Mosquitoes are responsible for upwards of half of all deaths in human history. Beyond a simple nuisance, the diseases they spread are a menace to humanity. A decade ago, we thought we’d had them beaten. We didn’t — and they’re winning. Abdul reflects on the simple tradeoff inherent in mosquito containment. Then he interviews New York Times Global Health Reporter Stephanie Nolen about her recent reporting on the resurgence of mosquitoes and the illnesses they spread.

TRANSCRIPT

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Dr. Abdul El-Sayed, narrating: Doctors in Minnesota and Wisconsin have formed the largest physicians union in the private sector. Medicaid expansion could decide an upcoming governor’s race in Mississippi. The FDA weighs a ban on hair straightening products containing formaldehyde. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] I really hate mosquitoes. Well, look, I guess nobody likes mosquitoes, but I really, really hate them. And that’s because they love me. I’m a mosquito magnet. I’m not really sure why. I’ve read that people with higher metabolic rates tend to attract more mosquitoes, but I can’t claim to have had that high of a metabolic rate. And the evidence for that hypothesis seems mixed. But let’s face it, I live in Michigan, and though mosquitoes can still carry some serious illnesses here. They don’t carry the worst of them, diseases like malaria or dengue fever. At least not yet anyway. To say that mosquitoes are deadly, that’s an understatement. The diseases they carry kill upwards of 700,000 people a year, every year. And that death rate used to be much worse. Over the past several decades we made great strides in our fight against the world’s deadliest animal. Global health organizations and governments in some of the hardest hit communities in sub-Saharan Africa, South America and South and Southeast Asia made serious investments in everything from bed nets to insecticides, and they were working until right around 2019. Mosquitoes are, we’ll call them, evolutionarily efficient. They reproduce quickly and adapt to changing circumstances. So as we deployed more bed nets and more insecticides, mosquito species began to adapt. And for the past four years, we’ve watched as rates of mosquito borne illnesses have jumped right back up. What’s even scarier? They started to crop up in places that never experienced them in the past. For a mosquito hater like me, in a place like Michigan, that’s downright terrifying. But let’s be clear. Mosquito borne illnesses don’t affect everyone equally. They hit the poorest people in the poorest places in the world. And that’s because poverty itself increases the probability of having to live in a place swamped by mosquitoes and lacking the basic resources to protect yourself. Think about it. If you can’t close your home off to the outside world, mosquitoes are going to get in. You can’t afford simple screens or a functioning window on your home. They’re going to bite you. And that’s why some of the poorest children in the world suffer multiple bouts of malaria a year, hundreds of thousands dying of them. These simple investments make a huge difference. On the other hand, scientists are busy devising newer, more complex ways to destroy mosquitoes, like seeding them with bacteria that reduce their ability to spread disease or releasing genetically modified mosquitoes that mate with the live ones, rendering a generation of females the ones that bite dead before they reach mating age. But when you mess with nature, it has a tendency to mess back. And while these methods are thought to be safe, ecosystems are complex, and we can’t always know what the long term impacts could be. I learned a lot about this when I read a series of articles by our guest today, Stephanie Nolen. She’s a global health reporter for The New York Times. And she’s been all over the world learning about why we’re losing the global war with mosquitoes and how scientists and communities are fighting back. She joined me to talk about it. Here’s my conversation with Stephanie Nolen. 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

Stephanie Nolen: My name is Stephanie Nolen, and I’m the global health reporter for The New York Times. And I’ve spent a year studying how we’re losing the war with mosquitoes. 

Dr. Abdul El-Sayed: That sounds really frightening, considering I don’t think most people recognize that we were in a war with mosquitoes. Like, unless it’s is like you know the pits of August. 

Stephanie Nolen: Well, then they’re not paying attention. 

Dr. Abdul El-Sayed: Right. And that’s probably why the mosquitoes are winning. Um. 

Stephanie Nolen: Right. 

Dr. Abdul El-Sayed: So just stepping back, you know, given that you’re a global health reporter, this makes a lot of sense to me, but can you connect it for folks? Why focus on mosquitoes? I mean, oftentimes we think about mosquitoes as in they bite you, but like, why focus on mosquitoes? What’s the connection? 

Stephanie Nolen: So mosquitoes kill more people than any other creature, right? And over the course of history, there are estimates that say they’ve killed as many as half of the humans who’ve ever been alive. So you underestimate the mosquito at your peril. Um. I think up until now, probably a lot of the folks listening to this have had the luxury of thinking, okay, like mosquitoes, malaria, not a problem for me in New York or wherever, right? And what’s happened in recent years is that all kinds of mosquitoes that carry all kinds of scary things have started to expand their range. And the mosquitoes that were already causing us problems have developed ways to get around all of the strategies we had for controlling them. And so uh we’ve, I think, been operating with a certain degree of complacency for a while now that we were slowly and steadily kind of technologically, you know, pulling ahead in this race. And I will be totally honest with you, this is embarrassing, but I went into this planning to wait write one quick story about how we were doing well uh and there were some great new innovations coming and it just took a few phone calls to discover that uh that that was not the case. I mean, there are some great new innovations coming, but the piece I had missed is how urgently we need them because of all of these problems. 

Dr. Abdul El-Sayed: So you ended up writing a six piece spread on mosquitoes, and that sounds like a lot to cover mosquitoes, but there are a lot of pieces to this, this set of stories you’ve written, and I want to get into more of them. But like first question, how many mosquito bites did you get? Like real talk.

Stephanie Nolen: [laugh] Remarkably few, actually. Like very, very few. I think the only place that I really got bitten was inside the mosquito factory in Columbia. Um. The rest of the time. [sigh] You know, I always travel with a bed net. I also usually travel with repellant. But I learned very quickly that you uh if you’re with a team of entomologists who are studying mosquitoes and you pull out your repellent like how to make yourself a social pariah instantly. [laughing] 

Dr. Abdul El-Sayed: Yeah. 

Stephanie Nolen: People studying mosquitoes don’t want you to have repellent on. Um. Yeah I, biting was a fairly only in the factory was the biting really kind of unpleasant. 

Dr. Abdul El-Sayed: So two things, A, Stephanie Nolen is personally winning the battle against mosquitoes. [laughter] So clearly you just should have written like a memoir version of your [?] this is how I deal with mosquitos. 

Stephanie Nolen: No but it’s–

Dr. Abdul El-Sayed: But–

Stephanie Nolen: –because I have a healthy terror for mosquitoes. I spent 25 years living in places where mosquitoes carry all kinds of terrible things. I lived in Brazil through the Zika outbreak. Right. And like we’re casual about Zika now, but like the day before I reported on that story. If you had gone to entomologists and virologists, infectious disease people and said, could a virus that was found in a forest in Uganda 60 years ago jump into a mosquito species and suddenly erupt in cities in Latin America and cause like thousands of babies to be born essentially with with no, you know, like no functioning brains. Like, it was horrifying. It was terrifying. It was unknown. 

Dr. Abdul El-Sayed: Yes. 

Stephanie Nolen: I was back in Brazil last year to write a follow up to that story because it went away. But we don’t know why. Right. So there’s not a lot for me there’s not a lot of comfort in that. It was not like we got rid of this. 

Dr. Abdul El-Sayed: Right. 

Stephanie Nolen: Zika and this huge epidemic. It vanished as quickly as it had come. We don’t know why. So and it didn’t vanish. There is still Zika cases. But like that, that horrifying moment that we had, those poor families. I went to see the families of some of those babies who are now six and seven years old. Right. And it’s been a terrible struggle for them. So all of this has given me a very healthy respect for the mosquito. So I go out of my way [laugh] to keep a little distance between us. 

Dr. Abdul El-Sayed: I respect that. And I guess the second question is there’s a thing called the Mosquito Factory. 

Stephanie Nolen: There sure is. Uh. And that was that’s sort of how I wound up there. I was like, wait, this sounds like the place for me. Um. So that was a story. It’s part of a series that you mentioned, and it was a look at, you know, because we’re not winning and the things that we’ve been doing up until now no longer work as well as we need them to. Um. Part of this series looked at some of the really bold new ideas about how you can counter the effect of mosquito borne disease. So this story was a look at uh what’s called the Wolbachia method. And Wolbachia is a bacteria that’s found in all kinds of insect species, but it’s not naturally found in the mosquito that transmits those viruses in the family with Zika. So yellow fever, dengue is the big one. We really worry about dengue fever, um uh chikungunya. So if you can that mosquito is called Aedes aegypti. And if you can infect that mosquito with the bacteria, it can no longer transmit the virus. So, you know, might sound deceptively easy. It turns out that infecting a mosquito egg, which is considerably smaller than a poppy seed uh with the bacteria, is not straightforward. But then you have to get that bacteria through every mosquito in a place, right? So the strategy they’ve used is factories. You mass produce them. The factory that I went to in Medellín in Colombia produces 100 million mosquitoes a week, and so they breed them. It’s kind of like the battery hen approach to mosquitoes right? There are room full of these little mesh cages where the mosquitoes are reproducing constantly and they take them out, the ones they’re using in Colombia, they release them off the backs of motorbikes. So now they’re using a drone to sift them out over the city or you package them up and transport them in in refrigerated trucks to the places that you’re going to release them. And so for that kind of an operation, so the city of Medellín, right, which is about 6 million people, you need a lot of mosquitoes and they will pass on the bacteria. So once you release them, the hope is they’ll go out, find a friend, hook up, uh pass on the bacteria in their eggs. Females will lay eggs that have the bacteria and you’ll move it through the population that way. But you need a base level of billions of mosquitoes. 

Dr. Abdul El-Sayed: Hmm. They’re like Manchurian candidates for mosquitoes. This is fascinating. 

Stephanie Nolen: Yeah. 

Dr. Abdul El-Sayed: Um. So I want to you know step back just, you know, put it in context. You cited this extraordinary statistic, which is that mosquito borne illness has taken nearly half of the lives that ever lived. What are we talking about today? You know, if we looked at the burden of mosquito borne illness today, uh where is it mainly and how predominant is it? 

Stephanie Nolen: So the one that we still worry about the most is malaria and about 650 thousand people died of malaria last year. Most of those people were children and most of them were in sub-Saharan Africa. So that’s still the big burden of disease. 

Dr. Abdul El-Sayed: Major. 

Stephanie Nolen: Like on the one hand, that’s huge progress right? It was a million people 20 years ago, we’re down to 650,000. That’s that’s a hard won gain. Uh. It is significant. Um. We’re still talking, you know, hundreds of millions of cases every year and, you know, not dying, obviously. [laugh] But, you know, I went to places where kids are getting ten cases of malaria a year. Uh. That has an impact on them neurologically, on their ability to learn. It keeps them out of school, it wipes out their family’s savings every time somebody gets sick. It’s costing sub-Saharan Africa about $12 billion dollars a year just in–

Dr. Abdul El-Sayed: Wow. 

Stephanie Nolen: –economic losses to malaria. So it’s enormous. Right. Um. But I think a strong contender in the number two position coming up close behind is dengue. And dengue is horribly debilitating if you ever if you talk to anybody who’s ever had a case, leaves you um kind of demolished for a long time afterwards. It’s colloquially known as break bone fever. Right. Feels like your bones are being broken. That’s your regular dengue and your severe dengue will kill you. Hemorrhagic dengue will kill you and requires, you know, the response to hemorrhagic dengue. I don’t have to tell you this like it requires a fairly um sophisticated medical response. Right? You can’t just– 

Dr. Abdul El-Sayed: Right. 

Stephanie Nolen: –be in the village and the way you kind of can now with malaria. I’ve been to really rural areas in sub-Saharan Africa where there is a lab or a rapid test that can diagnose malaria, and the meds are available like all over the place. Right. Which is one of the things that that helps reduce malaria deaths. It’s not true for dengue, like if you’ve got hemorrhagic dengue, they’re not fixing that, you know, in your little– 

Dr. Abdul El-Sayed: No. 

Stephanie Nolen: –local community primary care clinic. So the reason that I think dengue really deserves more attention uh is that Aedes aegypti, this mosquito that carries it, is spreading really quickly and it’s turning up in all kinds, so right now there are three or four different places in the world that have massive dengue outbreaks. Bangladesh is in the middle of a massive dengue outbreak um in places that just haven’t had this problem historically. I think France is a great example. France was not a dengue country. France is now a dengue country. Um. The southern United States is seeing all kinds of dengue cases, California is seeing dengue cases. So uh as this mosquito spreads and it’s a really adaptable uh hardy mosquito, as it spreads, dengue is going with it. And like again, to go back to my example about Zika, right, this mosquito can carry a lot of things and we don’t we don’t know what else this mosquito could start to carry with it. Right? So that’s why I think you need some of these interventions. So I spoke about Wolbachia, another one that I went to look at. Um. I went to Sao Tomé and Principe, which is a little island off the west coast of Africa, is genetic modification. And one of the appeals of genetic modification is theoretically you find a method that would work for this particular, the project I went to see is one mosquito species, and they’re looking at protecting against malaria transmission. But the idea is it would pretty it would be pretty easy to swap in to use CRISPR and gene drive to swap in a different modification and protect against something else. And I think, like those are the kinds of solutions we need to be focused on because, you know, we know the problems we have now. We don’t know the problems that are coming. And you’re going to want something that allows you to respond to a lot of different threats. 

Dr. Abdul El-Sayed: Yeah. So those are the the nuclear weapons of mosquito control. Can you give us a sense of what trench warfare was? Like what were the heavy hitters of traditional mosquito control? 

Stephanie Nolen: Well, it still is because it’s still because we still do the same things. You know. 

Dr. Abdul El-Sayed: Right. 

Stephanie Nolen: We do the things that we did 60 years ago. So um insecticide spraying uh you know in a lot of places that have a heavy malaria burden, they still do what’s called indoor residual spraying, where they spray everywhere inside a house, bed nets uh you know, bed nets have been responsible for a huge amount of that decline in malaria death. Um. Uh. You know, [laugh] so this is like not very glamorous. But the other thing that really made a difference, right, Like the reason the Southern [?] is not a malarial zone anymore uh is you move people out of swamps and you put them into better houses. Right. As as people’s uh livelihood and economic status improves. They have better housing and they’re not vulnerable anymore. And that was true in the US 150 years ago and it will need to be true I concluded after this project in in the places that still have that malaria burden. [music break]. 

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Dr. Abdul El-Sayed: So when we talk about losing the war. How come these tried and true you know utility grade interventions are not containing mosquitoes like they used to? 

Stephanie Nolen: [laugh] Because mosquitoes are good at what they do. Um. A mosquito generation is somewhere like between six, ten, eleven weeks. Right? Mosquitoes, every generation of mosquitoes has a lot of genetic mutations they are just a highly mutating organism. Um. So we take ten, fifteen years to get a mosquito intervention through clinical trials and into the market and then into people’s houses. And mosquitoes in you know a couple of months have been through a few generations. So mosquitoes are resistant to the entire class of chemicals that make up all of the insecticides that are in use now. Some species in some places are more resistant than others. But globally, mosquitoes resist. They are not killed by the insecticides that we used the way they were 25 years ago or even ten years ago. Um. The bed nets don’t do it anymore the way they did. Again, like all of these things still offer you some protection. But if you think back, like maybe you remember Bill Gates launching the big bed net drive 25 years ago, right? Everyone used the word elimination. We were going to get to malaria elimination and bednets and indoor spraying were the things, we we’re going to roll them out along with better drugs and tests. And we were going to get to elimination. And like you do still hear that optimistic conversation about elimination these days, but like less of it, let’s say. Um. So with bednets, there was incredible success getting bed nets into people’s homes. Uh. So getting, you know, every family, every kid sleeping under a bed net and then mosquitoes again with the adaptation and the rapid evolution. If we can’t bight at night where people are sleeping, which was our old preferred practice, we’ll bite during the day, we’ll bite outdoors, you create an ecological niche, right, for the mosquitoes that are, you know, the species that are more adapted or even individuals um to to sort of change their behavior. And so bed nets just can’t protect people if when they’re being bitten is at school or working in their fields or when they’re outdoors cooking outside their house. Right. Like it just the mosquitoes have found a way around the intervention. 

Dr. Abdul El-Sayed: So these organisms are so evolutionarily efficient that they’ve been able to both adapt so that they’re resistant to our chemical interventions. But also they shifted their entire sleep schedule. I mean, that’s motivation. Like, I have a six year old– 

Stephanie Nolen: –[?] commitment. [laugh]

Dr. Abdul El-Sayed: And it’s really tough to get her to wake up on time, like she can learn a thing or two from these mosquitoes. Right. This is this is–

Stephanie Nolen: Yeah. Totally.

Dr. Abdul El-Sayed: –how you win the battle. They just decide that I used to be a nocturnal being, but not anymore. Right? These humans have–

Stephanie Nolen: Yeah. 

Dr. Abdul El-Sayed: –figured me out. And so they shifted–

Stephanie Nolen: Yeah. 

Dr. Abdul El-Sayed: –their entire sleep schedule so that now they are biting during the day. I mean, I feel like there’s a lot that goes into that. 

Stephanie Nolen: I’m going to say that I’m not sure I I’ve only had a crash course in entomology here, I’m going to say I’m not 100% sure what kind of a sleep schedule a mosquito has. I definitely saw a lot of mosquito napping in the course of the day. There’s a lot of just hanging out somewhere where it’s cool, somewhere where it’s safe. They just hang out on the wall. Um. Yeah, I don’t know. Do they sleep all night? I don’t know. I don’t actually know that question. I did learn that they um they actively seek out shelter from rain. So that was interesting. [laugh]

Dr. Abdul El-Sayed: Hmm. So obviously, sleep is like the it’s the analogy we use. Right. But they they figured out how to be more robust during the day when in the past they used to come out at night. I imagine it probably has less to do with–

Stephanie Nolen: Yeah or you have species that were always like, there’s a lot of debate in the entomology world about it. How much of this is that species malaria, transmitting species that always were daytime biters have just flourished in this scenario because the nighttime biters have kind of died away and the daytime biters– 

Dr. Abdul El-Sayed: Because of the selection against them.

Stephanie Nolen: –have moved into that space. 

Dr. Abdul El-Sayed: Yeah. So there’s a selection effect against the nighttime biters that created a space where the daytime biters can– 

Stephanie Nolen: And some people, like, again, if you want to fire up a room full of entomologists and really get them going, like throw down your throw down the thesis that, no, it’s the nighttime biters who change their schedule when they’re biting in the day versus no, it’s the it’s the– 

Dr. Abdul El-Sayed: As you spray yourself with Deet. [laughter]

Stephanie Nolen: Don’t do that. [laughter] Because that is just not. [?] You’re not going to win that popularity contest. 

Dr. Abdul El-Sayed: You know, there’s there’s we always talk about, you know, folks who run into a burning building like these folks walk into a mosquito infested space, which actually ends up being very dangerous and like even if you don’t–

Stephanie Nolen: Oh and they’re thrilled. They’re so excited. The the places I went, I mean, I developed like a deep love for out of all of the nerdy science people that I have spent time with in sort of 30 years of covering global health. The entomologists, I think might be my fave. Like they we like we like headed right into the sewage ponds and into the drainage ditches and like crawling into these little low roofed animal houses. And it’s just like the the, like more horrifying a place you can find the mosquito, uh the more excited they were about it. And the when I was in Tanzania at this great public health research Institute called the Ifakara Health Institute, I learned that they every researcher there, so many of them work on malaria. Everybody is assigned a cage of mosquitoes. So the whole staff, like all of these people who’ve done all this incredibly award winning science, they have to go by the lab every day or two and stick their arms in and just hold them there for about ten or 15 minutes while their mosquitoes feed. [laughing] Like it’s kind of great. 

Dr. Abdul El-Sayed: That’s uh that’s real commitment. 

Stephanie Nolen: Yeah. 

Dr. Abdul El-Sayed: That’s real commitment. Um. I want to ask you in particular about about a relatively newcomer on the scene, at least when it comes to Subsaharan Africa, and that’s Anopheles stephensi. Um. Can you tell us a little bit about the story of um I know, I know our entomologist friends call him Steve or her Steve. 

Stephanie Nolen: Her. 

Dr. Abdul El-Sayed: Actually. Um.

Stephanie Nolen: They call her Steve. [laughing]

Dr. Abdul El-Sayed: Uh. Can you tell us a little bit about Steve? 

Stephanie Nolen: Yeah, so I didn’t know anything at all about Steve. About a year ago, I was living in blissful ignorance um and I called up an entomologist at the CDC. We had a long conversation about, like this general thesis I was exploring about how there was an urgent need for new tools. And at the end of the conversation, I said to her, as journalists often will, is there anything I haven’t asked you about that you think is important? And she said, well, you haven’t mentioned Anopheles stephensi. And I said, I don’t know what that is. And she said, it’s an it’s an insecticide, a fully insecticide resistant urban malaria vector that has moved from Asia into sub-Saharan Africa. Uh. And that sentence might not [laugh] that might not seem like an overly ominous sentence, but it absolutely I think my next words to her were that’s terrifying. Um. And the reason is that, uh you know, I think for a lot of people who don’t pay a lot of attention to what’s happening in malaria, the idea that there would be another mosquito that carries malaria in a place which, as we’ve just said already has most of the global burden of malaria doesn’t sound like a big deal. Uh. But the thing is that malaria in sub-Saharan Africa is a rural disease. And so the infrastructure and the expertise and the whole malaria response is focused on rural malaria. And, you know, those are mosquitoes that um have a very predictable kind of outdoor breeding pattern. Anopheles stephensi is a South Asian mosquito. It’s come from from India and Pakistan. Uh. And it has it turned up first in sub-Saharan Africa, in Djibouti, the little country on the on the Horn of Africa. Uh. And that was ten years ago. And it was found there by some entomologists. But nobody really paid too much attention until a few years later, when all of a sudden Djibouti, which was a country that was right on the cusp of malaria elimination, like they were reporting a few dozen cases every year, all of a sudden they had an absolute malaria explosion. And it happened in the city, in Djibouti City. And from there, the cases just kept going up. And then a year ago, the same thing happened in Dire Dawa which is the second largest city in Ethiopia. And again, it’s a place that like never had malaria. And this is like saying like and then malaria exploded in Boston, right? Like, it’s just not a place where you would ever have encountered the disease. And all of a sudden clinics were filling up with I mean, they didn’t even know what was wrong with people initially because they weren’t testing for malaria, because who gets malaria in Dire Dawa? Like nobody. Um. And it turned out and it was a it was a huge outbreak. And that tells you like exactly what the what the real risk is with this mosquito is that it moves into places that don’t have the experience, they don’t have the diagnostic infrastructure or they don’t instantly recognize the disease. And this mosquito, Steve, as she’s known, uh she’s like a colleague of mine referred to her as the supervillain. Right? She [laugh] she’ll feed on humans. But if there’s no humans, she’ll feed on animals, and she’d like it better when it’s cooler. But if it’s really hot like it is in Dire Dawa, that’s okay. She likes it when it’s wet, but it’s okay if it’s dry and she can breed in like a tiny splash of water. So you don’t need swamps or streams if you have like an old flower, if you have a flower pot in your yard and there’s like a little bit of water that drained out the bottom in a dish, that’s more than enough for her to breed. Um. She in Dire Dawa they found the largest infestation of of larva in um infestation’s not really fair. She’s not infesting anything. She’s just doing her thing. They found the heaviest population of larva in sewage ponds at the water treatment plant on the edge of the university that was the heart of the epidemic. And so once that had, I went to Dire Dawa to see this and like, once I started to understand all the places she could breed, like everywhere you looked right like every ditch and every bucket in Dire Dawa like a lot of African cities doesn’t have great municipal services, so the trash isn’t collected all that often. So there’s like old you know tires and buckets and stuff lying around and the water service doesn’t run very often. So it might only come on a couple of times a week, which means that everybody’s storing jerry cans of water all around their home. Right. And so then if you if you start to extrapolate from Dire Dawa to these enormous African cities like Lagos, which is twice the size of New York or Nairobi or Kinshasa, and you imagine that, you know, you imagine this mosquito in those cities and it’s, you know, every month the W.H.O. reports that it’s been found in another place uh that’s an additional 600 million people. There are 600 million people in sub-Saharan Africa living in cities. And the initial estimates say that 160 million of them are like living in areas that clearly would be hospitable to Steve. So–

Dr. Abdul El-Sayed: Wow. 

Stephanie Nolen: You know, if you talk about [laugh] like when you like those malaria cases are coming down, if in the space of a couple of years, 160 million people suddenly live in malaria areas where the National Malaria Program has no experience or infrastructure in place to respond to urban malaria, then like, that’s the it’s just a potential for disaster. Right. And I–

Dr. Abdul El-Sayed: Yeah. 

Stephanie Nolen: Like not to like over like to be the like complete voice of doom, right? Because I did speak to entomologists who said, we don’t know. Like it’s too early to say that it’s the sole driver of malaria explosion in these places or that that could happen everywhere. There’s still just a lot of questions, but certainly there’s like pretty compelling early evidence that it’s a disaster when this thing moves into a city. 

Dr. Abdul El-Sayed: Yeah, that is that is terrifying. 

Stephanie Nolen: Right? 

Dr. Abdul El-Sayed: Considering that– 

Stephanie Nolen: That was me! [laughing]

Dr. Abdul El-Sayed: Yeah, you’re talking about a extremely hardy, robust mosquito that clearly can carry and spread malaria in places where malaria was uncommon. And the point that you made about it being urban is really important because the vast proportion of of malaria that we’d seen you talked about earlier on in the south, in the United States was largely because people were in these um largely uninhabitable swamp like areas. But what happens now when you’ve got a mosquito that can that can breed in tiny amounts of water and therefore can, you know, can go urban in a way that um most mosquitoes that carry this disease can’t. So like this is a doomsday scenario. Um. It’s like a great leap forward for mosquitoes. I want to ask, how much does does the climate crisis shape this movement of mosquitoes? Do we understand the connection? 

Stephanie Nolen: Yeah, I think we don’t know. Um. It’s all. It’s all so fast, right? Like, I feel like four or five years ago when I used to ask people sort of that question, they would say, you know, well we our modeling suggests that X percent of space could become suitable habitat. And all of a sudden, the acceleration of this stuff is is so fast that I feel like the people I ask that question to today, they don’t answer with any degree of certainty. Um. It’s definitely true. There are, you know, warmer, wetter places um that are proving to be habitat for mosquitoes, that are the vectors for the things we worry about the most. I think the that’s sort of like the obvious connection, the less obvious one, which I hadn’t really thought about till I started working on this is also refugees, right? So just to talk about malaria again for a second, 8% of of malaria cases globally every year uh are in refugees, uh probably because they’re in substandard housing, most of them right? And super vulnerable. But we know that climate is rapidly accelerating the creation of new refugee populations. Right? So there’s this kind of this whole intersection of ways in which that climate change is making people vulnerable. And it’s not just that that uh there’s more places that are hospitable to dangerous species. 

Dr. Abdul El-Sayed: Hmm. Another another aspect here is just the limited public health infrastructure and how much of it got waylaid by COVID-19. Do you feel like with the COVID pandemic, there was almost a taking of the eye off the ball um that that helped to accelerate some of this? Or was this kind of just happening in the background? And there’s really not that much that public health officials could have done about it?

Stephanie Nolen: You know, anything that I ask uh that I ask folks about these days, they they talk about the COVID impact in terms of the diversion of resources, the diversion of um of healthcare workers. And I think definitely you see you see that in in the sort of bump up again in malaria deaths. I didn’t, though, in the mosquito world, I didn’t get such a sense of this the way that I do. You know, right now I’m in the middle of reporting out some stuff on tuberculosis and tuberculosis programs got absolutely hijacked by COVID right across the board. The staff, the infrastructure, the laboratories, the just everything. I think that’s less true in the bug world. That’s less true uh of malaria and of entomology specifically um there are and, you know, there are in some ways some silver lining, right? Um. For example, the folks that that are doing the work on stephensi, they have new capacity to do genetic sequencing of mosquitoes that wasn’t around uh they have the ability to sequence parasites and to figure out which in–, you know, are they dealing with insecticide resistant parasites? Are they dealing with insecticide resistant mosquitoes? There was a building out of of um molecular analysis capacity, which, you know, probably wouldn’t have happened at the same pace without COVID. But I, I don’t I think public health everywhere took a hit with the diversion and everywhere in the Global South took a hit with the the diversion to uh to COVID for a couple of years there. But I don’t feel like in the malaria or mosquito world that hit was as big as it was other places. 

Dr. Abdul El-Sayed: Hmm. I want to um move now to some of the interventions. You know we talked about uh bacterial infestation. We talked about genetic modification. What are some of the other advances that entomologists are advancing to to try and take this on? 

Stephanie Nolen: So I saw some neat um. I don’t really want to call it like lower tech, but like maybe more straightforward or certainly requiring less massive infrastructure interventions. Um. And a couple of those are are aimed at this problem you were talking about uh with bed nets not protecting people anymore. Um. Spatial repellents are um just like little clear sheets of plastic that release a chemical that confuse mosquitoes and keep them from being able to bite. And so if you’re in your house but not under your net, so you’re not getting that protection from your bed net, you’re watching TV, you’re cooking, you’re doing your homework, whatever. You can hang these on the walls. And they really the early um clinical trials suggest that they really reduce the amount of bites people get. And then there’s something called an attractive targeted sugar bait, um which is kind of the same idea. But for outdoors, it’s a little um like a little plastic uh grid of pouches that contain an insecticide and they’re covered in a membrane that’s just thin enough for a mosquito to bite through. And all kinds of chemistry work has gone into devising a thing the the sugar bait that will be really, really attractive for mosquitoes. So all mosquitoes, and only females bite humans or animals for blood, but all mosquitoes, male and female, need nectar, sugar, a form of sugar to survive. And so they drink and they get that from plants typically. And so this thing kind of mimics the plant smell and taste, um and then you’re mosquitoes drinking poison. But of course, it was like really hard to develop this. And like in some ways it seems like a sort of astoundingly simple idea, right? But you need to develop something that will attract mosquitoes, but not any other insect that might serve as a pollinator. You can’t be poisoning the bees. Right. And you’ve got to have it durable enough that it can hang outside a house for six months, um that you have to hang it high enough that the goats aren’t going to eat it so that the kids aren’t accidentally going to come near it. So it’s like a whole it’s like an interesting little engineering or design puzzle. But those also have clinical trials that show that they really are quite protective. Um. They’re still early, but they seem the early results are that they’re quite protective for that outdoor biting. Um. And then I guess the one that I would say the thing that became the last story in the series that I did, that I just thought was really interesting was if you come at this from the whole other direction. So if you want a really low tech intervention that We know works against mosquitoes, window screens, right? Like, if you have a proper roof on your house, and screens on your windows and your doors, then you don’t get mosquito bites. And that’s what made a difference in you know Italy, the southern U.S.. And so there’s really interesting work being done in Tanzania and a couple of other places to say what would that actually cost? Right. So we know that in Tanzania, about 80% of the malaria cases occur in people who live in the lowest 10% quality of houses. So if you went to those people and you said, what would it take to malaria proof your house? And I and I kind of learned about this by going and wandering around with these researchers in villages. And people were like super nice and let us like, crawl up and like, look in their ro–, like in their attic, at their roof and and um and crawl around on the floor of their house looking at the walls inside. Um. If you put on a metal roof and screens in the windows and a proper door, what does that cost? And and, you know, if you start to think about the millions of people who live in malaria vulnerable areas, your first instinct is this is impossibly expensive. And then you think we spend $22 billion dollars a year at a conservative estimate trying to control mosquitoes. Most houses don’t need this resea– these researchers I was with have found they don’t need tens of thousands of dollars of intervention. They need 100 bucks worth of window screens. They need, you know, $500 maybe to do the roof, but not you know, most houses only need the doors and windows. And that’s, of course, because people are making those improvements themselves. Right. Everybody wants a better house, not just for mosquitoes. And so they’re saving up their money here. And, you know, this year they can afford a door and that year they can afford a window. So if you just gave people the cash, they figured out it comes out to about 250 bucks on average to give people if you were to figure out a way low cost loans, subsidized materials, whatever, to malaria proof people’s houses, you can leave the mosquitoes alone. And then it doesn’t matter how the mosquitoes are evolving, right, or what they’re resistant to because people are protected in their houses. 

Dr. Abdul El-Sayed: Yeah. And I mean, this is sort of classic public health, which is if you invest in fundamental well-being, it tends to improve–

Stephanie Nolen: Yeah. 

Dr. Abdul El-Sayed: –health outcomes as well. 

Stephanie Nolen: Yeah. On a number– 

Dr. Abdul El-Sayed: And then–

Stephanie Nolen: –of levels, right? Not just mosquitos. 

Dr. Abdul El-Sayed: Right. Exactly. Exactly. Having a better house if you’re in the lowest decile of housing quality, has a lot of knock on effects beyond you not getting malaria or your child not getting malaria. Um. And the other side of it, you know, some of these quite dramatic interventions, whether it’s genetic modification or seeding bacteria, one has to imagine there’s the risk of unintended consequences we haven’t yet mapped out. What are some of those? You know, theoretically, have you talk to folks about them and are there ways that this could catastrophically backfire in our face?

Stephanie Nolen: Yeah. I mean, it’s the it’s the Jurassic Park effect, right? Um. [laugh] If you’d like to also irritate, once you’re done with your repellant, if you would like to further irritate [laugh] that that hypothetical table of entomologists you’re sitting with [laugh] just mention Jurass– [laugh] mention the Jurassic Park effect. Um. The answer is we don’t know. Right. Like, I mean, I’m. I’m joke about Jurassic Park, but like, the fundamental premise is true. You don’t actually know what the what the knock on effects of these things potentially are. And uh the folks who work in genetic modification say they, you know, there are there’s kind of two streams of approach in the world of genetic modification and one works to alt– like give the mosquito a characteristic that means that it wipes out its own population. So it’s a population eradication method. The other approach, which is the one I went to see uh in part because it’s more kind of publicly palatable because you don’t you’re not messing with the ecosystem, as they say, in the same way uh modifies the mosquito so it can’t pass on a parasite or a virus, but it doesn’t take the mosquito out of the ecosystem. So the eradication people say, look, there’s 3500 species of mosquito and there’s not one single creature on earth that depends solely on mosquitoes as a food source. You could take them out of ecological web without consequences. The people who say, well, leave the mosquito in the ecological web so you don’t have to worry about it say, you know, could there be like in a you know, again, evolutionarily, will mosquitoes evolve to be like resistant to the, will the parasite evolve so that this modification doesn’t keep it from from being able to be passed on anymore? They say yes, like the lesson of evolution is eventually that will be true. They don’t think you know. And the hope is there that, like by the time that happens, we’ve made that progress through elimination. Right. Um. They don’t think there’s a way in which it could evolve or mutate to be dangerous in a new way. Although, again, you can’t say that for sure. And the Wolbachia folks say the same thing, right? Like they it’s very well-studied. It’s been used for quite a while now. There’s a heap of lab analysis and a bunch of clinical trials. They say there is no evidence. There is no way in which this uh poses. Uh. You know, there are no you can never say there’s no unintended consequences that we don’t know about. There’s obviously the unknown unknowns, but the known unknowns are are not a risk. I will tell you, the thing that I heard from folks in Burkina Faso who are working on genetic modification from regular people that I interviewed in Sao Tomé and Principe, which um where they’re hoping to be able to do a release of genetically modified mosquitoes. They say, like, of course there are questions and we don’t love the idea of being a guinea pig and uh we wish more was known about this. We don’t like the idea of being first. But also, I used to have malaria six times a year when I was a kid. I had a younger–

Dr. Abdul El-Sayed: Yeah. 

Stephanie Nolen: –brother who died of malaria. My mother died of malaria when she was pregnant. If you have lived in a really high burden malaria place, if you’re a mother who’s lost four children to malaria, then you’re willing to roll the dice on the mosquitoes. 

Dr. Abdul El-Sayed: Yeah. I really appreciate you offering us the voice of the folks in these communities. Right. Because so often there are very large, very powerful agencies uh in the scientific community who have a debate and then unleash a lot of this on on the people. And it’s really helpful to hear what folks have to say. Um. One last question I know a lot of people have about mosquitoes because I do, what is it that predicts the probability of getting bit by them? Because I get destroyed by mosquitoes, like I walk outside and if there are mosquitoes around, I’m the one who’s getting multiple mosquito bites. And then, like my friends would be like, Yeah, I got one bite. Like that’s cute. I got 15. Um. [laughter] I remember one summer trip to the tiny little village in India where my wife’s family was from, and I woke up one morning with 61 mosquito bites and she had none. And I was just like, how is this? Like, how did this happen? So do we know much about about why some folks are are targets and and others are not? 

Stephanie Nolen: I just some people do know–

Dr. Abdul El-Sayed: Or Steve’s just got a crush on my maybe I don’t know. [laughter]

Stephanie Nolen: It’s irresistible magnetism. Um. I think some people do know. Uh. As far as uh my my very minimal reading on this suggests people do know and I am not one of those people. Um. But again, I would encourage you to make some entomologist friends because they are a good time. 

Dr. Abdul El-Sayed: They sound like a great rollicking crew. Just, you know, the idea of crawling into places where there are mosquitoes considering my–

Stephanie Nolen: Right. It’s maybe not your–

Dr. Abdul El-Sayed: –my my gentle temperment. 

Stephanie Nolen: You’re maybe not the guy. [laughter]

Dr. Abdul El-Sayed: I’m not the guy. [laughing] I’m like, I found them. I found them.

Stephanie Nolen: Shame. 

Dr. Abdul El-Sayed: They found me. Uh. [laughter] Anyway, um we really, really appreciate you Stephanie, for um for your work on this and for sounding the alarm and uh for coming and sharing your learnings with us. Uh. Our guest today was Stephanie Nolen. She is a global health journalist at The New York Times. Uh. Once again, Stephanie, thank you so much for your time. 

Stephanie Nolen: Thanks very much for having me. [music break]

Dr. Abdul El-Sayed: As usual, here’s what I’m watching right now. Doctors, physician assistants and nurse practitioners in Minnesota and Wisconsin came together to form a union at Allina Health care. That’s a huge deal for a couple of reasons. First, these are mid-career practitioners. And second, Allina is a private health care company. We’ve watched resident unions take off since the pandemic, and we interviewed one of the leaders of that movement a few weeks back. But that’s been largely limited to trainee physicians at academic medical centers. This is something else entirely. Remember, this isn’t the first time we’ve talked about Allina, on the show. In fact, we talked about them this summer when they tried to ban patients who hold medical debt. Remember that? I share that because it shows just how powerful this first union could be. Think about what happens when the folks who actually provide care at a hospital have a real united voice in shaping hospital policies. Nobody goes to medical school to deny people health care after all. Mississippi isn’t known for being a, well, paragon of health care access. In fact, it’s quite the opposite on almost every single metric. Mississippians suffer worst of all. Mississippi has some of the worst health care access in the country. But that could change if a growing surge of voters have their way. Democrat Brandon Presley, a member of the state’s Public Service Commission, is challenging Republican Governor Tate Reeves. And though he’s trailing in polling, he’s cut the deficit down to single digits in what is perhaps the most Republican state in the country. Why? Well, he’s running on Medicaid expansion. You know, the feature of Obamacare that is almost single handedly responsible for cutting uninsurance in half. Turns out that lots of Mississippi voters are sick and tired of being sick and tired. In the words of Fannie Lou Hamer, one of the most famous daughters of Mississippi, who coined that statement back in 1964. And I’m hopeful those voters will show up to do something about it. Finally, the FDA is weighing a ban on hair straightening products that contain formaldehyde. Here’s Dr. Namandjé Bumpus, chief scientist who leads the cosmetic section for the FDA. 

[clip of Namandjé N. Bumpus] Now, studies have shown that when hair straightening products containing formaldehyde, which are often marketed towards Black women, are used with heat, the risk of certain cancers, including certain upper respiratory tract cancers and myeloid leukemias increases. 

Dr. Abdul El-Sayed: The products have been linked to endometrial cancer and leukemias. But as Dr. Bumpus notes, they’re far more likely to be used by women of color, among whom rates of endrometrial cancer have been rising the fastest. And that makes the story complex. On the one hand, as we discussed last week regarding California’s ban on cancer causing food additives, government stepping up to protect folks from products they don’t even know can hurt them. It matters. And that matters even more when these are products whose burdens fall hardest on the folks most likely to suffer disease in the first place. And at the same time, it’s important to consider the disproportionate impact of those bans on the same exact communities. Because let’s dig a little further. So much of the beauty industry, things like skin whitening creams or hair straightening products, exploit beauty standards that themselves are based on a particular ideal, the ideal that says that lighter skin or straighter hair is more beautiful an ideal based on whiteness. And when those same products can kill you, it means that those beauty standards can too. But however unfair those standards may be, they exist. And what’s worse, considering the way that our society still discriminates against certain hairstyles, appealing to them can have real economic consequences. So asking even forcing people to stop using products like these is not without harm. The industry has known about this risk for years, and yet they’ve hesitated to act on their own accord to take formaldehyde out of their products. So this, I hope, will force industry to act to research and develop safer alternatives that don’t put the people who use them at risk. It should have happened a long time ago. That’s it for today. On your way out. Don’t forget to rate and review the show. It goes a long way. Also, if you love our show and want to rep us, drop by the Crooked store for some America Dissected merch. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher, our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me, Dr. Abdul El-Sayed. Your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.