The Daily: The Mosquitoes Are Winning

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From New York Times, I'm Michael Borough.

This is A Daily.

For decades, the world seemed to be winning the war against mosquitoes

and the deadly diseases that they carry.

Now, we're once again losing that battle.

Today, my colleague, Stephanie Nolan, explains why.

It's Thursday, October 5th.

Stephanie, you have embarked on an entire line of coverage for the Times about mosquitoes.

Why? Why mosquitoes? And why now?

So, I went into this really thinking about solutions.

I was going to do some nerdy, geeky stories because I knew there was some great new technology coming to fight mosquitoes.

And, you know, they're our biggest enemy, right? They're the deadliest animal.

Well, just explain that. They're the deadliest animal.

So, they kill more humans than anything else, than any other living creature.

Because of the diseases that they carry?

Because of the diseases they carry, exactly.

There's West Nile, there's Dengue, there's Malaria.

So, I went into this planning to look at solutions and really quickly,

I realized that I hadn't really kept up with the scale of the problem.

Yes, we have new tools, but we need them because the problem has really gotten away from us.

And I covered public health, global public health for a living,

but I hadn't realized how much the kind of tide in this battle had shifted that the mosquitoes were winning.

And winning how?

They're winning in terms of our ability to control mosquito-borne disease.

And the place where you see that the most strikingly, I think, is with malaria, with malaria in Africa.

We were doing a really good job of bringing down malaria deaths and that progress has stopped.

That is genuinely surprising to me because I think of malaria as a disease that we have mostly gotten under control.

So, lay out for us exactly what happened and why that progress has stopped.

So, if you go back like 20 years, almost a million people were dying of malaria every year, almost all of them in Africa.

So, just to remind you, the way that malaria spreads is you have a mosquito who bites a person who has the parasite.

The parasite reproduces in the gut of the mosquito and then when it bites the next person, that person gets infected.

And you have these cycles of sickness that go through families and it can be deadly, of course, especially for small children.

But it's not just about death, right? It's horrible.

You get fevers that can be so severe, you get hallucinations, you get vomiting, you get this absolutely debilitating fatigue.

And you don't get it once, right? You can get it four or five times in a rainy season.

Kids are getting 10 cases in a year and that takes like a huge toll on their families.

They're spending their money on medical bills and people can't go to work because they're taking care of them.

There's a huge economic cost.

And so, for all of these reasons in the late 1990s, there's a decision by African governments,

by some philanthropists and global public health organizations to really make an effort to wipe malaria out in Africa.

We are first of all reaching out to other partners, making an alliance for rollback malaria.

And what does that look like?

It's a big investment.

Microsoft founder Bill Gates is giving up daily control of his company to concentrate on his foundation,

which funds health and education projects worldwide.

A lot of that money comes from philanthropy, from the Bill and Melinda Gates Foundation,

in particular, who make eradicating malaria a huge priority.

The fact that it kills over a million children a year and yet has almost no money given to it,

you know, that struck us as very strange.

And the decision is to try three strategies.

We'll take the diseases of the poor, where there's no market, and we'll get the best scientists working on those diseases.

One is better drugs, so there are new and better treatments for malaria,

and there's a real effort to get those into primary health care clinics across rural Africa.

There were also new and better insecticides, so in places with a heavy malaria burden,

they would spray insecticides inside people's homes, and they're long-acting, right?

And so that would provide you with protection for a while.

And then the last one, bed nets.

The thinking was that the main mosquitoes that transmit malaria in Africa,

they bite indoors and at night when people are asleep, and that's when people are getting infected.

And so you had this huge campaign to get an insecticide-treated bed net in every household, on every family.

Mothers were sent home from clinics with them, with their new babies.

Trucks would roll into villages and give them out.

And so as these elements come together, I'm quite optimistic that we will be able to eradicate malaria.

And how do these three solutions, including this quite low-tech bed net solution, actually work?

Well, it works really well.

Deaths come way down, cases come way down.

By about 2015, deaths bottomed out at about 550,000 people,

which obviously is still a horrifying number of people, but you've cut deaths in half, right?

Wow.

And people have really seen the difference in their lives and the economic impact on their families.

And so for a while there, as you're watching that curve of infections come down,

there's a belief that like, okay, if we keep investing in this and we keep going,

maybe we're going to get to elimination.

So how do we get instead to where you say we are, which is not elimination,

but instead mosquitoes and malaria, resurgent and winning?

Well, so here's what I have found in my reporting after talking to dozens and dozens of

malariaologists, parasitologists, entomologists, all kinds of people who were working in this all over Africa.

The short answer is the mosquitoes adapted.

Their lifespan might only be six or seven weeks, and they evolve really, really quickly.

So you get a lot of mutations within a mosquito,

which means that there's lots of opportunities for a mosquito to develop a way that it can survive what we're throwing against it.

And so really quickly mosquitoes have outmaneuvered the solutions that we had in place.

And one of the big changes ties directly to bed nets.

So if mosquitoes were not able to feed at night, they weren't able to feed on sleepers who were under nets,

some of those mosquitoes died out and there was an evolutionary advantage for those who started feeding at other times in other places.

And so now you have mosquitoes that are feeding outdoors, feeding during the daytime.

And obviously people are not wandering around all day long wrapped in a bed net, right?

So if you're not protected anymore at the time when those mosquitoes are biting,

suddenly you have cases starting to go back up.

And, you know, that seem evolutionary advantage issue comes up with the treatments and it comes up with the insecticides.

Mosquitoes are resistant at this point to almost all of the chemicals,

all of the insecticides that are being used across Africa.

They just don't kill them the way they did 20 years ago.

So those three very effective solutions you mentioned that really brought down death from malaria across Africa,

they create the conditions in which these mosquitoes adapt and adapt in ways that outsmart all three of these solutions.

Yeah, exactly. And brace yourself for this, Michael, it gets worse.

So I'm reporting on all of this and I call up a scientist at the CDC who runs their entomology program

and she tells me, yes, these daytime biters, these insecticide resistant mosquitoes,

it's all a really big problem.

But also she says that I've missed something huge.

Which is what?

Well, while the public health world has been focused on mosquitoes

and the way that they're adapting and how to respond to malaria in rural Africa,

there's a whole new mosquito.

And it's an urban mosquito. It's highly adapted to live and thrive in cities.

So suddenly there's a kind of double whammy nightmare scenario being presented to you.

Yeah, not only are mosquitoes out adapting all the tools that we had for rural malaria,

now you have a mosquito that's bringing the disease into urban areas

and they're totally unprepared to respond.

We'll be right back.

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So, Stephanie, tell us more about this second threat,

this mosquito that's now posing a risk to Africa's cities.

So, it's a mosquito called Anopheles...

Well, here's where it gets tricky.

It's called Anopheles stevensae or Anopheles stifensae.

And the entomologists I've interviewed are kind of split right down the middle about how to pronounce it.

And so, in fact, a lot of them now just refer to her as Steve.

Turns out these folks have a pretty good sense of humor in the face of some pretty awful information.

Yes, exactly.

And Steve, but we're using she-her because mosquitoes, of course, the ones that bite us,

are all the females who are in search of blood for the protein to lay eggs.

So, Steve is...

She's kind of the superhero of mosquitoes.

She's unbelievably adaptable.

She's great at high temperatures.

She likes it when it's wet, but she's also fine when it's dry.

She'll breed all year round so you're not talking about having a malaria season anymore,

like in a rainy season.

And on top of all of that, she's what, in the entomology world, they call a very competent vector,

which means she's really good at spreading the malaria parasite.

It lives well inside her, and it's very easy for her to pass it on to the next person she bites.

So perhaps not a superhero, but instead, like, a villain.

Yeah.

Is this one of the mosquitoes, Stephanie, that we think evolved across rural Africa

during this period when bed nets and insecticides were being used

and just has found her way into cities?

Great question, but no.

Steve is an immigrant.

She originates in South Asia, in India and Pakistan,

unknown in Africa, until way back in 2012.

So in 2012, it was found in the tiny little country of Djibouti on the Horn of Africa,

and the theory is that she was imported on container ships, maybe in old car tires.

And, you know, initially, nobody was overly concerned about this

until all of a sudden, in Djibouti City, malaria cases started to creep up.

And remember, malaria is not known as an urban disease, right?

Like, we're talking about a rural disease when we talk about malaria in Africa.

So it caused a lot of confusion.

Like, what exactly is going on in Djibouti?

And then in 2022, you get an outbreak of malaria in Ethiopia's second largest city,

which is a place called Diridawa.

And it's got about a half a million people.

And what happens is that a Diridawa University, which ends up being the center of this outbreak,

half of the students who live in the male dormitories fall ill.

The student clinic is overflowing with cases.

At first, they don't know what's wrong with these people,

and then they start to realize that they've got malaria.

And eventually more than 10,000 people are diagnosed with malaria

in a city where, like, a half dozen people might get malaria in the course of the year normal.

Like, they've just not seen anything like this before.

Fascinating. So it's very clearly the beginning of a new phase of Africa's relationship to malaria.

And it sounds like that is because of Steve.

Yeah, exactly.

And I wanted to see, what does it look like when Stephen's eye invades a city?

Why is that potentially such a problem?

And then I also wanted to see what cities, what health systems are able to do,

if anything, when they're trying to respond.

And, you know, the Ethiopian government is not receptive to foreign journalists,

and it took me many, many months.

But finally, back in May, I got to Deirdawa,

and I went to spend time with a couple of scientists,

a molecular biologist named Fitsim Tadesi,

and an entomologist named Jenny Gatteshu,

and they've been studying Stephen's eye and this outbreak since the moment it started.

Well, tell us more about this trip.

So I got to Deirdawa, and it's a very, very hot, very arid city in a river valley.

It's very close to the border with Djibouti and Somalia.

It's a very vibrant place, especially at night.

It really comes alive at night because of the heat.

It has lots of little narrow streets, and the houses are behind high walls.

It's very dense housing, actually.

Little blue auto rickshaws zip around in the street,

and you get women who are wearing really brightly colored hijab and robes.

And when I get there, basically the very first thing we do is we go to the place

where these scientists, Fitsim and Dijene, first found Stephen's eye.

Which is where?

Okay, you've got the gear. I'm ready.

Well, it's along the banks and little pools that have been left

along the sides of the bank of the river that runs through Deirdawa.

I'm ready to meet my first Stephen's eye.

I love a little segment water.

So we're standing in the shallow water on the edge of the river.

And Dijene is scooping up water from these pools and puddles

and looking at the larvae.

But you would say the chances are very high at Stephen's eye.

Very, very high.

And what he's trying to do when they collect samples in a place like this

is figure out how much of the mosquito population is actually Steve.

And they started doing this next to the river when the malaria outbreak began

because a lot of the initial cases that were reported

were in families who lived near here, near the river.

So we had 100 meter radius for the larvae area.

100 meter radius of everywhere you found a case.

And what they do is they go to the home of everyone who's diagnosed with malaria

and they trap the mosquitoes in and around the house.

So low and behold, 97% of the mosquitoes they catch are in awfully Stephen's eye.

Wow. So this mosquito is clearly thriving.

But is it mostly contained to the river?

No. So in fact, they found Steve in a lot of other places

that are a lot less predictable than a river.

The places this mosquito is turning up are really surprising

if you think about the ways that we traditionally think of mosquitoes in Africa behaving.

Steve is so adaptable that sure, she'll breed in these pools next to the river,

but she'll also breed in water tanks.

And she can breed in the amount of water that you might find in an old bottle cap.

She will feed on humans. Yes.

But she'll also feed on livestock.

And that's why actually the next place that Dejenne wanted to take me was into a goat shed.

So lots of families in Duradoa have these little outbuildings in their homes

where they keep a couple of goats or a couple of sheep, maybe a cow.

And it turns out that the mosquito will rest in there

because it's cool and it's dark and it's moist during the daytime when it's really hot.

And there's also, of course, a very accessible source of food.

Which is the goats. The goats.

So I'm following along behind Dejenne down these narrow alleyways.

An animal shed with a low roof.

And the next thing you know, he's down on his hands and knees

crawling into these little buildings.

They're maybe like three or four feet tall or crammed full of goats.

And he goes and, you know, he wants to show me how this works.

So in I go too.

Okay. I am crawling into the goat shed.

Here we go. I can see nothing.

I'm going to end up sitting on a goat.

I'm too tall.

I'm generally not made to be an entomologist.

Hi. Hi, goats.

There are one, two, three, four, five, six, seven goats.

He gets on his phone and he uses the flashlight to run it

sort of really quickly over the walls.

And there were mosquitoes.

What did we find?

Fed mosquito. You can tell from out here.

Yeah, it's black. Okay.

All right.

Dejenne is able, in the dark, in the gloom with the goats

to identify which mosquitoes they are.

I can barely see them.

Oh, oh, oh, oh, oh.

Angry goat.

Sorry, goats. Sorry.

He's like totally unfazed by the goats.

And when he sees the mosquitoes, what he does is

he's got what's called an aspirator,

which is like a little glass tube with a piece of rubber piping

on the end and he puts the rubber pipe in his mouth

and he holds the end of the glass tube up against the wall

where he's seen a mosquito and he gently sucks it in.

Got him.

So that it's alive but trapped.

And what they do is, again, like take them back to the lab

where they can sort them properly and identify which species it is

and then know whether he's finding Steve in these places.

This is an amazing thing to envision.

Well, it's particularly amazing if you think about doing it

with like a large herd of goats.

We're also very interested in what's happening

and are fully attempting to participate.

These goats are spiffing at me.

Excuse me, pardon me.

Okay, all right, I'm out.

So when DeGene had sucked all the visible mosquitoes off the walls,

we crawled back out of the shed

and walking through more of these narrow streets

I gotta tell you, I'm looking at the place in a whole new way now, right?

And I'm just thinking there are so many places where Steve could be.

If you think that she only needs small amounts of water to breed

and she's happy with artificial sources of water,

she's happy in containers, in old plastic containers.

I'm looking around and I'm seeing puddles under cisterns

and I'm seeing water storage containers in front of people's houses.

Duradella's municipal water only runs a couple of days a week.

So when it turns on, everybody fills up some barrels,

some jerry cans in front of their house and keeps them nearby.

And they don't have reliable trash collections,

so you'll get lots of these little bits of plastic around

that are a place for it to breed.

And when we talk about Stephen's Eye being a threat across Africa,

that's one of the reasons why, right?

Because these erratic municipal services, it's a very common problem.

So I'm looking around Duradella and I'm thinking Steve could be everywhere here

and I'm thinking the public health system is absolutely not in a state to respond to this.

Well, what exactly is the public health infrastructure in a city like this

that is now dealing with Steve and with so much malaria?

So Ethiopia has really been investing in primary care in public health,

but they don't have urban malaria response, right?

Remember, it hasn't been an urban disease.

So there's no muscle memory in the city for responding.

People don't have immunity.

They get very ill and clinics don't know what they're looking at.

I talked to a woman, a nurse who was pregnant when she got malaria.

She got incredibly sick, but it was 10 days and, you know,

a half dozen malaria tests before she got a confirmed diagnosis

because nobody was looking for it.

And this is a nurse who presumably has a lot of strong ties to the medical community.

Yeah.

When you get a sudden severe malaria outbreak in a place that's not expecting it,

it can really quickly start to derail things, right?

And if you think that there are 600 million people who live in cities in Africa,

then that's so many people who are potentially vulnerable to this mosquito.

So when you start to put all of those things together,

you get the scenario that keeps Ethiopian scientists awake at night

that's really terrifying that CDC scientists who first told me about this.

And somewhat counterintuitively, we think of cities as places that represent progress

and where healthcare is going to be better than in rural Africa.

You're saying that it's the opposite in this case.

Treatment is worse and the opportunities for the mosquitoes to grow are even greater.

Yeah. Look, I don't think it's hopeless, right?

I don't think that there's a reason why cities can't learn to respond to this,

why people can't develop this expertise, but it doesn't exist now.

Well, let's turn to the question of solutions,

which is definitely the thing you set out to report on.

Are there any and not just solutions to Steve and African cities,

but to the adaptations that are presenting such problems in rural Africa as well?

What can African governments do about this beyond what they've already done?

So there are some new solutions and each one of them comes with some challenges.

First of all, there are improvements on the things we have.

There are new classes of insecticides being brought to market

and those will hopefully kill mosquitoes more effectively.

There's also some really interesting new innovative technologies.

I went to Kenya to see a clinical trial of something called a spatial repellent,

which is this sheet of clear plastic.

It's about the size of a piece of loose leaf and it's soaked in a repellent

that confuses the mosquitoes, keeps them from being able to bite.

So the early indications are that both of these things are working really well,

but our mosquitoes all the time are adapting, right?

And so eventually you're going to run into this question of resistance again.

Right. All these things sound like they ultimately have a shelf life.

They can't last all that long given just how quickly mosquitoes evolve and adapt.

Yeah. So that's why you need to come at us from a couple of different directions, right?

And that's one of the places where I would say there's a lot of hope right now.

There's a new malaria vaccine that's being ruled out in Sub-Saharan Africa.

You give it to small children and it should be able to provide them with a lot of protection throughout their lives.

But you know, vaccines like we saw with COVID, they're challenging to deliver and they can be expensive.

They're coming in at about $10 per child, which maybe doesn't sound like so much.

But if you think about the fact that, for example, Tanzania, their whole health budget is $2 per person per year.

So stacked against that, these vaccines are really going to cost a lot.

So the solution situation is not where anyone wants it to be.

As you've been talking, Stephanie, it's occurred to me that we've spent this whole conversation talking about Africa.

But Steve seemed to come from outside of Africa to Africa and now it's Africa's problem.

I have to assume that a fear might be that as malaria becomes a bigger and bigger crisis in Africa for all the reasons we're talking about here,

Africa could export its malaria problem to somewhere else in the world.

Is that what the scientists you talk to fear?

You know, I think I would say it's not so much about export.

It's not about something that comes on a boat.

It's actually, it's about something much bigger than that.

What we've been seeing with mosquito-borne disease in the last few years is a really big impact from climate change.

Lots of places are becoming a better environment for mosquitoes that carry a lot of different diseases, not just malaria.

I think what we're seeing is that in a very quickly changing world, mosquitoes do better, move faster than we do.

And for me, that's the lesson from Steve that I saw in Ethiopia.

Not that Steve's going to leave Africa and come to other parts of the world, invade other continents,

but that the environmental issues that are present in a place like Africa are present elsewhere.

That's the problem.

That as humans, we create lots of situations where mosquitoes can flourish.

They look different in different places, cities and towns, Africa versus Latin America.

But what those places have in common is that mosquitoes are thriving and posing a threat that we're not nearly quick enough in providing solutions for.

Or it sounds like from the case of Africa, prepared to deal with in real time.

No, not yet.

I think for me, the lesson of what I saw in Deridawa, what's happened with Steve is really just how quickly things can go south, right?

You can think that you don't have the problem or you can think that you have the problem managed or that you have the tools you need.

And the way mosquitoes work incredibly quickly, you can find yourself with a public health crisis.

And I think as we think about the spread of mosquitoes and the threat they pose, I think that should be alarming for everybody.

Josefine, thank you very much. We appreciate it.

It's a pleasure.

We'll be right back.

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