To talk about Zika virus control is to talk about money. Vaccine development, mosquito abatement, and even the distribution of DEET repellant takes (and currently lacks) major federal dollars. When, last week, the US Department of Health and Human Services declared Zika a public health emergency in Puerto Rico, it was in part a means to a better-funded end.

But the real price of Zika, and the reason the disease has gone from arboviral nobody to world-wide bugaboo, is the devastating birth defects that can appear in children born to infected women. While it's hard to predict how many children will be born with Zika-related neurodevelopmental disorders, it is clear caring for these children will take a toll. And experts are already calculating the cost of a generation of US babies impacted by Zika.

It starts with the price of being pregnant with Zika. The cost of a regular, healthy pregnancy in the United States is already high, sometimes as much as $50,000 for those who deliver via C-section. But in states with Zika outbreaks, that number will climb when you figure in the two rounds of Zika testing and monthly serial ultrasounds the CDC recommends for monitoring. Right now, Zika is limited to southern states where the virus-spreading Aedes aegypti are most abundant, and that's where monitoring will stay concentrated. "But it’s hard to say where Zika’s boundaries are, because you only really need that one mosquito," says David Pigott, a spatial epidemiologist at the University of Washington.

That (expensive) vigilance is in the hopes of either avoiding Zika—or catching the infection soon enough that women have options for possibly terminating a pregnancy if they get it. Prevention can't be perfect, though. And many women won't choose to terminate if they legally can in their state (which is a big if).

The Cost of Care

For pregnancies carried during a Zika infection, researchers estimate anywhere from 1 to 13 percent will result in a birth defect. The best-known is microcephaly, a condition in which a baby’s head size is two standard deviations below the norm. But that's only part of the story. “We have plenty of patients with microcephaly who are very healthy, with few neurological impairments,” says Nassim Zecavati, a pediatric neurologist at Georgetown University Hospital. “But with Zika, the brain is not only small, but underdeveloped and malformed.”

Some babies with congenital Zika virus infections show signs of fetal brain disruption sequence, in which the brain stops growing and then atrophies, causing the skull to collapse during development. "The neurological manifestations of Zika are catastrophic,” says Zecavati. “Children with Zika are going to require a very high level of care." And that means money.

“We can easily say that there are certain tests these babies and children will require, like MRIs and EEGs,” says Zecavati. “But the cost of diagnostic testing will pale in comparison to cost of the long term healthcare.” Unable to walk, speak, swallow, or even breathe on their own, they'll need wheelchairs, feeding tubes, and breathing apparatuses. And they'll be more susceptible to pneumonia and infections, among other complications.

"A very, very conservative guess would be that the medical costs of Zika would be around $600,000 for these families," says Jorge Alfaro-Murillo, a research scientist at Yale’s Center for Infectious Disease Modeling and Analysis.

And that doesn't even factor in the indirect costs: the money families need to pay for special schooling, to modify their home and vehicles, and, critically, the loss of income for parents providing round-the-clock care. Alfaro-Murillo estimates the total lifetime costs, medical and indirect, will reach $4.1 million. The CDC puts the range at anywhere from $1 million to $10 million per case. "That’s a productivity loss for the country as a whole," says Alfaro-Murillo.

For families without millions of dollars sitting under their beds, Medicaid will probably cover the majority of the medical treatments. “About 20 percent of state budgets right now go toward Medicaid,” says Gerard Anderson, a health economist at Johns Hopkins University. “If you’re adding another million dollars per child every time we have another case like this, that number probably increases in Florida and in some of the other southern states.”

But the system still provides little help for indirect costs. And the burden of a child with Zika-related birth defects is so high—on the medical system, on states, on families—that the CDC is recommending flat out the government make the "full range of contraceptive methods approved by the Food and Drug Administration (FDA), including long-acting reversible contraception" accessible to women at risk of contracting Zika.

That makes sense. “No matter how you cut the mustard, LARC in the form of IUDs or implants or even injectibles like Depo-Provera, are highly cost effective,” says Paul Blumenthal, an OBGYN at Stanford. “A copper IUD costs a dollar. And even the cost of a visit is an infinitesimal fraction of what it would be able to take care of even just a Zika-risk pregnancy.” Those costs shrink away to nothing in comparison to the price of a generation of Zika-affected babies.