The Mosquito

by Timothy C. Winegard

  Currently, ACTs are expensive, and marketing campaigns target and chase wealthy vacationers and backpackers—to recoup the costs of research and development, but also because the resistance clock is ticking on ACTs. Drug companies need to make their money before the parasite evolves and adapts, and time runs out on artemisinin as it has on most other antimalarials. “As effective and robust as the artemisinin drugs are today,” forewarned the Institute of Medicine in 2004, “it is only a matter of time before genetically resistant strains emerge and spread.” Four years later, this statement became a reality.

  Unsurprisingly, given its more prolonged usage in Southeast Asia, resistance to the new drug was first confirmed in Cambodia in 2008, and by 2014, artemisinin-impenetrable strains of malaria had spread to the neighboring countries of Vietnam, Laos, Thailand, and Myanmar. As Sonia Shah reports, malaria was big money and numerous drug companies around the world “earned a snappy income selling artemisinin—untethered by a partner co-drug. . . . Exposing the malaria parasite to an artemisinin unfortified with another drug dared the parasite to develop resistance.” In other words, when used alone and not wrapped in other antimalarials (think back to our multilayered jawbreaker candy) the parasite could fight back and acclimate. With these cheap drugs being peddled across Africa and Asia, the malaria parasite did just that. For this artemisinin debacle, Paul Russell’s “resistant strains of Homo sapiens,” chided earlier in relation to the evolution of DDT-impervious mosquitoes, could be modified slightly to “greedy strains of Homo sapiens.” At times during our eternal war with mosquitoes, as Russell unabashedly points out, we are our own worst enemy.

  By this characterization, we are also guilty of creating resistance through our disastrous mass-cultural behavior as “hypochondriac strains of Homo sapiens.” Our ignorant overuse and patent misuse of antibiotics, which fight bacteria only, not viruses like the common cold or twenty-four-hour flu, has led to invulnerable and lethal bacterial “superbugs.” I cannot sugarcoat this point of truth since this horrible habit or even, perhaps, a genuine lack of understanding, is putting millions of lives at risk. The World Health Organization has repeatedly beseeched our collective that “this serious threat is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country. Antibiotic resistance—when bacteria change so antibiotics no longer work in people who need them to treat infections—is now a major threat to public health.”

  Yet people still shamefully rush to the doctor at the first sign of a sniffle and demand their antibiotics for nonbacterial, everyday illnesses. Unfortunately, many doctors, who should know better, pander to these absurd prescription requests. According to the CDC, “Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections,” at an annual cost of $1.6 billion. Unashamed abuse of antibiotics, emerging superbugs, and corresponding death rates are not limited to America: This trend is of global concern to our communal herd immunity. According to estimates from the WHO, if this steep graph continues its ascent, by 2050, superbugs will annually kill 10 million people worldwide.

  Like our bacterial superbugs, the mosquito in the closing decades of the twentieth century also underwent a renaissance of sorts. It flourished once more, its parasites and viruses oozed evolutionary creativity, it picked up a few new deadly zoonotic hitchhikers along the way, including West Nile and Zika, all leading to increased levels of human suffering and death. Zoonosis rates have tripled in the last ten years, and account for 75% of all human diseases. The goal of health researchers is to identify potential “spillover” germs before they make the zoonotic jump to humans. One such looming concern is the mutating mosquito-borne Usutu virus originating in birds. Although only three human cases have been identified—in Africa in 1981 and 2004, and in Italy in 2009—the virus is nevertheless capable of clearing the mosquito-vectored hurdle from birds to humans. The Ebola virus is another recent crossover, though vectored by fruit bats and other primates, not by mosquitoes. The first documented cases occurred in Sudan and Congo in 1976. Reminiscent of the 1995 Hollywood blockbuster Outbreak, “patient zero” in the recent Ebola eruption was a two-year-old boy from Guinea who was infected while playing with a fruit bat in December 2013.

  With a defeatist attitude following the termination of the WHO’s Malaria Eradication Programme in 1969, it was easier for the world to forget or ignore the mosquito’s resurgent renaissance than to pony up billions of dollars for research and eradication that could never be recouped. After all, 90% of malaria cases occurred in Africa, where most victims could not afford antimalarial drugs anyway. “The increasing costs involved with each new generation of antimalarial drugs threaten to further increase the price of control and the ability of countries to sustain control programs,” acknowledges Randall Packard in his thorough history of malaria. “The development and adoption of artemisinin-based combination therapies has already greatly increased the cost of drug treatment.” In our modern material world, capitalism, when chained to the cost-benefit profit margin of medical inquiry, can be a cruel master.

  “Insecticide-Resistance Testing in Uganda”: Entomologist Dr. David Hoel teaching children how to recognize mosquito larvae in northern Uganda, 2013. (Dr. BK Kapella, M.D., [CDR, USPHS]/Public Health Image Library-CDC)

  Dr. Susan Moeller, professor of media and international affairs at the University of Maryland, also blames the media for this apathetic atmosphere she calls “compassion fatigue.” New fashionable designer diseases, such as SARS, bird flu (H5N1), swine flu (H1N1), and especially the dreaded Ebola, could potentially threaten wealthy countries where mosquito-borne diseases have been relatively dormant for decades. AIDS also reminded wealthy nations that epidemic diseases were not historical phenomena or limited to remote continents. Younger generations of Americans, Canadians, Europeans, and other affluent westerners do not live in a malaria world as their bloodlines did, and do not fear mosquito-borne diseases, if they have ever even heard of them.

  Thanks to sensationalized media and a steady, nauseating stream of formulaic Hollywood “virus-borne zombie” and “culture of fear” films and shows such as Outbreak, 12 Monkeys, I Am Legend, Contagion, 28 Days Later, World War Z, The Walking Dead, The Andromeda Strain, and The Passage, to name only a few, our screen-time generations do fear Ebola, SARS, the flus, or some futuristic yet unknown man-eating virus. “Certainly Ebola’s entrance into metaphor superstardom had a lot to do with the pop status of the disease,” concedes Moeller. “When the admittedly sensational Ebola is represented in such a sensationalized fashion by the media and by Hollywood, other diseases pale in comparison. So, stories of more prosaic illnesses barely register; they’re ignored, underreported. The gauge of news values shifts.” The New York Times reporter Howard French, for example, wrote that “death by the thousands in annual measles outbreaks, or a toll of millions from malaria, are non-events for an outside world that has already moved on to associating Africa with endemic H.I.V. infection and has found an even more spectacularly grim image of a diseased continent: Ebola.” If you contracted a mosquito-borne disease on vacation or backpacking (or camping, as in our opening chapter), well, that was your own fault or just plain unlucky. Malaria, contends Karen Masterson, “is probably the most studied disease of all time, and yet it persists.”

  After DDT’s fall from grace, nearly forty years elapsed before the mosquito was again pursued as public enemy number one, the world’s most wanted criminal. “Out of sight, out of mind” was the attitude for most of the Western world, free from the bondage of mosquito-borne disease. Over the last two decades, a resurgent and increasingly lethal mosquito-mounted offensive waged by her battle-hardened veterans of malaria and dengue and her raw recruits of West Nile and Zika changed all that. Seemingly out of nowhere, in 1999, the mosquito attacked
New York City and struck fear into the heart of a panicking superpower. The United States summarily responded with a sustained and surging counterattack commanded by Bill and Melinda Gates.

  CHAPTER 19

  The Modern Mosquito and Her Diseases: At the Gates of Extinction?

  The Bureau of Communicable Disease Control in the New York City Department of Health received an unexpected and strange phone call on August 23, 1999, from Dr. Deborah Asnis. As the infectious disease specialist at Flushing Hospital Medical Center in Queens, Dr. Asnis was baffled and required some immediate, lifesaving answers. Four patients had been admitted presenting mysterious and unique symptoms of fever, confusion, disorientation, muscle weakness, and, eventually, paralysis of their limbs. Her patients were deteriorating quickly. Pressed for time, Dr. Asnis needed to find out what on earth was triggering this alarming illness.

  Initial tests on September 3 pointed toward a form of encephalitis, or swelling of the brain. There are numerous causes of encephalitis, including viruses, bacteria, fungi, parasites, and accidental hyponatremia (an imbalance of water and solutes or electrolytes in the brain). Blood and tissue samples of the patients were quickly screened and cross-matched against viruses known to cause brain inflammation and similar symptoms. The results came back positive for mosquito-borne St. Louis encephalitis, which is transmitted from birds to humans by the common Culex mosquito.

  Concentrated mosquito and larvicide spraying began in the city and surrounds the following day, but, clinically, something didn’t add up. By now, the CDC in Atlanta had entered the dialogue. After a quick scan of their database, the situation and contextual setting became even more puzzling. Since the end of the Second World War, and the creation of the CDC in 1946, there had been only 5,000 reported cases of St. Louis encephalitis in the United States and none in New York City. The CDC was not wholly convinced that St. Louis encephalitis was the culprit. There must be something else that was being overlooked.

  Bioweapons experts at the CIA and at the biological weapons research compound at Fort Detrick were also closely monitoring the events unfolding in New York. They were not alone. Hordes of probing journalists were scouring to be the first to get the scoop and break the exclusive story. Having sniffed out the gossip, but still without definitive answers, the media took this opportunity to sell its theories. Reputable global newspapers, trashy tabloids, and a lengthy exposé in The New Yorker all pointed the finger at a viral mosquito-borne biological terror attack, courtesy of Saddam Hussein. In 1985, they reported, the CDC had sent samples of a relatively new and rare mosquito-borne virus to an Iraqi researcher. Engaged in a brutal war with neighboring Iran from 1980 to 1988, Iraq was the recipient of billions of dollars’ worth of American economic aid, technology, military training, and armaments, including chemical weapons. The delivery of a deadly mosquito-borne virus was certainly not out of the realm of possibility for evidence-starved journalists.

  As the story began to take on a life of its own, Mikhael Ramadan, the former body double and political decoy for Saddam Hussein turned Iraqi defector and snitch, claimed that Saddam had weaponized this unusual American-gifted virus. “In 1997 on almost the last occasion we met,” Ramadan professed, “Saddam summoned me to his study. Seldom had I seen him so elated. Unlocking the top right-hand drawer of his desk, he produced a bulky, leather-bound dossier and read extracts from it.” Saddam boasted that he had engineered the “SV1417 strain of the West Nile virus—capable of destroying 97% of all life in an urban environment.”

  As these outlandish accusations of Saddam’s seditious newfangled West Nile supervirus were infecting media stories across the world, the phones at police stations and assorted health departments in New York and at the CDC began ringing off the hook. The Bronx Zoo reported the peculiar passing of its flamingos and the perplexing fatalities of other captive bird species. Numerous random callers recounted seeing the corpses of birds, predominantly crows, littering the parks, streets, and playgrounds of the city. While the St. Louis virus is vectored to humans by the mosquito directly from birds (not from human to mosquito to human like malaria, yellow fever, and most mosquito-borne diseases), the birds themselves are immune to the virus. It does not harm our feathered friends. Accounts also began to filter in about local horses displaying bizarre and eccentric behavior and becoming abnormally ill. This pandemic was not St. Louis encephalitis or one of the mosquito-borne equine encephalitis viruses, nor was it any of the common and catalogued avian pathogens. This was something very different, and at least for the United States, entirely new. The epidemic infecting birds, horses, and humans was in fact the mosquito-vectored West Nile virus. Saddam Hussein, however, had not unleashed his fabled media-fabricated Chimera supervirus on New York. He was proven innocent on all counts.

  During the 1999 outbreak, of the estimated 10,000 people who contracted West Nile, 62 people were hospitalized and 7 died. Twenty cases of West Nile were also detected in horses. Birds suffered the lion’s share of casualties. According to estimates, as many as two-thirds of the crow population inhabiting New York City and surrounds may have died from the virus. West Nile also killed birds from at least twenty other species, including blue jays, eagles, hawks, doves, and robins.

  Given that our animal comrades bore the brunt of the contagion, hypothetically speaking only of course, if it had been a bioterror attack, it would have been an unmitigated failure. In an era of terrorism, weapons of mass destruction, and paranoia over threats both real and imagined, the mosquito is not immune from registration on the offender list of potential biological weapons. “If I was planning a bioterror event,” admitted an anonymous senior FBI science advisor, “I’d do things with subtle finesse, to make it look like a natural outbreak.” Secretary of the Navy Richard Danzig added that, while biological terrorism was “hard to prove,” it was “equally hard to disprove.”

  Two years after West Nile infiltrated New York City, the Al-Qaeda attacks on 9/11 put the United States and its rattled population on red alert. If these terrorists could stealthily fund and organize attacks on the World Trade Center and the Pentagon, what else were they capable of? This fear was heightened in the weeks following the 9/11 strikes when “Unabomber” type letters laced with anthrax bacteria were mailed to several leading media offices and two US senators, killing five people and infecting seventeen others. The shadowy world of American covert institutions, including the various biological weapons agencies housed at Fort Detrick, began to assemble risk assessments for every scenario, including the threat of a biological terror attack. Smallpox, plague, Ebola, anthrax, and botulism headed the list. Serious consideration was also given to yellow fever and a genetically engineered strain of malaria.

  In V. A. MacAlister’s 2001 fictional biotech thriller, The Mosquito War, this is precisely what happens when terrorists nonchalantly release lethal genetically modified mosquitoes in the Washington, DC, mall on Independence Day. This is hardly an innovative idea. The devious formula and sinister strategic design predate Napoleon’s Walcheren Fever, Dr. Luke Blackburn’s macabre yellow fever missions, and the purposeful restoration of malarious mosquitoes to the Pontine Marshes by the Nazis at Anzio, among other historical samples of biological subterfuge. In his fourth-century BCE book, How to Survive Under Siege, Greek writer Aeneas Tacticus, one of the earliest scholars of the art of war, endorsed “releasing stinging insects” into the tunnels being excavated by enemy sappers. In 2010, a group of seventy leading mosquito experts met in Florida to discuss “Countering a Bioterrorist Introduction of Pathogen-Infected Mosquitoes Through Mosquito Control” by asking one simple question, “Consider what would happen if a lone bioterrorist infected with yellow fever infected 500 Aedes aegypti by feeding them on his/her blood and a week later released them in New Orleans’ French Quarter or in Miami’s South Beach.” Given the trail of wreckage left by yellow fever in the past, when superimposed on a contemporary unvaccinated and unseasoned general population lacking herd immun
ity, things would get very ugly, very quickly.

  The sudden unannounced and sweeping arrival of endemic West Nile to the United States in 1999 awakened us from our apathetic slumber. We had forgotten who our most dangerous and immortal enemy really was. Iraq did not possess the mobile bioweapons labs the Bush-Cheney administration professed it was secretly shrouding. However, there were legitimate weapons of mass destruction dating back millions of years droning and multiplying across the planet. She was far more lethal than anything in Saddam’s armory, and markedly more familiar—our time-honored mosquito foe and her arsenal of diseases.

  West Nile virus, closely related to dengue, was first isolated in Uganda in 1937 and popped up occasionally in Africa and India. Beginning in the 1960s, reports of minor outbreaks trickled in from North Africa, Europe, the Caucasus, Southeast Asia, and Australia. By the late 1990s, verifications of West Nile were growing in both geographical breadth and levels of infection. Prior to 1999, however, West Nile flew under the radar of the mainstream media as outbreaks were rare and limited to a handful of reports from secluded pockets. More importantly, West Nile was not in the United States. It was a foreign disease.

  That changed when West Nile paralyzed New York City with fear during the summer of 1999. This viral strain, likely originating in Israel (and not from some itinerant Iraqi mosquito factory), is thought to have hitched a ride in migratory birds, immigrant mosquitoes, or visiting humans. The New York outbreak was the first to strike the Western Hemisphere. Scientists at the CDC quickly realized that West Nile was here to stay. When the disease hit again the following summer, the CDC conceded, “We are beyond containment now. We have to live with it and do the best we can.” Since 1999, roughly 51,000 cases of West Nile have been diagnosed in the United States, with 2,300 fatalities. The virus inflicted its worst American death toll in 2012. According to the CDC, “A total of 5,674 cases of West Nile virus disease in people, including 286 deaths, were reported to CDC from 48 states (excluding Alaska and Hawaii).” The worst previous year and highest infection rate was 2003, with 9,862 cases and 264 deaths. By comparison, in 2018, there were 2,544 confirmed cases of West Nile, with 137 deaths across every US state, save New Hampshire and Hawaii.