An empty waiting room in the women’s center at a public hospital in Recife, Brazil. Because of the outbreak of Zika infections in 2015 and 2016, the number of newborns in Recife dropped substantially. (Joao Pina for The Washington Post)

In this city at the heart of the Zika outbreak, the gloom and dread have lifted from maternity hospitals and delivery rooms.

The scary government posters with giant mosquitoes have mostly come down. Fertility clinics are busy again. At one public hospital that has delivered 1,700 newborns over the past five months, doctors haven’t seen a single case of Zika-related birth defects. 

“It’s as if we’ve all forgotten about Zika,” said Erika Alcantara, 17 weeks pregnant, who had waited for the epidemic to pass before she and her husband tried for their second child.

A year after U.N. health officials declared Zika a global emergency, the city that produced some of the outbreak’s most terrifying and indelible images of badly deformed infants feels like a place that has mostly moved on. 

But not everyone has bounced back so fast. Not the parents of the babies in those heartbreaking photographs. 

Initially, many feared that the infants would be merely the first wave of Zika victims, with many more to follow. Yet as the virus spread across the Americas and infected hundreds of thousands, it did not inflict the kind of damage seen here in northeast Brazil, where three-quarters of Zika-related birth defects have been reported. 

Today those families are like the survivors of a natural disaster. Though Zika scared a lot of people, its lasting harm fell on a relative few.

Gleyse Kelly da Silva and Felipe da Silva are the parents of 15-month-old Giovanna Santos who suffers from microcephaly because of the Zika virus. The parents, here with Giovanna and two of their other three children, live in Recife. (Joao Pina for The Washington Post)

Those families have developed new routines. Eliane Paz ferries her son, Davi Lucas, to five different hospitals a week for visual, motor and auditory therapy. The 1-year-old was diagnosed with severe microcephaly when he was born in October 2015, weeks before doctors connected the condition to Zika. Paz, a former maid, wakes up at 4 a.m. to make the 90-minute journey to the rehabilitation centers where specialists work with her son. 

Recife’s rehab clinics are crowded with children who have microcephaly, a congenital condition defined by undersize heads and impaired cognition. Now toddlers, they struggle to swallow, roll over or simply hold up their heads. Many languish in a semi-vegetative state.

Their parents say they live for milestones that others take for granted. When their children learn to smile, laugh or grip items, it’s just enough to stave off the despair. 

At Davi Lucas’s motor therapy appointment, doctors insert cold bits of papaya into his mouth and stroke his cheeks to try to stimulate chewing. The mashed fruit mostly falls out. For months after he was born, the boy cried constantly, his mother said, but he wasn’t able to produce tears.  

Eliane Paz and 15-month-old Davi Lucas wake up at 4 a.m. at least three times a week to travel to Recife so Davi Lucas can receive therapy. (Joao Pina for The Washington Post )

“The day he shed his first tear, I started crying, too,” Paz said. Having quit her cleaning job, she receives a $300 monthly stipend from the government and devotes all of her time to the boy. It stings when strangers stare at his deformity or she overhears their comments: “Mosquito Boy.” “Devil’s child.”

Sixty families come for treatment to the IMIP public hospital’s clinic, the largest rehabilitation center in Recife for children with microcephaly. There are 40 more children on a waiting list. The demand for exams has stretched wait times for appointments from a few weeks to several months, and even the families who are grateful to receive care say it isn’t enough.  

Multiple medications have stopped Davi Lucas’s seizures, but he needs a chest scan to determine why he’s having breathing problems, and the machine at the hospital is broken. His mother worries that public attention is fading as Zika infections ebb. “What’s going to happen to us when people forget about Zika?” Paz asked.  

Gessycca Barbosa Queiroz, a 15-month-old who was born with microcephaly receives physical therapy at IMIP public hospital in Recife. (Joao Pina for The Washington Post )
The start of the outbreak

A year ago Zika was spreading rapidly across the Americas, prompting governments to warn women to avoid or postpone pregnancy. Today Zika is waning virtually everywhere in the Western Hemisphere. Epidemiologists say the pattern fits the typical trajectory of a virus that spreads explosively at first but fizzles out as it runs out of new hosts to infect. 

What researchers still don’t understand is why the majority of Zika-related birth defects have been so concentrated in one region of a single country.

Of the more than 2,600 cases of Zika-related congenital syndrome confirmed so far in the Americas, nearly 2,400 are in Brazil. The vast majority are in a cluster of northeastern states, including Pernambuco, where Recife is located. 

“Why was there so much microcephaly if it’s the same virus?” said Amilcar Tanuri, an epidemiologist at Federal University of Rio de Janeiro who formerly worked for the Centers for Disease Control and Prevention. “We’re looking at other possible co-factors, but we’re still in the middle of the investigation,” he said. 

With its heat, abundant mosquitoes and extensive slums, Recife, the largest urban area in Brazil’s northeast, became one of Zika’s most potent launchpads. The city and surrounding state typically register 11 or 12 cases a year of microcephaly, but by late 2015, hospitals were reporting 50 to 60 a month. “It was a tsunami,” said Sergio Negromonte, the director of the maternity ward at one of the city’s largest private hospitals. 

His hospital’s emergency room shut down because patients with Zika symptoms were spilling out into the hallways and parking lots. Sonogram exams became somber, fateful appointments — “like a sentencing,” said Pedro Pires, an obstetrician-gynecologist who specializes in Zika.

 State health records show that 2015 was a peak year for births in Pernambuco, precisely at the moment when Zika was most virulent but had yet to be identified.

As much as 70 percent of Recife’s inhabitants contracted Zika in 2015 and 2016, according to Pires, and that high rate of infection likely prevented a revival of the epidemic in recent months — summer in the Southern Hemisphere — because most of the population has become immune. 

A mother with her newborn in the infirmary at a public hospital in the city of Recife. (Joao Pina for The Washington Post )

Last year, the birthrate fell by about 7 percent statewide, according to the latest figures, but it dropped as much as 45 percent at the private clinics that cater to more affluent women. Negromonte and other doctors say they have never seen such a sharp drop in birthrates. 

The panic has mostly lifted. Alcantara, the mother who delayed pregnancy because of Zika, said she and her husband, Wilton, made that decision after the couple and their 3-year-old daughter, Lara, were infected in early 2015. 

But new research on the disease and its virtual disappearance convinced Wilton, himself an emergency room doctor, that it was safe enough to have a child in Recife again. 

The couple brought Lara with them on a recent morning to a routine sonogram check. It showed a healthy baby boy. The only tears were Lara’s. She wanted a sister.  

Her father hugged her, laughing. “We’ll try for another girl next year,” he said. 

Erika Alcantara, 36, is 17 weeks pregnant. She receives an ultrasound while her husband, Wilton, 35, and daughter, Lara, watch. (Joao Pina for The Washington Post )
‘I was shocked’

Gleyse Kelly da Silva had never heard of microcephaly when her unborn daughter was diagnosed with it in late 2015. “I was shocked by what I saw on Google,” she said. “I would cry myself to sleep every night, and when my husband thought I was no longer awake, he would start crying.” 

The hopelessness gave way to action. A few months after her daughter Giovanna was born, she formed a WhatsApp chat group for mothers of children with microcephaly. Within a week, the group had 100 members. What started out as a way to share tips on treatment facilities and navigating the bureaucracy became a source of 24-hour support.

When her daughter kept her up all night crying, da Silva would turn to the group and find other mothers also awake. “They would tell me, you’ve got this, keep going,” she said. 

Today, 400 mothers from across the state have joined the chat group. It has become their best megaphone whenever they need to amplify pressure on government health officials. And when one mother is tight on cash and can’t afford medicine, others step in to help. They share tips on which anti-seizure drugs work best and which sleeping positions can soothe inconsolable babies.  

“I joke that we’ve all become doctors without diplomas,” said da Silva, 28. 

Gleyse Kelly da Silva, 28, with her youngest daughter, Giovanna, who is 15 months old and has microcephaly. (Joao Pina for The Washington Post )

Giovanna, now 15 months old, is still unable to hold up her head for long. She eats better now but doesn’t sleep much. At night, da Silva and her husband, Felipe, settle onto the couch with the baby. She doesn’t cry if her father keeps her bouncing on his knee.  

He has had to quit his job as a security guard. But he has learned to sleep this way: head slumped into the armrest, television on mute, with Giovanna draped across his leg, bouncing, bouncing, bouncing.