Case Study: Responding to a Pandemic: WHO and CDC’s Response to the Zika Virus

Background

Brazilian maternity wards were in chaos. Nurses had never seen so many newborns with microcephaly-like symptoms. Babies were being born with enlarged heads that resembled a wizened old man rather than a newborn. Some babies were unable to move their arms or legs; others cried inconsolably. Some were deaf; others were blind. All were born to mothers who had contracted doenca misteriosa, or mystery disease, months earlier.

Today, the mystery disease known as the Zika virus derived its name from the Zika forest of Uganda where it was first discovered in 1947. The disease migrated to the Yap Islands in the Pacific before disappearing. Zika reappeared in the French Polynesia Islands and then arrived in Brazil, brought to the country by the FIFA Confederation Cup soccer games. From there, the Zika virus reached a pandemic state that led the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) to declare a world health emergency. This case study details the emergence of the Zika pandemic crisis and the response of the world’s health organizations to the crisis.

For most, Zika is a benign virus. When the mystery disease was first identified as the Zika virus, doctors breathed a sigh of relief. For most adults, Zika is not serious. The virus includes a rash, headache, and fever, leaving many adults to believe they have a cold rather than the virus. Zika does carry the possibility of serious health risk, such as Guillain-Barre. This syndrome is a slow-moving paralysis of the body and can be fatal if not treated immediately. Those cases are rare, and 99 percent of Zika cases for adults are classified as mild.

The Zika virus, however, is a serious threat for unborn babies, attacking the neurological functions of a fetus at any point during the pregnancy. Babies who appear perfectly healthy on the ultrasound can suddenly become unresponsive in the womb. The virus can cause serious malformation and even death. The attack stems from the virus’ presence in the mother’s body that is passed to the fetus. From there, the virus attacks the fetus’ neurological system, severely debilitating its development or prohibiting its development at all. 

Like most viruses, the Zika virus was originally assumed to spread through a bite from an infected Aedes aegypti mosquito. Later medical studies revealed that the Zika virus can also be transmitted sexually, the first mosquito-borne virus to do so.

Dilemma

Initially, the WHO and the CDC were slow to respond. Unwilling to disrupt tourism and the upcoming 2016 Olympic games in Brazil, the organizations offered little information about the Zika virus beyond the standard advice to avoid mosquito bites. Travelers were cautioned to wear mosquito repellent, especially those who were pregnant or who may become pregnant. No information was issued for residents of Zika-infected areas, and Zika’s connection to microcephaly was not mentioned.

Despite the preliminary precautions, the Zika virus continued to spread, leading the WHO to make another announcement. On February 1, 2016, the WHO declared a world health emergency, but they were reluctant to establish a link between Zika and microcephaly. Rumors and misinformation circulated on the “true” cause of the Brazilian microcephaly outbreak, further minimizing the connection between the Zika virus and micro cephalic newborns. As a result, the dangers of Zika to pregnant women were unclear.

Not everyone was silent about the dangers of Zika. New York Times science and health investigative reporter Donald McNeil, Jr. spent much of 2015 and 2016 describing the Zika virus and debunking the myths surrounding it. Previously, a rumor had circulated that Brazil had over-counted the cases of microcephaly, reducing the possible connection of Zika and micro cephalic newborns. McNeil proved differently. In December 2015, Brazil changed the definition of microcephaly, reducing the head measurements of newborns with microcephaly from less than 33 centimeters to less than 32 centimeters. Thus, McNeil reasoned, Brazil should have had far fewer microcephaly cases, not more.

Course of action

With the connection established, health ministers in the affected countries of Brazil, Columbia, Ecuador, Jamaica, El Salvador, and the Dominican Republic were convinced of the danger and asked women to consider delaying pregnancy if possible. Their request for universal delayed pregnancy was unprecedented, and the backlash against the request was immediate. Women’s reproductive rights groups protested, saying that the government cannot tell women what to do with their bodies. A spokesperson from Amnesty International said that such advice placed 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.” A spokeswoman from the Center for Reproductive Rights in New York called the health ministers’ announcement “irresponsible,” noting that they “were not issuing any recommendation for the men to use condoms, which is very unfair.” The news media also protested with headlines such as "Zika Virus and the Hypocrisy of Telling Women to Delay Pregnancy." The WHO and the CDC agreed, stating that pregnancy was a personal issue not a health issue.

McNeil was also outraged, but at the reluctance of the health organizations to communicate the dangers of pregnancy in Zika-infected areas. He reasoned that the only true way to avoid Zika-induced microcephaly in babies was to avoid becoming pregnant. He argued that the issue had been “hijacked,” and the public’s response was a result of the health organizations’ “terrible job explaining why they were asking women to wait.”

McNeil further charged the WHO and the CDC with doing a disservice to women exposed to the Zika virus. McNeil expressed his frustration with the CDC’s response in an exchange with Dr. Denise Jamieson, the leader of the CDC’s women’s health and fertility branch.

“Why,” McNeil asks, “will the CDC not advise women to wait?”

“I think the government getting involved in highly personal decisions about when to have a baby is not likely to be very effective,” Jamieson explained.

“Suppose you were in your job in 1964,” McNeil said, “and you knew that huge rubella outbreak was starting. There was no vaccine. You knew the consequences. Babies would suffer. What would your advice have been then?”

“I’d say,” Jamieson answered, “‘This is an extraordinarily risky time to get pregnant.’”
“But you won’t give the same advice now?”

“This is different,” she said. “There was no vaccine then. Highly motivated women can avoid mosquito bites.”

“For nine months, 24 hours a day?” McNeil asked. “Is that realistic?”

Realistic – probably not – and as the communication lagged, Zika continued to spread.

Consequences

The Brazilian epidemic peaked at 8,000 new Zika cases a week. The virus then moved to Puerto Rico where it was predicted that 25 percent of the population would be infected. In late 2016, the Zika virus arrived on the mainland of the United States. Current estimates believe the virus will circulate in the U.S. for at least three years. In the wake of these predictions, the WHO issued an advisory in June 2016 asking women to consider delaying pregnancy. The CDC did not issue similar advice. Rather, they continued to urge women who are pregnant or trying to become pregnant to avoid Zika-infected areas, and for those in Zika-infected areas, to take proper mosquito precaution.

Moral of the Story

McNeil believes that the CDC’s lack of a response is the real disservice for women. ‘The debate had been hijacked,” said McNeil. “Millions of poor women were being denied life-saving advice because it has become politically incorrect.” Others disagree, believing that advocacy of a universal plan for pregnancy avoidance was equally unethical.

Discussion Questions

1. What values can you identify that guided McNeil’s response and the WHO and CDC’s response to the Zika virus? How do their values compare?
2. Which ethical orientation(s) best describes the health organizations’ response to the Zika virus?
3. Using the different ethical orientations (axiology, deontology teleology, situational ethics), how would you approach this situation? How would you counsel the WHO and the CDC in their response to the Zika pandemic?
4. Using three of your identified values from the Barrett personal values assessment, how would you respond to the Zika pandemic crisis? Explain how your values guide your response.

Additional Resources

Fox, M. (2016, February 1). WHO declares Zika a public health emergency. NBC News. Retrieved from https://www.nbcnews.com

Garrett, L. (2016, July 28). Review: ‘Zika” tracks the trajectory of an epidemic. The New York Times. Retrieved from http://www.nytimes.com

McNeil, D.G. (2016). Zika: The emerging epidemic. New York: W.W. Norton & Company.

McNeil, D.G. & Cobb, J.S. (2016, October 31). Columbia is hit hard by Zika but not by microcephaly. The New York Times. Retrieved from http://www.nytimes.com

Satel, S. (2016, July 24). Book review: Zika: The emerging epidemic. The Denver Post. Retrieved from http://www.denverpost.com

Zika virus: What we need to know. (n.d.). Retrieved from https://www.cdc.gov/zika/prevention/index.html