At the Mirebalais Hospital in Haiti's central plateau, Dr. Louise Ivers and Dr. Roman Jean-Louis are examining a baby girl who was born in early July with microcephaly, a smaller-than-normal skull often associated with Zika infections.
The baby, named Chinashama, is dressed in a white smock adorned with small flowers. Her legs cross unnaturally over her shins, and her mother, Chrisnette Sainvilus, says the baby cries a lot and has trouble passing stool. "Day and night she's crying," the mother of two says. It's unclear what physical and mental problems Chinashama is facing.
Ivers lifts Chinashama's legs and tries to move them apart. "See, her legs are still crossed. The muscle development is not what we'd want to see," she says. "This baby definitely needs physical therapy."
Chinashama is one of three babies born with microcephaly at the Mirebalais Hospital in July. The Haitian Ministry of Health says there have been 11 others born nationwide over the past two months with this usually rare birth defect. But only one has been officially confirmed as a result of the Zika virus.
Haiti has all of the ingredients for widespread transmission of Zika. The mosquito that carries the virus flourishes in Haiti's tropical heat. As the outbreak wanes in Brazil and Colombia, the Caribbean is currently the epicenter of Zika transmission. The region is reporting high numbers of cases. Puerto Rico, for instance, has a population a third the size of Haiti and is reporting roughly 1,500 new cases of Zika each week.
Yet as of August, Haiti had confirmed only five cases to the World Health Organization.
Many people who get infected with Zika have mild symptoms or no symptoms at all. In Haiti, it can take all day for a patient to see a doctor, so most people don't come to health facilities unless they are extremely ill. But if they're pregnant and have Zika, the virus could still pose a threat to their fetus.
Sainvilus, Chinashama's mother, says she doesn't remember having a fever or other signs of Zika during her pregnancy — although she thinks she had a bout of fever that she thought was chikungunya just before she got pregnant.
But even if Sainvilus had gotten sick, it's highly unlikely that she would have been tested for Zika. For the last four months, a doctors' strike in Haiti has brought the public health care system to a standstill. The Mirebalais Hospital, which remained functioning, is a five-hour bus drive from her home on the road that leads from Port-au-Prince to the Dominican Republic.
Secondly, Haiti just doesn't have the infrastructure to do widespread Zika testing. The only place that can test for Zika is the national laboratory run by the Ministry of Health. They've been doing a limited number of tests that will only come back positive if the actual virus is still in the blood sample being tested. Zika clears from the blood fairly quickly, so unless you test while the person is still sick, it's going to come back negative.
Other more complicated tests have to get sent out to Costa Rica, Trinidad and Tobago or the U.S. — and it can take months for a doctor to get those results if they get them at all.
Ivers, from Partners in Health, a global health organization based in Boston, says she's quite anxious that Zika is spreading widely across Haiti — but it's not being detected.
"We don't have a good idea of what's going on. Now that we've seen three babies born [with microcephaly] in the span of three weeks in our own facility, we are very concerned that it's being under-reported in other parts of the country," she says.
On top of that, she's worried that Haiti's severely limited health system, which isn't picking up Zika cases, is also ill-equipped to deal with a wave of children with severe birth defects.
"Children with developmental delays or disability need individual care with lots of different resources," Ivers says. "Those resources are not really available in Haiti."