Original subtitles

How do you personally feel about mosquitoes?

Oh, I'm certainly annoyed by them.

Uh, in the summer in Seattle,

you know, they bite and you... you get welts.

And, uh...

But I've never lived anywhere where there was malaria.

Mosquitoes of the genus Anopheles are the transmitters of malaria to man,

and malaria is transferred from man to insect,

and then on to man again.

You know, malaria kills 400,000 kids a year.

But it's not in rich countries at all.

So, it's a type of neglected disease.

When it comes to diseases,

the opportunity is to develop cutting-edge technologies

like vaccines, antibodies,

and even more controversial techniques like gene editing,

and use those to try and eradicate these diseases

from the face of the planet.

It would be one of mankind's biggest achievements

to finish off malaria.

Malaria is such a problem here.

You have to go to the hospital,

and if you don't have money, malaria will kill you.

It can kill the baby.

It has killed many babies.

It killed a baby who was close to me.

My sister's baby.

She started convulsing.

Her fever was high. I did not waste time.

I caught a ride and rushed her here.

She had very strong malaria.

Sorry. Sorry, baby girl.

We got one. One oxygen.

Ma'am, can you fill for us, oxygen?

When you sit in those wards, you know, you just see how frantic things are

because the wards are never adequately staffed

because malaria is quite seasonal.

It's as the rainy season comes,

then the mosquito population grows exponentially.

As a kid,

I can't even tell you how many episodes of malaria I went through.

I can still clearly see, you know, the picture of my father.

He was standing next to my bed,

looking at me.

I could really see, you know, a lot of fear in his eyes.

If malaria was killing 600,000 people in the US or in Europe,

the problem would have completely changed by now.

Malaria tends to be most concentrated in the poorest populations,

the populations with the least access to health care.

There's this arc from Mali, Burkina Faso, Côte d'Ivoire,

through Nigeria and the Democratic Republic of Congo,

where the sheer intensity of transmission that needs to be stopped

is unlike just about anything else we have to face.

Malaria is a parasite that you get from mosquito bites.

The parasite travels and infects your liver,

and after staying in the liver for a period of time,

one infected liver cell will release 400,000 extra parasites

that start invading your red blood cells.

The parasite invades a red blood cell, digests the red blood cell,

then bursts the red blood cell to keep invading more and more.

So it takes over your bloodstream.

When all your red blood cells that are infected burst,

you... you feel it.

You feel the intense chills, the spikes of fever, the sweats.

You're exhausted.

In some cases, it's hitting your body so hard

that you feel nausea, and you're vomiting,

and that's a relatively mild case.

As it progresses, it can lead to respiratory distress,

cause long-lasting anemia, inflammation in your brain,

and in far too many times, it can lead to death.

The youngest children, the vulnerable,

pregnant women will experience a real devastating burden of malaria.

Originally, malaria was a form of aquatic algae,

some 600 to 800 million years ago.

It actually still has vestiges of photosynthesis.

We think more modern malaria comes from birds,

roughly 130 million years ago.

It's a symbiotic relationship.

The pathogens use us, essentially, to help them procreate,

and malaria needs two hosts.

It needs the mosquito and then a secondary host,

whether that be humans, reptiles, amphibians, the great apes.

Uh, we all have malaria.

People don't pay attention to it.

Americans are particularly good at not thinking about anything

that doesn't affect them instantly.

Malaria was something that affected my grandparents.

At the turn of the 20th century, it was a big deal.

I mean, the Centers for Disease Control is in Atlanta

because that's where malaria was devastating.

Malaria-carrying mosquitoes are nearby,

searching for their evening meal of human blood.

Malaria was a big deal in this country,

and it went from being a really big deal

to nothing.

People don't die of malaria anymore because we are able to control it.

If you rewind to the big global malaria eradication effort

that was launched in the mid-20th century,

the tools that were used at the time like environmental modification,

making sure there were no mosquito breeding sites,

doing large-scale spraying of insecticides.

All of these things worked at the time.

But those aren't necessarily the right set of tools to deploy now

in the places where malaria still remains entrenched.

The ski jumping. That's pretty exciting, isn't it?

It was in the 1990s, I was thinking along with Melinda about,

"Okay, where should the resources go?"

And looking at what children die of

and stunned to find out it was pneumonia, diarrhea, and malaria.

When I saw how little money was going into malaria,

it was a rather shocking thing.

Literally tons of DDT are used on this dread disease

that attacks our young.

Again war, destructive and terrible,

contributes one of its discoveries to save life.

Armies used to fund a lot of malaria work

because soldiers would go off to malarious places and die.

But then the medicines that protect the soldiers were considered good enough,

and so it was no longer a priority for them.

There's more money put into baldness drugs than are put into malaria.

Now, baldness is... it's a terrible thing.

Uh...

In the year 2000, the Gates Foundation is created,

and, you know, this saving children's lives

could be our top priority and really make a huge difference there.

Uh, malaria is getting worse.

Bed nets can make a fantastic difference.

Eventually, uh, there will be a vaccine.

In terms of value for money, which is what American people want,

they won't find better value for money.

I met Bill Gates

over some cheeseburgers,

um, to discuss global health.

I think he get... He's... he's offended by

the stupid, wanton waste of anything,

but human life at the top of the list.

That seems to set him off.

I mean, but he'll argue with anything.

In the early days, it was wild.

You know we call him Kill Bill?

I can remember finance ministers being in meetings, and he's going...

"You're lying."

"You're lying. That's a lie. You know it's a lie."

And I'm like, "Uh..."

Yeah, he's a bit punk rock, Bill Gates. You don't think of that, do you?

New vaccinations are needed so that, uh, the children live.

How much are we, all as one humanity, trying to help each other?

You know, we made a $30 million grant for malaria work.

I was shocked that made us the biggest funder in the entire field.

The people who die of malaria don't have a voice in the marketplace.

There's not a profit opportunity.

The market for dog food is 40 times bigger than the market for malaria.

Since 1990, we have cut extreme poverty and childhood mortality in half.

You tend to believe

when Bill says we can do something that we can do it.

Do you think we can do it?

Absolutely.

So tell me about Diabaté.

Uh, Diabaté is leading the Target Malaria work in Burkina Faso.

His background was a lot in entomology. He...

Mosquitoes?

Mosquitoes. The world expert in identifying

where mosquitoes are gonna be swarming for mating.

- Hi. - Hello.

- Good to see you. - Good to see you too.

First of all, I will say that statistics are really good storytellers.

Of these 247 million cases worldwide every year,

Africa's bearing about 235 million cases...

- That's incredible. - ...alone.

The real problem today is that

when you look at the conventional tools that we have in hand,

you take bed nets and then you take the new drugs and everything,

they have done a really incredible job.

But right now, it seems like they have reached the protective limit.

With the current tools, basically,

it looks like you are sitting in a really very fast driving car,

and your target is the moon.

How are you going to make it?

You absolutely need a completely different engine.

We need to put a lot of effort and research

trying to come up with new tools.

To beat malaria, we'll have to put a number of different tools together.

We have to get better at going after the mosquito

and keeping mosquitoes from transmitting to people.

We also have to do a better job of protecting people,

and we have to do a better job of killing the parasites that do get to people.

And we're also looking at,

"How can we protect people when they still get bites

to make sure that the parasite never really has a chance to take root?"

The reason that we are still dealing with it now

is because the malaria parasite, it's got a complicated life cycle.

The parasite looks different at every stage of its life cycle.

The malaria parasite has a bunch of really complicated machinery

that it uses to confuse the immune system,

to evade the best thing that our immune systems can throw at it.

Uh, the parasite, it's evolving.

The drugs that we use that have been saving many lives,

the parasite is now evolving resistance to those drugs.

And so to develop a vaccine, we have to really outsmart the parasite.

Obviously, the big goal is to have an effective vaccine

that's cheap, reliable,

and that could be distributed throughout the world.

How are you?

Yeah.

These are where the seminal studies were done for the RTS, S malaria vaccine.

When we did our first vaccine trial,

it was all done in this room and this room.

And so I have a lot of history between these two rooms.

I had worked on a malaria vaccine for close to seven years.

We had great excitement when we started this trial.

I really thought it would work,

and when we got the results, it was extremely disappointing.

Malaria causes death every two minutes.

I think that's what it comes out to be.

It's around ten, fifteen thousand deaths per week.

Every week, every year.

You have to take the data at hand,

look at it, and then come up with a different solution.

And so that led me to pivot to a new intervention.

We've isolated a monoclonal antibody

that is extremely effective at preventing malaria.

And so the question is, "Is this something safe that could work?"

Since there are only a few hundred malaria parasites

that are injected each time a mosquito bites you,

if you can stop the parasite there with a shot of antibody,

you can essentially stop malaria from happening inside the human host.

It binds the parasites before they get into the liver.

It... It's called controlling the host.

You're giving them the immune response you want.

Can we give a single dose at one time,

and will that dose of antibody provide protection over the course of one year,

or would you need a second dose at six months?

So, that's how the study is designed, and we're now halfway through.

We've given a single dose,

and we'll be looking at the six-month data.

We're done. Hmm?

We have recruited so far 324 children for this, uh, second part of the trial.

Our syringe is one ml.

Confirm that it is one ml.

- The baby has come for a scheduled visit. - Mm-hmm.

The baby is not sick.

Okay. Which visit is this?

- Visit 112. - 112.

- Yes. - Okay.

It's mostly mothers who participate in the trial.

I'm Bernadina Odhiambo,

and I'm 26 years.

I'm a mother of two.

There is Ian and Margaret.

Here in Siaya, there is high risk of malaria.

We know that there's some measures that we can take by ourselves to control it.

I've made it as clean as possible.

There are no stagnant waters around.

We are all sleeping under treated mosquito nets.

We can use mosquito repellents.

We heard of malaria studies that are being conducted in Siaya County.

I was much interested since I'm a victim of malaria.

My older son got malaria when he was two months old.

So, when it came to the studies,

I just decided to be part of them.

Once we started the study, we were called upon.

We went to Kogelo.

They were taking some blood for tests.

So, after that, they were given a dose for malaria.

You can see we're driving through western Kenya, but we're seeing corn.

We could be in, you know, western Nebraska.

This is our second site. This is the Kogelo dispensary.

Kogelo, it's in a rural area.

One of its claim to fame is that's where President Obama's father was born.

I think you have to understand that if you're bringing in a new intervention,

they wanna have a good understanding of what that data is.

So, we're really excited that Bob is here today

to give us an update on the field of malaria monoclonal antibodies.

There you go.

Welcome, and thank you all for coming.

When we all get vaccinated,

the vaccine is given, and you make an antibody response.

You generate antibodies that are really good,

that do the protection.

You generate antibodies that don't do anything at all.

Okay, so you have a team of antibodies.

So, who knows who Michael Jordan is?

The basketball player.

No?

How about Mbappé?

Can he seal it now? Mbappé!

Oh, what an accomplished finish!

Suppose your entire team, every single player was Mbappé.

The odds of that team winning would increase.

So, that's what a monoclonal antibody is.

How many doses should be given?

We're at a stage now where one dose could work for six months.

We'd like to get it that one dose would work for an entire year.

- Thank you. - Thank you for your questions.

The question I most often get is just cost.

That, to me, is really the biggest hurdle.

I... I don't think it's necessarily a scientific hurdle.

And then we try to convince people that we can get this made much cheaper.

If they get the cost down enough and the effectiveness to be super high,

then wherever you give out that antibody, those kids don't get malaria.

The main thing we've always done for malaria is had drugs

that, as you detect the fever, you take the drugs.

Cinchona trees are things that grow at heights in South America,

and somebody figured out

if you boil the bark of the tree, which is quinine, and you drink it,

that you recover from your malaria very quickly.

Interesting thing about quinine,

it's actually one of the ingredients in tonic water.

You know, tonic is a word that we use to refer to medicine.

A tonic.

And tonic water, quinine water,

was what sailors back in the 18th and 19th century

were typically taking as a preventative.

It has a bitter taste,

so the British colonists in India added gin to cut the taste,

and the gin and tonic was born.

Obviously, now people don't drink gin and tonic as an anti-malarial, but...

Coffee also has a connection.

Originally, coffee was touted as a malarial cure,

and that enters the lore of coffee,

and it's advertised right up really until the late 1800s

as a cure for malarial fevers.

The ancient Egyptians bathed in human urine.

The Romans wore amulets around their neck with the magic word "abracadabra."

That's where it comes from, uh, to ward off malaria.

I mean, malaria is very, very hard to eradicate.

There have been many failed attempts.

For a long time, we've talked about infectious diseases

in terms of, "Can we eradicate them?"

We've eradicated one, smallpox.

We came close with polio, but we haven't quite gotten there,

but with malaria, it's a different kind of conversation.

- How are you? - Tony. How are you?

- Good to see you. Welcome. - Thanks for having me.

Oh, it's a pleasure. Come on in.

I think it's a very important proof of concept

that's going on now in the antibody studies

that are being done in Kenya and elsewhere,

but I'm concerned that we lose attention before we get to the endgame.

I think elimination in different regions, different countries,

is entirely feasible with malaria.

Eradication in the classic sense is gonna be very, very difficult

because of the prevalence of mosquitoes, the climate, the need for control.

So, I'm really high on hope with the science.

Eventually, our tools will get so good that,

you know, we'll be ambitious to take some geography

and try to have the intervention be so extreme

that we completely clear the parasite out of that area.

There are multiple steps and approaches.

Mosquito approach, treatment approach, prevention approach.

What does the public health need,

and what is the scientific opportunity?

And you either pursue the existing scientific opportunities,

or you create scientific opportunities.

To combat the mosquito menace,

scientists continually study the mosquitoes that carry diseases.

They seek new ways to control and destroy them.

To get to zero, you have to give people medicine,

but you also have to go after mosquitoes as well.

I think one of the difficulties we have is

that we... we have a disease that's preventable and treatable.

I started my career by looking at a cage of mosquitoes

and suddenly realizing if you kill these mosquitoes,

you can stop everything else that happens afterwards.

Historically, DDT is the most famous anti-mosquito tool.

It had negative effects,

and the environmental movement said we should move away from that.

Now there's this idea we call gene drive,

which is using the genetics of mosquitoes

so that they... they can't grow their population.

That's the most exciting thing we have.

I got into this because when I was a kid, I was always interested in living things,

and my parents took me to the Galápagos, and that got me reading Darwin.

I was just fascinated by

how this incredibly intricate tapestry of life had been woven,

and I thought, "I want to learn to do that."

"I want to learn to shape species."

If you could invent a technology that would eradicate malaria forever,

would you do it?

So, the answer must involve CRISPR.

CRISPR genome editing technology, which is basically genomic scissors

that allows us to cut at one particular sequence in a genome

and provide a DNA sequence to be inserted at that site that gets cut.

It could be used to build what's called a gene drive

that can allow us to spread an alteration from one organism

out into entire populations in the wild.

In the full-power version of this,

what we call a self-propagating gene drive,

has no limit to this beyond the species boundaries.

That is, if there is gene flow within a population,

it will spread to affect the entire population.

If you have CRISPR, the ability to change genes,

and you have gene drive which passes on heredity,

we could actually rewrite genes in such a way to decide what to pass on,

and you can make 'em all male,

and that way you can't have them mate with anyone.

So, if you make them all male,

that's the end of that species,

and it's the end of that disease in theory.

People are like, "Well, could it get out of the mosquitoes?"

"Could it cross to pollinating insects that, you know, give us fruit?"

There are legitimate questions about such a powerful technique.

Mosquitoes absolutely have benefits to society.

They're part of natural ecosystems.

Other animals feed on them.

Trout, salmon, top-water feeders.

Birds eat them.

Bats eat them.

Certain orchids would probably go extinct if those mosquito species went extinct.

So, mosquitoes are a valuable part of any natural ecosystem.

When you remove one species from an ecosystem,

you can have what's called a trophic cascade

of unintended consequences to other ecosystems.

So, for example, when the woolly mammoth went extinct,

so too did the hapless ticks that fed on the woolly mammoth.

There's over a thousand species of mosquitoes just in Africa.

There's just so many species that removing a few,

the ones that spread malaria, which is vanishingly few,

the odds of anything ecologically going wrong is very, very small.

Not zero, but very, very small.

Research is kind of a long process.

We want something right now, but if you want to do research,

like, you know, the specific technology that we are developing, it takes time.

And I'm part of the project Target Malaria.

We are using advanced genetic tools to get rid of malaria in the future.

We don't have the gene drive mosquitoes in Africa yet

for many reasons.

There are so many other elements around it,

and all these different pieces need, you know, to fall in place

just to make sure that you have something really very solid

and very safe for the community.

You know, malaria is rural,

and it's happening during the rainy season.

Taking mosquitoes, you know, to spread the gene for you,

and even in a really very difficult area,

if you cannot get access, the mosquito will do the job for you.

So, we really feel that this is a very transformative tool,

but, you know, to release mosquitoes in the field is really very easy.

It's going to take me just only 30 minutes,

but we took seven years to get there.

If you start right away with the gene drive, then it's spreading,

then you have all these different aspects that you did not look at,

then it's going to be very difficult.

You need to work for the community to get the social license.

And this is not something which is granted.

You really need to build trust with them.

I cannot just pop up in any single village with a bucket of mosquitoes

on the assumption that I'm a scientist working for the good of the public.

People really need to understand what you're doing.

Ah, good morning.

How are you?

Great. Thank you.

Good morning.

- How are you? - I'm very fine.

Great. Thank you.

We're very delighted to welcome you this morning.

As you can see, this is our insectary.

All the mosquitos are here.

We know there are a number of concerns that are out there,

so sometimes it's really very good

if you can take the leaders of the community

into the insectary and then you show them the mosquitoes,

how you do the transformation,

and allow them, you know, to ask all kinds of questions.

As you can see, the whole building is painted in white.

This makes it easier to see when something sits on the wall.

With the fans, if you stand here, you'll feel the wind.

Everything is done in such a way to keep the mosquitos inside.

All the mosquitos on this line have been genetically modified.

Here's the paraffin, which is like human skin.

You also have the source of the heat that you put on it.

It makes the paraffin warm, and the mosquitos can feel it right away.

When they feel it, they come and start sucking.

I learned a lot today in the insectary.

I was amazed at how a mosquito could be modified.

The mosquito is so small,

and to say that it can be modified,

well, it's astonishing.

That's what we call DNA.

When the modification is integrated into the mosquito's genome,

you will see that it has red eyes.

So, mosquitos that aren't modified don't have red eyes?

No, they don't have red eyes.

It's hard to change the genetics of a species

and know for sure what the ultimate implications are.

We can edit a certain receptor on one cell that will prevent people from getting HIV.

It would increase their chance of getting West Nile disease.

Most people today would say, "That's an easy choice,"

but is it gonna be an easy choice in 10,000 years?

It might turn out that West Nile disease will wipe out humanity.

It's very difficult to see down the field.

You know, we'll get people who say

even the benefit of reducing those malaria deaths,

you know, doesn't justify opening Pandora's Box.

I completely disagree with that.

If you just got a few species in Africa,

you'd get, you know, 80% of the disease burden.

Um, it's not on the list of, you know, Dr. Evil's toolbox,

Uh...

...and sadly, that list is not an empty list.

- But, uh, this is not... this is not on it. - No, no.

Very often people will come to you and say

that if you remove the mosquitoes, then what is going to happen?

But my question is that we have 600,000 deaths every year.

Something bad is already happening.

So you absolutely need to do something about it.

It's still hard to come in from another place

and tell a country we want to use your people,

and that you might benefit greatly, but we're not sure, and in the end,

we'll decide what to do with this technology when we're done with it.

The whole history of colonialism is white people going into Africa

to use human beings like they're minerals or something.

The population really wants the success of this project

because we have seen grave cases of malaria,

and the people are desperate

for an adequate solution.

If it's your environment, it's your call,

and I don't live in Africa, and my kids are not at risk of malaria,

but if my kids were at risk and did live there,

I would say, "Do it now."

Self-propagating, go straight ahead, no more ecological local field trials.

If my kids were at risk, I would just say, "Do it."

Don't keep messing around.

This is a good example of why we in the developed world

need to pay attention globally to global diseases.

I think there are two reasons.

One, I actually think we have a moral responsibility as a rich country

to not have people unduly suffer from preventable and treatable diseases

just because of where they happen to be born,

but there's an enlightened self-interest

when you're dealing with infectious diseases.

They can creep into other regions.

The CDC is out with a new health warning

after confirming five cases of malaria in the US.

Breaking news is out of Maryland tonight...

First malaria infection in more than four decades.

Malaria is intensely unforgiving.

And if we look in the face of climate change,

we're likely to see more and more things go wrong.

We don't want the world to be in a place where anytime something goes wrong,

tens to hundreds of thousands of people die, avoidably, from malaria.

We have a susceptible environment in the US,

especially in parts of the South where the climate is warm

and... and you find the Anopheles mosquito.

The potential for local transmission is really worrisome.

- Good evening. - Good evening.

- How is family? - Good.

- Are you all doing well? - Yes.

Since this morning, do you know what happened?

What?

I visited the laboratory to see how the malaria work has been going.

So, how does someone recognize a modified mosquito?

When you look at them, the modified mosquitos have red eyes.

Oh.

Mama, Ian, how are you?

I am okay.

Ian, say hello to the doctor!

Okay.

Uh, in the last, uh, one month,

from the time you came to the clinic, there's no problem with the child?

- He is good. - Okay.

So, anything that you'd want to report about the child generally?

This is now six months.

Eh, home visits, clinic, home visit and clinic.

I'm so privileged to be a part of this study

because the boy, he has been good.

He has not tested for malaria for six months.

Before, I was afraid

because I was one of the victims of malaria.

And although it has not been proven that it will work,

but we are hoping, in a few years coming.

And I am praying, and it's my humble prayer

that this antibody...

...will be going to work.

So I'm not afraid.

Are the redesigned mosquitos going to stay with them

inside the laboratory?

You don't need to be afraid of the modified mosquitos.

The aim of this work is to eradicate female mosquitos

in order to combat malaria.

It scares us because we often hear that white people have done this, done that,

and added things to our illnesses.

If you go to the lab,

the truth is that it's breathtaking,

and the people there work hard, and the work is going really well.

It's really important to remember that malaria is a disease of poverty,

and when children are sick,

they can't go to school, so they can't learn,

and when they can't learn, they can't, uh, get a job

and... and earn a proper living for themselves.

Parents have to look after them. They can't earn a living.

They have to spend money on malaria treatments,

and their health expenditure goes up,

and getting out of that cycle

is absolutely key to help get out of the cycle of poverty.

As long as malaria will be killing people here in Africa a lot

and completely destroying our economy,

we will struggle, you know, to develop.

This is where my roots are.

I was born here, raised here.

All my family is here.

Nobody's going to build my country for me.

I have to do it.

We have to do it.

Bye.

- Bye. - Bye.

My hope

is that we will be able, you know, to eradicate malaria in my lifetime.

I want to eradicate it in my lifetime, which is a tougher constraint, so...

You're gonna be in good shape. Just stay healthy.

Well, you always have something before you feed the thing

where you... you figure out what to put into the prompt buffer,

but the, you know, math expert...

Bill Gates is exactly where he... he should be.

...expert. What are called plug-ins...

The idea that you have a mind like that trying to crack the code,

you know, working every which way.

This is a very good thing.

By creating, you know, let's call it a system's architecture...

If he didn't exist, we'd have to make him up,

but if we did, no one would believe the character, you know?

I... I just think this is a man who wants to be useful.

It's sort of beautiful.

It's about outcomes.

But even the men with the deepest pockets,

they can't fix a lot of these problems.

They're too big.

We need government buy-in, and this is where advocacy comes in.

This is where storytelling comes in and storytellers.

Left and right brain talking, that's where we need to be.

The world is facing a lot of big challenges right now,

but I believe we can solve them.

♪ If today was not a crooked highway... ♪

Overall, the world's improved a lot,

and, you know, I enjoy being a small part of that.

♪ If tomorrow was... ♪

There are challenges of political polarization,

and limited resources, and avoiding a climate disaster,

and we have to drive the innovation in order to get ahead of those challenges.

♪ If I could hear... ♪

We'll get it, you know.

Will it be 15 years or 20 years or 30 years?

That depends on great work and making it a priority.

♪ Then I'd lie ♪

♪ In my bed once again ♪

♪ I can't see my reflection in the water ♪

♪ I can't speak the sounds To show no pain ♪

♪ I can't hear the echo of my footsteps ♪

♪ Or remember the sounds of my own name ♪

♪ Yes, and only If my own true love was waiting... ♪