquitoes off your skin all day while you try to watch your kids play Little League, now is the time to get out there, spend that money, and take those steps. The longer we wait, the further we get into hot weather, the harder mosquito control gets.

Unfortunately, not very many states are putting that kind of money to sound purpose at this time. So for you personally, you protect yourself with DEET, you know, mosquito repellant. Wear long sleeves when you’re outdoors during mosquito feeding time. And protect your children. And of course eliminate anything in your backyard or in your living space that can be a breeding site for the mosquitoes, which is pretty much anything that could pool water and hold clean water, rainwater and so on, for the mosquitoes.

As far as sexual transmission goes, it is the CDC’s recommendation that any man who thinks he may have been exposed to the Zika virus should use condoms when having intercourse with his female partners.

VEMSANI: Thank you.

FASKIANOS: Thank you.

Next question.

OPERATOR: Thank you.

(Gives queuing instructions.)

FASKIANOS: Laurie, can you talk about the efforts underway to research and develop a vaccine for Zika?

GARRETT: Yeah. There’s very vigorous research efforts, public and private, going on right now related to a range of aspects of the Zika problem, not just vaccine but also appropriate diagnostic tools and treatments.

One of the things that’s making the whole Zika problem so difficult to understand is that there’s no easy, quick way to diagnose who has it. The reason is that in South America the Zika epidemic is actually part of three epidemics: dengue and Chikungunya and Zika. All of these are mosquito-carried viral diseases.

And it turns out when you try to do a quick diagnostic blood test, you get cross-reaction between the three of them and it’s very hard to tell which particular disease your patient has until you become familiar with Zika. You see a lot of patients and you start to be able to notice some of the symptom differences. We need a much better, quick test. We don’t have time to run several-day-long DNA analysis to figure out who has Zika and who doesn’t.

And that also gets us to another problem, that we’re not certain what trimester of exposure is most likely to result in fetal malformation. And it would be very nice to be able to tell women who are pregnant, look, you know, it’s OK; it was first trimester, or, it’s not OK; it was first trimester. We actually don’t know how to answer those questions, which of course every woman who is likely to be pregnant as we have our mosquito season this summer is going to be asking.

And as far as vaccine development goes, the good news is that there has been a recent major breakthrough in vaccine development for dengue virus and an experimental vaccine has been developed that, on a small trial, is one-hundred percent protecting. Amazing. I mean, really, really a homerun. And that may serve as a hopeful template for how to approach coming up with the Zika vaccine. It certainly has, you know, invigorated the whole industry and quite a number of different academic centers, government labs, and private sector labs are working on the problem now.

But even if somebody right now, today, had a Zika vaccine candidate, the whole regulatory process, the process for clinical trials and so on, would not possibly result in the availability of a vaccine this summer. So no matter what, we will be facing the risk of Zika without either the rapid diagnostic or a vaccine.

FASKIANOS: Laurie, can you talk a little bit about the international response? I mean, we obviously had the Ebola outbreak and there was a very slow response to that. Has the international community learned their lesson from that in this crisis?

GARRETT: Yes and no. At least sixty-two countries have now had Zika and it is active in more than half of those right now. And that means that we really do have a global emergency. It’s not even as restricted as Ebola was, which was primarily about three countries. And actually it’s not over yet. There are new active cases in Liberia and Guinea.

But the WHO definitely moved more swiftly in this case than it did with Ebola. It learned those lessons and a public health emergency was declared by WHO on February 2nd, within thirty days of Brazil’s official notification that this seemed to be much bigger, a call for a kind of global-scale concern.

The problem is that the world has not really backed WHO up. WHO requested $26 million in emergency assistance from donors for its response and the response of its sister organization, the Pan American Health Organization. It has only received $3 million. You can’t possibly mount a global response to something that is spread out to sixty-two countries now on three continents with $3 million.

FASKIANOS: That is a very sobering and alarming figure. Would you say—what more can the Latin American governments be doing? How much have they contributed to the effort? What’s the proportion?

GARRETT: Well, Brazil is facing the biggest crisis by far both in terms of absolute numbers and probably, in key parts of Brazil in terms of sort of per capita, incidents of both adult and fetal—newborn cases. And Brazil has borne the brunt of the research effort with its key research institute Fiocruz turning into an almost one-hundred percent Zika overdrive, you know, in an attempt to really get into it.

But as I think everybody on this phone knows, the president of Brazil is battling impeachment calls that have nothing to do with Zika. Somewhere in the ballpark of forty (percent) to forty-five percent of the Brazilian legislative body is potentially to be indicted or impeached related to a series of scandals, most of which go back to their giant oil production company that’s sort of a mixed public-private company, Petrobras. And the country itself is in dire financial straits. With, you know, the Olympics coming to Rio, reportedly ticket sales have plummeted, in part due to international fear of contracting Zika, and, you know, just a really big problem.

And for quite a while—I’m talking about January, February, well into March—other neighboring countries were either denying that they had Zika—which would be the case with Venezuela—or were agreeing, yes, we have Zika infections but we have no microcephaly and we’re not even sure Zika causes any of these problems. The Brazilians kept saying, just wait; it’s so new to you, you haven’t seen those babies yet. And indeed now we see a skyrocketing problem in Colombia. Now Venezuela is beginning to be more honest with global reporting and we’re seeing they have huge numbers, and the numbers are rising all across—up into Central America and across the Caribbean, one country after another.

And our territory, Puerto Rico, is really struggling. It also is bankrupt. It hasn’t officially declared bankruptcy. It has rather pleaded with the U.S. Congress to help bail the—I mean its territorial economy out, but in the meantime it’s trying to do battle with Zika, which is spreading by direct mosquito spread within the island territory, and do so with a very small budget and significant technical support from our CDC.

FASKIANOS: Thank you.

Next question.

OPERATOR: Our next question will come from Maria Mendez with Alabama State Port Authority.

MENDEZ: Yes, my question is, when you mentioned the Caribbean, for example, in the instance of trade where all that cargo is going into the Caribbean and you have the empty containers coming back, sometimes there could be some water lying inside. Are there any precautions being taken to make sure that the Zika virus doesn’t come via ocean-carrying vessels?

GARRETT: Such an important and smart question, and I wish I could give you reassurance. We know that the mosquitoes that carry Zika, as is also the case with dengue and Chikungunya, have managed to get inside and lay their eggs in cargo holds. How did Zika get from one island in the Pacific to the next island over to the next island over? In cargo holds. And you know, the Aedes albopictus mosquito, sometimes called the tiger mosquito, is originally an Asian mosquito. It also can carry Zika, though the major one is Aedes aegypti. And we know that Aedes albopictus got to the Americas in cargo ships.

This has been a very big issue. The California authorities have been able to identify that certain U.S. Navy ships docking off of San Diego have unwittingly released key mosquito populations from Asia into California. Obviously shipping between the Caribbean nations and our southern states, especially Florida, is a big issue and continues to be. Cuba had a big dengue outbreak more than a decade ago that seemed to be related to shipping and transport. And all of this means that at port authorities there has to be an increase of attention to either fumigating cargo holds and shipping containers or demanding that the shipper execute control measures.

I would just give as a classic example—I mean, it’s textbook at this point for people in public health—we know the Aedes albopictus mosquito got from Malaysia to Brazil about twenty years ago in a ship that was carrying used tires from Asia back to Brazil for recycling, rubber recycling. And those tires were simply stacked in the cargo hold. There was rain. Therefore, there was water pooled inside of each tire. Mosquitoes went in, laid their larvae, and when the ship reached Brazil the baby mosquito flew out as adult mosquitoes and brought Aedes albopictus to Brazil.

FASKIANOS: Thank you.

Next question.

OPERATOR: (Gives queuing instructions.)

FASKIANOS: Laurie, what are the economic costs of this epidemic? You know, obviously Brazil is going to see it, given the Olympics, the downturn in tourism that they’ve got.

GARRETT: Well, obviously the economic consequences of Zika are complicated because it’s not going to be the case—let’s just do a scenario up here. Zika comes to, say, the Florida Keys and then some infected mosquitoes are spotted in the Miami-Dade County area, then perhaps in the New Orleans area, then in Houston, and perhaps up in Charlotte, North Carolina and a few other pockets. It’s not as if these places will become sort of economic pariahs because of Zika. Rather, it’s going to continue to spread and expand across the United States, with the southern states, you know, bearing the brunt at the front end of it.

And so, economically, the good news is you won’t have the sort of pariah affect that the Ebola countries have suffered and continue to suffer as the world kind of isolates them in order to keep the Ebola virus at bay. I hope people are smart enough in the United States to realize that if it’s in mosquitoes in one part of the United States, it will soon be in mosquitoes in another, and isolating Louisiana because they have Zika would make no sense at all.

But, you know, we have to keep in mind that all this is coming in an election year, and it’s a big, ugly, messed-up election year in which almost everything that happens becomes fodder for crazy political statements by one party or another. And, you know, the last thing we need is for the sector on Zika coming from one state to another become a reason to carry out some other political agenda against state number one by state number two, or to try to put embargoes on trade of some kind or another out of desire to protect one state from another state or one country from another country. You just can’t stop these mosquitoes that way.

FASKIANOS: Laurie, as you know, we have state and local officials on this call, and the religious leaders. Do you have recommendations for how local communities can better prepare for this here on our soil and what we can be doing to—you know, a sort of call to action to our government and the international community to allocate more resources to deal with this problem?

GARRETT: Yeah. I mean, you know, I actually did a long piece for Foreign Policy magazine, going through the key cities at highest risk for Zika and their mosquito budgets, and showing, you know, which cities seem better prepared and which don’t. I would recommend that you go on the foreignpolicy.com website and pull up my piece to see, where does your city fit?

But it goes beyond that to ask the question, you know, how seriously does your locality take the whole concept of controlling mosquitoes? And you will find that politically it’s all over the place. It has nothing to do with science. It has everything to do with local politics and, you know, when there’s budget constraints what do people cut? When does somebody step up and say, eh, we haven’t had any malaria in decades so let’s get rid of the mosquito budget?

Unless there’s voices screaming now, the sad news is those monies probably won’t surface at an adequate level until you have people with Zika, until you have babies born with microcephaly. That’s terrible. And by then, you know, you’ve got massive mosquito populations and infection. So everybody is going to be in a reactive mode unless there’s pressure placed on your political leaders right now.

The good news is, in a way, that our public health efforts, and particularly mosquito efforts, are a county function. So it’s less abstract than telling your congregation or your political constituency to lobby Washington. Heck, they can go right down the street and lobby their board of supervisors or their city hall or their mayor. It’s that immediate. And those are the folks that control the purse strings. It’s not Washington.

On the other level that’s much more about ethics and religious issues, you know, we will face the question in every locality across the Zika-infested country: What is appropriate for a mother to do if she has a sonogram or some other test that indicates she has a microcephalic baby?

Now, some members of Congress and some state legislatures have already handed down their answer to that question, and it is that mothers should have that baby and should raise that microcephalic baby. In some places it’s a deeper set of questions that may include that mother’s right to choose whether she carries that baby, and while we’re at it, the father. You know, it takes two to tango here.

And I think these are all questions that it’s wise to be thinking about and having discussion about before the crisis hits, and to begin to try and have a rational conversation about it. My big fear is that that conversation in particular, in the context of Zika, ends up being part of our political election process, and therefore lacks all the sort of nuance and compassion that makes sense and turns into just wild political inanity, which would be devastating, I think.

FASKIANOS: I think if there are no last questions I can ask you just to say a few final words.

Terri (sp), are there any last questions?

OPERATOR: No, ma’am, there are no further questions in the queue.

GARRETT: OK. Well, I guess the last things I would just suggest—I mean, there is a federal dimension to this, obviously, whether or not Congress will ultimately vote in any new monies related to Zika.

It is kind of surprising that they’ve been so reluctant, given that the southern states are the most likely to be affected, both first and profoundly, and these are the states that have GOP leaderships that have declined to let the Zika funding question come out of committee for a vote or a discussion. You know, there will be—I don’t know; somebody is going to pay a price down the road on this. It’s hard to understand how we can be looking down the barrel of this, you know, Zika mosquito problem and not have a higher level of preparedness and concern.

 I also think that as we get larger numbers of people infected and are able to observe them under more sophisticated medical circumstances as we have in the United States, the whole sort of gamut of what this syndrome really is and how this virus affects brain cells and cells of the spinal cord will become more obvious and perhaps more frightening. And this may end up involving more dimensions that affect not just fetuses but adults and growing children. And this is, of course, cause for concern.

And then, finally, there’s considerable discussion about the use of genetically modified mosquitoes that are sterile and unable to reproduce, or key pesticides to control the mosquito population. Many of these things have already been tried in Brazil and other neighboring countries in South America. As those options come to our shores we will surely see vigorous debate, both environmentalists concerned about the impacts of genetically modified insects or pesticide residues and companies interested in promoting products that they have developed, a range of things.

And they will all be on your plate, whether your plate is your congregation or your political constituency. And you would be wise to be looking at the discussions and debates now and preparing your positions and arguments rather than waiting for a very emotional period of screaming and concerns down the road.

And I thank you all—

FASKIANOS: Laurie—

GARRETT: —for listening in. I hope my remarks prove helpful.

FASKIANOS: They were terrific, Laurie. And I just wanted to ask you one more thing—if you could just give us a quick overview of that great vaccine map that you developed on the Council website, because it’s a terrific resource that I just wanted to point out to people.

GARRETT: Oh, thanks.

Yeah, several years ago we developed an interactive map of the United States that allows you to track both over time, since 2007, and over geographic space—actually, not just the United States, the whole world—for outbreaks of the six main vaccine-preventable diseases that are associated with childhood vaccination.

It allows you to see, where are outbreaks of measles, of polio, of diphtheria, rubella, and so on, and why are these outbreaks occurring? Where is it because of lack of supply and distribution of vaccine? Where is it because of the resistance by the Taliban or other Islamist forces against vaccination? And where is it because of vaccine denial by parents and the refusal to have their children vaccinated?

And it’s a good guidepost to track what may be going on in your community or nearby communities. And we’re constantly updating it. Just about every week we update the map, and have been for several years.

FASKIANOS: Well, Laurie, thank you very much for your call today and for the work you’re doing heading up the Global Health Program here at the Council. We’ve made a considerable to follow these issues. And Laurie is doing groundbreaking work on it, so thank you very much.

I hope you all will follow Laurie Garrett on Twitter @laurie_garrett and will also take a look at our website for the map and other resources and commentary that she and other global health experts are writing here at the Council on Foreign Relations.

So thank you again, Laurie Garrett, and thanks to all of you.

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