Some Bad Mother Suckers with Stephanie Nolen

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Abdul El-Sayed.

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, and 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've 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. If 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 Nolan. 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 Nolan.

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 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 write one quick story about how we were doing well. And there were some great new innovations coming, and it just took a few phone calls to discover 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.

The rest of the time.

You know, I always travel with a bed net, I also usually travel with repellent. But I learned very quickly that 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, people studying mosquitoes don't want you to have repellent on. Yeah, biting was a fairly...

Only in the factory was the biting really kind of unpleasant.

It was terrifying, it was unknown. 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.

For me, there's not a lot of comfort in that. It's not like we got rid of this Zika and this huge epidemic. It vanished as quickly as it had come, we don't know why it didn't vanish.

There are still Zika cases. But that horrifying moment that we had with those poor families. I went to see the families of some of those babies who are now six and seven years old, and it's been a terrible struggle for them. All of this has given me a very healthy respect for the mosquitoes, so I go out of my way to keep a little distance between us.

That was a story, part of a series that you mentioned, and it was a look at. 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. Part of this series looked at some of the really bold new ideas about how you can counter the effect of mosquito-borne disease. This story was a look at what's called the Wolbachia method. 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 Wazika yellow fever.

Dengue is the big one, we really worry about, dengue fever.

Chikungunya.

That mosquito is called Aedes aegypti. If you can infect that mosquito with the bacteria, it can no longer transmit the virus.

It might sound deceptively easy. It turns out that infecting a mosquito egg, which is considerably smaller than a poppy seed, with the bacteria is not straightforward. Then you have to get that bacteria through every mosquito in a place. The strategy they've used is factories, you mass produce them.

The factory that I went to in Medellin in Colombia, produces 100 million mosquitoes a week. They breed them. It's kind of like the battery hen approach to mosquitoes. There are rooms full of these little mesh cages where the mosquitoes are reproducing constantly. They take them out.

The ones they're using in Colombia, they release them off the backs of motorbikes, now they're using a drone to sift them out over the city. Or you package them up and transport them in refrigerated trucks to the places that you're going to release them for that kind of an operation. The city of Medellin, which is about 6 million people. You need a lot of mosquitoes, they will pass on the bacteria.

Once you release them, the hope is they'll go out, find a friend, hook up. 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, you need a base level of billions of mosquitoes.

If we looked at the burden of mosquito-borne illness today, where is it mainly and how predominant is it?

It was a million people 20 years ago. We're down to 650,000, that's a hard one gain. It is significant. We're still talking hundreds of millions of cases every year and not dying, obviously.

I went to places where kids are getting 10 cases of malaria a year. That has an impact on them neurologically, on their ability to learn. It keeps them out of school, it wipes out their family savings every time somebody gets sick. It's costing sub-Saharan Africa about $12 billion a year, just in economic losses to malaria.

It's enormous, I think. Strong contender in the number two position, coming up close behind is dengue. Dengue is horribly debilitating. If you talk to anybody who's ever had a case, it leaves you demolished for a long time afterwards. It's colloquially known as breakbone fever.

It feels like your bones are being broken. That's your regular dengue. your severe dengue will kill you. hemorrhagic dengue will kill you. It requires the response to hemorrhagic dengue.

I don't have to tell you this. It requires a fairly sophisticated medical response. You can't just be in the village the way you 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. The meds are available all over the place, which is one of the things that helps reduce malaria deaths.

It's not true for dengue. if you've got hemorrhagic dengue, they're not fixing that in your little local community primary care clinic. The reason that I think dengue really deserves more attention is that Aedes aegypti, this mosquito that carries it, is spreading really quickly and it's turning up in all kinds. 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 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. The southern United States is seeing all kinds of dengue cases.

California is seeing dengue cases as this mosquito spreads, and it's a really adaptable, hardy mosquito as it spreads, dengue is going with it again. To go back to my example about Zika, this mosquito can carry a lot of things, and we don't know what else this mosquito could start to carry with it.

That's why I think you need some of these interventions. I spoke about Wolbachia. Another one that I went to look at, I went to Sao Tome and Príncipe, which is a little island off the west coast of Africa. Is genetic modification? 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.

The idea is it would be pretty easy to swap in to use CRISPR and GeneDrive to swap in a different modification and protect against something else. Those are the kinds of solutions we need to be focused on, because 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.

Bed nets have been responsible for a huge amount of that decline in malaria death.

This is not very glamorous, but the other thing that really made a difference, the reason the southern U.

S is not a malarial zone anymore. Is you move people out of swamps and you put them into better houses? As people's livelihood and economic status improves, they have better housing and they're not vulnerable anymore. That was true in the U.S 150 years ago, and it will need to be true, I concluded after this project in the places that still have that malaria burden.

That's a pretty big deal. Look, I love smalls because my cats love smalls, and well, if they love it, I love it. And the notion that cats should be eating food that's well, fresh, that makes sense to me.

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And mosquitoes in 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 use the way they were 25 years ago, even 10 years ago.

The bed nets don't do it anymore the way they did again. All of these things still offer you some protection. But if you think back, maybe you remember Bill Gates launching the Big bed Net drive 25 years ago. Everyone used the word elimination. We were going to get to malaria elimination, and bed nets and indoor spraying were the things. We were going to roll them out, along with better drugs and tests, and we were going to get to elimination.

And you do still hear that optimistic conversation about elimination these days, but like, less of it, let's say so. With bed nets, there was incredible success getting bed nets into people's homes, so getting every family, every kid sleeping under a bed net. And then mosquitoes again, with the adaptation and the rapid evolution. If we can't bite 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 for the mosquitoes that are either the species that are more adapted, or even individuals 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.

Like it, just, the mosquitoes have found a way around the intervention.

Right, this is how you win the battle. You just decide that. I used to be a nocturnal being, but not anymore, right? These humans have figured me out.

And so they shifted 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.

They just hang out on the wall.

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 actively seek out shelter from rain.

So that was interesting.

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.

And some people like, again, if you want to fire up a room full of entomologists and really get them going. 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.

As you spray yourself with.

And.

The more horrifying a place you can find the mosquito, the more excited they were about it. When I was in Tanzania at this great public health research institute called the Ifekara Health Institute, I learned that every researcher there, so many of them work on malaria. Everybody's assigned a cage of mosquitoes, the whole staff, 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 10 or 15 minutes while their mosquitoes feed. It's kind of great.

I know our entomologist friends call him Steve, or her Steve.

I was exploring about how there was an urgent need for new tools. 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? She said. Well, you haven't mentioned Anopheles de Vencae. I said, I don't know what that is, she said. It's an insecticide, a fully insecticide resistant urban malaria vector that has moved from Asia into sub-Saharan Africa.

That sentence might not seem like an overly ominous sentence, but I think my next words to her were, That's terrifying.

The reason is that, 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. The thing is that malaria in sub-Saharan Africa is a rural disease, the infrastructure and the expertise and the whole malaria response is focused on rural malaria.

Those are mosquitoes that have a very predictable outdoor breeding pattern. Anopheles de vencae is a South Asian mosquito. It's come from Indian Pakistan. It turned up first in sub-Saharan Africa, in Djibouti, the little country on the horn of Africa that was 10 years ago.

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, they were reporting a few dozen cases every year. All of a sudden, they had an absolute malaria explosion. It happened in the city, in Djibouti city. From there, the cases just kept going up.

Then, a year ago, the same thing happened in Diridawa, which is the second largest city in Ethiopia. Again, it's a place that never had malaria, this is like saying, and then malaria exploded in Boston. It's just not a place where you would ever have encountered the disease. All of a sudden, clinics were filling up with....

They didn't even know what was wrong with people initially because they weren't testing for malaria because.

She's.

A colleague of mine referred to her as the supervillain. She will feed on humans, but if there's no humans, she'll feed on animals. She'd like it better when it's cooler, but if it's really hot, like it is in Diridawa, that's okay. She likes it when it's wet, but it's okay if it's dry.

She can breed in a tiny splash of water. You don't need swamps or streams if you have an old flower, if you have a flower pot in your yard. And there's a little bit of water that drained out the bottom in a dish, that's more than enough for her to breed. In Diridawa, they found the heaviest infestation of larva in infestation is 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.

I went to Diridawa to see this once I started to understand all the places she could breed. Everywhere you looked. Every ditch and every bucket in Diridawa, like a lot of African cities, doesn't have great municipal services. The trash isn't collected all that often, there's old tires and buckets and stuff lying around.

The water service doesn't run very often, it might only come on a couple times a week, which means that everybody's storing jerry cans of water all around their home. Then, if you start to extrapolate from Diridawa to these enormous African cities like Lagos, which is twice the size of New York or Nairobi or Kinshasa. And you imagine that you imagine this mosquito in those cities. Every month, the WHO reports that it's been found in another place. That's an additional 600 million people.

There are 600 million people in sub-Saharan Africa living in cities. The initial estimates say that 160 million of them are living in areas. That clearly would be hospitable to Steve if you talk about 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 it's just a potential for disaster. Not to.

Be the complete voice of doom. Because I did speak to entomologists who said, we don't know. 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 a lot of questions, but certainly there's pretty compelling early evidence that it's a disaster when this thing moves into a city.

I want to ask, how much does the climate crisis shape this movement of mosquitoes? Do we understand the connection?

It's all so fast, right? I feel like four or five years ago, when I used to ask people that question, they would say, well. Our modeling suggests that X percent of space could become suitable habitat. And all of a sudden, the acceleration of this stuff is so fast that I feel like the people I ask that question to today, they don't answer with any degree of certainty. It's definitely true. There are warmer, wetter places that are proving to be habitat for mosquitoes. That are the vectors for the things we worry about the most, I think.

That's sort of the obvious connection, the less obvious one, which I hadn't really thought about until I started working on. This is also refugees, to talk about malaria again for a second, eight percent of malaria cases globally every year are in refugees. Probably because they're in substandard housing, most of them and super vulnerable. We know that climate is rapidly accelerating the creation of new refugee populations. There's this whole intersection of ways in which climate change is making people vulnerable.

It's not just that there's more places that are hospitable to dangerous species.

Do you feel like with the Covid pandemic, there was almost a taking of the eye off the ball 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.

Healthcare workers and I think, definitely you see that 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. 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, just everything. I think that's less true in the bug world.

It's less true of malaria and of entomology specifically.

And you know, there are in some ways, some silver lining, right? For example, the folks that are doing the work on Stiphenzi. They have new capacity to do genetic sequencing of mosquitoes that wasn't around. They have the ability to sequence parasites and to figure out which are they dealing with insecticide-resistant parasites. Are they dealing with insecticide-resistant mosquitoes?

There was a building out of.

Molecular analysis capacity, which probably wouldn't have happened at the same pace without Covid, but I don't. I think public health everywhere took a hit with the diversion, everywhere in the south took a hit with the diversion 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.

Plastic 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 sugar bait, that will be really, really attractive for mosquitoes. So all mosquitoes, only females, bite humans or animals for blood, but all mosquitoes, male and female, need nectar, a form of sugar, to survive. And so they drink, they get that from plants typically, and so this thing kind of mimics the plant smell and taste, and then your mosquito's drinking poison. But of course, it was 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. That you have to hang it high enough. That the goats aren't going to eat it, 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. They're still early, but they seem the early results are that they're quite protective for that outdoor biting. And then I guess the one that I would say. The thing that became the last story in this 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?

If you have a proper roof on your house, the 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 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 kind of learned about this by going and wandering around with these researchers in villages and people were super nice. And let us crawl up and look in their attic, at their roof, and crawl around on the floor of their house, looking at the walls inside. If you put on a metal roof and screens on the windows and a proper door, what does that cost? 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 a year, at a conservative estimate, trying to control mosquitoes. Most houses don't need these researchers I was with have found they don't need tens of thousands of dollars of intervention. They need $100 worth of window screens, They need, you know, $500, maybe to do the roof, but 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 on average.

You 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. Yeah.

On 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 talked to folks about them? And are there ways that this could catastrophically backfire in our face?

If you'd like to also irritate once you're done with your repellent, if you would like to further irritate that hypothetical table of entomologists you're sitting with. Just mention the Jurassic Park effect. The answer is, We don't know, right? Like, I mean, I joke about Jurassic Park. But, like the fundamental premise is true, you don't actually know what the knock-on effects of these things potentially are. And.

The folks who work in genetic modification say they, you know, there's kind of two streams of approach in the world of genetic modification. And one works to, 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.

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. 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 3,500 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 the 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, you know, again? Evolutionarily, will mosquitoes evolve to be like resistant to? will the parasite evolve? So that this modification doesn't keep it 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 to elimination, right? 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 poses.

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 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 Tome and Principe. Which 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 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 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.

I walk outside and if there are mosquitoes around, I'm the one who's getting multiple mosquito bites. Then my friends will be like, Yeah, I got one bite. I'm like, that's cute, I got 15..

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. I was just like, How is this? how did this happen? Do we know much about why some folks are targets and others are not? Or Steve's just got a crush on me, maybe.

I don't know.

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 Alena on this 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 healthcare. After all, Mississippi isn't known for being a well paragon of healthcare access. In fact, it's quite the opposite.

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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. Nomanje Bumpus, chief scientist, who leads the cosmetic section for the FDA.

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 in 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.

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