Mosquitoes bearing Zika — a virus that can cause birth defects when contracted by pregnant women — are expected to reach the United States as soon as this summer, with Florida and Texas likely to be among the hardest-hit states.
But in both, support for women's health care, along with family planning resources, has been dramatically scaled back, in part because of funding restrictions placed on women's clinics that, in addition to other services, provide abortions. Also, both states declined to expand Medicaid. Those decisions, many advocates say, are putting a squeeze on the health care system's ability to educate women about Zika's risks and minimize its impact.
"The ways to prevent it are to either, one, not be pregnant and, number two, if someone is pregnant, avoid exposure — which I think can be more challenging," said Anthony Ogburn, chairman of the department of obstetrics and gynecology at the University of Texas-Rio Grande Valley School of Medicine in Harlingen.
Texas and Florida are advancing prevention plans that emphasize mosquito surveillance and targeted spraying. Some public health campaigns also have been launched to raise awareness, but funding is limited. Neither state's legislature has provided specific funding for those initiatives and neither is scheduled to meet again until after mosquito season.
And those campaigns miss a key element, advocates say, given the heightened stakes for pregnant women. The states aren't addressing the challenge low-income women face in getting birth control. And, for those who do get pregnant, there are still major barriers to accessing potentially helpful prenatal care.
"No amount of mosquito repellent is going to get us out of this," said Christine Curry, an assistant professor of obstetrics and gynecology at the University of Miami Miller Medical School.
For most people visibly affected, Zika's symptoms are comparable to at worst a bad flu, plus maybe a rash. Although much less common, it also has been connected to Guillain-Barre, an autoimmune disorder that causes weakness, temporary paralysis and, in rarer cases, permanent nerve damage or death. But for pregnant women, the virus can cause severe birth defects like microcephaly, which impairs brain development, or loss of the pregnancy altogether. That underscores the need to ensure women of child-bearing age know the risks and protect themselves.
In Florida, the state health department is sending out multiple updates each week to anyone who's expressed interest — "media and community partners," mostly, said Mara Gambineri, a department spokeswoman. These updates note confirmed cases and strategies to avoid mosquito bites. It's also put up billboards and distributed educational door-hangers for residents of high-risk areas and infographics for doctors.
Similarly, Texas is launching a media blitz, using venues like local radio, social media and ad buys to talk about prevention. Outreach is in English and Spanish. The state is leaning on local governments and health departments to help with prevention efforts, said Carrie Williams, a spokeswoman for the state's Department of State Health Services.
Congress has debated allocating emergency funding, but its progress has been slow. The Centers for Disease Control and Prevention has indicated that, if additional dollars are provided, it would use some of that money to support such state activities.
The federal government has said states can use Medicaid dollars to help with Zika prevention, covering services from purchasing mosquito repellent to family planning. But Texas still "is reviewing" that proposal and how Medicaid could fund the Zika fight, said Bryan Black, a spokesman for the state's health and human services commission. In Florida, Medicaid plans are encouraged to cover repellent, said Shelisha Coleman, a spokeswoman for the state's Agency for Health Care Administration.
But Medicaid eligibility is tight in both states, so even that added benefit skips over a fair number of women. Since neither Florida nor Texas opted into the health law's Medicaid expansion, these women fall into a so-called "coverage gap." They are too poor for subsidies to buy insurance on the exchange but too wealthy for the low-income health insurance program. Since they don't have coverage, family planning and prenatal care can be cost-prohibitive or difficult to get, so they may have limited access to health providers who could help with taking precautions against the virus.
That makes outreach efforts now, early in the season, critical. While people are hearing about Zika, it hasn't yet triggered the level of action that drives women to see the doctor, said Linda Sutherland, executive director of Healthy Start Coalition of Orange County, a Florida nonprofit clinic that focuses on child and maternal health.
In Florida, the uninsured can visit a community health center, or a clinic run by the state health department, Sutherland said. If Florida sees Zika transmission, and patients get worried — so there's "an avalanche of people" trying to avoid pregnancy — she doesn't think there are enough affordable family planning facilities to meet that demand. And state clinics have seen budget cuts in the past several years, meaning they are smaller and less likely to offer comprehensive prenatal care.
As a result, "it is a daily occurrence that someone who has lived in this state her entire pregnancy presents for delivery having not interfaced with the public health system," said Curry, who also sees patients at Jackson Memorial Hospital, in Miami.
Those services take on new importance now, in addressing the Zika virus, she added. "These are huge opportunities for preventive care."
Texas has made it easier for pregnant women to enroll in Medicaid, which can cover services like prenatal care, said Melissa McChesney, outreach coordinator at the Center for Public Policy Priorities, a left-leaning Texas think tank. Most women do get some kind of check-up before giving birth, but getting care as early as medically wise is another question. About 40 percent of pregnant women won't see a doctor in their first trimester. That's likely in part because of challenges like not knowing how to pay for it or lacking experience navigating the health care system, McChesney said.
No amount of mosquito repellent is going to get us out of this
Improving on-time access to prenatal care is "a top priority in Texas" — especially given the Zika threat, said Black of the state's health and human services commission.
Community health centers in both states are trying to help educate women of child-bearing age. The women relying on these clinics are often among "the poorest of the poor," said Jose Camacho, executive director and general counsel for the Texas Association of Community Health Centers. They might live in housing that lacks air-conditioning, or that allows easy mosquito entry. Or they may not have the money for repellent or preventive clothing.
"We're extremely concerned that health centers, because of the housing and conditions around the housing that our patients live in, are going to start seeing quite a few of the Zika patients," Camacho said.
Providers at those clinics are trying to advise women at risk — telling them to avoid standing water and repair mosquito netting around their houses, Camacho said. But for many, getting to the clinic is even a challenge. Transportation is a barrier. And it can take weeks to get an appointment.
And if clinicians hope to reach women, they really should visit them at home, Camacho said. That requires manpower, time and money. All are in short supply. Most states rely on information pamphlets produced by the CDC, he added. And those are available in English and Spanish, but many patients also speak other languages.
"Are the proper things being funded that help at the local level? I'd have to say no," he said. "And the communities our patients reside in are usually the last ones to get the attention."