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A brush with death led Hans Berger to invent a machine that could eavesdrop on the brain.

In 1893, when he was 19, Berger fell off his horse during maneuvers training with the German military and was nearly trampled. On that same day, his sister, far away, got a bad feeling about Hans. She talked her father into sending a telegram asking if everything was all right.

To young Berger, this eerie timing was no coincidence: It was a case of “spontaneous telepathy,” he later wrote. Hans was convinced that he had transmitted his thoughts of mortal fear to his sister — somehow.

So he decided to study psychiatry, beginning a quest to uncover how thoughts could travel between people. Chasing after a scientific basis for telepathy was a dead end, of course. But in the attempt, Berger ended up making a key contribution to modern medicine and science: He invented the electroencephalogram, or EEG, a device that could read the brain’s electrical activity.

Berger’s machine, first used successfully in 1924, produced a readout of squiggles that represented the electricity created by collections of firing nerve cells in the brain.

To celebrate our upcoming 100th anniversary, we’re launching a series that highlights some of the biggest advances in science over the last century. For more on the past, present and future of neuroscience, visit Century of Science: Our brains, our futures.

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In the century since, the EEG has become an indispensable clinical tool. It can spot seizures, monitor sleep and even help determine brain death. It has also yielded fundamental insights into how the brain works, revealing details about the brain’s activity while at rest, or while crunching numbers or tripping on hallucinogens.

When Berger was young, the idea of paranormal psychic communication didn’t sound as wacko as it does now. “The hangover from the 19th century was this idea of trying to explain cases of telepathy,” says communications expert Caitlin Shure, who wrote her thesis at Columbia University on the concept of brain waves. At that time, scientific societies and serious research initiatives were devoted to probing these occurrences. British physician and author Arthur Conan Doyle, of Sherlock Holmes fame, was a staunch believer. It was, as Shure puts it, “peak telepathy enthusiasm time.”

In a way, this makes sense. Scientific understanding of the world was deepening, along with technological advances in radio. “Why shouldn’t thoughts be able to travel through the universe just like wireless telegraphy?” Shure says.

Berger slogged away to prove how telepathy worked, trying to measure mental activity. He scrutinized blood flow and brain temperature before turning to electrical output. His breakthrough finally came on July 6, 1924, while studying a man with a skull injury called Patient K. Using a vacuum tube amplifier to enhance the electrical signals, Berger was finally able to spot a brain wave.

In 1929, Berger finally published his results, the first of a series of papers with the exact same title, numbered 1 to 14: “Über das Elektrenkephalogramm des Menschen,” or “On the Electroencephalogram of Man.”

The findings “go down like the proverbial lead balloon,” says medical historian and forensic psychiatrist Robert Kaplan of the University of Wollongong in Australia. A more prominent scientist, Nobel laureate Edgar Adrian of the University of Cambridge, was deeply skeptical of Berger’s findings, and repeated the experiments. But Adrian confirmed the results and began to publicize the method and Berger along with it.

The rest of Berger’s story takes a dark turn. In the run up to the second World War, he was ousted from his research position at the University of Jena in Germany and forced into a non-research job at a nursing home. Convinced that he had a fatal heart disease and sick with an infection and depression, Berger died by suicide in 1941 — “a terrible, sad ending to this story,” Kaplan says. The year before, Adrian had nominated Berger for the Nobel Prize in physiology or medicine, but no prize was awarded that year.

Berger wrote late in his life that the waves he discovered couldn’t explain the psychic transference he sought; his waves could not have traveled far enough to reach his sister. But, as Shure points out, echoes of that idea ripple into today’s world, in which we are all instantly and digitally connected. “There’s a way in which these false beliefs, or fantasies, about brain waves or telepathy or thought transference ended up creating that reality,” Shure says. Technology has already begun linking brains wirelessly.

It’s not Berger’s telepathy. But today’s technology is getting us closer to something like it. And at the very least, if you had a near-death experience this morning, your sister would soon know about it.

The National Suicide Prevention Lifeline can be reached at 1-800-273-TALK (8255).

As a geologist who studies Stone Age cave art, Iñaki Intxaurbe is used to making subterranean treks in a headlamp and boots. But the first time he navigated a cave the way humans thousands of years ago would have — barefoot while holding a torch — he learned two things. “The first sensation is that the ground is very wet and cold,” says Intxaurbe, of the University of the Basque Country in Leioa, Spain. The second: If something chases you, it will be hard to run. “You are not going to see what is in front of you,” he says.

Torches are just one of several light sources Stone Age artists used to navigate caves. Intxaurbe and colleagues are wielding these fiery tools in dark, damp and often cramped caves in an effort to understand how and why humans journeyed beneath the earth and why they created art there (SN: 11/7/18).

In the wide chambers and narrow passageways of Isuntza I Cave in the Basque region of Spain, the researchers tested torches, stone lamps and fireplaces — nooks in cave walls. Juniper branches, animal fat and other materials that Stone Age humans would have had at hand fueled the light sources. The team measured flame intensity and duration, as well as how far away from the source light illuminated the walls.

Each light source comes with its own quirks that make it well suited to specific cave spaces and tasks, the team reports June 16 in PLOS ONE. Stone Age humans would have controlled fire in varying ways to travel through caves and make and view art, the researchers say.

Torches work best on the move, as their flames need motion to stay lit and produce a lot of smoke. Though torches cast a wide glow, they burn for an average of just 41 minutes, the team found. That suggests several torches would have been needed to travel through caves. Concave stone lamps filled with animal fat, on the other hand, are smokeless and can offer more than an hour of focused, candlelike light. That would have made it easy to stay in one spot for a while. And while fireplaces produce a lot of light, they can also produce a lot of smoke. That type of light source is best suited for large spaces that get plenty of airflow, the researchers say. 

For Intxaurbe, the experiments confirmed what he has seen himself at Atxurra cave in northern Spain. In a narrow Atxurra passageway, Paleolithic people had used stone lamps. But near high ceilings where smoke can rise, they left signs of fireplaces and torches. “They were very intelligent. They use the better choice for different scenarios,” he says.

While the findings reveal a lot about how Stone Age people used light to navigate caves, they also shed light on 12,500-year-old art that Intxaurbe helped discover deep in the Atxurra cave in 2015. Stone Age artists painted about 50 images of horses, goats and bison on a wall accessible only by climbing up a roughly 7-meter-tall ledge. “The paintings are in a very common cave, but in very uncommon places of the cave,” Intxaurbe says. That may partly explain why previous explorers had failed to notice the art.

A lack of the right lighting also played a part, Intxaurbe and colleagues say. By simulating how torches, lamps and fireplaces lit up a virtual 3-D model of Atxurra, the team saw the cave’s art with fresh eyes. Using just a torch or a lamp from below, the paintings and engravings stay hidden. But lit fireplaces on the ledge illuminate the whole gallery so that anyone on the cave floor can see it. That suggests the artists may have wanted to keep their work hidden, the researchers say.

Cave art wouldn’t exist without harnessing fire. So to unravel the mysteries of subterranean studios, it’s key to understand how prehistoric artists lit their surroundings. “Answering the small questions in an accurate way,” Intxaurbe says, is a path toward answering a main question about Stone Age people, “why they painted these things.”

This is the story of how the world travels of a 19th century explorer, two bar magnets and the World War II hunt for enemy submarines led to the invention of the portable fluxgate magnetometer. And how that invention, in turn, led to the “magic profile,” a powerful piece of evidence for the theory of plate tectonics.

In the 1950s, the idea that Earth’s continents might be on the move was largely ridiculed, and the seafloor was still mostly a mystery. But that was about to change: In the aftermath of World War II and its naval battles, researchers suddenly had powerful new tools, such as submersibles and sonar systems, to map and probe the seafloor in greater detail than ever before. Among these new technologies was a small, portable device known as a fluxgate magnetometer.

Magnetometers, devices that measure Earth’s magnetic field, were far from a new technology at that point. Scientists had known for centuries that Earth produces its own magnetic field; sailors used compasses to navigate by it. But the strength of that field was puzzlingly inconsistent from place to place.

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During his travels around the globe in the early 1800s, the German explorer and geographer Alexander von Humboldt collected measurements of Earth’s magnetic field at different locations, noting that the field’s intensity increased farther from the equator. Those variations led Humboldt in 1831 to initiate a coordinated effort to precisely measure this magnetic intensity around the world. Among others, he enlisted the help of German mathematician Carl Friedrich Gauss in this effort.

Gauss delivered. In 1833, he reported devising the first magnetometer, which could measure the absolute intensity of Earth’s magnetic field at any location. His magnetometer was deceptively simple, consisting of two bar magnets, one suspended in the air by a fiber and one placed a known distance away. The deflection of the suspended magnet from geomagnetic north depends on both the intensity of Earth’s magnetic field and the pull of the second bar magnet. These measurements succeeded in providing the first global maps of Earth’s magnetic field strength.

But by World War II, the U.S. Navy was looking for even more precise measurements of magnetism. Specifically, the Navy wanted to be able to map very small anomalies in Earth’s magnetic field — anomalies that might be due, for example, to the presence of metallic objects, such as submarines, beneath the surface of the water.

In 1836, scientists designed such a precise sensor, called a fluxgate magnetometer. In a fluxgate magnetometer, instead of a spinning needle like in a compass, a bar of iron is wrapped in two coils of wire. One coil carries an alternating current along the length of the iron core, tinkering with the core’s magnetic state, first saturating it with magnetism and then desaturating it. When in the unsaturated state, the core can pull in an external magnetic field, such as Earth’s. When saturated, the core pushes the external field back out. The second coil is there to detect those changes in magnetism — and along the way can very precisely measure the strength of the external field.

But to use this device to look for submarines, it would have to be portable, able to be mounted on an airplane. That’s where Russian-born geomagnetist Victor Vacquier enters the story. Vacquier was at the Pittsburgh-based Gulf Research Laboratories, an arm of Gulf Oil, where, for several years, he had been hard at work on a portable version of the fluxgate magnetometer.

In 1941, successful tests of Vacquier’s device drew the attention of the Navy, which saw the defense potential of his device. With naval funding, fluxgate magnetometers were airborne by December 1942 and busily hunting for enemy submarines.

After the war, scientists were eager to see what this precise, portable magnetometer could reveal about the seafloor. Oceanographers refitted the device so it could be towed behind research vessels as they swept back and forth across the oceans. During the 1950s and early 1960s, Vacquier (by then at Scripps Institution of Oceanography in La Jolla, Calif.) and other researchers began using the fluxgate magnetometer to measure and map magnetic anomalies preserved in the seafloor rocks.

The maps revealed a curious zebra-stripe pattern of magnetic polarity on the seafloor, something never seen in continental rocks. In this pattern, bands of rocks with normal polarity — the north-south orientation corresponding to that of Earth’s current magnetic field — alternated with bands of reversed polarity. These stripes, scientists hypothesized, might be due to Earth’s magnetic field reversing direction from time to time.

Even more tellingly, the zebra-stripe pattern turned out to be symmetrical on either side of the long, snaking underwater mountain chains known as mid-ocean ridges. That pattern became one of the most powerful lines of evidence for the hypothesis of seafloor spreading, the idea that as Earth’s crust pulls apart at the mid-ocean ridges, magma wells up to form new ocean crust. As the new crust hardens, its iron-bearing minerals align with the current orientation of Earth’s magnetic field, and the hardening rocks become a new stripe in the pattern.  

In 1968, about 100 earth scientists met for what was about to become a seminal moment in the story of plate tectonics. At the meeting, a two-day symposium held at the Goddard Institute for Space Studies in New York City, geologists Walter Pitman and James Heirtzler of Lamont-Doherty Earth Observatory in Palisades, N.Y., presented a profile of magnetic anomalies they had measured in 1966 from aboard the R/V Eltanin.

The symmetry on either side of the Pacific-Antarctic Ridge was crystal clear, so perfect that it became known as the “magic profile.” This profile, made possible by a series of inventions over the previous century that culminated in a portable, precise magnetometer, became one of the most convincing lines of evidence for seafloor spreading — and ultimately, for the theory of plate tectonics.

Fingers crossed for finding nothing: July marks the main trapping season to check for Asian giant hornets still infesting Washington state.

The first of these invasive hornets found in North America in 2021, in June, was probably not from a nest made this year, scientists say. So that find doesn’t say how well, or if, the pests might have survived the winter. Yet that hornet shows quite well the relentless risk of newly arriving insects.

That initial specimen, a “crispy” dead male insect lying on a lawn in Marysville, Wash., belongs to the hefty species Vespa mandarinia. Nicknamed murder hornets, these were detected flying loose in Canada for the first time in 2019 and in the United States in 2020 (SN: 5/29/20). Yet the “dry, crispy” male is not part of known hornet invasions, said entomologist Sven Spichiger at a news conference on June 16.

Testing shows the male “is definitely not the same genetic line as the ones we have found,” said Spichiger, of the Washington State Department of Agriculture in Olympia. Neither the U.S. finds, until now all from Washington’s Whatcom County, nor British Columbia’s on the other side of the border are closely related to the newfound hornet. It’s a separate incursion no one had noticed until now.

This oddball new specimen may help correct the skewed impression that sneaky invasive arrivals are rare. The hornets’ appearance in North America may have been a shock to some, but in reality, worrisome insects show up often, and will probably keep doing so. Fortunately making a permanent home is harder than getting here, scientists say.

When news of the Asian giant hornets’ arrival first broke in 2019, one of the people who was not at all surprised at a foreign species was entomologist Doug Yanega of the University of California, Riverside. “It is very fair to say that there are many invasive species,” he emphasizes. “We just got a new African mantis species in California this past year in LA, and the expectation is that it is likely to spread.”

But even alarming pest arrivals rarely kick up the fuss prompted by Asian giant hornets. At a peak in hornet news during May 2020, Yanega contrasted the new intruders with the South American palm weevil (Rhynchophorus palmarum). That big weevil had reached southern California and could “wipe out every palm tree in the state,” according to Yanega. Yet, “there have been ZERO [national] mainstream media reports about this, an insect that seriously threatens to have a VASTLY greater negative impact on the economy and our way of life than those hornets ever will,” he fumed in an e-mail.

That relentless influx of invading insects may be one reason so few make it into the general news. For instance, U.S. Customs and Border Protection reported 31,785 incidents detecting some pest just for fiscal year 2020.

For 2021, to pick just one example of worrisome arrivals that have not gone viral, inspectors at Washington Dulles International Airport in Virginia and later at Baltimore/Washington International noticed little brown pests called Khapra beetles (Trogoderma granarium) in Basmati rice and then in dried cow peas that travelers were trying to bring in from abroad. Officials banned the contaminated foodstuffs.

The Dulles contraband had the bigger number of living insects: 12 larvae and four adults. Even that tiny number of tiny insects was unacceptable. This is the only insect species that U.S. customs officials act upon even when all specimens are found dead. The beetles nibble stored seeds but will also soil the goods with stray body parts and hairs that can make human babies fed dirty grain quite sick and adults uncomfortable. In 1953, a major California effort started to stamp out infestations of Khapra beetles and eventually preserved crop marketability. But the effort was expensive, costing the equivalent of about $90 million in today’s economy.

Beetles aside, menacing hornets of other species have shown up before the latest Asian giants, says Paul van Westendorp, an apiculture specialist who now strategizes British Columbia’s fight against V. mandarinia. In May 2019, just months before the discovery of an Asian giant hornet’s arrival, a V. soror hornet appeared in Canada. It was “alive, but not for long,” van Westendorp says. “I had a chance to admire that specimen.” Not a frail beast, this species hunts down other insects and has been reported to catch prey as large as a gecko. V. soror looks very much like a V. mandarinia, he says.

Even Asian giant hornets themselves have turned up at least once in the United States before 2020. An inspector in 2016 flagged a package coming into the San Francisco airport holding a papery insect nest but not mentioning insects on the label. The nest held Asian giant hornet larvae and pupae, some still alive when discovered. These and other species of hornets, including the ominously named V. bellicosa, accounted for about half of the 50 interceptions of hornets and yellow jackets flagged from 2010 to 2018 at U.S. ports of entry, researchers reported in 2020 in Insect Systematics and Diversity.  

Only some stowaways will manage to make permanent homes in new territory. Of these, the real troublemakers seem to be a minority. For instance, out of 455 plant-attacking insects that settled into forests in the continental United States, 62 cause noticeable damage, according to a 2011 tally from U.S. Forest Service researcher Juliann Aukema and colleagues. Even a few rampaging invasive pests, though, can get expensive. Biologists are throwing themselves into the fight.

Relentless as the onslaught of unwanted arrivals is, there’s hope for stamping out the more noticeable invasions if caught early. Vespa hornets are “very large-bodied and obvious, so people will see them,” says entomologist Lynn Kimsey of the University of California, Davis, one of the authors of the 2020 hornet overview. A Vespa affinis nest showed up in San Pedro, in Southern California at least a decade ago. However, she says, “it was killed and there’s been no sighting of the species since, as far as I’ve heard.”

Catching such intrusions early isn’t always easy, however. The port of Oakland takes in about 1 million shipping containers from overseas a year, but at best U.S. Department of Agriculture inspectors can check maybe only 10 percent for stowaway insects, Kimsey says. Add to this all the cargo coming into Long Beach, San Diego and the other West Coast ports — plus all the cargo jets. “What’s amazing is that we don’t see more invasives,” she says. “I think this tells you how hard it is for exotic species to get established.”

They’ll keep arriving though. All the more reason to keep an eye out for something funny on the lawn, even if it’s just a withered nugget.

In a one-two punch, a malaria vaccine in development pairs a shot of the live parasite that causes the disease with a whammy of infection-fighting drugs to immediately quell it.

The candidate is the latest vaccine to show promise against a formidable foe, bolstering hopes that an effective shot might be on the horizon. Malaria, a disease caused by the parasite Plasmodium falciparum, affects more than 200 million people around the world every year. In 2019, an estimated 409,000 people died from the mosquito-borne disease, 67 percent of whom were children younger than 5.

The live parasite vaccine and drug combo showed 87.5 percent efficacy in a small group of healthy adult participants, researchers reported June 30 in Nature. The live parasite shot — which is followed by a dose of one of two anti-malarial drugs to eliminate the infection — not only protected people from the same strain included in the vaccine, but most people could also fend off a different parasite strain that circulates in Brazil.  

If the results hold up in a larger study, “it would be fantastic,” says Wilfred Ndifon, a mathematical biologist at the African Institute for Mathematical Sciences in Kigali, Rwanda, who was not involved in the study. Even as newly emerging diseases like COVID-19 have killed millions and martialed global attention and resources, “we are still falling short of controlling the ones that already exist,” Ndifon says.

Currently there is only one malaria vaccine, called RTS,S, in use in Africa that provides partial protection in young children. Rather than live parasites, the shot uses a key malaria protein that helps the parasite infect liver cells to train the body to recognize the pathogen. In a late-stage clinical trial, it prevented 39 percent of malaria cases among children 5 to 17 years old. Now, it’s given to children in Ghana, Malawi and Kenya as part of a pilot program through the World Health Organization.

Another malaria vaccine candidate called R21 was designed to improve protection by helping the body better home in on attacking that same malaria protein. That jab recently showed 77 percent efficacy among 450 children in Burkina Faso, researchers reported May 15 in the Lancet.

Still, the world is in desperate need of good malaria vaccines. And using live organisms to protect people is “the oldest way of making a vaccine,” says Patrick Duffy, a malaria vaccine researcher at the National Institute of Allergy and Infectious Diseases in Bethesda, Md. Shots for diseases like measles and chickenpox also rely on using live, albeit weakened, viruses to teach the immune system what to attack.  

In the new study, Duffy and his colleagues gave 44 healthy people in the United States three intravenous doses of the vaccine spaced about a month apart. Another 12 people were included as controls. Two or three days after the shot, vaccinated participants took one of two anti-malaria drugs — pyrimethamine and chloroquine — to weaken and eliminate the parasite.  

Taking anti-malaria drugs is a crucial part of the vaccination process. That’s because “these malaria parasites in the vaccine are fully infectious,” says David Cook, an infectious diseases physician also at NIAID. “If we weren’t to give [participants] any medication at all, people would develop a malaria infection.”

When P. falciparum infects a new host, sporozoites — the life stage of the parasite that is transmitted from mosquitoes — first attack the liver. Then the parasite bursts into the bloodstream, infecting red blood cells and causing symptoms like fever, headache or chills. Pyrimethamine curbs the infection in the liver; chloroquine tackles parasites in the blood. So while participants who got chloroquine might develop malaria symptoms, those who get pyrimethamine wouldn’t, Cook says. 

A low-dose vaccine with around 51,200 sporozoites followed up with chloroquine protected four out of five participants when they were exposed to the parasite three months after the last dose. A dose of pyrimethamine protected only two out of nine people.

Increasing the amount of parasite in each dose to 200,000 sporozoites, however, bolstered immune defenses. Seven out of eight people, or 87.5 percent, who got a high-dose shot and then took pyrimethamine were protected when exposed to the same parasite strain three months later.

The higher dose shot also worked against another malaria parasite strain from Brazil, protecting six out of six people who took chloroquine and seven out of nine people given pyrimethamine. That type of cross protection is important because malaria is a diverse parasite, says Kirsten Lyke, a vaccinologist at the University of Maryland School of Medicine in Baltimore. So people need to mount an immune response that can recognize multiple strains, not just the one included in a vaccine.

Still, because the trial was so small, there’s “some degree of uncertainty about whether this approach to vaccinating is highly effective,” Ndifon says. What’s more, getting people to come back to the clinic for three doses plus drug treatments will be a challenge, both Ndifon and Lyke say.

Some experts “see this as a traveler’s vaccine,” more accessible to those who have the time and resources to follow up with the treatment, says Adrian Hill, a vaccinologist at the University of Oxford and director of the Jenner Institute who is involved with the R21 malaria vaccine. “If you give people [in Africa] a whopping dose of malaria and then for any reason that drug is expired or it isn’t the right drug or they took it too late — who’s going to take responsibility for that?” What’s more, the shot must be stored in liquid nitrogen and is “impossible to [manufacture] at the scale you need to make an impact on malaria,” Hill says.

Ideally anti-malarial drugs like chloroquine and pyrimethamine would be given at the same time as the shot to minimize the chances people will miss treatments, Duffy says. The team has plans to test that regimen in upcoming trials, as well as figure out how long protection might last.

As India reels from a devastating second wave of the COVID-19 pandemic, a new horror is plaguing people there. Some COVID-19 patients “go home only to come back to the hospital with a damaged nose, swollen cheeks and so on,” says SP Kalantri, a physician at the Mahatma Gandhi Institute of Medical Sciences in Sevagram, a small town in the state of Maharashtra.

The cases aren’t unique to Kalantri’s hospital. Medical facilities across the country are seeing a surge in people who have recovered from COVID-19 and are now being preyed upon by a rare fungal infection called mucormycosis. The fungus can invade the nasal cavity and the sinuses and, in some cases, even reach the brain, turning the affected areas black. Colloquially dubbed black fungus, an infection can maim patients, and kills up to half of those who contract it, researchers reported June 4 in Emerging Infectious Diseases. 

Since April, mucormycosis infections have skyrocketed across India; more than 28,000 cases had been officially reported as of June 7. Of those, 86 percent were COVID-19 patients. Local media reports in India now estimate that as of June 11, cases had reached more than 31,000. At St. John’s Medical College Hospital in Bangalore, “in the pre-COVID period, we had approximately 30 patients per year” with the infection, says Sanjiv Lewin, chief of medical services. But in a recent two-week period, “we had a sudden surge of 63 patients.” 

People with COVID-19, especially those that end up in an intensive care unit, already are vulnerable to secondary infections. Other countries have reported a smattering of post–COVID-19 fungal infections, including Oman, which on June 15 reported its first mucormycosis infections in COVID-19 patients. “There have been some cases reported in the United States, but they have been very few,” says Stuart Levitz, an attending physician at the University of Massachusetts Memorial Medical Center in Worcester. However, no country matches the sheer number of black fungus cases being reported in India right now.

Here’s how a perfect storm of conditions came together to create the country’s rash of black fungus infections.

Fungus among us      

Mucorales, the group of fungi that includes molds responsible for mucormycosis, is ubiquitous in hot and humid climates like India. So even before the pandemic, the estimated rate of these fungal infections was much higher in India than any place else in the world.

“The environment has such amount of spore, that when you give it a fertile ground, it becomes a problem,” says Arunaloke Chakrabarti, a medical mycologist at the Postgraduate Institute of Medical Education & Research in Chandigarh, India.

India typically has 140 cases of mucormycosis per million people, he and a colleague estimated in a March 2019 study in the Journal of Fungi. “That’s 70 times that of the Western world,” Chakrabarti says. In comparison, there are about 3 cases per million people in the United States, the researchers estimated.

Despite the ubiquity of these fungal spores in India, infections among healthy individuals are quite rare. But here’s where other factors of this perfect storm come into play.

Fertile ground

People with uncontrolled diabetes are at a high risk of contracting the fungal infection, studies have shown. That’s because as blood sugar levels spike, the pH of blood turns acidic, creating a favorable environment for the fungus to thrive. Diabetes “overshadows all the other risk factors,” Chakrabarti says.

Given India’s reputation as the diabetes capital of the world — with an estimated 77 million diabetics — that’s bad news. “Every eighth person admitted to the hospital either [has] diabetes or developed high blood glucose during the hospital stay,” Kalantri says.      

So India already was a fertile ground for mucormycosis infections. Then the pandemic hit. Desperate for treatments, doctors and families have scrambled to get patients one of the few treatments for COVID-19: steroids. Studies have shown drugs such as dexamethasone can reduce the risk of death for severely ill COVID-19 patients (SN: 9/2/20).

 “The recommendation is very clear and crisp: eight milligrams of dexamethasone only for 10 days and only in hypoxic patients,” Kalantri says. When administered at the correct time and in the right dosage, steroids can save lives by dampening the overreacting immune system and preventing inflammation in the lungs.

But given too early in an infection, when the body is trying to fight off the coronavirus by itself, steroids can be counterproductive and can hamper the body’s ability to rein in infections, leaving it vulnerable to other secondary infections. Desperation during India’s second surge of the pandemic has led to excessive and indiscriminate use of the drugs, which can be bought over the counter (SN: 5/9/21). “The message that went through the media to the lay public as well as to the regular doctor is probably that steroids are the only thing which helps, so as soon as they made a diagnosis of COVID, they gave steroids,” Lewin says.

And that exacerbated the risk for fungal infections. “Gross and irrational abuse of steroids and high glucose levels created a perfect milieu for the fungus to grow, thrive and destroy the tissues,” Kalantri says.

A July 2021 study in the Indian Journal of Ophthalmology that looked at 2,826 mucormycosis patients in India supports that conclusion. The research found diabetes and the use of steroids to be the “most important predisposing factors” for developing post–COVID-19 black fungus infections. Still, Kalantri says, “this isn’t the entire story.”      

For instance, the novel coronavirus has been implicated in affecting insulin production, researchers reported February 3 in Nature Metabolism. “COVID virus itself damages the beta cell of the pancreas, which then hinders insulin production … so the blood sugar goes further high,” Chakrabarti says.

What’s more, several experts have also pointed that the rampant use of antibiotics in general could have helped the fungus gain entry. “By getting rid of bacterial flora in the sinuses and the nasal cavity, if the fungi that cause mucormycosis gets into the sinuses, you don’t have competition from the bacteria and so it may help the fungus gain a foothold,” Levitz says.    

For now, it is difficult to pinpoint all of the factors responsible for India’s rising fungal infections. But the ongoing crisis provides an opportunity for epidemiological investigations to find answers and hopefully help in preventing future outbreaks. In the meantime, doctors are scrambling to do whatever they can to help people suffering now.

Treatment troubles

The good news is that, while a black fungus infection can be deadly, treatments do exist.

Liposomal amphotericin B, the primary drug used for treatment, can stop the fungus from growing and spreading to other tissues, and surgery can remove the affected tissue. But getting this treatment underway hinges on a timely diagnosis, which can be difficult to make in a resource-starved setting.

What’s more, because of the infection’s ability to affect numerous types of tissue, “you need multi-specialty teams of ophthalmologists, [ear, nose and throat] surgeons, physicians, with a neurosurgeon on standby,” Lewin says. In an already overwhelmed health care system, a team like that can be difficult to assemble. And the antifungal drug is now also hard to come by as demand has swiftly outpaced supply. Even if the drug is available in the open market, it is extremely cost-prohibitive for most Indians.

“You have to spend 30,000 rupees [the equivalent of $400] a day on the drug alone, and it doesn’t include the cost of hospitalization, CT scans, surgery, monitoring, etcetera…. Ninety-nine percent of Indians won’t be able to afford that,” Kalantri says. Even in sophisticated, tertiary-care hospitals, the situation is bleak. “I have six ampules of amphotericin B presently with me. Six! And I’ve got presently 36 patients in my ward,” Lewin says. “Without amphotericin, I am in deep trouble because the infection will continue to spread, blind my patients, even kill my patients.”

While new cases of COVID-19 in India have dropped from their peak in May to about 60,000 a day now, fungal infections continue to add up. But there is some hope. For one, the Indian government has stepped in to ramp up domestic production of liposomal amphotericin B and to facilitate importation of the drug. One doctor tweeted, “Last couple of days, few of our patients getting their full dose. So something seems to be working for now.” The long-term hope, however, hinges on ending the COVID-19 pandemic, in whose shadow the fungus has thrived.