Can a Penn Epidemiologist Prevent a Bedbug-Driven Outbreak?

Epidemiologist Michael Z. Levy curbed a Chagas disease epidemic in Arequipa, Peru. Can he prevent an outbreak in Philadelphia?

By Lauren Ingeno

The signs are subtle, at first. You notice two pink bumps on your ankle, and then another, on your wrist. “Mosquitoes,” you think. But then, you wake up scratching a line of itchy bites across your torso. “Maybe fleas?” your doctor suggests. One month later, you find a handful of bedbugs — flat and brown like apple seeds — burrowed in a crevice of your box spring. You squish one and watch your own blood spatter from its abdomen.

Your landlord refuses to foot the $800 exterminator bill, so you dip into your savings to cover the treatment. While lugging trash bags of clothes to the laundromat, you unknowingly spread the pests to a neighbor. Months later, your building is finally declared “bedbug-free.” Still, the scars have not yet faded on your skin. You lie awake at night, fearing that the parasites are hiding in the cracks of your floorboards, waiting to make their return.

Michael Z. Levy, PhD, an associate professor of Epidemiology in the Perelman School of Medicine, has heard versions of this story from Philadelphians — some much more haunting — dozens of times.

After nearly 20 years researching the intersection of ecology, public health, and urban policy, Levy understands, better than most, how infectious disease outbreaks happen — and that we’re not doing enough to prevent them.

“My big worry right now is that we’re going to have warehouses full of masks, and the next pandemic won’t be airborne — it’s going to be carried by a bug,” Levy says. “If we wait until bedbugs start spreading disease, then we are going to be in the same situation we are in now with COVID. We’ll have missed any opportunity to stop it.”

A Baby Dies in Arequipa

The chirimacha is not a bedbug, or even closely related, but it behaves almost identically — hiding in the corners of bedrooms, feeding on humans at night, and reproducing rapidly.

“It’s a miracle of convergent evolution,” Levy says of the similarities between the two species.

The insect has fascinated Levy for more than 15 years.

Though it’s known best as the chirimacha locally in Arequipa, Peru, its scientific name is Triatoma infestans. The bug and its relatives are most abundant in South America, Central America, Mexico, and the southern United States, but have been found as far north as New Jersey.

In the U.S., they are called triatomines, or, more often, “kissing bugs.” The affectionate name comes from the insect’s decidedly unromantic way of earning its blood meal: As you sleep soundly at night, the bug — large and brown, with orange stripes around its perimeter — bites and then defecates near your mouth (or eyes, or open wound).

If you’re especially unlucky, that deposit might expose you to Trypanosoma cruzi (T. cruzi) — the parasite carried by the bugs that causes life-threatening Chagas disease.

It is unclear how many people Chagas affects worldwide, but Levy suspects the number is around 6 million. Most people have few symptoms and may never know that they were infected. For about 30 percent of its victims, Chagas disease causes chronic health problems, and can even be deadly. Sometimes, the complications — like heart failure — might strike many years after the chirimacha bites.

Levy first came to fear the chirimacha after reading about the bug in an old “Lonely Planet” guide about Chile. He had graduated from Amherst College and was spending a year bouncing around the country’s southern border with a traveling circus. (It’s a long story, but one worth listening to if you ever find yourself spending long afternoons in City Hall with Levy, as this writer did in the fall of 2019.)

While sleeping in all sorts of places with the circus, Levy would lie awake at night, a flashlight in hand, scanning his sheets for the lethal insect. “I had this real phobia of the Chagas bugs. It’s a terrifying disease,” he says.

Fear gradually turned into obsession, with both the chirimacha and the parasite it spread.

“In college, I loved a class about the evolution of infectious disease. So I knew I was interested in how things evolve to make you sick,” he says. “Eventually, the circus broke up. I started going to the library to read up about the evolution of Chagas. And that’s when I decided to go to grad school.”

Levy returned to his Philadelphia hometown to take pre-graduate courses at Penn, where he interned in the lab of Susan Weiss, PhD, a professor of Microbiology who specializes in coronaviruses. He was accepted into a PhD program at Emory University in Atlanta but spent most of his time during graduate school flying to Peru’s capital city of Lima, where he worked with a scientist who was studying infectious diseases. When Levy said that he was interested in Chagas, his advisor told him, “You’re too late. It’s already gone.”

What Levy’s “Lonely Planet” guidebook didn’t say, but he would later learn, was that the chirimacha had been essentially eliminated from Chile years before he arrived. Chagas was largely seen as a rare disease exclusive to poor, rural areas. The scientist turned his attention, instead, to tuberculosis.

Then, in 2001, tragedy struck. Spread across the front pages of newspapers in Peru, Levy read: Aquí, un bebé muere de la enfermedad de Chagas.

Chagas had killed a baby in Arequipa, Peru’s sprawling, second-largest city of one million people.

“When an infant has an acute case of Chagas disease, that means there is usually another 1,000 cases that you’re not seeing,” Levy says.

The burgeoning epidemiologist knew he needed to go to Arequipa to battle the disease that had haunted and captivated him for years.

Once he arrived in the White City — nicknamed for Arequipa’s white, volcanic stone architecture — Levy and a colleague from the Centers for Disease Control and Prevention met with representatives from the city’s Ministry of Health, who introduced them to Arequipa’s resident Chagas expert: the late Eleazar Córdova, then a microbiologist at the Universidad Nacional de San Agustín.

With funding from the Canadian government, the Ministry of Health embarked on a conventional door-to-door insecticidal treatment campaign, with methods dictated from afar by the Pan American Health Organization. Levy worked with Córdova to embed studies into the effort in order to understand the local epidemic — the largest ever in a city — and to tailor and recreate control strategies for other urban areas.

“There was a lot of press, and press gets politicians moving,” Levy says. “When there is political will, you can control a disease.”

In 2004, the Zoonotic Disease Research Center, located in the center of Arequipa, was created, funded by a Tropical Medicine Research Center award. The researchers planned to find the households where the infected insects were hiding, target those homes with insecticide, and then use data and epidemiological modeling to track where the next outbreak of disease might occur.

It would take more than 10 years to achieve their goals.

In Philadelphia, the Bedbug Battle Heats Up

By the fall of 2019, Levy had been back in Philadelphia for almost a decade, facing another nightmarish insect: He was confident that the city was finally ready to do something about bedbugs.

For the past four years, he had served on a city-commissioned Bedbug Task Force — composed of local scientists, pest management experts, and community activists — who worked diligently on a bill intended to stop the spread of the pests in a city that has been dubbed by Terminix as “the most bedbug-infested” in the country.

In October, Levy was scheduled to testify in favor of the bill, which was expected to pass easily through the Committee on Licenses and Inspections and on to a full City Council vote a few days later. He made plans for celebratory beers with friends after the meeting.

But by the time his name was called to testify, the scientist was conspicuously absent from the room.

“Michael Levy,” Councilmember Maria D. Quiñones Sánchez called into her microphone. Silence followed. “Michael Z. Levy?”

Two doors down the hall, Levy was caught in the middle of a heated argument between activists, landlord lobbyists, and city staffers about an amendment added to the bill — one he learned about just minutes before he was set to testify.

The bill, as originally written, would require landlords to notify tenants about past bedbug issues, develop bedbug control plans, and, most critically, to pay for the treatment of infestations in a timely fashion. However, the eleventh-hour amendment — pushed by the city’s landlord lobby — would shift costs of treatment to tenants if the infestation was detected after the 90th day of a lease. Levy and his task force colleagues found the amendment antithetical to the intent of the original legislation and argued that it would move the city backward in the fight against bedbugs.

Levy reentered the room, threw his planned testimony on a chair, and faced the row of four councilmembers with an indignant scowl.

“I’m Mike Levy, an associate professor at the University of Pennsylvania and a lifelong Philadelphian....” he began, with urgency and desperation mounting in his voice.

“As far as I know, I’m the only person here who has actually eliminated a bug from a city. And I’m here to tell you today that it can be done,” he continued. “What you need is smart policy that will encourage people to report the infestation, quickly. And that’s why I’m so concerned with the amendment to this bill. If you put the onus on the tenant to pay for treatment, they may not report it. I don’t care who is responsible — if they're not reporting it, it’s going to spread.”

Chasing Chirimachas

Each morning in October 2004, Levy rose at dawn in Arequipa. Already a Spanish speaker, his language skills reached fluency, as he followed behind the Ministry of Health workers, who were sent to spray insecticides at homes in Tiabaya, one of the city’s 29 districts. Tiabaya was located in the center of Arequipa, near where the baby had died three years earlier.

The workers, clad in green coveralls, sprayed the walls — as the chirimachas were often squeezed between bricks — while Levy and his colleagues caught the scurrying bugs. If they were agreeable, the residents of the infested homes were also screened for Chagas with a blood draw and an antibody test. By nightfall, Levy and the fieldworkers returned to Córdova’s lab and ate empanadas before they began the dirty work: carefully squeezing out the contents of the insects’ guts to observe under the microscope in search of the Chagas parasite.

After spraying households in Tiabaya, the team moved on to Guadalupe, a rural community of just 400 homes atop a hill on the southwestern edge of the city.

As Levy collected data from the inspections, he would use an old GPS to plot what he found on a map, with green dots showing parasite-free households, and red dots for those infested with chirimachas that were carrying T. cruzi.

Observing the map, Levy saw that about half of the homes in Guadalupe were infested with chirimachas. Some areas of the community had bugs, but those bugs had not been infected by the T. cruzi parasite. Within the areas that did have the parasite present, Levy noticed hot spots of human disease. Those who were infected were not living in random areas throughout the community, but instead, they were clustered in space.

“This told me that if we could figure out where the hot spots were, we could target our diagnosis and treatment,” Levy explains.

Over the next five years, the insecticide applicators, Levy, and his team repeated this pattern, in a new district each year, moving west to east, from rural to fully urban neighborhoods.

“Screening blood supply is the first step, then getting rid of the bugs is the second, and then treating people is the third,” Levy says. “The government usually won’t treat people until they get rid of the bugs, because they think they’ll just get re-infected.”

As the team reached more parts of the city, Levy’s maps began to reveal something unexpected: The prevalence of infected chirimachas was high in older communities nearer to the city center (though not in the center itself). Yet chirimachas were very rare in the recently established, poor communities at the far eastern areas of Arequipa.

The researchers had two hypotheses for the unusual pattern: Either the chirimachas were moving slowly throughout the city and had yet to reach the eastern outskirts; or the bugs had reached an environmental limit — perhaps some combination of temperature, humidity, and other factors.

To figure out why disease was spreading in some areas of the city and not others, the researchers needed to find out when the bugs had first arrived in a person’s home — a kind of critter-based contact tracing for Chagas.

“We asked everyone when they had first seen the bugs in their house. No one could answer that question,” Levy says. “That’s not something that people remember.”

Instead, the researchers used a surveying approach called event history calendars, in which households were questioned about important life events (like the birth of a child or an earthquake), and then those events were used to jog their memory. “Were you worried about the chirimachas when your son was born?” an interviewer might ask.

The field workers also surveyed the houses for bugs, documented domestic animal populations at the properties, and recorded descriptions of the homes’ construction.

From these site visits, Levy and his team were able to slowly piece together a likely story of the chirmachas’ voyage.

“Chirimachas were very common in the 1960s, but then they went away. Then, poverty was so high in the rural areas of Peru, that people started immigrating into the cities in large numbers, during the ‘80s and ‘90s,” explains Claudia Arevalo-Nieto, a biologist at the Zoonotic Disease Research Center.

During this time period, Peru created legislation aimed at formalizing property rights, which led to 1.4 million new land titles issued in the country between 1996 and 2004. Once migrants who had moved into Arequipa obtained title to their land, they could build up their homes without fear of eviction, bringing with them lots of belongings — not only furniture and goods, but also guinea pigs, chickens, dogs, and cows.

In Peru, chirimachas dine on guinea pigs, animals that are commonly traded and eaten. And crowded, densely packed homes become ideal hiding places for the bugs.

Meanwhile, other, poorer migrants continued to occupy vacant land on the eastern outskirts of the city. These settlements are known in Peru as “invasions,” and in contrast to the land-owning communities, they might remain underdeveloped for many years.

What the chirimacha research team discovered was that the bugs never crossed the line from the formalized property areas into the invasions, even if there was only a street separating them. It seemed that formalizing property rights may have inadvertently created conditions that favored the proliferation of the bugs, and, eventually, Chagas disease in these areas.

“Formalization of land invasions brings numerous social, economic and health benefits to residents of these communities, as well as increased tax revenue to local and regional governments,” Levy and his colleagues wrote in a 2014 paper about the trends they observed.

However, the researchers warned, “when such formalization is not accompanied by reasonable and enforceable zoning codes, it leads to an influx of building materials, people, and animals that creates prime habitats for triatomine bugs and other insects of epidemiological importance.”

Levy says the study opened his eyes to how thoughtful housing policy can mitigate disease spread. While potentially difficult to enforce, zoning codes — such as those related to how property owners house small animals or measures to prevent cock fighting — could go a long way in Arequipa.

“Policy matters,” Levy likes to say.

In 2010, Levy accepted an assistant professorship at Penn. While no longer living in Peru full-time, he continued to oversee the disease control campaign in Arequipa and returned frequently to the field. He also retained his connection with the Zoonotic Disease Research Center that had been established in Arequipa when he was in graduate school. Today, the center is a collaboration between Penn’s Center for Global Health and the Universidad Peuana Cayetano Heredia, which is co-led by Levy and employs a group of full-time biologists, epidemiologists, veterinarians, health communicators, nurses, and data managers.

By 2011, the insecticide spraying — which had been put on hold by the government for three years — resumed, and in 2014, international funders were ready to declare the city free of Chagas disease transmission.

Yet Levy was wary. The claimed victory was not so simple.

“There were still a lot of bugs, but the government was calling the campaign a success based on negative serology tests in kids,” Levy says. “We knew that once they declared that it was free of transmission, then all the resources and personnel would be reassigned from Chagas.”

Levy and his team pushed on. By 2016, they had reached all 29 city districts and treated an estimated 70,000 homes. The chirimacha was essentially eliminated from the city.

Still, the work is not over, Levy says.

“It’s like cleaning your house — you have three rooms, and then two, and then, finally, you get to the last room. So, OK, the house is pretty clean. That doesn’t mean you won’t have to keep sweeping,” Levy says. “For one day, it feels pretty good to be in that house...until the kids get the Legos out.”

With just a few new infestations — left unreported and untreated — Chagas disease could reemerge.

“After a very long spraying campaign, surveillance is the most important step,” Arevalo-Nieto says. “If you don’t have a plan for surveillance, then you were wasting all of your efforts.”

The surveillance program Levy’s team has created is called “An Immune System for the City,” which “adapts aspects of the immune system from the scale of cells to that of landscapes.”

In this program, community health workers are the circulating “immune cells.” They travel around their neighborhoods asking neighbors if they have seen chirimachas. If they hear about an infestation, they signal an alarm to bring in the “effector cells” — the insecticide applicators. They also “clonally expand” by training others in the area to serve, for a time, as more community health workers.

Levy is hopeful that this grassroots strategy will help to control any potential disease outbreaks, at a time when political will and resources for the project are in short supply — and a different epidemic is monopolizing his attention in Philadelphia.

Competent Vectors

When Levy inspects a bedbug-infested home, the first place he looks is under the sink. There, he’s not searching for bugs, but for chemicals. When people can’t afford an expensive extermination, they often turn to risky DIY treatments.

“I’ve seen a lot of dangerous, unmarked bottles obtained second-hand,” he says.

Many infested bedrooms resemble snow globes: White diatomaceous earth — a bug-killing powder intended to be sprayed lightly into cracks and crevices — is instead dumped on every inch of the floor.

Eliminating bedbugs from a home is not an easy task for anyone. “But wealthy people can get rid of them,” Levy says. “Poor people can’t.”

Reports of victims dousing their homes in alcohol, setting their beds on fire, and even attempting suicide, show the psychological turmoil that the bloodsucking terrors can inflict. Moreover, bedbugs — though they can strike anywhere, from five-star hotels to nursing homes — are still accompanied by stigma, and so the infested end up battling them silently and alone.

For homebound people, bedbugs can cause even greater harm. Since health workers are often reluctant to enter infested houses, they can prevent people with disabilities, senior citizens, and the chronically ill from receiving care. The loss of home care means more individuals who might otherwise live independently are being left with no option but to enter assisted living facilities — many of which, of course, are also struggling with infestations.

“The effect of bedbugs on our society is huge, pervasive, and hidden,” Levy says.

According to Jeni Wright, a housing attorney at the AIDS Law Project of Pennsylvania, many low-income residents in Philadelphia have leases that specify that the tenant is responsible for bedbug remediation — even though it is virtually impossible to know how or who introduced the bugs into a residence.

During the October 2019 City Council hearing, Wright told the story of a 51-year-old man living with HIV who discovered a bedbug infestation in his rented apartment. His landlord said the tenant was responsible for treatment.

“My client knew if he paid the $500 extermination fee, he wouldn’t be able to pay his rent. So what did he do? He started sleeping in the kitchen. When bugs followed him to the kitchen, he started sleeping in the bathtub,” she said.

When Levy began his professorship at Penn in 2010, the transition from chirimachas to bedbugs seemed natural. Bedbug horror stories were all over the newspapers and whispered through his neighborhood, and he felt confident that he could replicate his Arequipa success story in Philadelphia. Surely, if a major public health fight could be won with limited resources and grassroots efforts in a developing country, then the same could be possible in a major American metropolis.

He was surprised at what he found. Without the same kind of support that the local and federal government had awarded him in Peru, tracking the spread of bedbugs in Philadelphia proved more difficult than hunting chirimachas in Arequipa.

In the summer of 2013, Levy and his research team decided to focus their efforts on a single part of the city — South Philadelphia — to conduct a door-to-door campaign, similar to the efforts made in Arequipa.

After interviewing residents in 596 households, the researchers found that 11 percent — or 66 homes — were infested with bedbugs.

“That was more than we expected,” Levy says.

While large cities like New York, San Francisco, and Detroit all have bedbug policies requiring landlords to report and pay for treatment, Philadelphia had never enacted such a law. In 2014, after suffering from an infestation himself, Philadelphia City Councilmember Mark Squilla created Philadelphia’s first bedbug task force, which was charged with establishing legal requirements for landlords and tenants related to bedbug infestations.

The idea that legislation could reverse the course of an epidemic was more than a pipe dream. Research led by Kathryn Hacker, PhD, a postdoctoral fellow in the Perelman School of Medicine, shows that in New York City — which has enforced an intense and proactive campaign to detect, report, and treat bedbugs — infestations have declined. The city is not just flattening the entomologic curve, but forcing the effective reproductive number — the average number of newly infested homes that arise from a single infested property — below one, which leads to the end of an epidemic.

“It’s really hard to get bedbugs out of a home. It’s not so hard to get them out of a city,” Levy says.

In Philadelphia, the city decided early on that the proposed bedbug ordinance would be enforced by the Department of Licenses and Inspections, rather than the Department of Public Health.

That is because Philadelphia’s health department contends that bedbugs are not a public health issue. “Vector Control Services does not provide control services for bedbugs. This program is charged with the abatement of disease-carrying pests like rats and mosquitoes, of which bedbugs are not one,” a health department spokesperson explained in an email this past summer.

However, Levy’s research suggests that is untrue. Bedbugs are in fact “competent vectors” for at least two diseases: Trench fever and Chagas.

Back in Arequipa, in 2016, just as the chirimacha problem was dwindling, local bedbug infestations were picking up. Curious as to whether there may be a connection between bedbugs and Chagas disease, Levy’s collaborator Renzo Salazar searched through the scientific literature.

There, he found one, single-page manuscript — detailing findings from a study conducted in 1912 by the French scientist Emile Brumpt. Three years after Carlos Chagas had described Chagas disease, Brumpt infected two mice with T. cruzi and fed them to 100 hungry bedbugs. Nearly all 100 bugs contracted the parasite.

Salazar and Levy decided to repeat the experiment. In their lab in Peru, they exposed 10 mice infected with T. cruzi to 20 uninfected bedbugs. Almost all the bedbugs eventually acquired the parasite. When they reversed the experiment — exposing infected bedbugs to healthy mice — 9 out of 12 mice tested positive for the parasite.

But these were manipulations in a laboratory. It doesn’t mean that bedbugs are picking up and transmitting Chagas in real-world settings — at least not yet.

“It’s possible,” Levy told City Council. “It means they are competent vectors.”

And it’s that possibility that worries Levy the most.

He says there are thousands of people already living with Chagas in the United States (mostly people who became infected in other countries). Let’s say that, in a bedbug-infested home, a bug might bite a father who is already infected with Chagas disease. That bug then bites a newborn sleeping in a crib next to her parents’ bed. There haven’t been many documented instances of people contracting Chagas while in the United States so far. But it’s possible, we know now, that in this scenario, that the baby could then also contract Chagas. Or perhaps it’s already happening on a small scale, and we are just blind to it.

Would this lead to an uncontrollable Chagas outbreak in a city or state? Most likely not, Levy posits. However, something else is possible, he says: If bedbugs cause an epidemic, it wouldn’t necessarily be Chagas, but something else entirely — a brand new virus, perhaps.

“Competent means they can transmit it. We don’t know if they will. We use a term called ‘vectorial capacity,’ which is basically a measure of how many of them there are, and how frequently they bite us. On those numbers, the math is really worrisome,” Levy testified.

The plea was to Council’s Licenses and Inspections Committee, but it was also an argument for the health department.

“If there is an epidemic of a mosquito-borne illness, we can go inside. We can put on DEET. What are we going to do if there’s an epidemic of bedbugs? You can’t hide.”

Small Victories

On a chilly Thursday morning in December 2019, Levy and a small group from the Bedbug Task Force were shuffled into an over-crowded room on the fourth floor of City Hall. It was the final meeting of the year, before Council would break for the holidays. Bedbugs were finally back on the day’s agenda after the landlord lobby’s surprise amendment ended the October vote in a stalemate.

Oblivious to the new, mysterious virus that was sickening dozens of people 7,000 miles away in Wuhan, China, the mood in the room was cheerful and energetic.

Organizers pushing for the city to eliminate paper bags mingled with those opposed to the 10-year real estate tax abatement. Old friends hugged goodbye to Councilmember Jannie Blackwell, who had lost her seat in the Third District to a political newcomer. A team of middle school football players elbowed each other while waiting to receive an honor from the city.

Amid the commotion, George Gould shuffled through the crowds, shaking hands with members of Council and whispering in their ears.

Gould, an attorney with Philadelphia’s Community Legal Services since 1970, is a fixture at Council, with a long track record of fighting for — and winning — major housing policy battles. In 2019, for example, legislation requiring Philadelphia landlords to conduct lead testing every four years on housing units built before 1978 was passed, in large part, thanks to Gould’s lobbying.

After making his rounds, Gould huddled with Levy and the rest of the task force.

“Okay, we’re good. They promised they’re not going to change it,” he told the group.

After four years of drafting bedbug legislation and two months of intense lobbying with Council members to backtrack on the “90 day” amendment, the task force had finally come to a compromise with the lobbyists and the city.

The bill being voted on that afternoon would require landlords to pay for bedbug remediation up until one year into the lease. After that first year, extermination becomes a shared cost between tenant and landlord. The landlord also must disclose to new tenants any bedbug infestations in the previous 120 days.

Levy sat down in a wooden chair and sighed.

“You know, in Peru, you’re going door to door, interacting with people. You feel like you’re making a difference. Here, you’re just part of a circus,” he said.

Hours later, Bill 190106 passed quickly through Council, without protest or fanfare. There were no celebration beers.

The ordinance took effect on January 1, 2021. After a four-year battle, Levy knows he hasn’t yet won the war.

“It’s a start,” he says.

The Current Pandemic, and the Next One?

“One thing I’ve learned from being an epidemiologist is that the past is not a good predictor of the future. While it may be comforting to say that we haven’t seen an epidemic of Chagas disease caused by bedbugs, the truth is we haven’t been looking...No one foresaw the emergence of Zika virus, but we all knew that the Aedes mosquitoes that transmit it were at dangerously high densities...Our only recourse is prevention — to use policy to keep their numbers low.”

These are the final words Levy submitted in his written testimony to City Council a year and a half ago. Today, in a world upended by COVID-19, the warning reads like a prophecy. That’s the thing about epidemics: They are at once inevitable and unpredictable.

And while the COVID pandemic has complicated Levy’s work — both at home and abroad — it also seems as if years of debugging cities have led him precisely to this moment. He has pivoted his research focus, once again, from chirimachas, to bedbugs, and now to SARS-CoV-2. His latest study shows how renter evictions could fuel uncontrollable COVID spread in cities across the U.S.

That’s how Levy found himself once again in front of City Council in October 2020 — this time via Zoom — testifying in favor of a city-wide eviction moratorium. Testifying opposite him were the same landlord lobbyists who had attempted to reverse the bedbug legislation exactly one year earlier.

The irony is not lost on the epidemiologist.

In Peru, it wasn’t T. cruzi alone that killed a baby all those years ago — it was, at least in part, political neglect that opened the door to the Chagas epidemic. Likewise, elsewhere, personal responsibility alone won’t evict a parasite or pandemic from a city — bedbugs, viruses, or otherwise. It will require the will of public officials to protect and strengthen communities.

“The truth is, we need to stop preparing for epidemics,” Levy says, “and start dealing with the conditions that we are creating, which the pathogens are able to take advantage of.”