A procession of mothers pushed children in wheelchairs down a long corridor at a health center in this northeastern Brazilian city, passing patients who looked at the children, then looked back, quickly and uneasily.
Children were turned out in Disney clothing. Many girls wore bright colored glasses. All were profoundly disabled, their limbs rigid, their mouths slack, many with foreheads that sloped back above their dark eyes.
As soon as they see them, most Brazilians know that they are the babies of mothers who were bitten by the mosquito that carries the virus. Microcephaly was the main signifier at birth because of the small heads that indicated brain damage caused by the virus.
Many of them are almost as big as their mothers. People who haven't thought about them for a long time are starting to notice them. Brazil and the rest of the world moved on despite the fact that the world did not see a Pandemic.
In this corner of Brazil, where the epidemic began, families are struggling alone to get help for their children, who have a mysterious condition. They come each week in a procession of wheelchairs for free physical therapy at the private foundation. Many of the women are wearing T-shirts that say "fight like a mother"
Scientists can't answer basic questions about the virus because of it.
In Latin America and South and Southeast Asia, the virus is still circulating at a low level. After the global concerns faded, attention and funding stopped.
When there is a public health emergency that affects tropical countries, it doesn't have the global impact Covid had. There was a lot of interest in developing treatments and diagnostic tests at the beginning. Everything has gone quiet since the beginning of last year.
The Centers for Disease Control and Prevention and the National Institute of Allergies and Infectious Diseases scaled back their funding for work related to the disease after it failed to cause much damage in the US. The president of Brazil made deep cuts to scientific research.
After the outbreak of the coronaviruses, the few infectious disease specialists who were still working on it were forced to stop.
When a public health threat is gone, this occurs. There are still mysteries to be solved in 2016 according to a neonatologist who leads a project following children born with a birth defect.
Seven years after the first mysterious cases of microcephaly were identified in Brazil, scientists are not much closer to understanding how a virus that was first identified 75 years ago in a forest in Uganda and never known to be harmful was found in the northeast of Brazil.
It took advantage of a heavy rain season and a booming crop of mosquitoes that made a fine new host to roar through the population, infecting about three-quarters of the residents of Recife and other cities. The first case of a mosquito-borne virus crossing the barrier of the uterus in the womb was established by scientists, but they don't know why some babies were unaffected.
Between 7 percent and 14 percent of babies born to mothers who caught the mosquito-borne disease while pregnant have a congenital abnormality, according to the Centers for Disease Control and Prevention. Microcephaly is included in about 3% of the effects.
There are differences between them. Moreira didn't know. The earlier a mother catches the virus, the more severe the impact on the baby. We don't have the money to do research anymore.
The researchers think they haven't identified all of the children. Babies with normal head sizes and no major brain damage were not a cause of concern until they missed basic development milestones and were found to have brain damage.
As the children born at the peak of the outbreak begin to attend school, screening may identify more of them. We don't know if there is damage to the nervous system or not.
There is a spectrum of symptoms for the children who have struggled. Many people have problems with hearing and sight. They need feeding tubes because they can't swallow. Their arms and legs are held stiff by their muscles. Many people are having hip surgeries because their joints are not strong enough. There are a number of cognitive defects.
At six months, they froze in motor and intellectual development, according to Dr. Demcrito de Barros Miranda-Filho.
There are some children who have died from the disease. About one-fifth of the children in the group she has followed since birth have died from respiratory infections.
The once-robust support for the Zika families has waned as research funds dwindle.
Vernica's son Joo Guilherme is 7 years old and she spends her days and nights close to him.
Joo Guilherme now weighs almost as much as his mother does, but he needs her to lift and move him, to attach and clean his feeding tube, to change his diaper, and to leap up from the floor where she sleeps.
When Joo Guilherme's father lifts him in the air, his mother smothers him with kisses, and his sisters kiss on his head, he twitches and groans. That is just the beginning of his communications.
When I leave, I wonder what will happen to him. Ms.Santos spoke.
Ms.Santos is a fierce advocate for her son and he gets a lot of therapy. The Altino Ventura Foundation, a private charity, gives free physical therapy and audiological and ophthalmological care to about 80 of the children who are affected by the mosquito-borne disease. There are a few hundred people receiving therapies and support through the hospital.
Many other people are being raised by families in the rural interior of the country and have no access to services.
A group of children who were born with microcephaly but don't have brain damage have been identified. According to Dr. Miranda-Filho, they have caught up as they've grown.
He said it was unexpected.
Albert Ko is an epidemiologist and professor of public health at Yale University. In low-income neighborhoods in northeastern Brazil, where he had been studying infectious disease for years, he dove into research on the mosquito-borne disease.
He said that since so many people were affected by the epidemic seven years ago, immunity will likely last for a long time. Most of the population in Brazil and Latin America have never been exposed to the Aedes aegypti mosquito, which is the main transmitter of the Zika virus.
He thought there was transmission, but it wasn't hitting the books. Seven years ago, a high rate of infections caused enough babies to be born with microcephaly at the same time that there was a rush to find out what was going on.
By the end of July, Brazil had recorded almost 20,000 probable cases of the mosquito-borne disease. If people seek medical help for their symptoms, they may be diagnosed with or tested for a different mosquito-borne disease. A person can easily be misdiagnosed if they have a cross-reactive with a mosquito-borne illness.
It is still as urgent as it was a year ago.
A test for the mosquito-borne disease is only effective for a short time. Only a few of the women who were affected took the test, leaving researchers trying to establish if they had the mosquito-borne disease. Dr. Moreira wants to develop a test that can be administered at the birth of a child to every woman living in an area with Aedes aegypti mosquitoes to show if she has recently been bitten.
At the height of the epidemic, a large number of the women who had babies with congenital Zika syndrome were black or mixed race, at least in part because they were more likely to be from the lowest income group.
A number of studies have shown that the incidence of the disease in low-income areas was more pronounced than in high-income areas. A survey done by an associate professor of infectious diseases and microbiology at the University of Pittsburgh found that almost two-thirds of low income women did show evidence of the mosquito-borne disease, while one-third of high income women did. Low-income women are less likely to have air conditioning, are more likely to live at the ground level, and are more likely to have been bitten by mosquitoes.
Dr. Ko said that living in poor communities made the risk worse.
He wondered if there were other factors at work. 97 percent of the cases are low-income, and only 3 percent are high-income. He asked, why is that? It could be immunological background, it could be other infections you have already had, it could be stress during the pregnancy. Poverty is associated with these things that allow the virus to cross the placenta.
While African ancestry has been shown to be protective against the mosquito-borne diseases, he wonders if Indigenous ancestry will increase vulnerability to the mosquito-borne diseases.
The most minimal work on the virus can be done by Dr. Marques and his team. He said that everyone was obliged to work on Covid. I couldn't do work if it was related to Covid.
The United States government invested in the search for a vaccine to fight the mosquito-borne disease. It is a model for the search for a Covid-19 vaccine.
He said that this wasturtle speed, not warp speed, and the vaccine candidates didn't get past Phase 1 before most interest passed.
It is difficult to test a vaccine if there is an active outbreak of the disease. There is no treatment for the mosquito-borne disease.
After the outbreak in Brazil, the mosquito-borne disease was found in South and then Southeast Asia, and then again in Africa, where babies with microcephaly were born. Two billion people live around the mosquitoes, almost all of them in areas without reliable access to testing or standard maternal screening for fetal development, because of climate change.
If the virus arrives in a new place when there isn't a peak mosquito season, it won't cause a noticeable outbreak. Are Indians and Thais more vulnerable to it? "Dr. Ko, what do you think?" Is it being misdiagnosed as a disease like toxoplasmosis?
He said that it was urgent to answer the question of why the global trajectory of the disease was different from that in Brazil. He said that it is going to hit us in the Americas or anywhere else in the world. In low-income countries, we haven't done what's necessary.
The research institute is old and cramped. The researchers spoke with a reporter in a meeting room that was flooded because of the muddy water that crested over the pathways between buildings. They don't have enough resources to investigate the many questions they have.
Will it come back? We don't know. If there is another wave, we need to learn as much as we can about what went wrong.
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