CAMPINA GRANDE, Brazil — On a recent Friday morning, Dr. Alba Batista conducted what has become a routine procedure: a weekly neurological exam of an infant born with microcephaly, a birth defect that leaves newborns with abnormally small heads.
“Fridays are always difficult for me,” said Batista. “Every week, you see a new case.”
One year ago, the mosquito-borne Zika virus broke out in this impoverished northeast region of Brazil, producing a surge in microcephaly cases linked to the virus and spreading the disease to more than 60 countries, including the United States.
Still unknown is why Zika has had such a devastating effect in Brazil, where the government estimates approximately 2,000 infants have been born with what is known as Congenital Zika Syndrome — a series of disorders that can include but is not limited to microcephaly.
USA TODAY visited this city at the epicenter of the outbreak to examine how a team of health professionals and public officials have combined research, treatment and support to understand the illness and mitigate its effects.
Though the World Health Organization announced this month that Zika is no longer considered a "Public Health Emergency of International Concern," communities like Campina Grande still struggle to deal with fallout from the health crisis a year later.
In an area where many expectant mothers can barely afford insect repellent and with only limited federal government support, the program’s success is fragile. Each new birth exacts a heavy emotional toll on the front-line doctors.
“Another one,” Batista sighed after the infant's exam. “That’s the 124th baby I’ve seen this year.”
An alarming upsurge in microcephaly cases a year ago sent doctors in Brazil scrambling for answers. Prior to that, Paraiba state averaged five microcephaly births per year, but in November 2015, Campina Grande, Paraiba’s second-largest city, recorded five cases alone.
That same month, Adriana Melo, a fetal health specialist, confirmed the presence of Zika in two of her patients’ amniotic fluid, a key breakthrough in establishing the link to microcephaly.
“In the beginning, there was a fear of the unknown,” said Luzia Pinto, Campina Grande’s health commissioner. “At first, our concern was finding enough beds in the intensive care unit in the hospital. Then the question became, 'What should be done with these mothers? What kind of support will they need?'”
The health specialists set up a microcephaly unit in a wing of a local hospital. The staff of five grew to 12 to include specialists, a psychologist to counsel mothers and a gynecologist to discuss family planning.
Early on, the doctors struggled to provide mothers with answers about what the disturbing brain scans would mean for their children’s future. “Every day, I woke up and came to work in panic,” said Jeime Leal, a physiotherapist. “I woke up thinking, ‘My God, how are they dealing with this situation?’”
As the oldest babies turn 1 year old, it remains unclear whether they will be able to walk, talk or interact normally. Some are not responding to visual or auditory stimulation and many are unable to sit up without assistance.
The list of health problems associated with these patterns of brain damage is extensive: partial paralysis of the limbs, muscle weakness, seizures, difficulty swallowing and vision problems.
The hospital staff find that early stimulation appears to help. “When we first saw the brain scans, we said, ‘these babies won’t get out of bed,’” Melo said. “But when the infants began to go through early stimulation ... they began to follow us and interact with us.”
Ten-month-old Samuel Santiago, who entered the program at 15 days old, recently took his first assisted steps. Doctors remain hopeful that the rigorous rehabilitation program will improve each child’s development.
“Congenital Zika Syndrome is a box of surprises,” said physiotherapist Leal. “Every day, there is ... something new which we didn’t know about before.”
Some of the doctors also are involved in cutting-edge research. Melo and Batista, working alongside Brazilian and American researchers, co-published images in the medical journal Radiology showing the severity and extent of the brain damage associated with Zika.
Separately, the Brazilian Ministry of Health recently launched an investigation to determine whether Zika is acting alone, or if other environmental, socioeconomic, or biological factors are at play that caused an explosion of cases of microcephaly in northeastern Brazil but not in neighboring countries such as Colombia.
Some doctors in Colombia believe the dramatically lower rates there are due to easier access to abortion than in Brazil, where a debate about legalizing abortion in cases of Zika has reignited.
Melo, who personally opposes abortion, says the debate by activists on both sides of the issue is a distraction from the main problem — the babies already infected. “Most people are interested in their causes,” she said, "but nobody wants to take care of these mothers and the children who are already born."
Indeed, determining who is responsible for the babies has proved challenging. Campina Grande is paying staff salaries at the microcephaly unit and the cost of medical exams. Mayor Romero Rodrigues has pledged to allocate apartments in a new public housing project for women with babies enrolled in the treatment program.
“Campina Grande has needs that are really the country’s responsibility,” said Thiago Trapé, a São Paulo-based researcher who is leading up ZikaLab, a privately-funded initiative that will train primary-care workers to deal with Congenital Zika Syndrome. “They have still been able to organize a model here, even with scarce resources.”
Many impoverished mothers with babies in the treatment program can't afford diapers, formula, medicine or clothing. Doctors and the mothers solicit private donations to cover the cost of everything from high-tech medical equipment to colorful inflatable toys needed to stimulate development.
In Brazil's capital, the newly installed conservative government is pushing a constitutional amendment that would cap public spending for the next 20 years to help reduce the budget deficit. Health professionals around the country fear the result will be drastic cuts in health programs.
City health commissioner Pinto says the medical team’s tenacity and resourcefulness will continue to make the program successful even under challenging circumstances. “You learn to do the work, but the team suffers with every one of these children.”